Fracture, Humeral Head



Ovid: 5-Minute Sports Medicine Consult, The


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
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


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