(See also Overview of Fractures Overview of Fractures A fracture is a break in a bone. Most fractures result from a single, significant force applied to normal bone. In addition to fractures, musculoskeletal injuries include Joint dislocations... read more .)
Proximal humeral fractures are especially common among older patients. A few patients have axillary nerve damage (reducing sensation over the middle deltoid) or axillary artery damage. Contractures may develop after only a few days of immobilization, particularly in older patients.
Key anatomic landmarks in the proximal humerus
The surgical neck of the humerus is fractured.
Etiology of Proximal Humeral Fractures
Most of these fractures result from a fall on an outstretched arm; less often, a direct blow is involved.
Fractures are classified by the number of parts that result; a part is defined as a key anatomic structure that is displaced ( > 1 cm) or angulated (> 45°) in relation to its normal anatomic position. The 4 key anatomic structures of the proximal humerus are the
For example, if no structures are displaced or angulated, the fracture has one part. If one structure is angulated or displaced, the fracture has 2 parts (see figure One- and 2-part fractures of the proximal humerus One- and 2-part fractures of the proximal humerus ). Almost 80% of proximal humeral fractures have only one part; they are usually stable, held together by the joint capsule, rotator cuff, and/or periosteum. Fractures with ≥ 3 parts are uncommon.
One- and 2-part fractures of the proximal humerus
If no structures are displaced or angulated, the fracture has one part. If one structure is angulated or displaced, the fracture has 2 parts.
Symptoms and Signs of Proximal Humeral Fractures
The shoulder and upper arm are painful and swollen; patients have difficulty raising their arm.
Diagnosis of Proximal Humeral Fractures
X-rays should include at least
A true anteroposterior internal rotation view
A trans-scapular Y (oblique) view
An axillary view to assess the glenohumeral joint
CT is done if fractures are complex or poorly visualized on plain x-rays.
Treatment of Proximal Humeral Fractures
Usually a sling and early range-of-motion exercises
Sometimes open reduction with internal fixation (ORIF) or prosthetic joint replacement
One-part fractures rarely require reduction; most (almost 80%) are treated with immobilization in a sling, sometimes with a swathe (see figure Joint immobilization as acute treatment: Some commonly used techniques Joint immobilization as acute treatment: Some commonly used techniques ), and early range-of-motion exercises, such as Codman exercises Codman exercises . These exercises are particularly useful for older adults. Because contractures are a risk, early mobilization is desirable, even if alignment is anatomically imperfect.
The patient bends at the waist with the affected arm hanging down perpendicular to the floor. The arm and shoulder should be relaxed, and knees bent. Patients should
These exercises should cause only minimal pain. Patients should do each exercise 2 times per set and do several sets per day. Patients should gradually increase the duration of the exercises.
Fractures with ≥ 2 parts are immobilized, and patients are referred to an orthopedic surgeon. These fractures may require ORIF or placement of a prosthetic joint (shoulder replacement).
Classify proximal humeral fractures based on the number of key humeral structures (anatomic neck, surgical neck, greater tuberosity, lesser tuberosity) that are displaced or angulated.
Almost 80% require only a sling.
Patients, particularly older patients, should start range-of-motion exercises as soon as possible.