Shoulder Fracture Flashcards
Most common site of shoulder fracture.
Proximal humerus
Primary mechanism of proximal humeral fractures.
Low energy injuries in elderly by FOOSH.
Osteoporosis is a big factor.
Less common mechanism of injury in proximal humerus fracture.
Younger patients from high energy traumatic injury.
This is also commonly associated with soft tissue or neurovascular injuries.
Risk factors of proximal humeral fracture.
Osteoporosis
Female
Early menopause
Prolonged steroid use
Recurrent falls
Frailty
Clinical features of PHF
Pain around upper arm and shoulder
Restriction of arm movement
Inability to abduct the arm
Examination findings of PHF
Significant swelling
Bruising
This can spread to chest and down the arm
What other examinations are important in PHF?
Neurovascular status
Assessing the joint above and below shoulder
Neurovascular damage that might occur in PHF
Damage to axillary nerve and circumflex vessels
Can cause loss of sensation in the lateral shoulder (Regimental Badge Area) and loss of power of the deltoid.
Investigations of PHF
Urgent bloods (Coagulation and Group & Save (in case they need transfusion))
If there is a pathological cause suspected serum calcium and myeloma screen might be warranted
Plain film radiographs is the initial imaging modality.
CT scan can be used for preoperative planning or if position of any of the humeral segments is unclear.
What X-ray views are needed for PHF assessment?
To appropriately visualise and classify AP, lateral scapular and axillary views are all required.
Classification of PHF.
Neer classification system
Bassed on the relationship between 4 main segments:
Greater tuberosity
Lesser tuberosity
Articular segment (anatomical neck)
Humeral shaft (surgical neck)
When are these segments considered separate?
If there is displacement >1cm between segments or if there is at least 45 degrees of angulation.
Categorises injuries into either minimal displacement or two to four part injuries.
Types of management of PHF.
Majority of PHF can be managed conservatively especially if the fracture is minimally displaced without neurovascular compromise.
Surgical intervention might be needed if more complicated.
Explain conservative management of PHF
Immobilisation with early mobilisation.
This includes pendular exercise at 2-4 weeks post injury depending on the fracture pattern.
Correctly applied polysling to allow their arm to hang.
Gravity on arm will aid the reduction of the fragments of most humeral fractures.
Indications of surgical management
Displaced, open or neurovascularly compromised fractures.
Type of surgery depends on the classification and complexity of the fracture + patient factors.
Types of surgical management
Open reduction internal fixation (ORIF)
Intermedullary nailing
Hemiarthroplasty
Reverse shoulder arthroplasty (RSA)
When is ORIF considered?
Open reduction internal fixation is indicated in multiple segment injuries and often preferred in a head splitting fracture.
When is intermedullary nailing considered?
Multiple segment injuries
If the fracture involves the surgical neck or if the fracture is combined with a humeral shaft fracture
When is hemiarthroplasty done in PHF?
Small number of patients who experience complex injuries
Injuries that include splitting of the humeral head and likely to have signficant complications if treated with ORIF.
When is reverse shoulder arthroplasty considered in PHF?
Low demand patients or patients who require revision after a failed previous procedure.
It involves total shoulder arthroplasty in which ball and socket portions of the shoulder joint are reversed.
Complications of PHF
Reduced range of motion
Extensive physiotherapy will be required to regain full function and reduce pain.
Rehab time is around 1 year.
Risk of avascular necrosis of humeral head if there is injury to anterior and posterior humeral circumflex arteries. In that case hemiarthroplasty or reverse shoulder arthroplasty might be required.
Axillary nerve can also get damaged
Explain scapular fractures.
Very rare type due to its protection by surrounding muscles.
Associated with high energy trauma and a mortality rate of 2-5% due to their concurrent severe injuries.
Treatment of scapular fractures.
Usually non-operatively as around 90% of fractures are aligned acceptably.
ORIF is indicated for individuals with glenohumeral instability, displaced scapular neck or complex fracture patterns.
Prognosis of scapular fractures.
Good results with not functional deficits almost always in non-operative.
If surgery is needed there is 70% chance of good outcome.
