Fx proximal humerus
INTRODUCTION — Proximal humerus fractures ส่วนใหญ่พบใน elderly และ incidence เพิ่มขึ้น
ส่วนใหญ่ Fx proximal และ midshaft จะเป็น nondisplaced และไม่ต้องผ่าตัด
PERTINENT ANATOMY — Humerus เป็น bone ขนาดใหญ่สุดใน upper limb
Proximal humerus articulate กับ glenoid ของ scapula เป็น glenohumeral joint
Muscles และ tendons ของ rotator cuff, acromion, และ ligament ต่างๆ เช่นระหว่าง coracoid process ของ scapula และ acromion
According to the Neer classification
Proximal humerus แบ่งเป็น
– anatomical neck
– surgical neck
– greater tuberosity
– lesser tuberosity (figure 4)
 Displaced proximal humeral fractures. I. Classification and evaluation. Neer CS 2nd. J Bone Joint Surg Am. 1970;52(6):1077. https://www.ncbi.nlm.nih.gov/pubmed?term=5455339
●Anatomical neck consists of the widened articular surface of the humeral head.
●Surgical neck is located at the constriction distal to the humeral head and tuberosities. The surgical neck is where the articular capsule attaches and several penetrating arteries enter to provide part of the vascular supply to the humeral head.
●Greater and lesser tuberosities = sites of attachment for the tendons of the rotator cuff muscles (figure 5).
– located lateral to the humeral head on the superior aspect of the humerus
– provides the attachment for three of the rotator cuff muscles: supraspinatus, infraspinatus, and teres minor.
– located on the anterior surface of the humerus
– provides the attachment for the subscapularis muscle
– supplies the attachment for a number of powerful muscles
– Pectoralis major inserts on the proximal shaft
– Deltoid muscle attaches to the midshaft
– Biceps brachialis and triceps muscle groups attach more distally
– Tendon of the long head of the biceps brachialis muscle passes between the lesser and greater tuberosities as it courses in a shallow groove on the anterior surface of the humerus
– Long head tendon attaches to the scapula on the superior portion of the glenoid where its fibers merge with those of the fibrocartilaginous superior glenoid labrum
– Proximal humerus receives its blood supply from branches of the axillary artery
– Two branches,
Anterior humeral circumflex artery
Posterior humeral circumflex artery
Both originate distal to the anatomic neck
Both travel proximally to supply the humeral head (figure 6).
Clinical pearls: Fx anatomic neck จะ disrupt blood supply แล้วเกิด AVN ของ humeral head
Humeral shaft มี axillary artery และ brachial artery ซึ่งก็มี arterial injury ได้เช่นกันถ้า displacement ระดับหนึ่ง
– More likely if there is a proximal humeral fracture that is significantly displaced or a concomitant humeral dislocation .
Axillary nerve และ Subscapular nerves >> most often affected
Radial nerve injuries
– may occur with significant displacement of mid to distal shaft fractures
Median and ulnar nerve injuries >> uncommon
EPIDEMIOLOGY AND RISK FACTORS — Proximal humerus fractures account for 4-5% of all fractures  and are the 3rd most common fracture in elderly patients after those of the hip and distal radius.
Incidence of proximal humerus fractures
– increases with age
– > 70% occurring in patients > 60 years of age
– highest incidence 73-78 year olds 
– females:males = 3-4:1 
Major risk factors
– frequent falls & low bone density [5-7]
This fx impair the ability to perform activities of daily living.
MECHANISM OF INJURY
-falls (the most common cause of proximal humerus fractures; 87-93% of fractures occur after a fall from standing [3,4,6,7])
-a direct blow
– violent muscle contraction (eg, seizure)
Anterior or posterior dislocations of the humeral head can occur in association with proximal humeral fractures
SYMPTOMS AND EXAMINATION FINDINGS
– Shoulder pain that increases with shoulder movement (moderate to severe)
– tend to hold the affected arm adducted against their side
– Swelling and ecchymosis may be apparent shortly after injury
– Gross shoulder deformities can occur, particularly if the fracture is associated with an anterior or posterior dislocation of the humeral head.
