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Proximal Humerus Fracture
Aka: Proximal Humerus Fracture, Upper Humerus Fracture, Humeral Fracture, Humerus Fracture, Humeral Anatomical Neck Fracture, Humeral Surgical Neck Fracture, Humeral Head Fracture, Neer Classification, Neer Fracture Type
- See Also
- Humerus Shaft Fracture
- Epidemiology
- Most common in elderly women
- Surgical neck Fracture is especially common
- Risk Factors
- Osteoporosis
- 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
- Symptoms
- Severe pain at upper arm
- Provoked by any arm movement
- 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)
- Concurrent Shoulder injuries
- Shoulder Dislocation
- Rotator Cuff Injury
- Evaluate for other Fractures distant to Shoulder
- Distal Radius Fracture
- Leg injury (e.g. proximal Femur Fracture) due to high mechanism, multiple Trauma injury
- Imaging: Standard Shoulder XRay series
- Anteroposterior Shoulder view
- Axillary view (if able despite pain)
- Scapular Y view
- Differential Diagnosis
- Acromioclavicular Separation
- Rotator Cuff Tear
- Biceps Tendon Rupture
- Shoulder Dislocation
- 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)
- Fracture fragments
- One part Fracture (80% of Proximal Humerus Fractures)
- Less than 1 cm displacement
- Less than 45 degree angulation
- Two part Fractures
- Surgical neck Fracture (Most common 2-part)
- Distal to lesser tuberosity
- Humeral Head Fracture (Anatomic neck Fracture)
- Greater tuberosity Fracture
- Lesser tuberosity Fracture
- Three part Fractures (uncommon)
- Humeral head and shaft and one of tuberosities
- Four part Fractures (rare)
- Humeral head and shaft and one of tuberosities
- 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
- Management: Orthopedic referral indications
- Urgent Consultation
- Open Fracture
- Neurovascular compromise
- Fracture-Dislocation
- Open reduction and internal fixation
- Young and active patients with 2-4 part Fractures
- 2-part Fracture greater tuberosity (>1 cm displaced)
- Displaced 2-part Fractures of humeral head
- Displaced 3-part Fractures
- Anatomic neck Fracture
- Prosthesis (hemiarthroplasty) may be needed
- Displaced 4-part Fractures
- 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
- 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
- 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]