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dx.
Clinical Reference
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ECG
Interpretation guide
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Humerus Fracture (Proximal)
Cardiovascular Presentations
Abdominal aortic aneurysm
Acute coronary syndrome (NSTEMI)
Acute coronary syndrome (STEMI)
Acute decompensated heart failure
Acute limb ischemia
Acute mesenteric ischemia
Aortic dissection
Aortic stenosis
Atrial fibrillation and flutter
Bradyarrhythmia and heart block
Cardiac arrest
Deep vein thrombosis
Myocarditis
Pericarditis
Pulmonary embolism
Stable angina
Superficial thrombophlebitis
Superior vena cava syndrome
Supraventricular tachycardia
Syncope (cardiogenic)
Unstable angina
Ventricular tachycardia
Respiratory Presentations
Acute bronchitis
Acute respiratory failure
Aspiration pneumonia
Asthma exacerbation
Bronchiolitis
Community-acquired pneumonia
COVID-19 pneumonia
COPD exacerbation
Croup
Croup (laryngotracheobronchitis)
Epiglottitis
Hemothorax
Hospital-acquired pneumonia
Pleural effusion
Pneumothorax (traumatic)
Pulmonary contusion
Spontaneous pneumothorax
Neurological Presentations
Bell's palsy
Benign paroxysmal positional vertigo
Brain abscess
Cauda equina syndrome
Cervical radiculopathy
Concussion (mild traumatic brain injury)
Encephalitis
Guillain-Barré syndrome
Hemorrhagic stroke (intracerebral)
Ischemic stroke
Lumbar radiculopathy
Malignant spinal cord compression
Migraine
Peripheral neuropathy (acute)
Retropharyngeal abscess
Schizophrenia (acute exacerbation)
Seizure (breakthrough:known epilepsy)
Seizure (first-time)
Spinal cord injury
Status epilepticus
Subarachnoid hemorrhage
Tension headache
Transient ischemic attack
Traumatic brain injury (moderate-severe)
Vestibular neuritis
Viral meningitis
Gastrointestinal Presentations
Acute appendicitis
Acute cholecystitis
Acute diverticulitis
Acute pancreatitis
Anal fissure
Choledocholithiasis and cholangitis
Clostridioides difficile colitis
Gastritis
Gastroenteritis (viral and bacterial)
Gastroesophageal reflux disease
Incarcerated or strangulated hernia
Inflammatory bowel disease flare
Large bowel obstruction
Lower GI hemorrhage
Peptic ulcer disease
Perforated viscus
Small bowel obstruction
Upper GI hemorrhage
Genitourinary and Reproductive Presentations
Acute prostatitis
Acute urinary retention
Ectopic pregnancy
Epididymitis
Orchitis
Ovarian torsion
Paraphimosis
Pelvic inflammatory disease
Priapism
Pyelonephritis
Renal laceration
Ruptured ovarian cyst
Testicular torsion
Tubo-ovarian abscess
Urinary tract infection (uncomplicated)
Urolithiasis (renal colic)
Vaginal bleeding (non-pregnant)
Infectious Disease Presentations
Acute sinusitis
Acute tonsillitis
Acute upper respiratory infection
Animal bite
Bacterial meningitis
Cellulitis
Conjunctivitis (bacterial)
Dental abscess
Endocarditis
Febrile neutropenia
Fournier gangrene
Hand-foot-mouth disease
Hepatitis (acute)
Herpes zoster
HIV-related illness
Human bite
Impetigo
Infected diabetic foot ulcer
Infectious mononucleosis
Influenza
Necrotizing fasciitis
Osteomyelitis
Otitis externa
Parasitic infection
Periorbital cellulitis
Peritonsillar abscess
Scabies
Sepsis
Septic arthritis
Spontaneous bacterial peritonitis
Tick-borne illness (Lyme disease)
Tinea infection
Tuberculosis
Viral exanthem
Wound infection
Trauma Presentations
Achilles tendon rupture
ACL and mceniscus tear
Ankle fracture
Ankle sprain
Burn
Calcaneus fracture
Cervical spine fracture
Clavicle fracture
Dental avulsion
Distal radius fracture
Drowning
Elbow fracture and dislocation
Electrical injury
Facial bone fracture
Facial laceration
Femur fracture
Fingertip amputation
Forearm fracture (radius and ulna)
Frostbite
Hand:finger laceration
Heat exhaustion
Heat stroke
Hip fracture
Humeral shaft fracture
Knee dislocation
Knee sprain
Lightning injury
Mandible fracture
Metacarpal fracture
Metatarsal fracture
Muscle strain
Nasal fracture
Non-accidental trauma
Orbital fracture
Patella fracture
Phalanx fracture (finger)
Proximal humerus fracture
Pulmonary contusion
Rib fracture
Rotator cuff tear (acute traumatic)
Scalp laceration
Scaphoid fracture
Shoulder dislocation
Skull fracture
