Rosen & Barkin's 5-Minute Emergency Medicine Consult (354 page)

• Open fractures for operative management and parenteral antibiotic therapy
  
• Fractures associated with vascular compromise
  
• Displaced fractures that cannot be treated adequately through closed reduction
  
• Significant associated injuries that require admission and observation
  

• Nondisplaced fracture
  
• Fracture treated with closed reduction
  
• Most closed humeral shaft fractures without other injuries
  
• More complicated proximal humeral fractures, (i.e., proximal humeral fracture of Neer 3 and 4 type), that may require nonemergent surgery. Discharge should be done in consultation with orthopedist.
  

• Pediatric patients are often less compliant with immobilization and less able to verbalize complaints; they may benefit from admission.
  
• Assess safety of environment in cases suspicious of NAT.
  

• Most humeral fractures should have outpatient orthopedic referral.
  
• Complicated proximal humeral fractures (Neer classification 2–4) should be reviewed with orthopedist to develop outpatient plan and possible nonemergent intervention.
  
• Some single-part nondisplaced proximal humeral fractures may be managed by the PCP.
  
• Displaced humeral shaft fractures require orthopedic referral for definitive care (functional bracing, hanging cast, ORIF, etc.).
  

• Most patients should be seen in close follow-up for repeat exam of the injured extremity, to verify adequate pain control, and to review treatment plan soon after ED visit.
  
• Proximal humeral fractures that are stable should be evaluated for early ROM therapy to minimize risk of adhesive capsulitis.
  

• All humeral fractures should have diligent neurovascular exams:
  
  • Neurovascular exam should be repeated after manipulation.
    
  • Radial nerve injuries are the most common deficits seen in humeral shaft fractures.
    
  • Most radial nerve deficits will resolve spontaneously over time (months).
    
• Avascular necrosis is a risk in proximal humeral fractures that involves the surgical neck or articular surface.
  
• Patients with multiple-part proximal humeral fractures (Neer 2 or higher) may often be discharged from the ED, but a plan must be developed with the orthopedist because surgical intervention and/or hemiarthroplasty are possible.
  

• Cavigilia H, Garrido CP, Palazzi FF, et al. Pediatric fractures of the humerus.
  Clin Orthop Rel Res
  . 2005;432:49–56.
  
• Green A, Norris TR. Proximal humerus fractures and glenohumeral dislocations. In: Browner, ed.
  Skeletal Trauma: Basic Science, Management, and Reconstruction
  . 4th ed. Saunders–Elsevier; 2008.
  
• Rothberg D, Higgins T. Fractures of the proximal humerus.
  Orthop Clin North Am.
  2013;44:9–19.
  
• Walker M, Palumbo B, Badman B, et al. Humeral shaft fractures: A review.
  J Shoulder Elbow Surg.
  2011;20:833–844.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Conscious Sedation
  
• Elbow Fracture
  
• Shoulder Dislocation
  

CODES

• 812.01 Closed fracture of surgical neck of humerus
  
• 812.02 Closed fracture of anatomical neck of humerus
  
• 812.20 Closed fracture of unspecified part of humerus
  

BASICS

• Noninvasive localized tumors arising from trophoblastic tissue
  
• Can be associated with malignancy
  
• Twinning with normal pregnancy possible:
  
  • Higher risk for persistent maternal disease and metastasis
    
  • Possible to have normal infant
    
• Complete mole:
  
  • Estimated in 1/1,500 pregnancies
    
  • Fetal tissue not present
    
  • Diffuse chorionic villi swelling
    
  • Diffuse trophoblastic hyperplasia
    
  • Malignancy associated in 15–20%, usually lung
    
  • Genetics:
    
    • Karyotype: 46,XX (90%); 46,XY (10%)
      
    • Paternal DNA expressed
      
    • Enucleate egg fertilized by 2 sperms or by a haploid sperm that duplicates
      
• Partial mole:
  
