Proximal humerus fracture
|Proximal humerus fracture|
|Other names: Proximal humeral fracture|
|Multi-fragmented fracture of the proximal humerus with involvement of the greater tuberosity|
|Symptoms||Pain, swelling, decreased ability to move the shoulder|
|Types||1 part, 2 part, 3 part, 4 part|
|Causes||Fall onto the arm, direct trauma to the arm|
|Diagnostic method||X-rays, CT scan|
|Treatment||Arm sling, specific exercises, surgery|
A proximal humerus fracture is a break of the upper part of the bone of the arm (humerus). Symptoms include pain, swelling, and a decreased ability to move the shoulder. Complications may include axillary nerve or axillary artery injury.
The cause is generally a fall onto the arm or direct trauma to the arm. Risk factors include osteoporosis and diabetes. Diagnosis is generally based on X-rays or CT scan. It is a type of humerus fracture. A number of classification systems exist.
Treatment is generally with an arm sling for a brief period of time followed by specific exercises. This appears appropriate in many cases even when the fragments are separated. Less commonly surgery is recommended.
Proximal humerus fractures are common. Older people are most commonly affected. In this age group they are the third most common fractures after hip and Colles fractures. Women are more often affected than men.
Signs and symptoms
Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, musculature may cause absence of deformity on inspection.
Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury.
Young adults without risk factors usually require significant trauma, such as in the setting of a motor vehicle collision.
Older adults more commonly experience proximal humerus fractures after a fall from standing height.
The shoulder joint consists of the glenoid cavity of the scapula and the head of the humerus. It as an extremely mobile joint that is stabilized by surrounding soft tissues such as the joint capsule, muscles, and ligaments. The greater and lesser tuberosities are bony landmarks of the proximal humerus and serve as attachment sites for musculature.
The axillary nerve courses inferior to the shoulder joint and innervates the deltoid and teres minor muscles. It also provides sensation at the skin overlying the shoulder. This nerve is the most commonly injured nerve in proximal humerus fractures due to its location close to the proximal humerus.
The standard x-ray views of the shoulder include a true anterior-posterior view, a lateral (Y or outlet) view, and an axillary view. A Velpeau view can be done as an alternative to the axillary view if an examinee is unable to position the shoulder for an appropriate image. This can be obtained by having the examinee lean backward 45 degrees while an xray beam is aiming towards the floor.
The Neer classification of proximal humerus fractures is the most commonly used classification system. It classifies fractures depending on the number of segments (2-4 parts), and whether or not there is displacement present. This classification has a low amount of agreement between physicians using the classification system, although formal training sessions may improve agreement.
The AO/OTA classification system is another commonly used system that groups fractures depending on whether the fracture is unifocal or bifocal, and whether or not the fracture goes through the articular surface.
There are both non-surgical and surgical options for treatment of proximal humerus fractures. The recommended treatment is decided based on fracture stability as determined with imaging and clinical exam.
Most proximal humerus fractures are stable and can be treated without surgery. Typical non-operative treatment consists of shoulder immobilization with a sling. Close follow-up and weekly x-rays are recommended in order to ensure that the fracture is healing and maintaining good alignment.
When properly indicated, non-surgical treatment options for proximal humerus fractures have good outcomes in terms of fracture healing and restoration of arm function.
Surgical options for unstable proximal humerus fractures include:
- Closed reduction with percutaneous pinning (CRPP)
- Open reduction with internal fixation (ORIF)
- Intramedullary rod fixation
- Shoulder arthroplasty
- Reverse shoulder arthroplasty
Proximal humerus fractures account for approximately 4-7% of all fractures in adults. It is the most common fracture of the humerus, as well as the most common fracture at the shoulder girdle.
They are more common in women than men, and occur more often in older adults. The average age of people who sustain a proximal humerus fracture is 63–66 years.
Proximal humerus fractures in children can commonly be treated non-operatively due to the large amount of bone growth that occurs at the proximal humerus. In older children where there is less time for bone remodeling, surgery may be indicated more frequently.
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