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Proximal Humerus Fracture

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Other Names

  • Humeral Head Fracture
  • Humeral Neck Fracture
  • Shoulder Fracture
  • Shoulder Fracture-dislocation

Background

  • This page refers to all proximal Humerus fractures

Epidemiology

  • Represent 4-5% of all fractures[1]
  • Most commonly seen in geriatric patients[2]
  • Increasingly common as population ages[3]
  • 2:1 Female:Male (need citation)

Pathophysiology

Etiology

  • Lower energy
    • Most commonly occurs after a low energy fall
    • Likely to be minimally displaced, isolated injury
    • Elderly patient
  • Moderate/high energy
    • E.g. MVC
    • More likely to have have significant displacement
    • Younger patient

Pathoanatomy

Associated Injuries


Risk Factors


Differential Diagnosis


Clinical Features

  • General: Physical Exam Shoulder
  • History
    • Pain, swelling, bruising
    • Loss of range of motion
  • Physical
    • Ecchymosis may extend across shoulder, arm and into chest
    • Neurovascular exam, especially axillary nerve

Evaluation

  • Radiographs
    • Standard Radiographs Shoulder
    • Usually sufficient for diagnosis
    • Generally demonstrate cortical breaks with varying degree of angulation, displacement, comminution, impaction
  • CT
    • Useful for surgical planning or clarifying fracture pattern
  • MRI
    • Used if suspected soft tissue injury

Classification

Neer Classification

  • Based on anatomic relationship of 4 segments
    • Greater tuberosity
    • Lesser tuberosity
    • Articular surface
    • Shaft
  • Criteria for displacement
    • >1 cm displacement
    • >45° angulation

AO classification

  • Type A: extra-articular unifocal (either tuberosity +/- surgical neck of the humerus)[5]
    • A1: extra-articular unifocal fracture
    • A2: extra-articular unifocal fracture with impacted metaphyseal fracture
    • A3: extra-articular unifocal fracture with non-impacted metaphyseal fracture
  • Type B: extra-articular bifocal (both tuberosities +/- surgical neck of the humerus or glenohumeral dislocation)
    • B1: extra-articular bifocal fractures with impacted metaphyseal fracture
    • B2: extra-articular bifocal fractures with non-impacted metaphyseal fracture
    • B3: extra-articular bifocal fractures with glenohumeral joint dislocation
  • Type C: extra-articular (anatomical neck) but with compromise to the vascular supply of the articular segment
    • C1: anatomical neck fracture, minimally displaced
    • C2: anatomical neck fracture, displaced and impacted
    • C3: anatomical neck fracture with glenohumeral joint dislocation

Management

  • No clear, evidence-based consensus for management of many of these fractures
  • Most uncomplicated cases are treated nonoperatively
  • Expectation that fracture will heal and patient will regain some or full function of shoulder

Nonoperative

  • Indications
    • Most cases with minimal displacement of surgical or anatomic neck
    • Displacement < 5 mm
    • Poor surgical candidates
  • Immobilize: Shoulder Immobilizer
  • Start early range of motion at ~2 weeks

Operative

  • Technique
    • closed reduction with percutaneus pinning
    • ORIF
    • IM Nail
    • Arthroplasty

Rehab and Return to Play

Rehabilitation

  • 3 phase protocol[6]
    • Early passive range of motion
    • Progress to active range of motion, resistance exercises
    • Advance stretching and strengthening program

Return to Play

  • Needs to be updated

Complications


See Also


References


  1. Konrad GG, Mehlhorn A, Kuhle J, et al. Proximal humerus fractures—current treatment options. Acta Chir Orthop Traumatol Cech. 2008;75:413–421.
  2. Horak J, Nilsson BE. Epidemiology of fracture of the upper end of the humerus. Clin Orthop Relat Res. 1975;(112):250–3.
  3. Bengner U, Johnell O, Redlund-Johnell I. Changes in the incidence of fracture of the upper end of the humerus during a 30-year period. A study of 2125 fractures. Clin Orthop Relat Res. 1988;231:179–182.
  4. Chu, Sarah P., et al. "Risk factors for proximal humerus fracture." American journal of epidemiology 160.4 (2004): 360-367.
  5. https://radiopaedia.org/articles/ao-classification-of-proximal-humeral-fractures-1?lang=us
  6. Hodgson, Steve. "Proximal humerus fracture rehabilitation." Clinical Orthopaedics and Related Research® 442 (2006): 131-138.
Created by:
John Kiel on 4 July 2019 08:04:37
Authors:
Last edited:
3 November 2021 19:49:33
Categories:
Trauma | Shoulder | Fractures | Acute