II. Epidemiology
- Most common in elderly women
- Surgical neck Fracture is especially common
III. Risk Factors
IV. Mechanism
- Older patients
- Fall on an Outstretched Hand
- Younger patients (<50 years old)
- Related to direct blow to Shoulder (sports or MVA)
- Tuberosity Fracture
- Traumatic fall
- Shoulder Dislocation
V. Symptoms
- Severe pain at upper arm
- Provoked by any arm movement
VI. Signs
- Swelling, Ecchymosis and pain over Shoulder
- Evaluate for open Fracture (rare)
- Evaluate affected arm for neurovascular injury
- Vascular injury
- Forearm or hand pallor (axillary artery injury)
- Radial pulse
- Sensory Exam
- Arm sensory changes especially laterally (Axillary Nerve Injury)
- Motor Exam
- Finger abduction against resitance (Ulnar Nerve function)
- Dorsiflexion against resistance (Radial Nerve)
- Opposition of thumb and index finger against resistance (Median Nerve)
- Vascular injury
- Concurrent Shoulder injuries
- Evaluate for other Fractures distant to Shoulder
- Distal Radius Fracture
- Leg injury (e.g. proximal Femur Fracture) due to high mechanism, multiple Trauma injury
VII. Imaging: Standard Shoulder XRay series
VIII. Differential Diagnosis
IX. Classification: Neer Classification
- Planes of Fracture cleavage
- Greater tuberosity Fracture
- Attaches supraspinatus, infraspinatus, teres minor
- Lesser tuberosity Fracture
- Attaches to subscapularis
- Humeral Head Fracture (Anatomic neck Fracture)
- Humeral Shaft Fracture (Surgical neck Fracture)
- Greater tuberosity Fracture
- Fracture fragments
X. Complications
- Axillary nerve or axillary artery injury
- Brachial Plexus Injury
- Brachial artery injury
- Non-union or malunion
- Posterior dislocation
- More common in Fracture of lesser tuberosity
XI. Management: Orthopedic referral indications
- Urgent Consultation
- Open reduction and internal fixation
- Prosthesis (hemiarthroplasty) may be needed
- Displaced 4-part Fractures
XII. Management: Conservative Therapy
- Indications (Neer 1-part Fracture, 80% of Fractures)
- Minimally displaced Fracture <1 cm
- Older patients
- Pearls
- Rehabilitation should be slow
- Sleep at 45 degrees (e.g. recliner) for comfort
- Range of motion should be minimal in first 3 weeks
- Start neck, elbow, wrist and finger range of motion immediately
- Excessive motion results in displacement
- Stay in sling for first 3 weeks, then start range of motion (pendulum may start at 2 weeks)
- Frozen Shoulder risk is less than displacement risk
- Reevaluate weekly with Shoulder XRays
- Displacement requires early referral
- Immobilization
- Sling for 3 weeks
- Intermittent use of sling for pain after 3 weeks
- Discontinue sling completely at 4-6 weeks
-
Exercise program
- Pendulum Exercises and Circumduction at >14 days
- Use caution in first 3 weeks (see above)
- Start with arm in sling
- Bend at waist
- Allow arm to fall toward floor
- Rotate arm in circle
- Advance Exercise
- Arm out of sling
- Circles of greater diameter
- Advanced range of motion at 3 weeks
- Abduction via wall walking with fingers
- Internal rotation
- Start by touching hip
- Progress to touching mid-back
- Flex and extend elbow out of sling as tolerated
- Additional Exercises
- Isometric Exercises of rotator cuff and deltoid
- Consider physical therapy
- Aggressive rotator cuff strengthening starting at 12 weeks
- Pendulum Exercises and Circumduction at >14 days
XIII. Prognosis
-
Shoulder stiffness results in Disability
