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Fracture, Humeral Head

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Fracture, Humeral Head
Julie J. Chuan
Basics
  • Caution: Excessive movement of the arm may produce further neurovascular injury.
  • Controversy: Prehospital reduction is not recommended because manipulation may lead to neurovascular compromise or further displacement of a fracture.
Description
  • Proximal humeral fractures involve fractures of the humeral head, lesser tuberosity, greater tuberosity, bicipital groove, and proximal humeral shaft.
  • Mechanisms of injury:
    • Fall onto an outstretched hand
    • High-energy direct trauma
    • Excessive rotation of the arm in the abducted position
    • Electrical shock or seizure
    • Pathologic fracture from metastatic disease (1)
Epidemiology
Incidence
  • Typically seen in adults >65 yrs old
  • Proximal humeral fractures account for 5% of all fractures.
  • Predominant gender: Female > Male
Prevalence
  • Proximal humerus fractures are the 2nd most common upper extremity fractures (2).
  • In patients >65, they are the 3rd most common fracture after radius and hip fractures.
Risk Factors
  • Risk factors for humeral head fractures include low bone mass and falls.
  • Indirect risk factors include those that increase the risk for falls, such as depression, epilepsy, diabetes with neuropathy, and hearing impairment.
  • Physical activity, menopausal hormone treatment, and fewer number of fractures since age 45 are associated with a decrease risk of fracture (2).
General Prevention
Increased moderate physical activity, calcium supplementation to optimize bone density, and fall prevention minimize the risk of proximal humerus fractures.
Diagnosis
Pediatric Considerations
  • In children, proximal humeral fractures consist of metaphyseal fractures and physeal separations. Three fracture patterns tend to vary depending on the age group.
    • Children <5 yrs: Salter-Harris type I fractures are seen.
      • Neonatal fractures occur from obstetric trauma, and pseudoparalysis is seen often.
      • Physeal separation in an infant also may be the result of physical abuse.
    • Children 5–10 yrs: Metaphyseal fractures tend to occur in this age group because rapid growth causes thinning of the metaphyseal cortex. Most fractures are transverse or short oblique.
    • Children >11 yrs: Salter-Harris type II fractures tend to be seen in adolescents.
  • Careful history and physical examination to localize the injury and to rule out any other significant injuries
  • Assessment of neurovascular status:
    • Assess function of radial, median, ulnar, axillary (sensation to the lateral aspect of the shoulder), and musculocutaneous nerves (sensation to the extensor aspect of the forearm).
    • Presence of radial, ulnar, and brachial pulses and good capillary refill in all digits
  • Shoulder radiographs: Try to obtain orthogonal views (3).
Physical Exam
  • Signs and symptoms include (4):
    • Pain, swelling, and tenderness about the shoulder, especially around the greater tuberosity
    • Difficulty in initiating active motion
    • Position of the arm is often adducted and held closely against the chest.
    • Crepitus may be present.
    • Shoulder effusion owing to hemarthrosis developing into ecchymoses within 24–48 hr at the area of fracture and may spread to chest wall, flank, and distal extremity
    • Diminished peripheral pulses or decreased sensation, especially over the deltoid muscle (axillary nerve)
  • Remember to examine:
    • Nerve: Sensation over the deltoid muscle (axillary nerve) and distal motor and sensory function in the hand and fingers
    • Vascular: Radial and ulnar pulse, capillary refill time
    • Associated injuries: Clavicle, scapula, wrist, and elbow for range of motion and tenderness for concomitant injury (1)
Diagnostic Tests & Interpretation
  • Standard radiographs:
    • Anteroposterior (AP), lateral, and axillary views or transscapular Y view
    • AP view shows the articular surface of the humeral head, glenohumeral joint space, and the greater and lesser tuberosities.
    • The axillary view provides better assessment of shoulder dislocations, humeral head compression fractures, and glenoid, coracoid, and lesser tuberosity fractures.
  • CT scan: Consider CT scan if articular involvement is suspected to evaluate the glenoid and humeral head (5).
Imaging
  • Standard radiographs (trauma series) can be taken while in sling:
    • AP, lateral Y, and axillary views allow for 3 orthogonal views.
    • True AP view, taken 35–40 degrees from the sagittal plane, shows the articular surface of the humeral head, glenohumeral joint space, and the greater and lesser tuberosities.
    • Scapular Y view, taken 90 degrees from the true AP and 40 degrees from the coronal plane, shows the scapular contour and position of the humeral head in the glenoid.
    • Axillary view, taken with the shoulder abducted 70–90 degrees with the beam cephalad, shows shoulder dislocations, humeral head compression fractures, and glenoid and lesser tuberosity fractures; may need to use trauma axillary view or Velpeau view.
  • CT scan:
    • Intra-articular fractures to evaluate the glenoid and humeral head
    • Suspected occult fractures
    • Posterolateral compression fractures
    • Evaluate for multipart fractures of humeral head (5).
Differential Diagnosis
  • Shoulder dislocation
  • Acute hemorrhagic bursitis
  • Traumatic rotator cuff tear
  • Acromioclavicular separation
  • Calcific tendinitis
  • Pathologic fracture
Treatment
Pediatric Considerations
  • In children nearing skeletal maturity, determining the degree of displacement or separation of the proximal humeral epiphysis is essential because exact reduction is important to prevent later growth disturbance.
  • Pediatric patients are often less compliant with immobilization and less able to verbalize complaints and may benefit from admission to the hospital for observation and neurovascular checks.