– No specific examination tests for the diagnosis of proximal humeral fractures
– Suspect this fracture in elderly patients who have fallen and present with the symptoms or findings described here
– Although overlying musculature makes palpation difficult, patients typically have focal tenderness at the proximal humerus.
– Distal pulses and nerve function must be evaluated, although assessment of motor function is often limited due to pain
– Neurovascular injury occurs most often with displaced fractures or fracture-dislocations and usually involves the axillary or suprascapular nerve [2,8]
– Axillary nerve injury manifests as deltoid muscle weakness and diminished sensation over the mid-deltoid region
– Suprascapular nerve injury can manifest as supraspinatus and infraspinatus muscle weakness (ie, weakness with initiation of abduction and external shoulder rotation respectively).
RADIOGRAPHIC FINDINGS — Plain film shoulder
– true AP) view (image 1)
– axillary view (image 2)
– scapular-Y view (image 3)
should be obtained if a proximal humeral fracture is suspected. This is standard trauma series of radiographs
– patient’s arm is held in internal rotation
– radiograph is oriented superior to inferior while the patient leans backward, is acceptable if an axillary view is unobtainable (figure 8)
CT scan with 3D reconstructions is recommended if the trauma series of plain radiographs described above is non-diagnostic or if further information is necessary regarding the amount of displacement or rotation of a fracture fragment 
CT scans are also recommended for fracture dislocations, humeral head-splitting fractures, and comminuted fractures.
There are a number of classification systems used to describe proximal humerus fractures
Given the complexity and variety of fracture patterns involved, it is not surprising that both inter-observer and intra-observer agreement for classification and treatment is relatively low, regardless of the imaging modality used or the experience of the physician
Of the many classification systems proposed for proximal humerus fractures, the AO and Neer classification schemes are used most often [10,11]
Of these, the Neer system is used most often in the United States.
AO classification system
– distinguishes three basic groups of fractures
– divides these into 27 subtypes
(A) extra-articular unifocal
(B) extra-articular bifocal
Type C fractures
– higher risk due to the limited vascular supply to the articular segment and the increased risk of avascular necrosis 
– based on the biomechanical forces involved and the resulting displacement patterns
– based upon the anatomical relationship of the four major segments of the proximal humerus: the anatomical neck, the surgical neck, the greater tuberosity, and the lesser tuberosity (figure 4 and figure 9) 
– Fractures are classified according to whether one or more of these four segments (or fragments) have been displaced
Displacement exists when a segment is
– angulated > 45 degrees or
– displaced > 1 cm from a normal anatomic position
●One-part = no fragments are displaced (image 4).
●Two-part = one displaced fragment (image 5)
●Three-part = two displaced fragments but the humeral head remains in contact with the glenoid (image 6)
●Four-part fractures: >=3 displaced fragments and dislocation of the articular surface from the glenoid (image 7)
1 and 2-part occur most commonly
The most common displaced fracture = 2-part of surgical neck
INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL —
80% non-displaced or minimally displaced (ie, one-part) >> can be treated conservatively by knowledgeable primary care clinicians 
1. Fx anatomic neck ไม่ต้องสนใจ displacement
(high rate of subsequent osteonecrosis and patients with this type of fracture should be referred to an orthopedic surgeon even if there is no significant displacement of the fragments )
[Whether surgery is the best treatment for anatomic neck and other complex proximal humerus fractures remains a matter of debate.]
