Proximal Humerus Fractures

Definition/Description

Proximal humeral fracture is a common injury in elderly patients and is one of the true osteoporotic fractures [1][2]. Proximal humerus fractures (PHF) include all fractures of the greater tuberosity (GT) or lesser tuberosity of the anatomical neck surgery neck, whether isolated or in combination. [3]

Clinically Relevant Anatomy

Osteology: Humerus

Classification: long bone

Features:

• Humeral Head: The proximal articular surface of the upper extremity. It articulates with the glenoid socket of the scapula.
• Greater Tubercle: Located on the lateral side of the proximal end of the head.
• Lesser Tubercle: Located on the front of the humerus, just below the head.
• Anatomical Neck: Located between the head and the tubercle.
• Surgical Neck: Located between the tubercle and the shaft.
• Internodular groove: the narrow groove between the greater and lesser tuberosities.
• Humeral shaft.

Function: As an appendage of 13 muscles, these muscles assist in the movement of the hand and elbow and therefore in the function of the upper body.

Muscles:[4] The intrinsic shoulder muscles that connect the scapula and/or clavicle to the humerus include:

• Deltoid
• Teres major
• Supraspinatus
• Infraspinatus
• Teres minor
• Subscapularis
• Latissimus dorsi
• Pectoralis major
• Coracobrachialis
• Biceps brachii
• Triceps brachii

Injury Mechanism/Pathological Process

Epidemiology

PHF is the third most common fracture in older adults after proximal femur and distal radius fractures, accounting for 10% of all fractures. [3] PHF accounts for approximately 5.7% of fractures in adults [5] and increases in incidence with age, making it one of the most common fractures in the population Over 65 years old[6][7] with a mean age of 70 years (16-97). [8]

In the United States, there were approximately 370,000 emergency department visits due to humeral fractures and PHF, accounting for 50% of humeral fractures in 2008. [9] In one study, the overall age-standardized incidence rates of PHF in men and women were 40.6 (95% CI 32.7 48.5) and 73.2 (95% CI 62.2 84.1) per 100,000 population, respectively Person-years were in southeastern Australia. [10]

The risk of PHF increases with age and is most prevalent in older women with osteoporosis. In addition to bone fragility due to osteopenia or osteoporosis, commonly reported risk factors include those associated with an increased risk of falls, such as low levels of physical activity that impair balance or lower extremity Pain or injury. [3]

Aetiology

The 2 most common mechanisms of PHF:

• High-energy trauma (eg, sports injuries and motor vehicle accidents)
• Low-energy trauma (such as a fall from a standing position or a direct blow to the shoulder)

Associated conditions

• Nerve injury: Common injuries include direct injury to the brachial plexus or traction to the axillary nerve. A fracture-dislocation is more likely to be present. [11]

• Vascular injury: Rare but more likely fracture-dislocation. Older adults are more likely. There may be no signs of distal ischemia, but there are massive expanding hematomas, pulsatile external hemorrhages, unexplained hypotension, tardive anemia, and associated nerve trunks or plexuses Injuries should increase the level of suspicion. [11]

Clinical Presentation

Symptoms

• Pain and swelling
• Decreased motion

Classification

There are 2 main classifications for PHF (Neer and AO/OTA classification) and one specific to GT fractures.

The Neer Classification

The four-segment classification system describes PHF by the number of displaced segments or sites and additional categories of joint fractures and dislocations. The articular surface of the GT lesser tuberosity and the humeral diaphysis are possible segments involved. The definition section is Displace when there is greater than 1 cm separation or 45° angle. [12]

• Single Part Fracture: No fragment meets displacement criteria. Fractures that did not account for fracture displacement were defined as partial fractures, regardless of the actual number of fracture lines or their location.

• Two-part fracture: one part is displaced, ie the GT lesser tubercle or the articular segment at the level of the anatomical or surgical neck.

• Three-part fractures: Displacement of the tuberosity on one side and displacement of the operative neck fracture. The remaining nodules are attached and rotationally deformed.

• Four-Part Fracture: All four parts (tubercular surface and axis) meet displacement criteria. The articular segments are usually displaced laterally and do not make contact with the glenoid. This is a serious injury and there is a high risk of ischemic necrosis.

• Valgus-affected four-part fractures: This pattern was added in 2002 as a separate category. The head is rotated to an everted position and pushed down between the tuberosities to accommodate the head. The articular surface remains in contact with the glenoid and there is no lateral displacement.

• Fracture-dislocations and articular surface injuries: A separate category has been added for dislocations because they represent more severe injuries and are more likely to develop avascular necrosis and heterotopic ossification. Likewise, articular surface fractures fall into a separate category for the following reasons Their unique management considerations. There are two types of head fractures and impact fractures.

