Shoulder / Proximal Humerus Fracture

shoulder pain treatment in singapore

Table of Contents

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 for Proximal Humerus Fracture in Singapore

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.

Appointment

If you would like an appointment / review with our shoulder & proximal humerus fracture specialist in Singapore, the best way is to call +65 3135 1327 or click here to book an appointment at the clinic. If you would like to speak to one of our clinicians first about e.g. humerus fracture treatment, humerus fracture surgery, then please contact contact@orthopaedicclinic.com.sg or SMS/WhatsApp to +65 3135 1327.

Rest assured that the best possible care will be provided for you.

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