Orthopaedic Surgery - Shoulder/Proximal Humerus Fracture

Basics

Proximal humerus fractures are:

Common fractures of the shoulder region

and occur particularly frequently in:

Older adults

especially those with:

Osteoporosis.

They are especially common after the age of:

70 years.

Sex Distribution

Women are affected more often than men, historically at approximately a:

2:1 ratio.

This reflects, in part, the higher prevalence of:

Osteoporosis

and fragility fractures in older women.

Mechanism by Age

In older adults, proximal humerus fractures usually result from:

Low-energy falls

such as a fall from:

Standing height.

In younger patients, they are more commonly associated with:

High-energy trauma.

Neer Classification

The:

Neer classification

divides the proximal humerus into four major anatomical segments:

Humeral head / anatomic neck segment

Greater tuberosity

Lesser tuberosity

Surgical neck / shaft segment.

Definition of a Displaced Part

Traditionally, a fracture fragment is considered a separate displaced part when it has:

More than 1 cm of displacement

or

More than 45° of angulation.

Number of Parts

Fractures are consequently described as:

1-part

2-part

3-part

or

4-part fractures.

Other Important Fracture Patterns

Additional important patterns include:

Fracture-dislocations

and

Head-splitting fractures.

These injuries often have greater:

Articular damage

and risk of:

Humeral head ischemia.

Blood Supply

The proximal humerus receives blood from branches of the:

Anterior humeral circumflex artery

and

Posterior humeral circumflex artery.

Modern anatomic studies suggest that the posterior circumflex system provides a substantial portion of the:

Humeral head blood supply.

Medial Calcar

Preservation of the:

Medial calcar

and associated soft-tissue attachments improves the likelihood that:

Humeral head perfusion

will remain intact.

Disruption of the medial hinge and vascular attachments increases concern for:

Osteonecrosis.

Prevention

Prevention is particularly important in:

Older adults with fragility fractures.

Osteoporosis Screening

A proximal humerus fracture after a low-energy fall should prompt consideration of:

Osteoporosis assessment

and treatment.

This may reduce the risk of subsequent:

Hip

Wrist

Vertebral

or other fragility fractures.

Fall Prevention

Patients with recurrent falls or balance problems may benefit from:

Balance training

Assistive devices

Medication review

Vision assessment

and

Home-safety evaluation.

Epidemiology

Proximal humerus fractures are among the most common:

Fragility fractures in older adults.

They traditionally rank behind:

Hip

and

Distal radius fractures

when vertebral compression fractures are excluded.

Proportion of Humerus Fractures

Approximately:

Half of all humerus fractures

involve the:

Proximal humerus.

Female Predominance

Historical series report that approximately:

50–70%

occur in:

Women.

Incidence With Age

The incidence rises sharply after approximately:

50 years of age

and continues to increase with:

Advancing age.

Peak Incidence

Peak incidence has been reported between approximately:

85 and 90 years of age.

Historical combined rates in men and women have approached:

300 per 100,000 persons per year.

Older Adults

Historical U.S. incidence estimates in people older than:

70 years

have been approximately:

424 per 100,000 women

and

150 per 100,000 men.

Population Aging

Because the population is aging, the overall burden of proximal humerus fractures is expected to:

Increase substantially.

Older projections estimated approximately:

275,000 U.S. cases annually by 2030.

Risk Factors

Important risk factors include:

Advanced age

Osteoporosis

Female sex

Low bone mineral density

Previous fragility fracture

History of falls

Low dietary calcium intake

Early menopause

Diabetes mellitus

Certain anticonvulsant medications

Alcohol intoxication

Obesity

and conditions that increase:

Fall risk.

Protective Factors

Some historical observational data have associated:

Calcium supplementation

and

Menopausal hormone therapy

with lower fracture risk in selected populations.

These interventions should be individualized according to overall:

Bone-health and medical considerations.

Genetics

There is no single common genotype that causes most proximal humerus fractures.

However, inherited disorders that weaken bone may increase fracture susceptibility.

Examples include:

Osteogenesis-related connective-tissue disorders

Ehlers–Danlos syndromes

and

Fibrous dysplasia.

Etiology

The injury mechanism varies substantially with:

Patient age

and

Bone quality.

Younger Patients

Adolescents and young adults typically sustain these fractures after:

Motor vehicle collisions

Sports injuries

Falls from height

Penetrating trauma

or other:

High-energy mechanisms.

