II. Epidemiology

  1. Most common in elderly women
    1. Surgical neck Fracture is especially common

III. Risk Factors

IV. 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

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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Ontology: 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
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