What is Proximal Humerus Fracture?
Fractures of the upper arm, specifically the proximal humerus, make up 5-6% of all adult fractures. There’s growing awareness about how to handle these injuries, especially in the case of older adults who have fallen from a standing height. This awareness is important because such incidents add to the worldwide cost of dealing with osteoporosis and frailty-related fractures. What’s more, as the general population gets older, and more people are recognized to have weak bone density, there is an increased focus on better ways to treat and manage these upper arm fractures, both with and without surgery.
What Causes Proximal Humerus Fracture?
Proximal humerus fractures (PHFs) generally follow a pattern of frequency based on age and the intensity of the incident causing the fracture. There are two main categories: high-energy injuries, such as car accidents among younger individuals, and low-energy injuries, like a simple fall among older adults.
PHFs are most likely to occur in people over 65 years old. In situations where their bones are already weakened by conditions like osteoporosis or osteopenia, even a low-level fall can lead to a PHF. This is referred to as a fragility fracture. Therefore, any patient presenting these injuries should be considered to potentially have osteoporosis, even if they haven’t officially diagnosed.
On the other hand, younger patients usually get these fractures from more intense accidents, such as car accidents.
Risk Factors and Frequency for Proximal Humerus Fracture
Proximal humerus fractures, or PHFs, typically occur in older individuals. The top three types of fractures that can happen due to weaker bones include:
- Vertebral compression fractures
- Distal radius fractures
- Proximal humerus fractures
Fractures from high-energy incidents can often result in additional injuries to the soft tissue or surrounding blood vessels and nerves. It’s also worth noting that as people age, the complexity of these fractures can escalate, leading to more shattered bone, displacement, and changing fracture patterns. These types of fractures happen to 4% to 6% of people, with women twice as likely to experience them as men.
Signs and Symptoms of Proximal Humerus Fracture
Doctors should always thoroughly examine any patient’s history and current health. This is especially important in cases where patients are older than 65 and suffered from a fall, or in younger patients involved in car accidents. Many patients are seen shortly after the injury. Key questions include:
- Details of the injury
- Pain description
- If pain travels to other parts of the same arm
- History of shoulder or arm injuries
- History of previous surgeries or implants in the same arm
- Which hand they use most
- The patient’s living situation (this is especially important for older patients living alone or with minimal support)
During the physical examination, the doctor will look for open bone fractures, bruising that may extend to the chest, arm, and forearm. Pain and a crunching feeling are typical over the fracture site. If the rounded part of the shoulder looks abnormal, it implies there might be a dislocated shoulder, suggesting a more intense injury. The doctor must also check for nerve or blood vessel injury. In cases of such injuries, patients might lose sensation (mostly a temporary numbness due to the damaged nerve around the armpit) especially when the bone is both broken and dislocated. Blood flow might be compromised in rare cases and it can occur despite having a normal pulse during the examination because of the vast network of blood vessels.
Testing for Proximal Humerus Fracture
For anyone suspected of a shoulder issue, radiographic imaging is usually done. This includes certain specific views such as a true AP view, scapular Y, and axillary lateral. Some additional views can be taken depending on how comfortable the patient is with the position.
One such position is the velpeau view, where the patient’s arm is held in a rotated state secured with a sling. The film is then taken from top to bottom with the patient leaning back into the beam field.
Another specialized view is the West Point x-ray. This involves the patient lying facedown on the x-ray table. The affected shoulder is brought to the top of the table, and then the x-ray is taken from the armpit. This view offers a clear image of the lower front rim of the glenoid rim, which is part of the shoulder joint.
In certain cases, a CT scan can be used, especially when it’s hard to determine the exact position of the humeral head or greater tuberosity, or if there are fragments within the joint. The information from the CT scan can also guide what kind of surgical treatment is best – whether to fix or to reconstruct the part. An MRI is rarely recommended, but it is useful in identifying if there are associated rotator cuff injuries.
Shoulder conditions or injuries are classified based on certain schemes. Neer’s Classification is based on four segments of the shoulder: the greater tuberosity, the lesser tuberosity, the articular surface, and the shaft. One, two, three, or four-part fractures are identified depending on how many segments are involved and if they are displaced (moved from their usual position).
The AO Classification splits fractures into three main groups and additional subgroups based on the fracture location and whether or not there is a dislocation. Type-A fractures involve just the greater tuberosity or surgical neck mainly. Type-B fractures are bifocal and include some unusual dislocations. Type-C fractures are all within the joint and include dislocation and splitting of the humeral head.
