FRACTURES OF THE PROXIMAL
HUMERUS
Fractures of the proximal humerus usually occur after
middle age and most of the patients are osteoporotic,
postmenopausal women.
-Mechanism of injury
Fracture usually follows a fall on the out-stretched
arm . the type of injury which, in younger people,
might cause dislocation of the shoulder. Sometimes,
indeed, there is both a fracture and a dislocation
Classification
-Neer
(1970) who drew attention to the four major segments
involved in these injuries: the head of the
humerus, the lesser tuberosity, the greater tuberosity
and the shaft
-###Neer's classification distinguishes
between the number of displaced fragments, with displacement
defined as greater than 45 degrees of angulation
or 1 cm of separation. Thus, however many fracture
lines there are, if the fragments are undisplaced it
is regarded as a one-part fracture; if one segment is separated from the others, it is a two-part fracture; if two
fragments are displaced, that is a three-part fracture; if
all the major parts are displaced, it is a four-part fracture.
Clinical features
-pain may not be severe.
-the appearance of a large bruise on the upper part of the arm.
X-ray
elderly patients there often appears to be a single,
impacted fracture extending across the surgical neck.
In younger patients, the fragments
are usually more clearly separated.
Treatment:-
MINIMALLY DISPLACED FRACTURES
need no treatment
apart from a week or two period of rest with the
arm in a sling until the pain subsides, and then gentle
passive movements of the shoulder.
after 6 weeks), active exercises are
encouraged
TWO-PART FRACTURES
Surgical neck fractures The fragments are gently
manipulated into alignment and the arm is immobilized
in a sling for about four weeks or until the fracture
feels stable and the x-ray shows some signs of
healing. Elbow and hand exercises are encouraged
throughout this period; shoulder exercises are commenced
at about four weeks. The results of conservative
treatment are generally satisfactory, considering
that most of these patients are over 65 and do not
demand perfect function. However, if the fracture
cannot be reduced closed or if the fracture is very
unstable after closed reduction, then fixation is
required. Options include percutaneous pins, bone
sutures, intramedullary pins with tension band wiring
Greater tuberosity fractures Fracture:- of the greater
tuberosity is often associated with anterior dislocation
and it reduces to a good position when the shoulder is
relocated. If it does not reduce, the fragment can be
re-attached through a small incision with interosseous
sutures or, in young hard bone,
THREE-PART FRACTURES
These usually involve displacement of the surgical
neck and the greater tuberosity.
FOUR-PART FRACTURES FRACTURES
-The surgical neck and both tuberosities are displaced.
These are severe injuries with a high risk of complications
such as vascular injury, brachial plexus damage, injuries
of the chest wall and (later) avascular necrosis of
the humeral head. Often
the most one can say is that there are multiple displaced
fragments, sometimes together with glenohumeral
dislocation. In young patients an attempt
should be made at reconstruction. In older patients,
closed treatment and attempts at open reduction and
fixation can result in continuing pain and stiffness and
additional surgical treatment can compromise the
blood supply still further.
-treartment of choice is prosthetic
replacement of the proximal humerus.
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