[13]

The AO/OTA Classification

The AO/OTA 2007 classification defines three main types (A B and C) based on the severity of the fracture and the articular/extra-articular and monofocal/bifocal patterns. [14]

• Type A: extra-articular and unifocal

•Type B: extraarticular and bifocal

•Type C: articular

Diagnostic Procedures

Radiological assessment[15]

• Plain radiographs: Plain radiographs are the primary baseline investigation for the diagnostic classification and management plan of PHF. X-rays should include:

• A true anteroposterior view
• A Trans-scapular Y view
• An axillary lateral view

• Doppler ultrasonography: can be used to evaluate associated vascular injury and concomitant rotator cuff tear.

• Computed Tomography (CT): Can be used to assess complex fracture patterns while also quantifying available bone mass and assessing the extent and location of fracture healing.

•CT angiography: It can be used for accurate diagnosis and guiding treatment of combined arterial injury.

• Magnetic Resonance Arthrography: An additional imaging tool used to evaluate the soft tissue surrounding a joint.

• Angiography: An additional imaging tool used to assess blood vessel damage.

Differential Diagnosis

Evaluation should begin with examination of the neurological and vascular condition of the affected extremity. Assess the entire limb for potential fractures. Concurrent fractures are especially seen with high-energy mechanisms of injury. The injuries most commonly associated with PHF include the axilla Suprascapular or brachial plexus injury, axillary artery injury, pneumothorax, hemothorax, and rotator cuff injury.

Outcome Measures

•Constant-Murley score[16]

• Arm shoulder and hand disability scores [16]

•Visual Analogue Scale[16]

• American Surgeons of Shoulder and Elbow Scale [16]

Management / Interventions

PHF can be managed conservatively and it is expected that the fracture will heal and the patient will regain function in the shoulder. [2] Treatment is usually a sling and early range of motion exercises, but can sometimes be open reduction and internal fixation (ORIF) or pseudarthrosis replace. The choice of conservative or surgical management depends on the type and severity of the fracture, accompanying soft tissue injury, and other individual factors such as age comorbidities, activity level, bone quality, and patient motivation. [3]

Conservative medical management

The vast majority of nondisplaced PHF can be successfully managed conservatively, with several systematic reviews and meta-analyses reporting that nonoperative management resulted in fewer complications and that surgical intervention did not show significant improvement in function and clinical symptoms Results.[17][18][19]

Patients treated conservatively are typically immobilized in a simple sling for 4 to 6 weeks with the glenohumeral joint in a resting position of internal rotation and 0° adduction. [3]

Recovery after initial conservative treatment

Purpose: To restore range of motion and normal shoulder strength and eventually function [3]

< Within a week after PHF >

• As tolerated by the patient, early passive movement of the shoulder in forward abduction and external rotation (external rotation should be limited to 30°-40° for the first 3 weeks to limit rotational stress on the fracture)
• education to prevent complications from braking)
• Pain control
• Active movement of neck, elbow, wrist and hands

< 3 to 5 weeks >

• Active-assisted mobilisation

< 4 weeks >

• Submaximal Isometric Exercises of Flexion, Abduction and Internal Rotation

< 4 to 6 weeks >

• Active mobility (when the sling is no longer needed and the fracture is sufficiently consolidated; start in supine and progress to sitting)

< 8 to 12 weeks >

• Exercises to strengthen the rotator cuff and scapula pectoralis

< 12 weeks >

• Functional exercises
• Resumption of leisure or physical activity (depending on patient tolerance and individual needs)

< 8 to 16 weeks >

• Return to work (depending on patient’s physical labor needs)

Surgical fracture management

Recent evidence suggests that surgery is not significantly superior to conservative management, even for complex fractures, in terms of functional outcome and health-related quality of life in older patients. [18] However, surgery is recommended for displaced active patients PHF after secondary displacement on initial X-ray or CT imaging or within the first 3 weeks of follow-up. [3]

List of common surgical complications

Most common surgical complications in surgical treatment of PHF [3]

Open reduction and internal fixation Shoulder replacement Avascular necrosis Joint instability/dislocation Screw removal Implant misalignment Nonunion Implant loosening Malunion infection (Propionibacterium acnes) Persistent joint dislocation Biceps pathology Infection ( Propionibacterium acnes) axillary nerve Paralysis Capsulitis Brachial Plexus Palsy Rotator Cuff Tear Hemiarthroplasty: Rotator Cuff Failure Biceps Lesion Reverse Arthroplasty: Glenoid Notch Axillary Nerve Palsy Periprosthetic Fracture Brachial Plexus Palsy Heterotopic Ossification bit ossification