A nonoperative approach to one-part fractures is supported by the findings of
– an observational study of 507 patients with minimally displaced humerus fractures treated conservatively  >> At one-year follow up, 88% of patients had good or excellent results according to the Neer criteria; no patients developed a nonunion
– Another study of 54 patients with one-part humerus fractures treated conservatively found similar results . All patients had clinical union of the fracture and symptom scores at one year were similar to preinjury levels. Forward flexion was not diminished but there was a 2 to 7 degree loss of internal and external rotation
– generally needed for significantly displaced, multi-part fractures, and thus all displaced fractures should be referred to an orthopedic surgeon for evaluation
– Treatment options
1. Minimally invasive osteosynthesis
2. Percutaneous pinning
3. open reduction and internal fixation (image 8)
4. primary hemiarthroplasty (image 9)
5. reverse shoulder arthroplasty
Further indications for referral include
1. fracture-dislocations and joint instability 
Emergency referral is indicated for
– all nerve and vascular injuries
– open fractures
– fracture dislocations
Three systematic reviews have assessed the outcomes of studies comparing conservative and surgical management of complex proximal humerus fractures and evaluating different surgical techniques [16-18]
– One systematic review suggests that
— patients with displaced fractures treated conservatively experience more pain and greater loss of motion .
However, other reviews and authors do not concur.
A subsequent systematic review found that
– surgery does not result in better outcomes in patients with displaced proximal humeral fractures involving the humeral neck, and often entails additional surgery 
All reviews determined that
– there is insufficient evidence from hiqh-quality randomized trials to determine which interventions are best for the management of different types of proximal humeral fractures.
In summary, we believe that
– patients with two to four-part proximal humerus fractures or
– those with anatomic neck fractures should be referred to an orthopedic surgeon to review treatment options, which are based upon the fracture type and patient characteristics
Small, primarily observational studies suggest that
– good outcomes may be achieved in select patients using nonoperative management of displaced fractures, but further research is needed:
●An observational study of 160 patients with humerus fractures treated conservatively showed that
– a majority had good outcomes 
The study consisted of 75 one-part, 60 two-part, 23 three-part, and 2 four-part fractures
Immobilization averaged 3 weeks
The mean difference in Constant scores (an assessment of shoulder function) between the affected and unaffected side was 8.2 points (95% CI 7.3-13.1)
The risk of delayed and nonunion was 7 % and 41 of 42 employed patients returned to work.
●A prospective study of 126 elderly patients with displaced two-part fractures treated conservatively reported that 64.5% achieved good or excellent results 
There was no correlation between fracture translation or angulation and the patient’s ability to return to daily activities
At one-year follow up
– no difference in shoulder function (using Neer scores) was found when these patients were compared to a cohort of surgically treated patients.
●In a randomized trial of patients with complex proximal humerus fractures, 40 patients (mean age 74) with three and four-part fractures were treated either with tension band wiring or nonoperative management 
– At one year, no significant difference in pain, range of motion, abduction or flexion power, or the ability to perform activities of daily living was found between the two groups
– Although the position of the fracture fragments improved in the operative group, this did not correlate with better function.
●The randomized PROFHER trial involving
– 250 patients with a displaced proximal humerus fracture
– reported no difference in
— overall shoulder function (as determined by the Oxford Shoulder Score [OSS]) at two year follow-up between patients treated surgically and those treated nonoperatively .
However, a high proportion of patients (188) with clear indications for surgery were excluded from the trial, rendering the results difficult to interpret.
The trial suggests that in a select group of patients without a clear indication for surgery, nonoperative management may be equivalent to surgery as determined by patient-important outcomes.
INITIAL TREATMENT —
Acute treatment for
– immobilization in a standard sling or collar and cuff sling (figure 10)
– A standard sling is recommended for impacted fractures
– A collar and cuff sling may aid in reduction of minimally displaced fragments
– Swathes (figure 11) can be used for pain control but are otherwise not necessary unless the shoulder is unstable
– Ice can be used to reduce pain and swelling
– Pain medications are generally necessary for the first week of treatment.
Patients generally prefer to
– sleep semirecumbent (eg, in a reclining chair or propped up with pillows or a wedge in bed) with a sling
Repeat clinical evaluation and radiographs are performed at one week
Careful attention should be paid to the skin, especially in elderly patients with swelling and ecchymosis.
