Proximal Humerus Fractures

 

Written by: Mitchell Melikhov-Sosin, MD; Edited by: Timothy Khowong, MD, MSEd

 

Background:

Proximal humerus fractures are the 3rd most frequent type of fracture in those over 65 (after hip and distal radius). However, these fractures can often be overlooked for a few reasons like low energy mechanisms and subtle presentation. Another issue making these even more difficult to detect in older patients is because they have higher rates of communication barriers: think of the elderly non-English-speaking patient or nonverbal nursing home patient.

How would you catch this fracture on somebody who cannot complain of it? What if it’s hidden underneath the shoulder’s own anatomy – not an obvious one? What if the fall wasn’t even from standing height? The answer is a good exam. Don’t just check the hips and head!

In younger people, these fractures usually result from higher-energy incidents like sports injuries, seizures, or intimate partner violence (IPV). We all know the boards questions about football players and epileptics. But that last group is a really important one. 

I once had a patient who was a thin, small, young woman around my age coming in with this fracture and said she fell off the bed. Initially, I didn't think too much of it and took the story at face value. But something felt off. She appeared more thoughtful than in pain. I talked to her more and she told me her boyfriend pushed her… 

In reviews of radiology literature, patients who suffer IPV have already been victims long before they can be medically or radiographically identified. IPV is a chronic, progressive, and often lethal process. If you want to save a life, don't just consult ortho. Make sure you address this part of it too.

Assessment

Like with every other orthopedic injury, you should always do a neurovascular exam. Your exam is guided by the function related to that anatomy (see graphic below). Since younger people tend to have higher energy mechanisms, it is all the more important to not miss concomitant injuries in them. Compartment syndrome is less likely in the proximal upper extremity but you might still get a CPK, especially for seizures, lightning, or electrocution

Anatomy & Neer classification

Now that we caught a fracture, let’s head back to med school anatomy. It will help us understand Neer's classification, which is the most common system used to describe the severity of proximal humerus fractures. This system divides the proximal humerus into four parts: the articular surface/anatomic neck, the greater tuberosity, the lesser tuberosity, and the humeral shaft/surgical neck. Neer's classification then categorizes fractures based on the number of parts involved: Neer 1 (one part), Neer 2 (two parts), Neer 3 (three parts), and Neer 4 (four parts). Pretty easy!

Let’s look at some examples below:

We all know our standard shoulder views (below). We want them pre and post any ortho manipulation. But how in the world are you supposed to get that last axillary view if it’s too unstable? Well, this is where the Velpeau view (right) comes in. It gets the information you want without having to undo the sling or ranging the extremity, ortho will recommend this.

Management and Treatment:

Assuming there are no other higher-priority injuries, AMS, burns, electrocution, indications for fasciotomy, polytrauma, etc. we can address the fracture. Then, we want to pay attention to open fractures, neuro deficit, vascular injury/malperfusion, and dislocation.

All good? Ok now you can put in your favorite consult! Since 80% of these are Neer 1 Ortho will likely recommend a simple and easy treatment: “sling to gravity as tolerated”. They are non-operative, except for Neer 1's at the anatomic neck because there is a high rate of AVN secondary to poor blood supply. 

Does that mean the other 20% get surgery? Well, not exactly. Although Neer 2-4 are technically operative candidates, multiple studies and reviews comparing conservative and operative management show similar outcomes. 

Of course, a lot of this is influenced by the fact that the primary population who gets these fractures is 65+, in a nursing home, poor functional status, and     already has limitations to being good operative candidates. Remember this if you get a patient with cognitive decline returning from the nursing home because they took their sling off and now the facility is worried.

Summary:

In Emergency Medicine, we are in a position to advocate for our patients. While our colleagues in Orthopedics are amazing at what they do, we in Emergency Medicine need to work with them to advocate for our patients. It can be easy to slap on a sling. Doing a proper exam can clue us into more significant injury. Reading our own films with Neer’s classification in mind can help us find the patient at risk for AVN. If your patient doesn’t have a good reason for the injury, think of IPV – do everything you can to support and protect them. Also, make sure you understand why the patient is not offered surgery especially if they injured their dominant arm, is an athlete/needs that arm for work, young/high functional status, or Neer classification is >1.

 

References:

  • Handoll HH, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022 Jun 21...

  • Launonen AP, et al. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019 Jul 18...

  • Rangan A, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10...

  • Handoll HH, et al. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017 Mar...

  • Hanson B, et al. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg. 2009 Jul-Aug...

  • Goudie EB, et al. Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults. J Bone Joint Surg Am. 2022 Jan 19...

  • Iyengar JJ, et al. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma. 2011 Oct...

  • Launonen AP, et al. Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial. PLoS Med. 2023 Nov 28...

 
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