Splenic laceration
Sternal fracture
Supracondylar pediatric fracture
Tendon laceration (hand:wrist)
Thoracic and lumbar spine fracture
Tibia:fibula fracture
Tibial plateau fracture
Toe fracture
Traumatic epistaxis
Traumatic hyphema
Toxicologic Presentations
Acetaminophen toxicity
Alcohol intoxication
Alcohol withdrawal
Anticholinergic toxicity
Anticoagulant overdose
Benzodiazepine overdose
Benzodiazepine:sedative overdose
Beta-blocker and calcium channel blocker toxicity
Carbon monoxide poisoning
Caustic ingestion
Digoxin toxicity
Drug eruption
Foreign body ingestion
Opioid intoxication
Opioid overdose
Opioid withdrawal
Organophosphate
Salicylate toxicity
Serotonin syndrome
Stimulant intoxication (cocaine, methamphetamine)
Tricyclic antidepressant overdose
Psychiatric Presentations
Acute anxiety
Acute psychosis
Agitation:behavioral emergency
Bipolar disorder
Conversion disorder
Major depressive episode
Neuroleptic malignant syndrome
Suicidal ideation and attempt
Musculoskeletal and Rheumatologic Presentations
Acute low back pain (mechanical)
Bursitis
Cervical radiculopathy
Costochondritis
Gout (acute)
Lumbar radiculopathy
Pseudogout
Tendinitis
Dermatology Presentations
Acute eczema (Eczema acute flare)
Allergic contact dermatitis
Erythema multiforme
Henoch-Schönlein purpura
Pressure injury
Psoriasis (acute flare)
Stevens-Johnson syndrome
Toxic epidermal necrolysis
Urticaria (acute)
Environmental and Exposure Presentations
Envenomation (snake, spider, insect)
High-altitude illness
Hypothermia
Hematologic and Oncologic Presentations
Acute chest syndrome
Coagulopathy
Hyperviscosity syndrome
Sickle cell crisis (vaso-occlusive)
Symptomatic anemia
Thrombocytopenia (severe)
Tumor lysis syndrome
Pediatric-Specific Presentations
Bronchiolitis
Croup
Emergency delivery
Febrile seizure
Kawasaki disease
Neonatal jaundice
Neonatal sepsis
Nursemaid's elbow
Pediatric fever 0 to 28 days
Pediatric fever 29 to 60 days
Pediatric fever 61 to 90 days
Pyloric stenosis
Slipped capital femoral epiphysis
Intussusception
Endocrine and Metabolic Presentations
Adrenal crisis
Diabetic ketoacidosis
Hypercalcemia
Hyperosmolar hyperglycemic state
Hypertensive emergency
Hypertensive urgency
Hypoglycemia
Myasthenia gravis crisis
Myxedema coma
Severe hyperkalemia
Severe hyponatremia
Thyroid storm
ENT and Maxillofacial Presentations
Acute laryngitis
Acute otitis media
Acute pharyngitis
Cerumen impaction
Epistaxis (anterior)
Nasal foreign body
Otitis externa
Tympanic membrane perforation
Ophthalmologic Presentations
Acute angle-closure glaucoma
Central retinal artery occlusion
Chemical eye injury
Corneal abrasion
Corneal ulcer
Globe rupture
Ocular foreign body
Orbital cellulitis
Retinal detachment
Obstetric Presentations
Hyperemesis gravidarum
Painful vaginal bleeding in pregnancy
Placenta previa
Placental abruption
Preeclampsia:eclampsia
Preterm labor
Threatened:inevitable:incomplete abortion
Systemic and Miscellaneous Presentations
Anaphylaxis
Angioedema
Cannabis-induced hyperemesis
Humerus Fracture (Proximal)
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate threats and stabilization
Neurovascular compromise screen
▶
Absent or diminished radial pulse
▶
Axillary artery injury risk with displaced fractures
Expanding hematoma in axilla or arm
Cold, pale, or mottled hand
▶
CTA of axillary and brachial vessels if vascular injury suspected
Urgent vascular surgery consultation
Axillary nerve deficit
▶
Absent sensation over lateral deltoid regimental badge area
Inability to contract deltoid
Brachial plexus deficit
▶
Multi-distribution weakness or numbness
Orthopedic and neurology consultation
Open fracture management
▶
Skin breach with bone exposure
▶
Saline-soaked sterile dressing
IV antibiotics within 1 hour of injury recognition
Contamination assessment
▶
Low-energy vs high-energy wound
Urgent orthopedic consultation for washout and debridement
Fracture-dislocation and high-risk patterns
Fracture-dislocation recognition
▶
Severe shoulder deformity with locked position
▶
Higher risk of humeral head avascular necrosis
CT shoulder required for surgical planning
Head-split fracture pattern
▶
Articular surface involved
Urgent orthopedic consultation
