Orthopedics Book


Proximal Humerus Fracture

Aka: Proximal Humerus Fracture, Upper Humerus Fracture, Humeral Fracture, Humerus Fracture
  1. See Also
    1. Humerus Shaft Fracture
  2. Epidemiology
    1. Most common in elderly women
      1. Surgical neck Fracture is especially common
  3. Risk Factors
    1. Osteoporosis
  4. Mechanism
    1. Older patients
      1. 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
  5. Symptoms
    1. Severe pain at upper arm
      1. Provoked by any arm movement
  6. 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
  7. Imaging: Standard Shoulder XRay series
    1. Anteroposterior Shoulder view
    2. Axillary view (if able despite pain)
    3. Scapular Y view
  8. Differential Diagnosis
    1. Acromioclavicular Separation
    2. Rotator Cuff Tear
    3. Biceps Tendon Rupture
    4. Shoulder Dislocation
  9. 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
    3. Resources
  10. 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
  11. 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
  12. 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
  13. 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
  14. 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]

Humeral Fractures (C0020162)

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
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
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
Derived from the NIH UMLS (Unified Medical Language System)

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
Derived from the NIH UMLS (Unified Medical Language System)

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