If there are neurological or vascular deficits or involvement of joints then an orthopaedic referral is required.
- Trauma, Osteoporosis, Paget's disease, Pathological fracture
- Fall onto outstretched hand
- May involve greater tuberosity, less tuberosity, anatomical and surgical neck
- Localised pain, tenderness and possible deformity arm hanging with bruising
- Check radial nerve function as runs in a spiral groove
- Check axillary nerve by testing for sensation in the regimental badge area over the deltoid muscle and assessing upper limb muscle power.
- Assess for brachial plexus injury through distal neurological examination.
- Check peripheral pulses.
- Proximal humeral fractures: falls on an outstretched hand, seizures, direct trauma, older patients. Check axillary nerve
- FBC, ESR, U&E, Ca
- X-rays - include AP, trans-scapular (or Y) and axillary views.
- CT scan may be needed in difficult cases.
- Axillary nerve damage is most common in proximal fractures.
- Suprascapular, radial and musculocutaneous nerves can also be affected.
- Axillary artery injury may (rarely) occur (look for expanding mass over the proximal shoulder girdle).
- Axillary/Brachial artery is also rarely injured.
- Radial nerve damage may be seen in midshaft fractures.
- Avascular necrosis of the humeral head: complex fractures. Leads to pain and stiffness in the shoulder.
- Malunion. Rotator cuff injury.
- Immobilisation and analgesia. Most proximal fractures are undisplaced and can be treated conservatively with a sling or hanging arm cast or simple collar and cuff to allow gravity to exert gentle traction. Give simple analgesia.
- Referrals to Trauma and orthopaedics
- Gross angulation or total distraction from humeral head
- Fracture dislocations
- Neurovascular damage
- Fractures of the anatomical neck
- Open fractures, those associated with a shoulder dislocation or combined with fracture in the forearm are a surgical emergency and an immediate orthopaedic opinion is necessary.