Shoulder / Proximal Humerus Fracture

• 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°.

• Osteoporosis prevention
• Fall prevention

• Risk for a proximal humeral fracture increases with age, peaking in the 9th decade.
• The risk is closely related to the prevalence of osteoporosis.

• 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

• 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.

• 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

• 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

Tests

• 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)

• 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.

Special Therapy

• 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.

• Most fractures unite without operative intervention.
• Some shoulder motion may be lost.

• 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

• 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.

FAQ