2. • In evaluating humerus injuries, being able to classify the fracture and if
necessary reduce, immobilize and know when to seek orthopaedic
consultation is important.
• 80% of proximal humeral fractures are non displaced or minimally
displaced and therefore can be managed nonoperatively.
• Distal humeral fractures are associated with ipsilateral proximal forearm
fractures.
• Rarely, vascular or nervous injuries are associated with humeral fractures.
4. 1. PROXIMAL HUMERUS FRACTURES
Primarily older population
arm pronation limits abduction
Older pts #, while younger pts dislocate
Both if middle aged
Arm held close to body, mov’t limited by pain
Tender, hematoma, bruising
7. Vascular Supply
• Lateral ascending branch of
anterior humeral circumflex
artery
•Damage may lead to AVN
8. Humeral Head Vascularity
Recent anatomic and clinical findings
confirm that perfusion from the posterior
circumflex vessels alone may be adequate for
head survival.
In the fractured humerus, the arcuate artery is
generally interrupted.
9. Proximal Humeral Fractures
Neer’s Classification
•The two main components of the class
ification are:
1.number of fracture parts
2.displacement
11. Parts
The Neer’s system divides the proximal hum
erus into 4 parts and considers not the fract
ure line, but the displacement as being signif
icant in terms of classification. The four parts
are:
1. humeral head
2. greater tuberosity
3. lesser tuberosity
4. humeral shaft Codman’s
4 parts
12. One-part fracture
•fracture lines involve 1 - 4 parts
•none of the parts are displaced
(i.e. <1cm and <45 degrees)
•These undisplaced / minimally displaced fractures accoun
t for ~ 70 - 80% of all proximal humeral fractures and a
re almost always treated conservatively.
13. Two-part fracture
fracture lines involve 2 - 4 parts
one part is displaced (i.e. >1cm or >45 degrees)
Four possible types of two-part fractures exist
(one for each part):
1. surgical neck: most common
2. greater tuberosity – frequently seen in the setting of anterior shoulder dislocation a low
er threshold of displacement (> 5mm) has been proposed
3. anatomical neck
4. lesser tuberosity: uncommon
These fractures account for approximately 20% of proximal humeral fractur
es.
14. Three-part fracture
fracture lines involve 3 - 4 parts
two part are displaced (i.e. >1cm or >45 degrees)
Two three-part fracture patterns are encountered
1. Greater tuberosity and shaft are displaced with respect to the lesser tuberosity and
articular surface which remain together
most common three part pattern
2. Lesser tuberosity and shaft are displaced with respect to the greater tuberosity an
d articular surface which remain together
These fractures account for approximately 5% of proximal humeral fractures.
15. Four – part fracture
•fracture lines involve 4 parts
•3 parts are displaced (i.e >1cm or >45 degrees) with
respect to the 4th.
•These #s are uncommon (<1% of proximal humeral #s)
•It has a high incidence of osteonecrosis
•These #s require operative mgt.
16.
17. Proximal Humerus Fractures
Management
•Minimally displaced
•# held together by capsule, periosteum, muscles
•Analgesia, sling and swathe x 3-4/52
•2,3,4 part – ORIF
•Fracture/dislocation – caution with force, don’t
want to displace segments
•Complications: adhesive capsulitis
18. Proximal Humeral Epiphysis #
Rare
Usually Males 11-17
FOOSH
# through zone of hypertrophy of
epiphyseal plate
Arm held close to body, swelling
Classification: Salter Harris
24. Midshaft Humerus Fractures
Children
Radial nerve injury is rare
accept 1-1.5cm shortening, 15-20 deg
angulation
4-6 wks in modified Velpeau or sling and swathe
(compliance difficult for hanging cast)
27. Supracondylar Fracture-
Classification
• Gartland
• I - nondisplaced
• II - displaced with intact posterior cortex
• III - displaced fracture, no intact cortex
• A: postermedial rotation of distal fragment
• B: posterolateral rotation
28. Supracondylar Fracture-
Management
• If NV compromise - urgent ortho consult
• if no response in 60 min may attempt 1 reduction
• watch brachial artery and median nerve
• Gartland I - splint and ortho f/u 24h
• Gartland II - controversy but most get pinned
• Gartland III - closed reduction and pin
30. PEARL *** Physical examination
• Pain occurs with palpation or movement of
shoulder or elbow.
• Ecchymosis and Oedema are usually present
• Perform careful neurovascular examination
• Radial nerve injury following humeral shaft fractures
is relatively common
31. Proximal #
• Patients presents with a painful shoulder and a very
restricted ROM.
• Obvious deformity is suggestive of glenohumeral
dislocation.
• Swelling and ecchymosis are common examination findings
• Nerve damage with proximal humeral # is rare
• Have risk of vascular injuries
32. Diaphyseal #
• Presents with painful deformed arm that may be
associated with radial nerve palsy.
• Usually the radial nerve palsy is reversible
• Crepitus may be observed
• Shortening of the arm suggests displacement
33. Assessment of radial nerve
• The radial nerve primary motor function is to innervate the
dorsal extrinsic muscles in the fore arm
• Motor testing should include extension of the wrist and
metacarpophalangeal (MCP) joints as well as abduction and
extension of the thumb.
• Proximal injury of the radial nerve causes wrist drop
• On examination, the fingers are in flexion at the MCP joints and
thumb is adducted.
34. Treatment and management
•Prehospital care
•Immobilization of the limb
•Hospital care
•Minimize the patients movements and
provide analgesia to make the patient
comfortable in the acute care settings
35. Proximal humerus #
• Most minimally displaced proximal fractures can be
managed non operatively.
• Sling and swathe application is the primary treatment
• Fractures of the anatomical neck should be referred to
orthopedist due to the risk of avascular necrosis
• Neers 2,3,4 - ORIF
36. Humerus shaft (diaphyseal) #
• Humerus shaft fractures should be stabilized using coaptation
splint.
• Wrap splinting material snugly from axilla to nape of neck,
creating a stirrup around the elbow.
• Fracture reduction is usually not necessary because reduction is
usually difficult to maintain.
• Because of the shoulders ability to compensate, 30 – 40
degrees angulation is acceptable
37. consultations
• Most isolated proximal and diaphyseal humeral fractures can be
managed by an orthopedist in an outpatient setting.
• Even patients with fractures that may eventually require surgery generally may be
discharged with early follow up care if fracture is otherwise uncomplicated.
• Fractures that can not be adequately reduced or when fracture reduction
can not be controlled with functional bracing because of patient obesity,
head trauma, or soft tissue injuries, surgical stabilization is indicated.
38. • Open fractures represent a surgical emergency, obtain an
immediate orthopaedic consult.
• Penetrating trauma requires particular neurovascular scrutiny.
• Glenohumeral dislocation in conjunction with a proximal
humerus fracture requires orthopaedic evaluation.
• Floating elbow (an ipsilateral humerus and forearm fracture)
requires operative repair.
39. medications
NSAIDS:
• Ibuprofen:
• Usually DOC for treatment of mild to moderately severe pain, if no contraindications.
• Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme
cyclooxygenase, which inhibits prostaglandin synthesis.
• 300 – 800 mg 6 – 8 hrly
• Ketoprofen
• Naproxen
• Flurbiprofen**.
40. ANALGESICS
• Acetaminophen:
• DOC for treatment of pain in patients with documented hypersensitivity to
aspirin or NSAIDS and in those with upper GI disease or taking oral
anticoagulants.
• Acetaminophen and codaine
• Morphine sulphate
ANXIOLYTICS
• lorazepam
