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Shoulder/Proximal Humerus Fracture

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Shoulder/Proximal Humerus Fracture

Shoulder/Proximal Humerus Fracture
Matthew D. Waites AFRCS (Ed)
Barry Waldman MD
Basics
Description
  • The proximal humerus consists of the
    articular surface of the shoulder joint and the attachments of the
    rotator cuff to the greater and lesser tuberosities.
  • Most of the blood supply to the humeral head comes from the anterior humeral circumflex branch of the axillary artery.
  • >90% of proximal humeral fractures result from a low-energy fall directly onto the shoulder (1,2).
  • Patients with osteoporotic bone are at the highest risk.
  • In nonosteoporotic patients, fractures result from high-energy trauma.
  • Classification:
    • Neer classification (3) divides the proximal humerus into 4 parts:
      • Articular surface
      • Greater tuberosity
      • Lesser tuberosity
      • Surgical neck (the border between the round proximal metaphysis and the diaphyseal portion of the bone)
      • Fractures are classified as having 1–4
        parts, based on the number of fragments, with a fragment defined as a
        part if it is displaced >1 cm and/or angulated >45°.
General Prevention
  • Osteoporosis prevention
  • Fall prevention
Epidemiology
  • Risk for a proximal humeral fracture increases with age, peaking in the 9th decade (4).
  • The risk is closely related to the prevalence of osteoporosis.
Incidence
  • 70 per 100,000 people (5).
  • 3:1 Female:Male incidence (4).
  • Proximal humerus fractures account for 10% of all fractures in patients >65 years old (6).
Risk Factors
  • Low bone mineral density
  • Predisposition to falls:
    • Diabetes mellitus
    • Previous falls
    • Epilepsy and seizure medication (1)
    • Poor vision and balance
  • Previous fractures after age 45 years (1)
  • Reduced physical activity
Genetics
No known genetic association
Etiology
  • Mechanism of injury:
    • In elderly osteoporotic patients, 76% result from a fall that has a direct impact on the shoulder or upper arm (2).
    • In younger patients, high-energy injury such as a motor vehicle accident is primary cause.
Associated Conditions
  • Dislocation of the glenohumeral joint
  • Complete rotator cuff tears occur in 20% of cases, particularly greater tuberosity fractures (7).
  • Axillary and suprascapular nerve injury
  • Vascular injury to axillary vessels or their branches, especially in the presence of atherosclerosis
Diagnosis
Signs and Symptoms
  • Subcutaneous hematoma in 68% of patients sustaining fracture from a low-energy fall (2)
  • Ecchymosis may extend to the elbow or chest wall and neck.
  • Pain with ROM
  • Patient supporting the affected arm
History
  • Discover the mode of injury, low- versus high-energy fracture
Physical Exam
  • Note loss of deltoid contour and limb posture, which may indicate an associated dislocation.
  • Examine the skin to check its integrity.
  • Palpate the humerus, clavicle, and scapula.
  • Perform a neurovascular examination of the entire upper extremity to rule out an associated injury.
    • It is important to document sensation in the “regimental badge” area supplied by the axillary nerve’s lateral circumflex branch.
Tests
Lab
No routine tests are indicated unless surgery is anticipated.
Imaging
  • 3 views of the proximal humerus should be obtained for all fractures:
    • AP
    • Lateral
    • Axillary
  • CT may be helpful in comminuted fractures when surgery is planned.
Differential Diagnosis
  • Acute rotator cuff tear or strain
  • Anterior or posterior shoulder dislocation (similar presentation)
  • Pain in the proximal shoulder (may be from AC joint dislocation or biceps tendon rupture)
Treatment
General Measures
  • Up to 85% of proximal humerus fractures are displaced minimally and can be treated nonoperatively (5).
    • A simple collar and cuff allows gravity to maintain alignment.
    • It is imperative that the patient maintains elbow and wrist movement.
  • Dislocated shoulders require reduction with intra-articular block or sedation.
Activity
  • Initially, the patient’s arm is placed in a sling.
  • The patient should begin gentle pendulum exercises of the shoulder.
Nursing
  • Skin care under the axillary fold is important.
  • A pad (changed daily) should be placed.
  • The patient will require assistance with washing.
Special Therapy
Physical Therapy
  • Patients with 2-part fractures have been
    shown to have less pain and better outcomes when treated with immediate
    physical therapy and pendular exercises than with delayed therapy (8).
  • Early passive movement also is important in surgically repaired shoulders.
  • Active motion should not begin until 4–6 weeks after surgery.
Medication
First Line
Oral narcotic analgesics are appropriate in the acute setting.
Surgery
  • Greater tuberosity fractures may need to be stabilized if they are displaced >5–10 mm.
  • Displaced 2-part fractures in the young
    polytrauma victim should be treated surgically (plate, intramedullary
    nail, or multiple pins) to aid mobilization.
  • Controversy exists over the best way to treat displaced osteoporotic 3- and 4-part fractures.
    • 2 studies have shown no benefit of
      surgical treatment over nonoperative treatment, although patients were
      not randomized to treatment groups and methods of fixation were not
      standardized (9,10).
  • Because operative treatment of displaced
    3- and 4-part fractures should preserve soft-tissue attachments and be
    mindful of the blood supply to the humeral head, treatment trends
    include minimal fixation with sutures, wires, or smooth pins.
  • Displaced 4-part fractures have a high risk of osteonecrosis, and prosthetic replacement should be considered.

