JUNIORBONES
Orthopaedics and trauma for junior orthopaedic trainees and medical students
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Assessment and management of proximal humerus fractures
by James Donaldson

Scenario: called to A&E to assess a 68 year old woman who fell from a height onto her shoulder.

History
Age – often elderly, in the young consider higher energy trauma
Occupation and handedness – useful for deciding treatment, rehab protocol, compliance
Time/date of injury

Past medical/surgical history

Medication/drugs and allergies

Last ate/drank (for timing of emergency surgery if needed)


Radiographs
3 radiographs are mandatory for all shoulder injuries:
  • AP, Scapula Y and axillary radiographs
  • Additional views +/- CT can be ordered by treating surgeon if needed
  • Assess bony contours and presence of fractures / dislocations
Evaluation
Acute pain after the injury
Loss of function and range of movement
Swelling, bruising and deformity

Associated injuries
Chest, lung, head, spine, scapula. Involve trauma team if necessary

Neurovascular exam
  • Especially axillary nerve palsy (up to 45%)
  • Brachial plexus - refer urgently to specialist centre (BOAST guidelines)
  • Arterial injury - emergency vascular consultation if suspected

Anatomy
Typically the shoulder is divided into 4 anatomical parts:
  • Greater tuberosity
  • Lesser tuberosity
  • Articular surface / head
  • Shaft of humerus
Considered separate parts if displaced on x-rays >1cm or >45 degrees (Neer)
Initial treatment
Analgesia, collar and cuff
Collar and cuff and 1 week fracture clinic follow up if non-operative treatment is indicated
Admit (and inform senior) if neurovascular injury or associated dislocation or if operative treatment is indicated
85% of fractures are treated non-operatively

Decision to operate depends on many factors including:
  • age
  • fracture type and displacement
  • bone quality
  • handedness
  • medical conditions and concurrent injuries
Management
Decision dependent on degree of displacement. Fractures classified by displacement rather than number of fracture fragments. If a fragment is undisplaced, it is not defined as a part.

One part fracture
Typically undisplaced can involve 1-4 fragments but none are displaced.
Surgical neck #. Commonest type. Non-operative management.
Anatomical neck #. ORIF in young. ORIF or hemi-arthroplasty in elderly if comminuted

Two part fracture
Involves one displaced fragment
ORIF if significantly displaced or angulated
ORIF greater tuberosity if >5mm displaced

Three or four part fractures

Involve two or more displaced fragments
ORIF or hemi-arthroplasty in elderly

shoulder fracture
AP x-ray shoulder demonstrates undisplaced fracture (one part fracture)
shoulder fracture
AP x-ray shoulder demonstrates displaced fracture of surgical neck of humerus (two part fracture)
shoulder fracture
AP x-ray shoulder demonstrates three part fracture
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