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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

History
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)
  • Third most common non-axial fracture pattern seen in patients over 65 (need citation)

Introduction

Illustration of the fracture sites for the proximal humerus[4]

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

Differential Diagnosis Shoulder Pain


Clinical Features

History

  • Pain, swelling, bruising
  • Loss of range of motion

Physical: Physical Exam Shoulder

  • Ecchymosis may extend across shoulder, arm and into chest
  • Neurovascular exam, especially axillary nerve
  • Evaluate for other shoulder and Thoracic injuries

Evaluation

Comminuted proximal humerus fracture at the surgical neck with posterior displacement
Nondisplaced proximal humerus fracture at the surgical neck
A four-part fracture of the proximal humerus was treated initially by plate fixation. The reduction was incorrect, and a severe tuberosity and humeral head malunion occurred (a). It was treated by reverse arthroplasty, and as a proximal humeral bone loss was found intraoperatively, an allograft and a long humeral stem were used. The allograft was placed around the proximal body of the prosthesis in the greater tuberosity area and fixed with a cable wire around the graft and the inner humerus. The prosthesis dislocated and was not stable upon adding an extension to the humeral neck component (b). Therefore, it had to be revised and converted to a hemiarthroplasty with a larger head cover (c). We could observe the allograft incorporated into the prosthesis 2 years later (d)[6]

Radiographs

  • Standard Radiographs Shoulder
    • Usually sufficient for diagnosis
    • Generally demonstrate cortical breaks with varying degree of angulation, displacement, comminution, impaction

CT

  • Indications
    • Pre-operative planning
    • Uncertainty of humeral head or greater tuberosity position
    • Intra-articular extension
    • Concern for "head split" fracture

MRI

  • Rarely indicated for
    • Evaluate for associated rotator cuff 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)[7]
    • 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

General

  • 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, Sling
  • Start early range of motion at ~2 weeks

Operative

  • Indications
    • 2-part surgical neck fractures
    • 3-part and valgus-impacted 4-part fractures
    • Greater tuberosity fracture displaced > 5 mm
    • Displaced 2-part fractures
    • 3- and 4-part fractures in younger patients
    • Head splitting fractures
  • Technique
    • closed reduction with percutaneous pinning
    • ORIF
    • IM Nail
    • Arthroplasty

Rehab and Return to Play

Rehabilitation

  • 3 phase protocol[8]
    • Early passive range of motion
    • Progress to active range of motion, resistance exercises
    • Advance stretching and strengthening program

Return to Play/Work

  • Needs to be updated

Prognosis and Complications

Prognosis

  • Needs to be updated

Complications


See Also

Internal

External


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. Image courtesy of www.jaortho.com.au, "proximal humerus fractures"
  5. Chu, Sarah P., et al. "Risk factors for proximal humerus fracture." American journal of epidemiology 160.4 (2004): 360-367.
  6. Martinez, Angel Antonio, et al. “The use of the Lima reverse shoulder arthroplasty for the treatment of fracture sequelae of the proximal humerus.” Journal of Orthopaedic Science 17.2 (2012): 141-147.
  7. https://radiopaedia.org/articles/ao-classification-of-proximal-humeral-fractures-1?lang=us
  8. 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:
14 March 2024 23:29:18
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