- Elderly are especially high risk (mortality is 10% at one year)
- Independent activity before injury predicts best outcome
- Start Shoulder Range of Motion Exercises early
- Permanent abduction loss is common
- Full Shoulder Range of Motion takes months to return
XIV. References
- Wirth in Greene (2001) Musculoskeletal Care, p. 131-3
- Guttmann in DeLee (2003) Sports Medicine, p. 1096-118
- Monica (2016) Am Fam Physician 94(2): 119-27 [PubMed]
- Quillen (2004) Am Fam Physician 70:1947-54 [PubMed]
Images: Related links to external sites (from Bing)
Related Studies
Definition (NCI) | A traumatic or pathologic injury to the humerus in which the continuity of the humerus is broken. |
Concepts | Injury or Poisoning (T037) |
MSH | D006810 |
ICD9 | 812 |
ICD10 | S42.3 |
SnomedCT | 157206006, 157210009, 208291001, 66308002 |
English | Fracture, Humeral, Fractures, Humeral, Humeral Fracture, Humeral Fractures, fracture of humerus (diagnosis), fracture of humerus, Humerus fracture, Fracture of humerus NOS, Fracture of upper arm NOS, Humeral Fractures [Disease/Finding], fracture humeral, fracture humerus, of fracture humerus, arm fracture upper, humeral fractures, Fracture;humerus, upper arm fracture, fractures humerus, fractures humeral, humeral fracture, arm fractures upper, humerus fracture, Fracture of humerus NOS (disorder), Humeral fracture, Fracture of Humerus, Fracture of humerus, Fracture of humerus (disorder), Fracture of upper arm, fracture; arm, upper, fracture; humerus, fracture; upper arm, humerus; fracture, upper arm; fracture, Fracture of humerus, NOS, Fracture of upper arm, NOS, Humerus Fracture, fractured humerus |
Italian | Frattura dell'omero, Fratture dell'omero |
Dutch | breuk van opperarmbeen, bovenarm; fractuur, fractuur; arm: bovenarm, fractuur; bovenarm, fractuur; humerus, humerus; fractuur, opperarmbeenbreuk, Fracturen, humerus-, Fractuur, humerus-, Humerusfracturen, Humerusfractuur |
German | Fraktur des Humerus, Humerusfraktur, Humerusfrakturen, Oberarmfrakturen |
Japanese | 上腕骨骨折, ジョウワンコツコッセツ |
Swedish | Överarmsfrakturer |
Czech | humerus - fraktury, Zlomenina kosti pažní, Zlomenina humeru |
Finnish | Olkaluumurtumat |
Russian | PLECHEVOI KOSTI PERELOMY, ПЛЕЧЕВОЙ КОСТИ ПЕРЕЛОМЫ |
Spanish | fractura del húmero (trastorno), fractura de húmero, fractura del húmero, fractura de húmero (trastorno), fractura de húmero, SAI (trastorno), Fracture of humerus NOS, fractura de húmero, SAI, Fractura de húmero, Fracturas del Húmero |
Croatian | HUMERUS, FRAKTURE |
Polish | Złamania kości ramiennej |
Hungarian | Humerus törése, Humerus-törés |
Norwegian | Overarmsbrudd, Overarmsfrakturer, Humerusfrakturer |
Portuguese | Fractura do úmero, Fraturas do Úmero |
French | Fracture de l'humérus, Fractures humérales, Fractures de l'humérus |
Ontology: Closed fracture of surgical neck of humerus (C0159680)
Concepts | Injury or Poisoning (T037) |
ICD9 | 812.01 |
SnomedCT | 73244003 |
English | Fracture of surgical neck of humerus, closed, closed fracture of surgical neck of humerus, closed fracture of surgical neck of humerus (diagnosis), Fx surg nck humerus-clos, Closed fracture of neck of humerus (diagnosis), fracture of humerus neck closed, Closed fracture of surgical neck of humerus, Closed fracture of neck of humerus, Closed fracture of surgical neck of humerus (disorder), Closed fracture of neck of humerus, NOS, Closed fracture of neck of humerus NOS |
Dutch | breuk van operatieve hals van opperarmbeen, gesloten |
