A proximal humerus fracture is a

break Break or Breaks or The Break may refer to: Time off from duties * Recess (break), time in which a group of people is temporarily dismissed from its duties * Break (work), time off during a shift/recess ** Coffee break, a short mid-morning rest ...

of the upper part of the

bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...

of the arm (

humerus The humerus (; : humeri) is a long bone in the arm that runs from the shoulder to the elbow. It connects the scapula and the two bones of the lower arm, the radius (bone), radius and ulna, and consists of three sections. The humeral upper extrem ...

). Symptoms include pain, swelling, and a decreased ability to move the

shoulder The human shoulder is made up of three bones: the clavicle (collarbone), the scapula (shoulder blade), and the humerus (upper arm bone) as well as associated muscles, ligaments and tendons. The articulations between the bones of the shoulder m ...

. Complications may include

axillary nerve The axillary nerve or the circumflex nerve is a nerve of the human body, that originates from the brachial plexus ( upper trunk, posterior division, posterior cord) at the level of the axilla (armpit) and carries nerve fibers from C5 and C6. ...

axillary artery In human anatomy, the axillary artery is a large blood vessel that conveys oxygenated blood to the lateral aspect of the thorax, the axilla (armpit) and the upper limb. Its origin is at the lateral margin of the first rib, before which it is c ...

injury. The cause is generally a fall onto the arm or direct trauma to the arm. Risk factors include

osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...

and

diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...

. Diagnosis is generally based on

X-rays An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...

. It is a type of

humerus fracture A humerus fracture is a break of the humerus bone in the upper arm. Symptoms may include pain, swelling, and bruising. There may be a decreased ability to move the arm and the person may present holding their elbow. Complications may include inj ...

. A number of classification systems exist. Treatment is generally with an

arm sling A sling, also known as arm sling, is a device to limit movement of the shoulder or elbow while it heals. A sling can be created from a triangular bandage. References Orthopedics {{health-stub ...

for a brief period of time followed by specific exercises. This appears appropriate in many cases even when the fragments are separated. Less commonly surgery is recommended. Proximal humerus fractures are common. Older people are most commonly affected. In this age group they are the third most common fractures after

hip In vertebrate anatomy, the hip, or coxaLatin ''coxa'' was used by Celsus in the sense "hip", but by Pliny the Elder in the sense "hip bone" (Diab, p 77) (: ''coxae'') in medical terminology, refers to either an anatomical region or a joint on t ...

and

Colles fracture A Colles' fracture is a type of distal radius fracture, fracture of the distal forearm in which the broken end of the Radius (bone), radius is bent dorsal (anatomy), backwards. Symptoms may include pain, Edema, swelling, deformity, and bruising. ...

s. Women are more often affected than men.

Signs and symptoms

Typical signs and symptoms include pain, swelling, bruising, and limited range of motion at the shoulder. Deformity may be present in severe fractures, however, musculature may cause absence of deformity on inspection. Numbness over the outside part of the upper arm and deltoid muscle weakness may indicate axillary nerve injury. Symptoms from poor blood circulation in the arm is uncommon due to

collateral circulation Collateral circulation is the alternate Circulatory system, circulation around a blocked blood vessel, artery or vein via another path, such as nearby minor vessels. It may occur via preexisting vascular redundancy (analogous to redundancy (engi ...

in the arm.

Cause

Young adults without risk factors usually require significant trauma, such as in the setting of a motor vehicle collision. Older adults more commonly experience proximal humerus fractures after a fall from standing height.

Risk factors

People with increased risk of falls are more likely to have a proximal humerus fracture, as this is also the most common mechanism of injury.

Osteoporosis Osteoporosis is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue leading to more porous bone, and consequent increase in Bone fracture, fracture risk. It is the most common reason f ...

increases the risk of proximal humerus fractures.

Pathophysiology

The

shoulder joint The shoulder joint (or glenohumeral joint from Greek ''glene'', eyeball, + -''oid'', 'form of', + Latin ''humerus'', shoulder) is structurally classified as a synovial joint, synovial ball-and-socket joint and functionally as a diarthrosis and m ...

consists of the glenoid cavity of the

scapula The scapula (: scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone). Like their connected bones, the scapulae are paired, with each scapula on either side ...

and the head of the

. It as an extremely mobile joint that is stabilized by surrounding soft tissues such as the joint capsule, muscles, and

ligament A ligament is a type of fibrous connective tissue in the body that connects bones to other bones. It also connects flight feathers to bones, in dinosaurs and birds. All 30,000 species of amniotes (land animals with internal bones) have liga ...

s. The greater and lesser tuberosities are bony landmarks of the proximal humerus and serve as attachment sites for musculature. The

anterior Standard anatomical terms of location are used to describe unambiguously the anatomy of humans and other animals. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...