Older Patients

In older adults, the most common mechanism is a:

Low-energy fall from standing height.

Historical series attribute approximately:

88% of proximal humerus fractures

in this population to:

Falls.

Mechanical Injury

During trauma, the relatively softer proximal humeral bone may fail when the:

Humeral head

is driven against the harder:

Glenoid.

Associated Conditions and Injuries

Most proximal humerus fractures are:

Isolated injuries.

However, associated trauma must be considered, particularly in:

Younger high-energy patients.

Associated Injuries in High-Energy Trauma

Possible accompanying injuries include:

Cervical spine fractures

Rib fractures

Other extremity fractures

Shoulder dislocation

and

Thoracic injury.

Nerve Injury

Peripheral nerve injury may occur from:

Traction

Direct trauma

or displacement of fracture fragments.

The:

Axillary nerve

is particularly important to assess.

Vascular Injury

Major vascular injury is:

Uncommon

but may occur.

Distal circulation must therefore be documented carefully.

Rotator Cuff Dysfunction

Fracture displacement involving the:

Greater or lesser tuberosity

may alter normal rotator cuff:

Force coupling

and cause loss of:

Strength

or

Shoulder motion.

Rotator Cuff Avulsion

Acute rotator cuff avulsion or tearing may also accompany the fracture, although this can be difficult to recognize during the:

Initial painful phase.

Diagnosis

Diagnosis is based on:

History

Physical examination

and

Radiographic evaluation.

Signs and Symptoms

Typical symptoms include:

Severe shoulder pain

Swelling

Bruising

and inability or reluctance to:

Move the arm.

Ecchymosis

Bruising may extend distally toward the:

Elbow

during the first several days to weeks.

This can be dramatic but is common after:

Proximal humerus fracture.

Physical Examination

The examination should evaluate:

Skin integrity

Alignment

Neurovascular function

and evidence of other:

Traumatic injuries.

Inspection

Inspect for:

Open wounds

Skin tenting

Marked swelling

Expanding hematoma

Ecchymosis

and abnormal:

Extremity alignment.

Skin Tenting

Prominent fracture fragments beneath the skin may threaten:

Skin viability

and require urgent:

Orthopaedic assessment.

Neurovascular Examination

A careful neurovascular examination is essential.

Document:

Peripheral pulses

Capillary refill

Motor function

and

Sensation.

Motor Examination

Motor assessment should extend from the:

Shoulder

through the:

Elbow

Wrist

and

Fingers.

Sensory Examination

Sensory function should be documented in relevant peripheral nerve distributions, particularly the:

Axillary nerve

over the lateral shoulder.

Entire Extremity Examination

The entire upper extremity should be inspected and palpated because associated injuries may involve the:

Clavicle

Scapula

Humeral shaft

Elbow

or

Forearm.

Trauma Examination

Patients injured through a high-energy mechanism require a:

Complete trauma assessment.

Older Fall Patients

In older patients following a fall, evaluation should also consider:

Head injury

and

Cervical spine injury.

This is especially important in patients taking:

Anticoagulants

or those with recurrent:

Falls.

Imaging

Plain Radiographs

Initial shoulder imaging should include appropriate orthogonal views.

Commonly obtained views include:

AP or Grashey view

and

Scapular-Y view.

Axillary View

A standard:

Axillary view

may be difficult because of pain.

A:

Modified axillary

or

Velpeau view

can be used when conventional positioning is not tolerated.

Purpose of Axillary Imaging

Axillary or equivalent imaging helps determine:

Glenohumeral alignment

and identify associated:

Fracture-dislocation.

CT

CT is helpful for:

Complex fracture patterns

Articular involvement

Tuberosity displacement

Head-splitting fractures

and preoperative:

Planning.

MRI

MRI is generally:

Not routinely required in the acute setting.

It may be used later when concern persists for:

Rotator cuff injury

or other:

Soft-tissue pathology.

Pathological Fracture

Histopathological testing is not usually necessary unless there is concern for a:

Pathological fracture.

When to Suspect Pathological Fracture

Concern should increase with:

Minimal or unusual mechanism

Suspicious radiographic bone lesion

Known malignancy

or concerning systemic:

Cancer history.

