Edited by Carew Giberson-Chen and Jeffrey "Spud" Olson - 7/1/2021
Descriptors
Neer Classification:
- Number of parts: minimally displaced, 2-part, 3-part, 4-part
- Definition of part = displacement >1cm (0.5cm GT) or angle >45 deg
- Fracture Location (part): anatomic neck, surgical neck, greater tuberosity, lesser tuberosity, head (split)
- Fracture-dislocation
Exam Pearls
Upper extremity neurovascular exam
Carefully inspect skin to rule out open fractures (including axilla)
Assess distal pulses
Assess brachial plexus, axillary nerve function
Workup
Radiographs: 3 views of shoulder - true AP (Grashey), scapular Y, axillary. If unable to abduct arm for axillary view, obtain Velpeau view instead
Other imaging: CT shoulder if operative (pre-op planning), uncertain of positions of fragments based on XR, c/f intra-articular comminution, dislocation, head-split fracture. CT angiogram if diminished pulses.
Labs: Pre-op labs if operative: CBC, BMP, T&S, CXR, EKG, UA, covid swab
Other: Surgical consent if operative, endocrine workup/FLS consult for fragility fracture if admitted
Management
Need for acute intervention: Yes, sling
Weight-bearing and range of motion: NWB in sling, encourage wrist and finger ROM
Type of immobilization: Sling immobilization without reduction
Admission or discharge status: If non-surgical: discharge home with 2-3 week f/u in ortho trauma clinic If surgical: d/c with follow up 1 week to schedule surgery vs. admit
Anticoagulation: None if discharged, lovenox 40mg SC QHS if admitted
Antibiotics: None unless open
Surgical Indications
Absolute:
Open fracture
Arterial injury
Relative: Greater tuberosity displaced > 5mm (will block external rotation and abduction)
45 degree apex volar angulation (will limit shoulder flexion)
Head split (risk of AVN)
<8 mm calcar spike (risk of AVN)
Young age
Surgical interventions:
CRPP: simple fractures (2-part or 3/4 part with min. comminution)
ORIF: first-line for young patients
Hemiarthroplasty: young patients with complex fx/dx or head-split
Reverse Shoulder Arthroplasty: elderly pt with 3 or 4-part fx, poor bone quality, comminution or unreconstructable tuberosities
Literature
PROFHER Trial:
- Rangan, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10;313(10):1037-47. doi: 10.1001/jama.2015.1629.
- Multi-center RCT of 231 patients (avg age 66 years) with displaced proximal humerus fx involving surgical neck, randomized to surgical (ORIF or hemi) vs non-surgical treatment (sling immobilization), 2 year follow-up
- No significant difference in functional outcomes at 2 years
- 5 year follow-up study demonstrated no significant differences at 5 years