and posterior humeral circumflex arteries branch off of the

to provide the majority of the blood supply to the proximal humerus. The

courses inferior to the shoulder joint and innervates the deltoid and teres minor muscles. It also provides sensation at the skin overlying the shoulder. This nerve is the most commonly injured nerve in proximal humerus fractures due to its location close to the proximal humerus. Muscles that attach to the proximal humerus and can cause a deforming force on fracture fragments include the pectoralis major, the

deltoid Deltoid (delta-shaped) can refer to: * The deltoid muscle, a muscle in the shoulder * Kite (geometry), also known as a deltoid, a type of quadrilateral * A deltoid curve, a three-cusped hypocycloid * A leaf shape * The deltoid tuberosity, a part o ...

, and the rotator cuff muscles.

Diagnosis

The standard

x-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...

views of the shoulder include a true anterior-posterior view, a lateral (Y or outlet) view, and an axillary view. A Velpeau view can be done as an alternative to the axillary view if an examinee is unable to position the shoulder for an appropriate image. This can be obtained by having the examinee lean backward 45 degrees while an xray beam is aiming towards the floor. A

of the injured shoulder can be done to help further characterize the fracture and determine articular involvement. CT scan is also an option if an axillary view is unattainable.

MRI Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to generate pictures of the anatomy and the physiological processes inside the body. MRI scanners use strong magnetic fields, magnetic field gradients, and rad ...

is not typically indicated in the setting of proximal humerus fracture, although it may be useful in assessing injury to soft tissue structures such as the rotator cuff muscles.

Classification

The Neer classification of proximal humerus fractures is the most commonly used classification system. It classifies fractures depending on the number of segments (2-4 parts), and whether or not there is displacement present. This classification has a low amount of agreement between physicians using the classification system, although formal training sessions may improve agreement. The AO/OTA classification system is another commonly used system that groups fractures depending on whether the fracture is unifocal or bifocal, and whether or not the fracture goes through the articular surface.

Treatment

There are both non-surgical and surgical options for treatment of proximal humerus fractures. The recommended treatment is decided based on fracture stability as determined with imaging and clinical exam.

Non-Surgical

Most proximal humerus fractures are stable and can be treated without surgery. Typical non-operative treatment consists of shoulder immobilization with a sling. Close follow-up and weekly x-rays are recommended in order to ensure that the fracture is healing and maintaining good alignment. Passive

range of motion Range of motion (or ROM) is the linear or angular distance that a moving object may normally travel while properly attached to another. In biomechanics and strength training, ROM refers to the angular distance and direction a joint can move be ...

exercises for the shoulder can be done when pain has subsided. This can be done with the assistance of a physical therapist. When properly indicated, non-surgical treatment options for proximal humerus fractures have good outcomes in terms of fracture healing and restoration of arm function.

Surgical

Surgical options for unstable proximal humerus fractures include: * Closed reduction with percutaneous pinning (CRPP) * Open reduction with

internal fixation Internal fixation is an Surgery, operation in orthopedics that involves the surgical implementation of Implant (medicine), implants for the purpose of repairing a bone, a concept that dates to the mid-nineteenth century and was made applicable fo ...

(ORIF) *

Intramedullary rod An intramedullary rod, also known as an intramedullary nail (IM nail) or inter-locking nail or Küntscher nail (without proximal or distal fixation), is a metal rod forced into the medullary cavity of a bone. IM nails have long been used to treat ...

fixation * Shoulder arthroplasty * Reverse shoulder arthroplasty

Epidemiology

Proximal humerus fractures account for approximately 4-7% of all fractures in adults. It is the most common fracture of the humerus, as well as the most common fracture at the

shoulder girdle The shoulder girdle or pectoral girdle is the set of bones in the appendicular skeleton which connects to the arm on each side. In humans, it consists of the clavicle and scapula; in those species with three bones in the shoulder, it consists o ...

. They are more common in women than men, and occur more often in older adults. The average age of people who sustain a proximal humerus fracture is 63–66 years.

Special populations

Children

A proximal humerus fracture in a young child may be a sign of

child abuse Child abuse (also called child endangerment or child maltreatment) is physical abuse, physical, child sexual abuse, sexual, emotional and/or psychological abuse, psychological maltreatment or Child neglect, neglect of a child, especially by a p ...

. In older children and adolescents proximal humerus fractures frequently occur in the setting of sports or trauma. Proximal humerus fractures in children can commonly be treated non-operatively due to the large amount of bone growth that occurs at the proximal humerus. In older children where there is less time for bone remodeling, surgery may be indicated more frequently.

References

{{Fractures Wikipedia medicine articles ready to translate Bone fractures Injuries of shoulder and upper arm