Treatment Options for Proximal Humerus Fracture
The initial treatment for a shoulder injury involves making sure the patient is comfortable and putting the injured area in a sling for support. In this stage, it’s important to manage the patient’s pain. After that, the treatment plan can either involve surgery or non-surgical options.
Non-surgical Treatment
When a shoulder injury isn’t too severe, patients often put their arm in a sling and slowly start a rehabilitation program. This non-surgical approach is usually recommended for shoulder injuries where the bones haven’t moved out of place too much. However, there is still some debate about how much displacement is okay before surgery is needed.
As part of the rehab program, patients often start gentle shoulder exercises around 10 to 14 days after the injury, depending on their comfort level.
In general, patients who do not have surgery for their shoulder injury recover well, with a success rate of around 80% to 85%. This non-surgical approach works best for shoulder injuries that are not severe, or in patients who are not good candidates for surgery.
Surgical Treatment
There are several options for surgical treatment, including using pins to hold the bones in place, opening up the area and fixing the bones (open reduction and internal fixation), inserting a rod into the bone (intramedullary nailing), or replacing part or all of the shoulder joint (shoulder arthroplasty).
Using pins to hold the bones in place is typically used for certain types of fractures, especially in patients with good bone quality.
Open reduction and internal fixation is used for fractures where the shoulder bone is displaced more than 3-5 mm, or for certain types of fractures in younger patients.
Intramedullary nailing is used for certain types of fractures, especially in younger patients.
Shoulder arthroplasty is often used in elderly patients with severe fractures that are not good candidates for non-surgical treatment. It can also be used for patients with certain types of injuries who are between the ages of 40 and 65.
Total shoulder arthroplasty is performed when the rotating cuff in the shoulder is healthy but the joint is damaged. This could result from conditions like arthritis or trauma. Reverse shoulder arthroplasty is usually recommended for elderly patients with severe injuries where the rotating cuff is compromised.
What else can Proximal Humerus Fracture be?
When dealing with patients who complain of shoulder pain, doctors consider several possible causes. These can range from physical injuries to neurological conditions, as seen below:
Injuries:
- Acute or chronic fractures
- Complications related to previous injuries, surgeries, or fractures
- Chronic problems like disability, pain, and shoulder dysfunction due to improper healing of fractures
Impingement Conditions:
- External and internal impingements including calcific tendonitis and glenohumeral internal rotation deficit (GIRD)
- Tears in the shoulder’s labrum (a ring of cartilage)
Rotator Cuff (RC) Problems:
- Partial or full-thickness tears
Degenerative Conditions:
- Advanced wear-and-tear arthritis
- Glenohumeral (shoulder joint) arthritis
- Adhesive capsulitis, also known as “frozen shoulder”
- Loss of blood supply leading to bone death (avascular necrosis)
Problems with the Top of the Bicep Muscle:
- Subluxation or dislocation often seen with subscapularis (a shoulder muscle) injuries
- Tendonitis and tendinopathy, inflamed or damaged tendons
Conditions of the AC (acromioclavicular) Joint:
- Separation
- Deterioration of the clavicle’s distal end, the bone that forms the shoulder
- Arthritis of the AC joint
Shoulder Instability:
- Unidirectional instability, usually after a dislocation event
- Multidirectional instability
- Associated labral injuries/pathology
Neurovascular Conditions:
- Suprascapular neuropathy, a condition where a shoulder nerve is compressed
- Scapular winging, where the shoulder blade sticks out
- Brachial neuritis, inflammation of nerves in the arm
- Thoracic outlet syndrome, a group of disorders occurring when blood vessels or nerves in the space between collarbone and first rib are compressed
Other Conditions:
- Scapulothoracic dyskinesia, abnormal movement of the shoulder blades
- Os acromiale, a condition where the shoulder blade does not fuse properly during growth
- Muscular tears such as pectoralis major, deltoid, and latissimus dorsi
Preventing Proximal Humerus Fracture
It’s important for patients to be fully informed about the risks and benefits of all treatment options, both surgical and non-surgical. Most patients see an improvement and go back to their normal function after either type of treatment. However, ongoing disability and reduced function remain common problems. Each shoulder fracture should be treated individually, taking into account factors like the patient’s age, which hand they use most, their ability to carry out daily activities, social circumstances, any other health conditions they may have, and their personal goals and expectations for recovery.