P.401


Follow-up
Prognosis
  • Most fractures unite without operative intervention.
  • Some shoulder motion may be lost.
Complications
  • Osteonecrosis of the humeral head
  • Nonunion
  • Malunion
  • Shoulder stiffness
  • Axillary nerve injury in up to 58% of patients diagnosed with electromyography (11)
  • Loss of fixation
  • Axillary artery injury
Patient Monitoring
Follow-up radiographs every 1–4 weeks to assess reduction of the fracture and bony healing.
References
1. Chu SP, Kelsey JL, Keegan THM, et al. Risk factors for proximal humerus fracture. Am J Epidemiol 2004;160:360–367.
2. Palvanen
M, Kannus P, Parkkari J, et al. The injury mechanisms of osteoporotic
upper extremity fractures among older adults: A controlled study of 287
consecutive patients and their 108 controls. Osteoporos Int 2000;11:822–831.
3. Neer CS, II. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg 1970;52A:1077–1089.
4. Nguyen
TV, Center JR, Sambrook PN, et al. Risk factors for proximal humerus,
forearm, and wrist fractures in elderly men and women: The Dubbo
Osteoporosis Epidemiology Study. Am J Epidemiol 2001;153:587–595.
5. Lyons
RP, Lazarus MD. Shoulder and arm trauma: Bone. In: Vaccaro AR, ed.
Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of
Orthopaedic Surgeons, 2005: 267–281.
6. Baron
JA, Karagas M, Barrett J, et al. Basic epidemiology of fractures of the
upper and lower limb among Americans over 65 years of age. Epidemiology 1996;7:612–618.
7. Schai PA, Hintermann B, Koris MJ. Preoperative arthroscopic assessment of fractures about the shoulder. Arthroscopy 1999;15:827–835.
8. Hodgson SA, Mawson SJ, Stanley D. Rehabilitation after two-part fractures of the neck of the humerus. J Bone Joint Surg 2003;85B:419–422.
9. Fjalestad
T, Stromsoe K, Blucher J, et al. Fractures in the proximal humerus:
Functional outcome and evaluation of 70 patients treated in hospital. Arch Orthop Trauma Surg 2005;125:310–316.
10. lchmann
T, Ochsner PE, Wingstrand H, et al. Non-operative treatment versus
tension-band osteosynthesis in three- and four-part proximal humeral
fractures. A retrospective study of 34 fractures from two different
trauma centers. Int Orthop 1998;22:316–320.
11. Visser CPJ, Coene LNJEM, Brand R, et al. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg 2001;10:421–427.
Additional Reading
Sher
JS, Lozman PR. Proximal humerus fractures and dislocations and
traumatic soft tissue injuries of the glenohumeral joint. In: Brinker
MR, ed. Review of Orthopaedic Trauma. Philadelphia: WB Saunders, 2001:239–254.
Miscellaneous
Codes
ICD9-CM
812.0 Fracture, upper end humerus, closed
Patient Teaching
  • Emphasize importance of early passive exercises and active movements of the ipsilateral elbow and wrist.
  • Explain that fractures may take 6–10 weeks to heal, and that some permanent shoulder stiffness is common.
Activity
  • As pain decreases, patients should increase their activity.
  • For the first 3 months, the patient should not lift >10 pounds.
  • After healing, the patient may resume normal activity gradually.
Prevention
  • Patients who have a fracture after the age of 50 years should be evaluated for osteoporosis with a DEXA scan.
  • Osteoporosis prevention should be instituted.
  • Elderly patients who fall should be evaluated to determine if falls can be prevented:
    • Physical therapist visit to the patient’s home
    • Medical checkup for comorbidities that may cause falls, such as cataracts, dizziness, dementia, and polypharmacy
FAQ
Q: How are most fractures treated in the elderly patient?
A: Most proximal humerus fractures in the elderly can be treated without surgery.

Q: How long should a sling be worn?
A:
The sling is for comfort in the first 2–4 weeks after surgery. A sling
prevents motion, and motion is desired after pain has resolved to
prevent stiffness.

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