  • Estimated in 1/750 pregnancies
    
  • Fetal or embryonic tissue often present
    
  • Focal chorionic villi swelling
    
  • Focal trophoblastic hyperplasia
    
  • Malignancy associated in 4–12%
    
  • Genetics:
    
    • Karyotype: 90% are triploid 69XXX, 69XXY, rarely 69XYY
      
    • Maternal and paternal DNA
      
    • Haploid ovum duplicates and is fertilized by normal sperm, or haploid ovum fertilized by 2 sperms
      

• Largely unknown
  
• Extremes of maternal age best estimated risk factor:
  
  • >35 yr old carries 5–10-fold risk
    
  • <20 yr old
    
• Previous molar pregnancy carries 1–2% risk in future pregnancies
  
• Frequency multiple times greater in Asian and Latin American countries:
  
  • 1 per 1,000–1,500 live births in US and Western Europe
    
  • Reported up to 1 per 12–500 live births in other countries
    
• Deficiency in animal fat and vitamin A
  
• Smoking (>15 cigs/day)
  
• Maternal blood type AB, A, or B
  
• History of infertility, nulliparity
  
• Finding in 1 of 600 therapeutic abortions
  

DIAGNOSIS

• Usually exaggerated subjective symptoms of pregnancy
  
• Complete mole:
  
  • Vaginal bleeding, most common (97%):
    
    • Late 1st trimester
      
    • Usually painless and like “prune juice”
      
  • May also have vaginal tissue passage:
    
    • Often described as grapelike vesicles
      
    • Usually occurs in 2nd trimester <20 wk
      
  • Hyperemesis from high levels β-hCG
    
  • Preeclampsia (27%):
    
    • Visual changes
      
    • HTN
      
    • Proteinuria
      
    • Hyperreflexia
      
    • Possibly convulsions
      
  • Hyperthyroidism (7%):
    
    • Marked tachycardia, tremor
      
    • Due to high levels of β-hCG or thyroid stimulating substance (thyrotropin)
      
  • Acute respiratory distress (2%):
    
    • Tachypnea, diffuse rales, tachycardia, mental status changes
      
    • Possible embolism of trophoblastic tissue
      
    • May also be due to cardiopulmonary changes from preeclampsia, hyperthyroidism, or iatrogenic fluid replacement
      
• Partial mole:
  
  • Usually does not exhibit dramatic clinical features of complete mole
    
  • Frequently presents with symptoms similar to patients with threatened or spontaneous abortion:
    
    • Vaginal bleeding
      
    • May have fetal heart tones
      
  • Often presents at more advanced gestational age
    

Similar to that of pregnancy:

• Missed menstrual periods
  
• Positive pregnancy test
  
• Nausea, vomiting, vaginal bleeding
  

• Uterine size/date discrepancy occurs in 50–66% of cases
  
  • Complete mole usually larger than dates would indicate
    
  • Partial mole can be smaller than dating suggests
    
• Ovarian masses:
  
  • Present in complete moles, rarely in partial moles
    
  • Usually from ovarian enlargement
    
  • Multiple bilateral theca lutein cysts due to high levels of β-hCG, usually found by US
    

• hCG
  
  • Complete mole β-hCG >100,000 mIU/mL, but can be normal
    
  • Partial mole: Usually lower than that seen with normal pregnancy
    
  • β-hCG >40,000 mIU/mL carries poor prognosis
    
• US:
  
  • Complete mole:
    
    • Characteristic “snowstorm” vesicular pattern
      
    • Absence of fetal tissue and swelling of chorionic villi with anechoic spaces
      
    • No amniotic fluid
      
    • Theca lutein cysts
      
  • Bilateral, multiloculated
    
  • Large at 6–12 cm
    
  • Partial mole:
    
    • “Swiss-cheese” appearance
      
    • Cystic changes in placenta with scalloping of villa and in shape of gestational sac
      
    • Fetus may be present