Proximal Humerus Fracture

Proximal Humerus Fracture is often seen in elderly population1 and post-menopausal female. The cause of fracture is osteoporosis. The fracture is also observed in children mostly following fall and young adults following direct impact, which results in fracture.

Proximal Humerus Fracture

What Is Proximal Humerus Fracture?

  • Proximal Humerus Fracture is quite a common injury among elderly population who are suffering with osteoporosis.
  • Proximal Humerus Fracture is also one of the common injuries in athletes who participate in contact sports.
  • Proximal humerus fracture includes the fracture of shaft of the humerus and greater tuberosity. If the fractured segment lies inside the joint then fracture is known as intra-articular fracture and if the fracture segment lies outside the joint or joint capsule then fracture is known as extra-articular fracture.
  • The fractured bones are either displaced or non-displaced. Fractured segment is known as Displace Fracture when the two fractured fragments are not aligned and are separated. Humerus fracture is known as non-displaced fracture when fractured fragments are aligning and maintained in anatomical positions.

Classification Of Proximal Humerus Fracture

  1. Extra-articular Fracture- Fracture is located outside the shoulder joint and joint capsule.
    1. Extra-articular Unifocal Fracture- Single fracture involves shaft of humerus or greater tuberosity
      1. Fracture of the shaft of the humerus
      2. Fracture of the greater tuberosity
      3. Fracture of lesser tuberosity

      Extra-articular Unifocal Fracture

    2. Extra-articular Multifocal Fracture- Multiple fractures involve greater tuberosity and shaft of the humerus.2
      • Multiple fractures involving shaft, greater and lesser tuberosity.

      Extra-articular Multifocal Fracture

  2. Intra-articular Fracture- Fracture is located inside the joint capsule known as intra-capsular or intra-articular fracture.

Intra-articular Fracture

Causes of Proximal Humerus Fracture

  • Osteoporosis- Osteoporosis is observed in elderly1 and menopausal females. Osteoporosis is a bone density disease which results in decreased bone mass and structure. Fall or impact, which may not result in fracture in normal individual, but may cause fracture in patients suffering with osteoporosis.
  • Sports Injury- Humerus fracture is often observed in athletes participating in contact sport. The twist and turn of the upper arm during fall and tackling while participating in contact sports like football, rugby or soccer often results in intra-articular humerus fracture.
  • Work Injury- Fall from heights or mechanical twist and turn of upper arm while using heavy equipment may result in humerus fracture.
  • Automobile or Car Accident- Automobile accident can be head-on or side collision, which results in direct impact of outstretch shoulder joint. The impact may cause fracture of humerus. The accident resulting in multiple turns and rolling of the car can cause abnormal turn and twist of the shoulder joint. Such injury causes intra or extra articular fracture of humerus.

Symptoms Of Proximal Humerus Fracture

  • Pain- Immediately following injury patient feels severe pain at rest. Pain is often intolerable following any attempt to use injured arm. Patient is unable to lie on the side of injured arm.
  • Deformity- The protrusion of fractured segment causes joint deformity. The palpation of the deformed joint suggests swelling is firm to hard unless the blood clot under the skin is overlapping the fractured fragments.
  • Swelling- The subcutaneous and joint bleeding causes hematoma (blood clot) and soft tissue trauma cause tissue edema. The blood clot and tissue edema causes soft tissue swelling over the joint. Examination of swelling indicates soft to firm consistency.
  • Inability To Move Upper Arm- Patient suffering with humerus fracture would be afraid to move upper arm because of fear of increasing intensity of pain. Patient is often unable to move the arm following displaced fracture of the shaft of the humerus. 
  • ingling and Numbness- Fracture of humerus may be associated with nerve damage. Sensory nerve damage causes tingling and numbness.
  • Weakness in Upper Extremity- Arm weakness is observed if nerve to muscles around shoulder joint is damaged following accident and injury. 

Diagnosis of Proximal Humerus Fracture

Clinical Examination-

  • Pain over proximal humerus and shoulder joint
  • Shoulder joint and proximal humerus deformity
  • Joint and humerus tenderness
  • Skin discoloration and bruises

Image Studies-

  • X-ray- X-Ray examination shows the fracture though it is often difficult to differentiate intra and extra articular fracture.
  • CAT Scan or MRI- The MRI study helps to differentiate intra and extra articular fracture. MRI also shows soft tissue injury like tendon, muscle or ligament tear or rupture.
  • Ultrasound Examination- Ultrasound examination shows soft tissue injury fracture as well as collection of blood and blood clot.