French | Fracture fermée du col chirurgical de l'humérus |
German | Fraktur des chirurgischen Humerushalses, geschlossen |
Italian | Frattura del collo chirurgico dell'omero, non esposta |
Portuguese | Fractura fechada do colo cirúrgico do úmero |
Spanish | Fractura del cuello quirúrgico del húmero, cerrada, fractura de cuello quirúrgico del húmero, no expuesta, fractura cerrada del cuello del húmero, fractura de cuello quirúrgico del húmero, no expuesta (trastorno), fractura cerrada del cuello quirúrgico del húmero (trastorno), fractura cerrada del cuello quirúrgico del húmero |
Japanese | 上腕骨外科頚骨折、閉鎖性, ジョウワンコツゲカケイコッセツヘイサセイ |
Czech | Zlomenina chirurgického krčku kosti pažní, zavřená |
Hungarian | Humerus sebészi nyak törése, zárt |
Ontology: Fracture of head of humerus (C0281849)
Concepts | Injury or Poisoning (T037) |
ICD10 | S42.21 |
English | Fracture of head of humerus |
Ontology: Fracture of upper end of humerus (C0435531)
Concepts | Injury or Poisoning (T037) |
ICD10 | S42.2 |
SnomedCT | 208288001, 157207002, 127286005 |
English | Frac proximal end of humerus, Fracture/upper end of humerus, fracture of humerus proximal end, fracture of proximal end of humerus (diagnosis), fracture of proximal end of humerus, Fracture of proximal end of humerus (disorder), Fracture of proximal end of humerus, Fracture of upper end of humerus, Fracture of upper end of humerus (disorder), fracture; humerus, proximal end, fracture; humerus, upper end |
German | Fraktur des proximalen Endes des Humerus |
Korean | 위팔뼈의 상단의 골절 |
Spanish | fractura del extremo superior del húmero (trastorno), fractura de extremo superior de húmero (trastorno), fractura del extremo superior del húmero, fractura de extremo superior de húmero |
Dutch | fractuur; humerus, boveneinde, fractuur; humerus, proximaal uiteinde, Fractuur van boveneinde van humerus |
Ontology: Closed fracture of proximal humerus, anatomical neck (C0435532)
Concepts | Injury or Poisoning (T037) |
ICD9 | 812.02 |
SnomedCT | 11870001, 208241000 |
English | Fracture of anatomical neck of humerus, closed, Cls # prxm humerus,anatom neck, closed fracture of anatomical neck of humerus, closed fracture of anatomical neck of humerus (diagnosis), Fx anatom nck humerus-cl, Closed fracture of anatomical neck of humerus (disorder), Closed fracture of proximal humerus, anatomical neck, Closed fracture of proximal humerus, anatomical neck (disorder), Closed fracture of anatomical neck of humerus |
Dutch | breuk van anatomische hals van opperarmbeen, gesloten |
French | Fracture fermée du col anatomique de l'humérus |
German | Fraktur des anatomischen Humerushalses, geschlossen |
Italian | Frattura chiusa del collo anatomico dell'omero |
Portuguese | Fractura fechada do colo anató,ico do úmero |
Spanish | Fractura del cuello anatómico del húmero, cerrada, fractura cerrada del cuello anatómico del húmero, fractura cerrada del cuello anatómico del húmero (trastorno), fractura no expuesta de húmero proximal, cuello anatómico (trastorno), fractura no expuesta de húmero proximal, cuello anatómico |
Japanese | 上腕骨解剖頚骨折、閉鎖性, ジョウワンコツカイボウケイコッセツヘイサセイ |
Czech | Zlomenina anatomického krčku kosti pažní, zavřená |
Hungarian | Humerus anatomiai nyakának törése, zárt |
Ontology: Neer fracture types (C0559823)
Concepts | Intellectual Product (T170) |
SnomedCT | 281960009 |
English | Neer fracture types, Neer fracture types (qualifier value) |
Spanish | tipos de fracturas de Neer (calificador), tipos de fracturas de Neer |