History

Most patients with fractures of the proximal humerus present to an acute care facility with pain following trauma. Pain and loss of function with swelling of the involved extremity are the most common symptoms on initial presentation. Document symptoms of paresthesias or weakness in the involved extremity.

Obtain a detailed history of the mechanism of injury (eg, whether the injury was the result of a direct impact to the lateral shoulder or the result of an indirect mechanism, as in a fall onto an outstretched hand). Indirect causes of proximal humerus fractures result in greater degrees of fracture displacement. Determine whether seizure or electrical shock was involved; these indirect mechanisms are associated with posterior dislocations.

Obtain the medical history, and stabilize any problems, if possible, before proceeding with operative management.

Physical Examination

Swelling and ecchymoses usually are present about the shoulder and upper arm. Extensive ecchymosis may become visible 24-48 hours following injury. It may spread to the chest wall and flank and may involve the entire extremity. Palpate the entire upper extremity and chest wall to evaluate for associated injuries.

To determine fracture stability, gently rotate the humeral shaft while palpating the humeral head to assess whether unified motion is present. Note any movement or crepitus. In high-energy injuries, inspect the skin closely for any disruptions that may allow fracture contamination (ie, open wounds). Pulsatile or expanding hematomas may indicate a vascular lesion.

It is essential to determine the presence of any associated neurovascular injury. The axillary nerve is the nerve most commonly injured in proximal humerus fracture. Carefully assess sensation over the deltoid muscle and isometric deltoid motor function. Additionally, perform distal neurologic testing for brachial plexus injuries.

Examination of peripheral pulses is helpful, but it does not exclude axillary disruption, because distal pulses may be intact because of collateral circulation around the scapula. Inspect the proximal shoulder girdle for an expanding mass, which may be the only sign of arterial rupture. If vascular injury is suspected, obtain an angiogram and a vascular surgery consultation immediately.

Evaluate associated injuries (eg, pneumothorax, other traumatized areas) with radiographic studies (see Workup). Radiographic examination of the shoulder should include Neer's trauma series, which consists of a true anteroposterior (AP) view of the glenohumeral joint, a Y-view, and an axillary view. Modifications of the axillary view, such as a Velpeau view or computed tomography (CT) scan, can be obtained to evaluate the relation of the humeral head to the glenoid. It is estimated that the initial treating physician nevertheless misses 50% of all fracture-dislocations.

Workup

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Author

Mark A Frankle, MD Adult Reconstruction and Arthritis Orthopaedic Surgeon, Florida Orthopaedic Institute

Mark A Frankle, MD is a member of the following medical societies: American Medical Association, Florida Orthopaedic Society, Shoulder and Elbow Society of Australia, American Shoulder and Elbow Surgeons, American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association

Disclosure: Received consulting fee from DJO for consulting; Received royalty from DJO for other.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mohit N Gilotra, MD, MS, FAAOS, FAOA Associate Professor, Department of Orthopaedics, Shoulder and Elbow Service, Associate Residency Program Director, Co-Director of Resident Research, University of Maryland School of Medicine; Chief of Orthopaedics, VA Maryland Healthcare

Mohit N Gilotra, MD, MS, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Shoulder and Elbow Surgeons, Maryland Orthopaedic Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Tigon<br/>Serve(d) as a speaker or a member of a speakers bureau for: Arthrex<br/>Received research grant from: Orthofix.

Additional Contributors

Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Matthew Teusink, MD, and Raymond Long, MD, FRCSC, are gratefully acknowledged for contributions made to this article.