Rosen & Barkin's 5-Minute Emergency Medicine Consult (353 page)

• 337.9 Unspecified disorder of autonomic nervous system
  
• 374.30 Ptosis of eyelid, unspecified
  
• 379.42 Miosis (persistent), not due to miotics
  

BASICS

• Proximal humeral fractures:
  
  • Typically described as nondisplaced, displaced, and/or fracture/dislocation
    
  • Account for 5% of all fractures
    
  • Increased incidence with age
    
  • 4:1 female to male
    
  • Vast majority of patients are >60 yr old
    
  • 3rd most common osteoporotic fracture, after hip and distal radius fractures
    
  • Neer classification
    : A system that identifies the number of fragments and their location:
    
    • Fractures consist of 2–4-part fractures; the locations include the anatomic neck, surgical neck, greater tuberosity, and lesser tuberosity.
      
    • Fracture/dislocations also part of the Neer classification
      
• Humeral shaft fractures:
  
  • Account for <3% of fractures
    
  • May be spiral, oblique, or transverse
    
  • Humeral shaft fractures (AO classification):
    
    • Simple
      
    • Wedge
      
    • Comminuted (complex)
      

• Proximal humerus fractures:
  
  • Most often a history of a fall (low energy)
    
  • Most common is fall on outstretched hand
    
  • Less common is violent muscle contraction from shock or seizure or higher-energy injury
    
• Humeral shaft fractures:
  
  • High-energy direct trauma (penetrating or blunt) or bending force
    
  • Less common from fall
    
  • Stress fractures from throwing injury
    

DIAGNOSIS

• Pain, swelling, and tenderness
  
• Difficulty in initiating active motion
  
• Arm often closely held against chest
  
• Shortening of the extremity
  
• Crepitus may be present
  
• Ecchymosis
  
• Neurovascular compromise
  

• Mechanism of injury
  
• Contributory comorbid factors (age, fall risk, malignancy)
  
• Associated injuries
  

• Complete exam of the affected extremity:
  
  • Inspect shoulder and humerus for obvious deformity, shortening, and open injuries
    
  • Assess ROM at shoulder, elbow
    
  • Neurovascular exam
    

• Assess individual nerves:
  
  • Radial (special attention in midshaft humeral fractures)
    
  • Median
    
  • Ulnar
    
  • Axillary (sensation to the lateral aspect of the shoulder)
    
  • Musculocutaneous nerve (sensation to the extensor aspect of the forearm)
    
• Assess vascular supply:
  
  • Presence of radial, ulnar, and brachial pulses
    
  • Good capillary refill in all digits
    
• Radiology exams to define injury
  

• Most common in age <3 or >12 yr
  
• Neonatal fractures from delivery trauma:
  
  • Most common in neonates >4.5 kg and breech births
    
  • May see pseudoparalysis
    
• Older children: Same injury mechanisms as adults
  
• Periosteum thicker in children and limits displacement of humeral shaft fractures
  
• Proximal humeral fractures:
  
  • Salter I fractures should be considered when films of proximal humerus are normal but significant pain is present
    
  • Salter II most common in younger children
    
• Consider abuse (especially <3 yr):
  
  • Injury patterns:
    
    • Transverse (direct blow)
      
    • Oblique/spiral (traction and humeral rotation)
      
    • Metaphyseal fractures (bucket-handle fractures)
      

• Plain films:
  
  • Proximal humeral fractures (at least 3 views):
    
    • Anteroposterior (AP), lateral, and axillary views
      
    • Axillary view to assess tuberosity displacement, glenoid articular surface, and relationship of the humeral head to glenoid
      
  • Humeral shaft fractures:
    
    • AP and lateral views of entire humerus are mandatory.
      
    • Include shoulder and elbow views to exclude associated joint involvement.
      
• CT scan:
  
  • Helpful in proximal humeral fractures to define complex/comminuted injures and plan surgery
    
  • Help define relationship of humeral head to glenoid fossa in suspected fracture/dislocations
    

Not applicable

• Acute hemorrhagic bursitis
  
• Traumatic rotator cuff tear
  
• Dislocation
  
• Acromioclavicular separation
  
• Calcific tendinitis
  
• Contusion
  
• Tendon rupture
  
• Neurapraxia
  
• Pathologic fracture
  

TREATMENT

Cautions:

• Avoid excessive movement of the arm, which may produce further neurovascular injury.
  
• Immobilize with sling and swath and transport.
  
• Rapid transport in the presence of neurologic or vascular deficits
  

• Primary and secondary survey for associated injuries
  
• Immobilization:
  
  • For comfort
    
  • Prevent fracture displacement
    
  • Prevent neurovascular injury
    
• Axillary pad may also be used for comfort.
  
• Pain control
  
• Application of ice to limit swelling
  
• Open fractures:
  
  • Cover with a sterile dressing
    
  • Tetanus prophylaxis
    
  • Parenteral antibiotics
    

• Patient should receive adequate analgesia during diagnosis and treatment of injury:
  
  • Narcotics PO/IM/IV are first-line therapy
    
• Proximal humeral fractures:
  
  • Single-part proximal humeral fractures:
    
    • >80% of proximal humeral fractures
      
    • Can be treated nonoperatively
      
    • Treatment is sling and swath
      
    • Early ROM exercises often employed
      
  • Displaced, multipart proximal humeral fractures:
    
    • Use Neer classification to describe
      
    • >1 cm separation or >45° are considered displaced
      
    • Orthopedic review and referral is appropriate for 2-part or higher fractures
      
    • Many 2-part fractures can be reduced and managed nonoperatively
      
    • 3- and 4-part fractures may need ORIF/hemiarthroplasty
      
    • Surgical options depend not only on type of fracture, but also patient’s age, comorbidities, and patient’s functional expectations of the extremity
      
  • Indications for emergent orthopedic consult for proximal humeral fractures:
    
    • Open fracture
      
    • Fracture/dislocation that cannot be reduced in ED
      
    • Vascular compromise
      
• Humeral shaft fractures:
  
  • Most humeral shaft fractures can be managed nonoperatively and do not require reduction (>90%)
    
  • 20° of anterior angulation and 30° of varus angulation are well tolerated by the musculature around the humerus.
    
  • Humerus can tolerate up to 3 cm of shortening with little functional deficit
    
• Nondisplaced humeral shaft fractures:
  
  • ED can treat with a coaptation splint
    
  • Except transverse fractures
    
  • Functional brace may be utilized by orthopedist
    
• Transverse fractures:
  
  • ED treatment should be sling and swath
    
  • Higher incidence of nonunion
    
• Displaced humeral shaft fractures:
  
  • Orthopedist may utilize hanging cast to treat and reduce displaced or shortened fractures.
    
• Indications for emergent orthopedic consult for humeral shaft fractures:
  
  • Neurovascular compromise
    
  • Segmental fractures
    
  • Fractures extending into articular surface
    
  • Open fractures
    
  • “Floating elbow” (fractures with concurrent ipsilateral forearm fractures)
    

In children nearing skeletal maturity, it is essential to determine the degree of displacement or separation of the proximal humeral epiphysis, as exact reduction is important to prevent later disturbance of growth.

• Pain medications:
  
  • Narcotics (first line)
    
  • NSAIDS (second line)
    
• Procedural sedation with closed reductions (see Procedural Sedation)
  

FOLLOW-UP