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ED Treatment
  • Proper immobilization, orthopedic consultation, and pain management
  • Operative versus nonoperative treatment is decided in conjunction with orthopedics.
  • Neer classification: This system identifies the number of fragments and their location.
    • The fractures consist of 2–4-part fractures, and the locations include the anatomic neck, the surgical neck, the greater tuberosity, and the lesser tuberosity.
    • Displacement is defined as >1 cm of separation or >45 degrees of angulation between fragments.
    • In general, the higher the number of fragments in the fracture and the greater the degree of displacement, the more difficult it is to manage the patient with a closed reduction.
  • AO (Arbeitsgemeinschaft fur Osteosynthese-fragen) classification:
    • A: Unifocal, extraarticular, 2-part fracture with an intact blood supply
    • B: Bifocal, extraarticular, 2-part fracture with possible injury to the blood supply
    • C: Articular fracture involving the anatomic neck, high likelihood of injury to the blood supply, and risk of avascular necrosis of the humeral head.
  • Nonoperative treatment:
    • Initial immobilization and early motion: Succeeds in many cases because most proximal humeral fractures are minimally displaced
    • Use a sling, swathe, and axillary pad to immobilize.
    • Closed reduction should be performed with consultation of an orthopedic surgeon.
    • Conscious sedation should be used for all closed reductions.
    • Following reduction, the stability of the fracture can be tested in different positions to ascertain that significant displacement requiring surgical intervention will not occur.
  • Surgical referral:
    • 1- and 2-part fractures are often treated successfully with closed reduction, but 3- and 4-part fractures are unstable and may need open reduction and internal fixation (ORIF).
    • If the blood supply is compromised, there is a risk of avascular necrosis of the humeral head, and surgical intervention should be considered (5).
Medication
  • Pain medications are indicated for comfort.
  • Conscious sedation should be used if attempting a closed reduction.
Additional Treatment
Additional Therapies
  • A fracture is considered a nonunion if it is not clinically healed after 3 mos.
  • Risk factors for nonunions include:
    • Displacement of the fracture
    • Aggressive rehabilitation
    • Patient noncompliance
  • Comorbidities that can be a risk factor for nonunions include:
    • Osteoporosis
    • Alcoholism
    • Tobacco usage
    • Mental illness
    • Systemic corticosteroids
    • Rheumatologic disease (6)
In-Patient Considerations
Initial Stabilization
  • Airway, breathing, and circulation (ABCs) and secondary survey for associated injuries
  • Immediate immobilization is important to prevent further fracture displacement or neurovascular injury.
    • Sling with arm supported at the side or in the Velpeau position
    • Axillary pad also may be used for comfort.
    • After immobilization, perform another neurovascular examination.
Admission Criteria
  • Open fractures for operative management and parenteral antibiotic therapy
  • Displaced fracture that cannot be treated through closed reduction and therefore require operation
  • Significant associated injuries that require admission and observation
Discharge Criteria
Patients with either a nondisplaced fracture or a fracture that is treated successfully through closed reduction and who have no associated injuries
Ongoing Care
The proximal humerus is supplied by the axillary artery, which is often disrupted with displaced fractures resulting in avascular necrosis of the humeral head.
Prognosis
  • Nonunions can be treated nonoperatively if pain is minimal with adequate range of motion and function.
  • Nonunions can be surgically reduced with internal fixation if the glenohumeral articular surface is preserved.
  • Arthroplasty is preferred when the articular surface is disrupted.
References
1. Rockwood CA, Green DP, Bucholz RW, et al. In: Rockwood CA, Green DP, eds. Rockwood and Green's fractures in adults. 4th ed. Philadelphia: Lippincott-Raven, 1996.
2. Chu SP, Kelsey JL, Keegan TH, et al. Risk factors for proximal humerus fracture. Am J Epidemiol. 2004;160:360–367.
3. Morrissy RT, Weinstein SL. Lovell and Winter's pediatric orthopaedics. Vol. II. 4th ed. Philadelphia: Lippincott-Raven, 1996.
4. Neer CS. Displaced proximal humeral fractures: i. classification and evaluation. J Bone Joint Surg. 1970;52A:1077–1089.
5. Robinson BC, Athwal GS, Sanchez-Sotelo J, et al. Classification and imaging of proximal humerus fractures. Orthop Clin North Am. 2008;39:393–403, v.
6. Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008;39:475–482, vii.
Additional Reading
Hawkins RJ, Angelo RL. Displaced proximal humeral fractures. Selecting treatment, avoiding pitfalls. Orthop Clin North Am. 1987;18:421–431.
Rasmussen S, Hvass I, Dalsgaard J, et al. Displaced proximal humeral fractures: results of conservative treatment. Injury. 1992;23:41–43.
Codes
ICD9
  • 812.00 Fracture of unspecified part of upper end of humerus, closed
  • 812.09 Other closed fractures of upper end of humerus
  • 812.19 Other open fracture of upper end of humerus
Clinical Pearls
  • Axillary artery is the most common neurovascular injury and can result in avascular necrosis of the humeral head.
  • When evaluating shoulder dislocations, consider associated humeral head fractures.
  • When the fracture is stable with some callus on radiograph, consider initiating gentle range-of-motion exercises as early as tolerated.


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