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Proximal Humeral Fractures

(Shoulder Fracture)

By Danielle Campagne, MD , Department of Emergency Medicine, University of San Francisco - Fresno

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Patient Education

Proximal humeral fractures are proximal to the surgical neck (see Figure: Key anatomic landmarks in the proximal humerus.). Most are minimally displaced and angulated. Diagnosis is by plain x-ray or sometimes CT. Most of these fractures can be treated with a sling, a swathe, and early mobilization.

Proximal humeral fractures are especially common among the elderly. 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 the elderly.

Key anatomic landmarks in the proximal humerus.

The surgical neck of the humerus is fractured.

Etiology

Most of these fractures result from a fall on an outstretched arm; less often, a direct blow is involved.

Classification

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

  • Anatomic neck

  • Surgical neck

  • Greater tuberosity

  • Lesser tuberosity

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.). 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

The shoulder and upper arm are painful and swollen; patients have difficulty raising their arm.

Diagnosis

  • Plain x-rays

  • Sometimes CT

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

  • 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.), and early range-of-motion exercises, such as Codman exercises (see Figure: Codman exercises.). These exercises are particularly useful for the elderly. Because contractures are a risk, early mobilization is desirable, even if alignment is anatomically imperfect.

Codman exercises.

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

  • Slowly swing their arm from side to side, from back to front, and in circles clockwise and counterclockwise

  • Shift their weight from foot to foot in the same direction that their arm swings

  • Gradually increase the arc as tolerated

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).

Key Points

  • 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 the elderly, should start range-of-motion exercises as soon as possible.

Resources In This Article

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