Table Of Contents
Proximal Humerus Fracture
The most common fracture pattern of the proximal humerus is a transverse fracture. Most fractures are non-displaced and are treated non-operatively.
It has a bimodal distribution. 70% of cases occur in women. It is the 3rd most common fracture in the elderly, typically occurring after a fall.
Neer’s classification of proximal humerus fracture
The proximal humerus is divided into 4 fragments:
- Head/articular surface
- Greater tuberosity
- Lesser tuberosity
- Humeral shaft
Fragments are considered separate parts if they are displaced > 1 cm (10 mm) or > 45 degrees of angulation. Some use 0.5 cm (5mm) as a measure of displacement.
2-part fractures
| Fracture | Description | Treatment |
|---|---|---|
| Surgical neck fracture | Most common pattern. The shaft is pulled anteriorly and medially by the pectoralis major | Closed reduction and sling. Operative treatment with CRPP, ORIF, and IM nail |
| Greater tuberosity | The greater trochanter is pulled superiorly and posteriorly by the rotator cuff | Non-operative treatment if displaced < 5mm. Operative treatment if displaced > 5mm |
| Lesser tuberosity | Associated with the forceful impaction of the humeral head against the glenoid cavity during posterior dislocation. | Non-operative treatment |
| Anatomical neck | Rare | Non-operative treatment for minimally displaced. ORIF in young patients. ORIF, hemiarthroplasty, or reverse total shoulder arthroplasty in the elderly |
3-part fracture
| Fracture | Description | Treatment |
|---|---|---|
| Surgical neck and greater trochanter | The articular fragment is internally rotated | Non-operative treatment for minimally displaced fractures. Operative treatment in young patients. Arthroplasty in elderly patients. |
| Surgical neck and lesser trochanter | The articular surface is pulled anteriorly by the rotator cuff | Non-operative treatment. Operative treatment in young patients. Arthroplasty in elderly patients. |
4-Part fracture
| Fracture | Description | Treatment |
|---|---|---|
| Valgus impacted | There is alignment between the medial shaft and head segment on X-ray | Operative treatment |
| 4-part with head-splittting fracture | Has a high risk of avascular necrosis. The shaft is pulled medially by the pectoralis major | Operative treatment |
- Risk factors
- Osteoporosis
- Diabetes
- Epilepsy
- Female gender
- Mechanism of injury
- Falling onto an outstretched hand (FOOSH) from a standing height in older osteoporotic patients
- High-energy trauma, e.g., MVA in young patients
- Excessive shoulder abduction in individuals with osteoporosis
- Direct trauma
- Electric shock or seizure
- Pathologic fracture (malignant or benign process)
- Associated injuries
- Axillary nerve injury
- Arterial injury
- Signs and symptoms
- Shoulder pain
- Swelling
- Tenderness
- Painful active/passive and decreased range of motion
- Signs of brachial plexus and axillary nerve injury
- Ecchymoses over the upper arm and chest
- Physical examination
- Axillary nerve damage
- Check for arm abduction and palpate the radial nerve
- Check for numbness over the regimental patch
- Axillary nerve damage
- Investigation
- XR affected shoulder (AP, Scapular Y-view, and axillary view)
- Pseudosubluxation due to muscle atony and blood in the capsule
- CT scan: for pre-operative planning, intra-articular comminuted fractures, or concern for head-split fracture
- MRI: for associated rotator cuff injury
- XR affected shoulder (AP, Scapular Y-view, and axillary view)
- Indications for non-operative treatment
- Indications for operative treatment
- Non-operative treatment
- Sling immobilization for 2 – 3 weeks
- Immediate physiotherapy for early range of motion exercises
- Operative treatment
- Closed reduction percutaneous pinning (CRPP)
- Open reduction internal fixation (ORIF)
- Intramedullary nailing
- Hemiarthroplasty
- Reverse shoulder arthroplasty
- Complications
- Avascular necrosis: less frequent than in lower extremity fractures
- Neurologic injury: involves the axillary nerve, subscapular nerve, or musculocutaneous nerve
- Malunion: commonly varus apex-anterior or malunion of the greater trochanter
- Non-union: commonly affects a 2-part surgical neck fracture
- Rotator cuff injury
- Injury to the long head of the biceps tendon
- Missed posterior dislocation (should be considered in patients with lesser tuberosity fracture)
- Adhesive capsulitis
- Post-traumatic arthritis
- Infection
Proximal Humerus Fracture Malunion
Defined as malposition of humeral tuberosities: rotation, angulation, and/or offset of the head-shaft junction, or articular incongruities
- Risk Factors
- Fracture characteristics
- Patient factors
- Osteoporosis
- Chronic renal disease
- Chronic alcohol or steroid use
- Signs and symptoms
- Pain and weakness
- Limited range of motion
- Physical examination
- Muscle atrophy
- Diffuse tenderness
- Blocks in the range of motion or crepitus in both active and passive movement
- Weakness in abduction and external rotation (greater tuberosity malunion)
- Weakness in internal rotation (lesser tuberosity malunion)
- Instability (positive apprehension test in humeral head malunion)
- Investigations
- X-ray (AP, scapular Y, and axillary view)
- Neck shaft angle- in varus or valgus (<120 or >150)
- Greater tuberosity superiorly and posteriorly displaced, externally rotated (>1cm from native anatomical position)
- Lesser tuberosity medially displaced (>1cm from native anatomical position)
- X-ray (AP, scapular Y, and axillary view)
- Non-operative treatment
- NSAIDs
- Physical therapy
- Occasional corticosteroid therapy
- Operative treatment
- Humeral head preservation techniques
- Hemiarthroplasty
- Total shoulder arthroplasty
- Reverse total shoulder arthroplasty