Several muscles have insertions on the proximal humerus and the forces exerted by these muscles make it difficult to maintain reductions of proximal humerus fractures:
●The supraspinatus and infraspinatus pull the greater tuberosity superiorly
●The subscapularis pulls the lesser tuberosity medially
●The pectoralis major adducts the humeral shaft
●The deltoid abducts the humeral shaft
Therefore, closed reduction of fracture fragments is NOT recommended.
FOLLOW-UP CARE —
Total healing time
– typically 6-12 wks for proximal humerus fractures.
Early callus formation
– usually occurs at 4-6 wks
Duration of immobilization
– important after proximal humerus fractures
– optimal timing for the start of rehabilitation remains uncertain
– Most experts agree that ROM exercises should be initiated by 2 weeks but some argue this should occur sooner
The following clinical studies are illustrative:
●One prospective study assigned 85 patients to one or 3 weeks of immobilization, to be followed by rehabilitation with shoulder and other motion exercises . For the initial 3 months of treatment, shoulder function scores were better in patients who initiated motion at day 7. However, there was no difference in function between the two groups at 6, 12, and 24 months.
●A similar trial of 74 patients compared aggressive early mobilization at 72 hours to standard mobilization at 3 weeks . Initially, Constant scores (assessment of shoulder function), pain scores, and mobility were better in the early mobilization group, but at 6 months no significant differences were noted.
●In a subsequent study, 86 patients with two-part fractures of the proximal humerus were randomly assigned to begin ROM exercises within the 1st week after injury or to continue shoulder immobilization for 3 weeks before beginning rehabilitation .
The group that started early therapy had significantly less pain and better function 4 months after the fractures occurred
However, there was no statistically significant difference between the two groups at 1 year.
●An uncontrolled study of 104 patients with minimally displaced (one-part) proximal humerus fractures found no difference in fracture healing but significantly better overall function and external rotation in those patients who started supervised physical therapy by day 14 compared with those who started after day 14 . The mean duration of follow up was 41 months.
In summary, it appears that for patients with nondisplaced or minimally displaced one or two-part fractures, a shorter period of immobilization, perhaps as little as 1 week, does not adversely affect fracture healing and may be associated with better short term pain control and shoulder function .
Patients are seen again within 4-7 days of their initial visit and plain radiographs are obtained to reevaluate for significant displacement
If pain is well controlled and no displacement of fragments is noted
– Pendulum exercises can be initiated in the sling to avoid loss of shoulder motion (figure 12).
– Passive elbow ROM as well as isometric strengthening exercises for the biceps and triceps should be initiated early.
Subsequent visits —
The first of a series of 2-week follow-up visits focuses on pain control and upper extremity ROM. Patients are encouraged to discontinue their sling within 2-4 weeks of the injury, and to perform gentle, passive ROM exercises of the elbow and shoulder.
If patients are unable to perform these exercises, a referral to physical therapy for assistance improving passive range of motion is necessary.
The goal of shoulder rehabilitation is
– to restore strength and mobility, including abduction, flexion, extension, and rotation
Exercises in which the patient places their hand on a wall or holds a ball against a wall to improve motion can begin within 2-4 weeks
Patients can initiate these motions against gravity at 4 weeks and progress to elastic band or resistance exercises once adequate motion has been achieved and there is sufficient evidence of healing by radiographs.
The details of rehabilitation for proximal humeral fractures are beyond the scope of this monograph, but the systematic review cited here emphasizes the importance of early mobilization and outlines a program suitable for most patients .
After 8 weeks, the time between visits may be increased to every 3-4 weeks. The focus of these visits is to further improve shoulder ROM and overall function.
Functional measures of motion include
– the ability to touch the neck and lower back and
– to abduct the arm overhead
Over subsequent weeks, the patient follows a progression of exercises designed to maximize shoulder mobility and strength.
Most patients with nondisplaced or minimally displaced fractures of the proximal humerus who adhere to a well-designed rehabilitation program regain over 90% of the function and 85% of the motion of their unaffected shoulder .
