Fracture - proximal humeral fractures

Initial assessment

Salter Harris Classification

Image reproduced with permission from RCH Melbourne ( http://www.rch.org.au/clinicalguide/guideline_index/fractures/Proximal_humeral_fractures_Emergency_Department/)

In the acute phase, care should be taken to assess as follows:

• Obtain a history including mechanism; assess for the possibility of a co-occurring dislocation +/- spontaneous relocation that may indicate injury to the surrounding soft tissue (note: this is exceedingly rare).

• Neurovascular status, particularly sensation to the deltoid patch (<1% chance of axillary nerve palsy) and distal perfusion of the limb.

• Ensure the patient is comfortable - early application of a sling optimises comfort and therefore improves quality of assessment and imaging.

Initial management

The hallmark of proximal humeral fracture management is the early application of a well-fitting sling. Patients with fractures within the acceptable parameters as outlined in table 1. below, are managed conservatively in a collar and cuff or broad arm style sling.

The goal of the sling is to implement gravity traction to the affected limb reducing both the fracture and the pain associated with spasms. Gravity traction is achieved best using a collar and cuff style sling where the elbow of the affected arm is gently flexed, the arm is then internally rotated and the wrist crease is brought to rest over the sternal notch. This is the ideal treatment position.

A suitable alternative where the collar and cuff style is not tolerated includes a poly-sling or adapted broad arm style sling wiht the wrist higher than the elbow where possible.

Ensure the sling straps do not touch the fracture site.

Acceptable displacement by age group

Table 1: Acceptable displacement and angulation

If concerns about degree of displacement at any age or if child > 12 years (girl) or 14 years (boy) then x-rays should be discussed with the on-call orthopaedic registrar. (This is because in older children there is less skeletal growth remaining to remodel residual deformity; note proximal humeral physis in boys grows to 16 - 18 years and girls to 14 - 17 years).

First appointment

First fracture appointment depends on management decision.

Fractures treated by surgical intervention

It is rare to operate on proximal humeral fractures; but for these cases, the post-op follow-up should be as per surgeon instructions.

Fractures treated by conservative means

Patients presenting with uncomplicated un-displaced or displaced fractures, managed in a sling in the acute phase, are seen in clinic 14 days post-injury:

• X-ray to assess fracture position.

• Assess:

  • Comfort and efficacy of sling

  • Neurovascular status in hand and sensation over deltoid muscle

• Provide and discuss proximal humerus fractures information sheet

• Offer face-to-face or telehealth review at 4-6 weeks with an x-ray to ensure comfort and healing.

Patients presenting with complications or concerns about significant displacement at the first fracture appointment are discussed with the fellow or SMO overseeing fracture clinic.

Activity advice at first appointment

If fracture alignment and neurovascular status is found to be satisfactory at the first appointment:

• Commence "tabletop" activities that allow for wrist and elbow flexion and extension.

• Practice leaning forward and swinging the arm in a small circle out of the sling.

• Advice to limit shoulder and overhead movement of affected limb save for prescribed shoulder extension exercises at 2-3 weeks post injury as led by pain.

• Encourage to continue in sling for a total of 6 weeks, particularly in a playground setting such as school.

• Gradual return to sport at 4-6 weeks post removal of sling, aiming for full return of function at 12-16 weeks.

Follow-up from first appointment

All conservatively managed fractures

• Telehealth or face-to-face clinic in 5-6 weeks after first visit: x-ray (offer community or more local district imaging), range of movement assessment and return to sport advice.

• Discharge buckle and metaphyseal fractures from follow-up at that time unless concerns about pain, range of movement.

• Salter Harris I and II fractures: recommend GP follow-up at 18 months post injury for:

  • X-ray to examine growth plate and exclude a bony bar

  • Clinical examination to rule out residual deformity

Key messages

• Collar and cuff style slings are largely used to facilitate gravity traction to reduce displacement. A broad arm sling may be more suitable for comfort as long as it is fitted in such a way that the elbow is hanging and not propped up.

• These fractures do very well with conservative management:

  • There is excellent remodelling potential as 80% of humeral growth is from the proximal humeral physis

  • Loss of range of movement post fracture is extremely uncommon (the shoulder is a universal joint)

• Re-referral and return advice should include:

  • On-going pain

  • Swelling

  • Slow return to baseline function

• Fractures referred to the Paediatric Orthopaedic Service are followed up to point of healing/recovering - either face to face or telehealth.

• First appointments are face to face to allow for in-depth examination.