Differential Diagnosis

Important alternative or associated diagnoses include:

Acromioclavicular separation

Subacromial bursitis

Clavicle fracture

Elbow fracture

Humeral shaft fracture

Rotator cuff tear

Scapular fracture

Shoulder dislocation

Treatment

General Principles

Treatment depends on:

Fracture displacement

Fracture pattern

Bone quality

Age

Functional demand

Medical comorbidity

and ability to participate in:

Rehabilitation.

Nonoperative Treatment

Most proximal humerus fractures are treated:

Nonoperatively.

Historical estimates suggest approximately:

Two-thirds

can be managed without surgery.

Minimally Displaced Fractures

Nondisplaced or minimally displaced fractures usually respond well to:

Sling immobilization

followed by:

Early progressive motion.

Fracture-Dislocation

A fracture-dislocation generally requires:

Urgent reduction.

Subsequent management depends on:

Fracture stability

Fragment displacement

Humeral head viability

and associated injuries.

Caution During Reduction

Forceful reduction should be avoided, especially when a fracture through the:

Surgical neck

is present.

Manipulation may further displace the fracture or compromise:

Humeral head blood supply.

Three- and Four-Part Fractures

Historically, many displaced:

3-part

and

4-part fractures

were treated surgically.

Current management is more individualized because some older or lower-demand patients may have similar functional outcomes with:

Nonoperative treatment.

Monitoring Nonoperative Fractures

Potentially unstable fractures treated without surgery should undergo:

Early repeat radiographs

to ensure that displacement has not:

Progressed.

Sleeping Position

During the acute period, many patients are more comfortable sleeping:

Semi-upright

in a chair or:

Recliner.

Activity

Sling Immobilization

A sling is commonly used for approximately:

2–4 weeks

depending on pain and fracture stability.

Early Distal Motion

Even while using the sling, patients should usually perform:

Elbow

Wrist

and

Hand range-of-motion exercises

several times daily.

Weight Bearing

The injured upper extremity is initially:

Non-weight-bearing

or restricted from lifting.

Shoulder Motion

For stable fractures, gentle passive or pendulum motion is often started:

Early

to reduce the risk of:

Posttraumatic stiffness.

Axillary Skin Care

The:

Axillary fold

should be kept:

Clean and dry

because prolonged sling use can lead to:

Skin irritation or maceration.

Preoperative Activity

Patients awaiting surgery are generally maintained in:

A sling

with lifting restrictions until definitive treatment.

Postoperative restrictions depend on:

Fixation stability

Implant type

and

Surgeon protocol.

Physical Therapy

Physical therapy should balance:

Fracture protection

with prevention of:

Shoulder stiffness.

Timing

For nonoperatively treated fractures, formal therapy often begins around:

2–4 weeks

although simple passive exercises may start earlier in stable patterns.

Pendulum Exercises

Early rehabilitation commonly begins with:

Pendulum exercises

and gentle:

Passive motion.

Progression

Motion may progress gradually to:

Pulleys

Passive forward elevation

and broader:

Passive range of motion.

Active-Assisted Motion

At approximately:

6 weeks

active-assisted and then active range-of-motion exercises may begin when:

Clinical and radiographic healing

are progressing appropriately.

Surgical Rehabilitation

After surgery, rehabilitation timing varies according to:

Fracture pattern

Fixation quality

Bone quality

and

Procedure performed.

The goal is to begin safe motion as early as possible to minimize:

Stiffness.

Medication

Acetaminophen

Acetaminophen is commonly used for:

Pain control.

NSAIDs

NSAIDs may also be used.

Some surgeons limit prolonged NSAID use because of theoretical concerns regarding:

Bone healing, although the clinical importance of this effect is uncertain.

Opioids

Short-term opioid medication may occasionally be necessary during the:

Acute painful period.

Prescribing should account for:

Age

Fall risk

Other medications

and overall:

Medical condition.

Tramadol

Tramadol may sometimes be used as an alternative analgesic, although similar precautions regarding:

Sedation

Falls

and drug interactions apply.

Surgery

Surgery is unnecessary for many proximal humerus fractures.

It may be considered when there is:

Major displacement

Unstable fracture configuration

Fracture-dislocation

Head-splitting fracture

or other circumstances in which acceptable function is unlikely with:

Nonoperative treatment.

Open Reduction and Internal Fixation

ORIF may use:

Plates

Screws

or other fixation devices.

