Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Shoulder/Proximal Humerus Fracture

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.
  • Patients with osteoporotic bone are at the highest risk.
  • In nonosteoporotic patients, fractures result from high-energy trauma.
  • Classification:
    • Neer classification 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.
  • The risk is closely related to the prevalence of osteoporosis.
Incidence
  • 70 per 100,000 people .
  • 3:1 Female:Male incidence .
  • Proximal humerus fractures account for 10% of all fractures in patients >65 years old .
Risk Factors
  • Low bone mineral density
  • Predisposition to falls:
    • Diabetes mellitus
    • Previous falls
    • Epilepsy and seizure medication
    • Poor vision and balance
  • Previous fractures after age 45 years
  • 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 .
    • 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.
  • 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
  • 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.
    • 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.
  • 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.
  • 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.
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
  • Loss of fixation
  • Axillary artery injury
Patient Monitoring
Follow-up radiographs every 1-4 weeks to assess reduction of the fracture and bony healing.
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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