Treatment For Proximal Humerus Fracture

Nonsurgical Treatment of Proximal Humerus Fracture-

  • Shoulder Joint Immobilization- Shoulder joint is immobilized to prevent separation of joint fragments and reduce pain. Shoulder joint sling is used to immobilize shoulder joint. Sling is often used for 6 to 10 weeks if fracture is non-displaced and alignment of the fragment is in normal anatomical position.

  • Cold Application or Cold Pack Therapy- Cold application is used for pain and reduced swelling or edema.

  • NSAIDs- Anti-inflammatory medications are used for inflammation and pain. Anti-inflammatory effects of NSAIDs help to reduce tissue edema and inflammation. Mild to moderate pain responds to NSAIDs. Most common NSAIDs used are Motrin, Naproxen and Celebrex.

  • Opioids- Severe to very severe pain is treated with opioids. Most common opioids used are hydrocodone and oxycodone.

  • Muscle Relaxants- Occasionally, after fracture of humerus, pain is associated with muscle spasm. Muscles around the shoulder have to work to keep the arms in neutral position and extra work often result in muscle spasm. Muscle spasm is treated with Baclofen, Flexeril and Skelaxin.

  • Physical Therapy (PT)- Physical therapy is advised before and after surgery. Before surgery physical therapy is advised to maintain the tone of the muscles in upper arm, forearm and hand

Surgical Treatment of Proximal Humerus Fracture-

Surgery is essential to repair intrathecal and displaced fracture.

  • Close Reduction- Close reduction is attempted under sedation for displaced fracture of shaft of the humerus or greater tuberosity fracture. Following close reduction, the arm is rested in sling for 6 to 8 weeks. Frequent x-ray is performed to evaluate re-fracture.
  • Open Reduction-
    • K-Wire Insertion- Extra-capsular fracture of lesser and greater tuberosity is treated by insertion of K-Wire in both fracture segment.
    • Plate and Screw Placement- Extra-capsular fracture of shaft of humerus is treated with Plate and Screw Placement.
    • Hemiarthroplasty- Multiple (multifocal) extra and intra articular fracture are treated with hemiarthroplasty. 3
    • Internal Fixation Using the MultiLoc Nail- Extra scapular multifocal fractures involving 3 to 4 fracture segments are treated with MultiLoc nail 4

Exercises For A Proximal Humeral Fracture

For Proximal Humerus Fracture, The Following Exercises Are Performed:

Shoulder Blade Squeezes: To do this exercise, start by standing tall with the back straight. Squeeze the shoulder blades together as much as possible without aggravating pain. Maintain this position for about 5 seconds and repeat around 10 times.

Shoulder Blade Squeeze Exercise for Proximal Humerus Fracture.

Pendular Exercises: Start this exercise by leaning forwards with uninjured arm placed on a table. Keep the back straight and relax the shoulder. Now, gently swing the affected arm forward and backward as far as possible without aggravating pain. Do it for around 10 times. Now, do the same exercise by moving the arm sideways.

Pendular Exercise for Proximal Humerus Fracture.

Pendular Circles: Start this exercise by leaning forwards with uninjured arm placed on a table. Keep the back straight and relax the shoulder. Now, slowly swing the injured arm in a circular fashion clockwise as far as possible without increasing pain. Repeat this by moving it anticlockwise. Do it about 10 times in each direction.

Pendular Circles Exercise for Proximal Humerus Fracture.

References:

1.Proximal humeral fractures in elderly patients.

Cadossi M1, Mazzotti A, Capra C, Persiani V, Luciani D, Pungetti C.

Aging Clin Exp Res. 2013 Oct;25 Suppl 1:S85-7.

2.A combined fracture of the greater and lesser tuberosity with head shaft continuity in the proximal humerus.

Takase K1, Shinmura K, Yamamoto K.

Arch Orthop Trauma Surg. 2007 Dec;127(10):895-8.

3.Hemiarthroplasty for head-split fractures of the proximal humerus.

Greiwe RM1, Vargas-Ariza R, Bigliani LU, Levine WN, Ahmad CS.

Orthopedics. 2013 Jul;36(7):e905-11.

4.Internal fixation of fractures of the proximal humerus with the MultiLoc nail.

Hessmann MH1, Nijs S, Mittlmeier T, Kloub M, Segers MJ, Winkelbach V, Blauth M.

Oper Orthop Traumatol. 2012 Sep;24(4-5):418-31.

Written, Edited or Reviewed By:

, MD, FFARCSI

Last Modified On: May 2, 2016

Pain Assist Inc.

Pramod Kerkar
  Note: Information provided is not a substitute for physician, hospital or any form of medical care. Examination and Investigation is necessary for correct diagnosis.

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