II. Epidemiology

  1. Accounts for 6% of Fractures in adults
  2. Incidence increases with age
  3. Most common in elderly women
    1. Surgical neck Fracture is especially common

III. Risk Factors

IV. Mechanism

  1. Older patients
    1. Fall from standing height is most common mechanism
    2. May occur with fall on an Outstretched Hand
  2. Younger patients (<50 years old)
    1. Related to direct blow to Shoulder (sports or MVA)
  3. Tuberosity Fracture
    1. Traumatic fall
    2. Shoulder Dislocation

V. Symptoms

  1. Severe pain at upper arm
    1. Provoked by any arm movement

VI. Signs

  1. Swelling, Ecchymosis and pain over Shoulder
  2. Evaluate for open Fracture (rare)
  3. Evaluate affected arm for neurovascular injury
    1. Vascular injury
      1. Forearm or hand pallor (axillary artery injury)
      2. Radial pulse
    2. Sensory Exam
      1. Arm sensory changes especially laterally (Axillary Nerve Injury)
    3. Motor Exam
      1. Finger abduction against resitance (Ulnar Nerve function)
      2. Dorsiflexion against resistance (Radial Nerve)
      3. Opposition of thumb and index finger against resistance (Median Nerve)
  4. Concurrent Shoulder injuries
    1. Shoulder Dislocation
    2. Rotator Cuff Injury
  5. Evaluate for other Fractures distant to Shoulder
    1. Distal Radius Fracture
    2. Leg Injury (e.g. proximal Femur Fracture) due to high mechanism, multiple Trauma injury

VII. Imaging: Standard Shoulder XRay series

  1. Anteroposterior Shoulder view
  2. Axillary view (if able despite pain)
  3. Scapular Y view

IX. Classification: Neer Classification

  1. Planes of Fracture cleavage
    1. Greater tuberosity Fracture
      1. Attaches supraspinatus, infraspinatus, teres minor
    2. Lesser tuberosity Fracture
      1. Attaches to subscapularis
    3. Humeral Head Fracture (Anatomic neck Fracture)
    4. Humeral Shaft Fracture (Surgical neck Fracture)
  2. Fracture fragments
    1. One part Fracture (80% of Proximal Humerus Fractures)
      1. Less than 1 cm displacement
      2. Less than 45 degree angulation
    2. Two part Fractures
      1. Surgical neck Fracture (Most common 2-part)
        1. Distal to lesser tuberosity
      2. Humeral Head Fracture (Anatomic neck Fracture)
      3. Greater tuberosity Fracture
      4. Lesser tuberosity Fracture
    3. Three part Fractures (uncommon)
      1. Humeral head and shaft and one of tuberosities
    4. Four part Fractures (rare)
      1. Humeral head and shaft and one of tuberosities

X. Complications

  1. Axillary nerve or axillary artery injury
  2. Brachial Plexus Injury
  3. Brachial artery injury
  4. Non-union or malunion
  5. Posterior dislocation
    1. More common in Fracture of lesser tuberosity

XI. Management: Orthopedic referral indications

  1. Urgent Consultation
    1. Open Fracture
    2. Neurovascular compromise
    3. Fracture-Dislocation
  2. Open reduction and internal fixation
    1. Young and active patients with 2-4 part Fractures
    2. 2-part Fracture greater tuberosity (>1 cm displaced)
    3. Displaced 2-part Fractures of humeral head
    4. Displaced 3-part Fractures
    5. Anatomic neck Fracture
  3. Prosthesis (hemiarthroplasty) may be needed
    1. Displaced 4-part Fractures

XII. Management: Conservative Therapy

  1. Indications (Neer 1-part Fracture, 80% of Fractures)
    1. Minimally displaced Fracture <1 cm
    2. Older patients
  2. Pearls
    1. Rehabilitation should be slow
    2. Sleep at 45 degrees (e.g. recliner) for comfort
    3. Range of motion should be minimal in first 3 weeks
      1. Start neck, elbow, wrist and finger range of motion immediately
      2. Excessive motion results in displacement
      3. Stay in sling for first 3 weeks, then start range of motion (pendulum may start at 2 weeks)
      4. Frozen Shoulder risk is less than displacement risk
    4. Reevaluate weekly with Shoulder XRays
      1. Displacement requires early referral
  3. Immobilization
    1. Sling for 3 weeks
    2. Intermittent use of sling for pain after 3 weeks
    3. Discontinue sling completely at 4-6 weeks
  4. Exercise program
    1. Pendulum Exercises and Circumduction at >14 days
      1. Use caution in first 3 weeks (see above)
      2. Start with arm in sling
        1. Bend at waist
        2. Allow arm to fall toward floor
        3. Rotate arm in circle
      3. Advance Exercise
        1. Arm out of sling
        2. Circles of greater diameter
    2. Advanced range of motion at 3 weeks
      1. Abduction via wall walking with fingers
      2. Internal rotation
        1. Start by touching hip
        2. Progress to touching mid-back
      3. Flex and extend elbow out of sling as tolerated
    3. Additional Exercises
      1. Isometric Exercises of rotator cuff and deltoid
      2. Consider physical therapy
      3. Aggressive rotator cuff strengthening starting at 12 weeks

XIII. Prognosis

  1. Shoulder stiffness results in Disability
    1. Elderly are especially high risk (mortality is 10% at one year)
    2. Independent activity before injury predicts best outcome
    3. Start Shoulder Range of Motion Exercises early
  2. Permanent abduction loss is common
  3. Full Shoulder Range of Motion takes months to return

XIV. References

  1. Wirth in Greene (2001) Musculoskeletal Care, p. 131-3
  2. Guttmann in DeLee (2003) Sports Medicine, p. 1096-118
  3. Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]
  4. Quillen (2004) Am Fam Physician 70:1947-54 [PubMed]

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