The goals are to restore:

Alignment

Tuberosity position

and sufficient stability for:

Early rehabilitation.

Locking Plate Fixation

Locking plates are commonly used in:

Osteoporotic bone

because fixed-angle support can improve fixation of:

Proximal fragments.

Intramedullary Fixation

Selected fracture patterns may be treated using:

Intramedullary fixation.

Its suitability depends on:

Fracture anatomy

and

Tuberosity involvement.

Bone Grafting

Allograft or other structural bone graft may be used when there is:

Poor bone quality

Medial column deficiency

or substantial:

Bone loss.

Arthroplasty

Arthroplasty may be appropriate when reconstruction of the native humeral head is unlikely to succeed.

Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty has become increasingly common for:

Displaced complex fractures in older adults

particularly when there is:

Poor bone quality

Comminution

or unreliable:

Tuberosity healing.

Hemiarthroplasty

Hemiarthroplasty historically was used more frequently for:

Complex fracture patterns

but has become less common because reverse arthroplasty can provide more predictable function in many older patients.

Follow-Up

Patients require serial clinical and radiographic assessment to ensure:

Maintained alignment

and

Progressive healing.

Radiographic Monitoring

During the early postinjury or postoperative period, radiographs may be obtained every:

Few weeks

depending on fracture stability.

Later Imaging

Once alignment is stable, imaging may be repeated approximately every:

4–6 weeks

until sufficient:

Fracture healing

is demonstrated.

Prognosis

Most minimally displaced fractures treated nonoperatively have:

Satisfactory functional outcomes.

Recovery Time

Recovery can be:

Slow.

Patients should understand that improvement in pain and motion may continue for:

Many months.

Historical studies suggest that approximately:

8 months

may pass before some patients achieve near-maximal recovery.

Displaced Fractures

Displaced fractures treated nonoperatively generally have less predictable outcomes than:

Minimally displaced fractures.

Residual:

Stiffness

Weakness

or

Malunion

may occur.

Complications

Stiffness

Posttraumatic shoulder stiffness is:

Very common.

Many patients experience at least some temporary loss of:

Range of motion.

Malunion

Nonoperative healing in a displaced position can lead to:

Symptomatic malunion

with altered:

Shoulder mechanics.

Nonunion

Failure of fracture union is:

Uncommon

but may occur, particularly with:

Poor bone quality

Severe displacement

or compromised biological healing.

Osteonecrosis

Disruption of the humeral head blood supply may result in:

Osteonecrosis.

Risk is greatest with:

Complex fracture patterns

Anatomic neck fractures

Fracture-dislocations

and loss of the:

Medial hinge.

Rotator Cuff Dysfunction

Tuberosity malposition or associated tendon injury may cause:

Persistent weakness

and impaired:

Shoulder elevation or rotation.

Infection

Surgically treated fractures carry a risk of:

Deep or superficial infection.

Fixation Failure

Implant-related complications include:

Loss of fixation

Screw penetration

Plate failure

and

Secondary displacement.

These are more common in:

Osteoporotic bone

and highly comminuted fractures.

Posttraumatic Arthritis

Articular injury, malunion, or osteonecrosis may eventually lead to:

Posttraumatic glenohumeral arthritis.

Patient Monitoring

Follow-up should assess:

Pain

Neurovascular status

Range of motion

Fracture alignment

Radiographic healing

and development of:

Stiffness or other complications.

Bone Health Monitoring

Older patients with a fragility-type proximal humerus fracture should also be evaluated for:

Osteoporosis

and future:

Fall and fracture risk.

Key Principle

Proximal humerus fractures are common fragility injuries in older adults, particularly women with osteoporosis, while younger patients usually sustain them through high-energy trauma.

Most fractures are:

Nondisplaced or minimally displaced and can be treated nonoperatively with short-term sling immobilization followed by progressive range-of-motion exercises.

More complex fractures require individualized assessment based on:

Displacement, number of fracture parts, bone quality, tuberosity position, medial calcar integrity, vascular risk, patient age, and functional demand.

Surgical options include:

Open reduction and internal fixation, bone grafting, and shoulder arthroplasty, with reverse shoulder arthroplasty increasingly used for complex displaced fractures in older adults.

Important complications include:

Stiffness, malunion, nonunion, osteonecrosis, rotator cuff dysfunction, fixation failure, and posttraumatic arthritis.