Makindo Medical Notes.com

If there are neurological or vascular deficits or involvement of joints then an orthopaedic referral is required.

About

• Common in older patients

Aetiology

• Trauma, Osteoporosis, Paget's disease, Pathological fracture
• Fall onto outstretched hand
• May involve greater tuberosity, less tuberosity, anatomical and surgical neck

Clinical

• 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 brachial plexus injury through distal neurological examination.
• Check peripheral pulses.

Types

• Proximal humeral fractures: falls on an outstretched hand, seizures, direct trauma, older patients. Check axillary nerve

Investigations

• FBC, ESR, U&E, Ca
• X-rays - include AP, trans-scapular (or Y) and axillary views.
• CT scan may be needed in difficult cases.

Complications

• 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.

Management

• 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.

References