Symptoms, Signs, and Diagnosis
The most common mechanism of injury is a fall on an outstretched hand. Patients present with shoulder pain and an inability to move the arm. On x-ray, the proximal humerus may show as many as four separate fragments: eg, an articular fragment containing the humeral head, a greater tuberosity fragment, a lesser tuberosity fragment, and a distal fragment including the humeral shaft. These fragments are prone to displacement because of the pull of the supraspinous, subscapular, and pectoral muscles. Displaced fractures are classified according to increasing order of severity into two-, three-, and four-part patterns. Fortunately, about 80% of proximal humerus fractures are minimally displaced, with < 45E angulation and < 1 cm displacement of any fragment. When displaced, the articular fragment may not lie in a satisfactory posture above the humeral shaft, as shown on anteroposterior and lateral x-rays. Fractures associated with a glenohumeral dislocation usually result from major trauma and constitute the most severe injuries.
Treatment and Prognosis
Treatment and prognosis depend on the number of fragments and the extent of displacement. Patients should be told to expect considerable swelling and discoloration that will spread to the lower arm and hand. If the alignment and position of the fragments are satisfactory, the arm may simply be immobilized in a sling. Otherwise, an orthopedist may attempt closed reduction. If satisfactory alignment cannot be achieved by manipulation, open reduction with internal fixation or insertion of a prosthetic replacement may be indicated.
Beginning range-of-motion exercises as soon as possible is essential. The most common complication after a shoulder fracture is adhesive capsulitis, which results from approximation of the inflamed surfaces of the joint capsule. Capsulitis can cause chronic pain and functional disability because of restricted motion.
For a stable two-part fracture, active motion and use of the hand and wrist should be encouraged immediately. A physical therapist should give instructions and monitor exercises. At 1 wk, pendulum exercises in the sling should begin. The patient leans forward and, using the noninjured arm to assist, swings the injured arm like a pendulum, making circles with the elbow. The sling may be removed daily to allow bathing and elbow motion. By 2 weeks, the patient should begin active and passive arm elevation. Regaining the ability to perform overhead activities, such as combing hair, may take several months.
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