Loss of shoulder mobility
– is among the more common complications of proximal humerus fractures
– The decrease in motion ranges from
: clinically insignificant to adhesive capsulitis (frozen shoulder), in which shoulder movement is painful and limited in all orientations
Loss of shoulder motion and function
– more likely to develop in patients who do not perform ROM exercises during recovery
Severely displaced or angulated fractures can cause neurovascular injury, most commonly to the circumflex artery and the axillary or suprascapular nerve
One prospective study of 142 patients with proximal humerus fractures found evidence of some denervation using an electromyogram in 67 percent of patients 
Injury to the axillary nerve accounted for 58% of cases, while injury to the suprascapular nerve accounted for 48%. All patients recovered full function of the nerve and muscles.
Proximal humerus fractures are sometimes associated with dislocations of the humeral head or rotator cuff tears, which can cause significant loss of motion or instability. Studies using dynamic ultrasound have found that 20-50% of patients with proximal humerus fractures have associated rotator cuff tears [27,28].
A prospective study involving MRI reported that 71% of patients had rotator cuff abnormalities and 40% had at least one torn or avulsed tendon . (See “Presentation and diagnosis of rotator cuff tears”.)
Although osteonecrosis of the humeral head is not common, it can occur, especially in fractures involving the anatomic neck or severely displaced fractures.
Other complications include
– impingement from avulsed fracture fragments
A study of 160 patients managed nonoperatively reported delayed union or nonunion in seven percent of patients .
RETURN TO SPORT OR WORK
Return to work typically occurs 2-3 weeks after a proximal humerus fracture, provided the patient can return in the sling and the job does not require full use of the affected arm.
Patients whose jobs include two-handed labor or lifting will likely not be able to return for 8-12 weeks.
Criteria for return to work include
– adequate range of motion and strength as well as
– stable callus formation on radiographs
The same criteria are used to determine the return to sports
Cardiovascular fitness after a proximal humeral fracture can be maintained by low impact activities such as walking or use of an elliptical trainer or stationary bike.
SUMMARY AND RECOMMENDATIONS
●Proximal humerus fractures account for four to five percent of all fractures and the incidence increases with advancing age. They often occur as a result of falling from a standing height. (See ‘Epidemiology and risk factors’ above and ‘Mechanism of injury’ above.)
●Swelling and ecchymosis may be apparent soon after the injury. Gross deformity of the shoulder suggests an associated anterior or posterior dislocation. Concomitant neurologic or vascular injury should be suspected and neurovascular integrity clinically assessed. (See ‘Symptoms and examination findings’ above.)
●The Neer classification system is often used for proximal humerus fractures. (See ‘Neer classification’ above.)
●Complex proximal humerus fractures (ie, Neer two-part to four-part fractures) and fractures that involve the anatomical neck should be referred to an orthopedic surgeon. These are initially managed with immobilization using a standard sling, or if unstable a sling and swathe. Closed reduction of the fracture is NOT recommended prior to orthopedic referral.
●Approximately 80 percent of proximal humerus fractures are impacted or nondisplaced (Neer one-part fractures) and are amenable to closed management. Orthopedic referral is not required for one-part fractures unless the fracture involves the anatomic neck, there are neurovascular complications, there is a concomitant shoulder dislocation, or the treating clinician is not experienced in fracture management. (See ‘Indications for orthopedic consultation or referral’ above.)
●Nonoperative management of one-part fractures includes initial immobilization with a standard or collar and cuff sling, ice, and analgesics. Neither splinting nor casting is required. We suggest that early mobilization with pendulum exercises be performed in the sling beginning one to two weeks after the injury. (See ‘Initial treatment’ above.)
●Periodic follow-up visits allow assessment of range of motion, muscle strength, and function. Generally, the first appointment occurs one week following the injury, with subsequent follow up every two weeks for two months, followed by visits every three to four weeks until complete radiographic healing is documented. (See ‘Follow-up care’ above.)
●Return to work can be expected in two to three weeks if the patient can perform the required duties while in a sling. Return to occupations that require full use of the shoulder or to sports is not advised until strength and range of motion are acceptable and stable healing is apparent on radiographs. (See ‘Return to sport or work’ above.)