Types of surgeries

• Closed reduction and percutaneous stabilization using needle or thread
• External fixation
• Open reduction and plating: e.g. support plate angle blade plate and proximal humeral locking plate
• Open reduction and fixation using the tension band principle
• The intramedullary nail is inserted antegradely or retrogradely; today, screws are often used to “lock” the nail in place
• Femoral head replacement (replacing the humeral head)
• Total shoulder arthroplasty (replacement of the entire joint; thus including the “ball” (humeral head) and the “glenoid” (glenoid)). This includes reverse polarity arthroplasty, in which the polarity of the joint is reversed, with the ball on the glenoid side and the socket on the humerus side. [19]

Rehabilitation after surgical treatment

Rehabilitation options are often variable, as limitations will depend on concomitant injuries and surgical options, such as associated shoulder dislocations or concomitant rotator cuff repairs. [3]

After open reduction and internal fixation (ORIF)

The protocol [1][20] is criteria-based and time-based (depending on tissue healing). Specific interventions should be based on individual needs, and the therapist should consider laboratory results and clinical decisions. The time frame for expected results contained in this agreement may vary Additional procedures and/or complications performed at the surgeon’s preference.

Goals

• Minimise pain and inflammatory response
• Protects fractures and optimizes bone healing
• Restoring passive range of motion (PROM) in the shoulder
• Maintain elbow, wrist and hand function

Precautions

• No abduction past 90°
• External rotation of shoulder joint 0°-40°
• No lifting greater than 1lb
• Do not drive without sufficient ROM straps removed and without narcotic pain medication
• No motions into painful ranges

Interventions

• Sling: For at least 3 weeks
• Pain/Swelling Management: Cryotherapy and Indicated Ways
• Range of Motion/Motion: Shoulder PROM / Shoulder Swing / Elbow Wrist and Hand AROM
• Strengthening: Ball Squeeze/Scapula Retraction and Mobility Exercises

Criteria to progress

• Wean from sling at 4 weeks
• Adequate pain control
• Full elbow AROM
• Shoulder PROM flexion to 140° external rotation to 40° abduction to 90°

Goals

• Full shoulder PROM
• Active Active Assisted Range and Active Range of Motion (AAROM/AROM) of the shoulder activated
• Start active range of motion at 6 weeks
• Begin gentle isotonic strengthening of the elbow
• Initiate shoulder isometrics
• Minimize compensatory movements of the affected upper extremity
• Encourage return to normal daily activities when precautions are lifted

Precautions

• Lifting no more than 2 lbs prior to 6 weeks
• Start shoulder AROM at 6 weeks post-op
• No strong end range beyond stress to involved shoulders
• No isotonic strengthening of the shoulder

Interventions

• Continue with Phase I interventions
• AAROM: Lawn Chair Progressive / Table Slide Rail Slide Wall Slide / Pulley
• AROM: supine shoulder AROM flexion / lateral shoulder ER, arm down towel roll / lateral shoulder abduction to 90° / lateral shoulder flexion / low punch
• Strengthen: Shoulder isometric flexion and extension internal rotation and external rotation / biceps curl / triceps extension / prone row

Criteria to progress

• Full shoulder PROM
• Full elbow AROM
• Adequate pain control
• Well tolerated with shoulder isometrics and elbow reinforcement

Goals

• Full shoulder AROM
• Initiate shoulder strengthening
• Progress elbow and wrist strengthening
• Adequate pain control

Precautions

• No lifting greater than 10bls
• No painful or forceful stretching
• No excessive weight bearing on affected extremity

Interventions

• Continue with Phase I-II interventions
• AAROM: Standing Shoulder Flexion/Abduction with Pins
• AROM: Standing Shoulder Raise / Standing Shoulder PNF Diagonal / Prone I Prone Y Prone T
• Stretches: Doorway Stretch / Chest and Biceps Stretch / Cross Body Stretch
• Strengthening: rowing/straight arm pulldown/resisted internal and external shoulder rotation (shoulder neutral position)/resisted low boxing/supine shoulder extension

Criteria to progress

• Full Shoulder AROM with Proper Mechanics
• Intensive Exercise Pain Free or Compensatory Strategies

Goals

• Improve shoulder strength with greater resistance and compound movements
• Return to normal functional activities
• Continue to improve shoulder ROM needed

Interventions

• Continue with Phase II-III interventions
• Strengthening: rhythmic stability/progressive push-ups (wall reverse knee-high plank)/high plank stability progression/flat raise/shoulder diagonal resistance/shoulder internal and external rotation 90°/quadruped stability Advanced/Shoulder Plyometrics / Resume exercise training at appropriate time intervals

Criteria to progress

• 80% or > strength of affected upper extremity compared to strength test of uninvolved arm
• Progressive strengthening exercises without pain
• Low or no disability scores on patient-reported outcome measures

[21]

[22]

Resources

Interventions for the treatment of proximal humerus fractures in adults

Proximal Humerus Fractures: Current Concepts in Classified Treatment and Outcomes

Management of proximal humeral fractures in adults

[23]