Basics
Description
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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.
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Most of the blood supply to the humeral head comes from the anterior humeral circumflex branch of the axillary artery.
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>90% of proximal humeral fractures result from a low-energy fall directly onto the shoulder.
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Patients with osteoporotic bone are at the highest risk.
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In nonosteoporotic patients, fractures result from high-energy trauma.
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Classification:
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Neer classification divides the proximal humerus into 4 parts:
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Articular surface
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Greater tuberosity
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Lesser tuberosity
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Surgical neck (the border between the round proximal metaphysis and the diaphyseal portion of the bone)
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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°.
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General Prevention
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Osteoporosis prevention
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Fall prevention
Epidemiology
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Risk for a proximal humeral fracture increases with age, peaking in the 9th decade.
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The risk is closely related to the prevalence of osteoporosis.
Incidence
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70 per 100,000 people .
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3:1 Female:Male incidence .
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Proximal humerus fractures account for 10% of all fractures in patients >65 years old .
Risk Factors
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Low bone mineral density
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Predisposition to falls:
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Diabetes mellitus
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Previous falls
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Epilepsy and seizure medication
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Poor vision and balance
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Previous fractures after age 45 years
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Reduced physical activity
Genetics
No known genetic association
Etiology
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Mechanism of injury:
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In elderly osteoporotic patients, 76% result from a fall that has a direct impact on the shoulder or upper arm .
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In younger patients, high-energy injury such as a motor vehicle accident is primary cause.
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Associated Conditions
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Dislocation of the glenohumeral joint
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Complete rotator cuff tears occur in 20% of cases, particularly greater tuberosity fractures.
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Axillary and suprascapular nerve injury
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Vascular injury to axillary vessels or their branches, especially in the presence of atherosclerosis
Diagnosis
Signs and Symptoms
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Subcutaneous hematoma in 68% of patients sustaining fracture from a low-energy fall
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Ecchymosis may extend to the elbow or chest wall and neck.
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Pain with ROM
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Patient supporting the affected arm
History
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Discover the mode of injury, low- versus high-energy fracture
Physical Exam
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Note loss of deltoid contour and limb posture, which may indicate an associated dislocation.
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Examine the skin to check its integrity.
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Palpate the humerus, clavicle, and scapula.
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Perform a neurovascular examination of the entire upper extremity to rule out an associated injury.
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It is important to document sensation in the regimental badge area supplied by the axillary nerve’s lateral circumflex branch.
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Tests
Lab
No routine tests are indicated unless surgery is anticipated.
Imaging
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3 views of the proximal humerus should be obtained for all fractures:
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AP
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Lateral
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Axillary
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CT may be helpful in comminuted fractures when surgery is planned.
Differential Diagnosis
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Acute rotator cuff tear or strain
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Anterior or posterior shoulder dislocation (similar presentation)
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Pain in the proximal shoulder (may be from AC joint dislocation or biceps tendon rupture)
Treatment
General Measures
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Up to 85% of proximal humerus fractures are displaced minimally and can be treated nonoperatively.
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A simple collar and cuff allows gravity to maintain alignment.
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It is imperative that the patient maintains elbow and wrist movement.
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Dislocated shoulders require reduction with intra-articular block or sedation.
Activity
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Initially, the patient’s arm is placed in a sling.
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The patient should begin gentle pendulum exercises of the shoulder.
Nursing
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Skin care under the axillary fold is important.
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A pad (changed daily) should be placed.
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The patient will require assistance with washing.
Special Therapy
Physical Therapy
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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.
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Early passive movement also is important in surgically repaired shoulders.
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Active motion should not begin until 4-6 weeks after surgery.
Medication
First Line
Oral narcotic analgesics are appropriate in the acute setting.
Surgery
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Greater tuberosity fractures may need to be stabilized if they are displaced >5-10 mm.
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Displaced 2-part fractures in the young polytrauma victim should be treated surgically (plate, intramedullary nail, or multiple pins) to aid mobilization.
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Controversy exists over the best way to treat displaced osteoporotic 3- and 4-part fractures.
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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.
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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.
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Displaced 4-part fractures have a high risk of osteonecrosis, and prosthetic replacement should be considered.
Follow-up
Prognosis
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Most fractures unite without operative intervention.
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Some shoulder motion may be lost.
Complications
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Osteonecrosis of the humeral head
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Nonunion
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Malunion
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Shoulder stiffness
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Axillary nerve injury in up to 58% of patients diagnosed with electromyography
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Loss of fixation
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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
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Emphasize importance of early passive exercises and active movements of the ipsilateral elbow and wrist.
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Explain that fractures may take 6-10 weeks to heal, and that some permanent shoulder stiffness is common.
Activity
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As pain decreases, patients should increase their activity.
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For the first 3 months, the patient should not lift >10 pounds.
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After healing, the patient may resume normal activity gradually.
Prevention
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Patients who have a fracture after the age of 50 years should be evaluated for osteoporosis with a DEXA scan.
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Osteoporosis prevention should be instituted.
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Elderly patients who fall should be evaluated to determine if falls can be prevented:
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Physical therapist visit to the patient’s home
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Medical checkup for comorbidities that may cause falls, such as cataracts, dizziness, dementia, and polypharmacy
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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.