2. proximal shoulder fractures

Question 1

What typically causes proximal humeral fractures?

Answer 1

Low energy fractures in the elderly, FOOSH, typically in the presence of osteoporosis

Question 2

When would they occur in younger individuals, what would they be associated with?

Answer 2

High energy injury, therefore likely to have soft tissue and neurovascular injury

Question 3

Risk factors?

Answer 3

Risk factors for low energy fractures:
- comparable to other osteoporotic fractures, including female gender, early menopause, prolonged steroid use, recurrent falls, and frailty

Question 4

Clinical features?

Answer 4

• pain around upper arm and shoulder
• restricted arm movements
• inability to abduct the arm
• swelling and bruising of shoulder which can spread to chest and down the arm

Question 5

What neurovascular structures are at risk?

Answer 5

• Axillary nerve

- Circumflex arteries of the humerus

Question 6

how would damage to axillary nerve present?

Answer 6

loss of sensation in the lateral shoulder (“Regimental Badge Area”) and loss of power of the deltoid muscle.(15 - 90 degree abduction)

Question 7

Investigations?

Answer 7

• urgent bloods, incl. coagulation and group and save

- plain film radiographs (AP, Lateral and axillary)

Question 8

What classificaiton system is used for proximal humeral fractures?

Answer 8

Neer classification

Question 9

How does Neer classification classify fractures?

Answer 9

Based on displacement of fragments. It categorises injuries into either minimal displacement or two to four part injuries, dependent on the number of separate segments present.

Question 10

What is considered dispalced in Neer classification?

Answer 10

• more than 1 cm displacement between segments

- more the 45 degrees of angulation

Question 11

What are 4 different segments that Neer classification considers?

Answer 11

• greater tuberosity
• lesser tuberosity
• articular segment (anatomical neck)
• humeral shaft (surgical neck)

Question 12

Which fractures are managed conservatively?

Answer 12

• majority
• especially if there is little displacement
• no neurovascular injury

Question 13

Conservative management?

Answer 13

• immobilisation with early mobilisation in 2-4 weeks

- immobilisation with polysling, gravity aids reduction

Question 14

Indications for surgical management?

Answer 14

• displaced, open or neurovascular compromise

- multiple fragments

Question 15

Surgical approaches?

Answer 15

• ORIF
• intermedullary nailing
• hemiarthroplasty
• reverse shoulder arthroplasty (RSA)