I. Epidemiology

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

II. Risk Factors

III. Mechanism

  1. Older patients: Fall on an Outstretched Hand
  2. Younger patients: Related to direct blow to Shoulder
  3. Tuberosity Fracture
    1. Traumatic fall
    2. Shoulder Dislocation

IV. Symptoms

  1. Severe pain at upper arm
    1. Provoked by any arm movement

V. Signs

  1. Swelling, Ecchymosis and pain over Shoulder
  2. Evaluate affected arm for neurovascular injury
    1. Arm sensory changes
    2. Forearm or hand pallor (axillary artery injury)

VI. Imaging: Standard Shoulder XRay series

  1. Anteroposterior view
  2. Axillary view
  3. Scapular Y view

VIII. 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

IX. 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

X. Management: Orthopedic referral indications

  1. Urgent Consultation
    1. Open Fracture
    2. Neurovascular compromise
    3. Fracture-Dislocation
  2. Open reduction and internal fixation
    1. 2-part Fracture greater tuberosity (>1 cm displaced)
    2. Displaced 2-part Fractures of humeral head
    3. Displaced 3-part Fractures
    4. Anatomic neck Fracture
  3. Prosthesis (hemiarthroplasty) may be needed
    1. Displaced 4-part Fractures

XI. Management: Conservative Therapy

  1. Indications (Neer 1-part Fracture, 80% of Fractures)
    1. Minimally displaced Fracture <1 cm
  2. Pearls
    1. Rehabilitation should be slow
    2. Range of motion should be minimal in first 3 weeks
      1. Excessive motion results in displacement
      2. Stay in sling for first 3 weeks
      3. Frozen Shoulder risk is less than displacement risk
    3. 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

XII. Prognosis

  1. Shoulder stiffness results in Disability
    1. Elderly are especially high risk
    2. Start Shoulder Range of Motion Exercises early
  2. Permanent abduction loss is common
  3. Full Shoulder Range of Motion takes months to return

XIII. References

  1. Wirth in Greene (2001) Musculoskeletal Care, p. 131-3
  2. Guttmann in DeLee (2003) Sports Medicine, p. 1096-118
  3. Quillen (2004) Am Fam Physician 70:1947-54 [PubMed]

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