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Fracture of humerus — Clinical Guidelines

Overview

Fractures of the proximal humerus are common injuries affecting the shoulder joint, with treatment approaches varying based on displacement and comminution, ranging from conservative methods to surgical interventions like arthroplasty and open reduction and internal fixation. 1

Diagnosis

Clinical Presentation: Pain, swelling, deformity, and limited range of motion.

Imaging: X-rays are essential for initial assessment; CT and MRI may be needed for complex fractures to assess soft tissue injuries and joint surface congruency. 2 3

Grading: Classification systems like the Neer or AO/OTA systems help categorize fractures based on location, displacement, and comminution. 1

Management

First-Line Treatments:

- Displaced Fractures: Arthroplasty or open reduction and internal fixation (ORIF) with plates and screws, especially for severe displacement to avoid humeral head avascular necrosis. 1 3 - Lesser Displaced Fractures: Closed reduction, traction, casting, and abduction splints. 1

Surgical Techniques:

- Greater Tuberosity Fractures: Surgical management recommended for displacements ≥5 mm, often using arthroscopic techniques for fixation at the rotator cuff tendon bone junction. 2

Adjunctive Treatments:

- Physical Therapy: Post-treatment rehabilitation focusing on restoring range of motion and strength. 3

Special Populations

Elderly: Higher risk of complications; arthroplasty may be preferred to preserve function despite potential implant-related issues. 1

Pediatrics: Not specifically addressed in abstracts; management typically involves careful reduction and immobilization to avoid growth plate damage. 3

Comorbidities: Patients with significant comorbidities may benefit from less invasive approaches to minimize surgical risks. 3

Key Recommendations

Consider Arthroplasty for Severely Displaced Proximal Humerus Fractures to reduce the risk of humeral head avascular necrosis. (Evidence: Moderate 1)

Use Arthroscopic Techniques for Greater Tuberosity Fractures when displacement exceeds 5 mm to optimize fixation and functional outcomes. (Evidence: Moderate 2)

Operative Correction for Malunion can yield satisfactory results in over 60% of cases, focusing on complete correction of osseous abnormalities. (Evidence: Weak 3)

References

1 Hanzlik SR, Pearson SE, Caldwell PE. Excision and Reimplantation of the Proximal Humerus After Fracture-Dislocation. Orthopedics 2016. link 2 DeBottis D, Anavian J, Green A. Surgical management of isolated greater tuberosity fractures of the proximal humerus. The Orthopedic clinics of North America 2014. link 3 Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. The Journal of bone and joint surgery. American volume 1998. link

Fracture of humerus