Pathologic fracture alarm
▶
Minimal mechanism with fracture
▶
Known malignancy or night pain history
Bone metastasis workup initiated
Seizure-associated posterior fracture-dislocation
▶
Often missed on AP-only views
Axillary view or CT mandatory
Monitoring and escalation
Pain and hemodynamic targets
▶
Pain score reassessment every 30 minutes
▶
Interscalene or supraclavicular nerve block for acute control
IV opioid titration for refractory pain
Vital sign stability
▶
Heart rate and blood pressure monitoring
Hematoma expansion monitoring
Escalation triggers
▶
Progressive neurovascular deficit
▶
Emergent operative intervention pathway
Vascular surgery on-call activation
Expanding axillary hematoma
▶
CTA axillary artery
Compressive dressing contraindicated
History
Mechanism and presentation
Mechanism of injury
▶
Fall on outstretched hand (FOOSH)
▶
Most common mechanism in elderly
Low-energy from standing height
Direct blow to lateral shoulder
▶
Contact sports
Motor vehicle collision in younger patients
High-energy trauma
▶
Higher fracture fragment count
Greater neurovascular risk
Symptom characterization
▶
Shoulder pain location
▶
Anterior or lateral shoulder predominance
Radiation to deltoid insertion
Functional loss
▶
Inability to abduct or elevate arm
Dominant vs non-dominant hand affected
Timing of injury
▶
Delay in presentation increases hematoma and stiffness
Alarm features and red flags
Neurovascular symptoms
▶
Numbness or tingling in hand or fingers
▶
Axillary nerve distribution lateral deltoid
Radial, median, or ulnar nerve distributions
Hand weakness or cold discoloration
▶
Vascular injury concern
Compartment syndrome upper arm (rare)
Pathologic fracture concern
▶
Known malignancy history
▶
Breast, lung, renal, thyroid, myeloma most common
Bone pain elsewhere
Prior fragility fractures or DEXA-confirmed osteoporosis
▶
Minimal trauma mechanism
Night pain at fracture site
Seizure-associated injury
▶
Witnessed or unwitnessed seizure preceding fall
▶
Posterior fracture-dislocation classically associated
ECG and metabolic evaluation for seizure cause
Risk factors and medical history
Osteoporosis risk
▶
Age over 65 years and female sex
▶
71 to 94% female in major trials
Low BMD or prior fragility fracture
Chronic steroid use
▶
Bone quality impairment
Slower healing
Alcohol use and smoking
▶
Impaired bone density
Impaired fracture healing
Fall risk factors
▶
Polypharmacy
▶
Antihypertensives, sedatives, benzodiazepines
Anticholinergics contributing to gait instability
Visual impairment and gait instability
▶
Cognitive impairment
Environmental hazards
Comorbidities affecting management
▶
Anticoagulation therapy
▶
Increases hematoma risk
Complicates surgical planning
Diabetes and peripheral vascular disease
▶
Healing impairment
Vascular assessment relevant
Seizure disorder
▶
Posterior dislocation pattern
Medication compliance review
Functional and social context
Pre-injury functional baseline
▶
Dominant hand and occupation
▶
Activity level and independence with ADLs
Relevance to surgical vs nonoperative decision
Living situation
▶
Alone vs with support
Home safety and fall risk environment
Collateral history
▶
Witnessed fall mechanism from bystanders or EMS
▶
Baseline cognitive function in elderly patients
Syncope or presyncope preceding fall
Physical Exam
Vital signs and general appearance
Stability assessment
▶
Heart rate and blood pressure
▶
Tachycardia from pain or hemorrhage
Hypotension if significant blood loss
General appearance
▶
Distress level
Ability to hold arm in protective posture
Shoulder and upper extremity exam
Inspection
▶
Swelling of shoulder and upper arm
▶
Ecchymosis extending to chest wall and arm within 24 to 48 hours
Skin integrity for open fracture
Deformity
▶
Asymmetry vs contralateral shoulder
Squared off appearance suggests dislocation component
Palpation
▶
Point tenderness over proximal humerus
▶
Greater tuberosity tenderness
Surgical neck tenderness
Crepitus on gentle palpation
▶
Do not force range of motion
Axillary region for expanding hematoma
Range of motion
▶
Severely limited by pain in most cases
▶
Gentle passive assessment only
Do not manipulate suspected fracture-dislocation without imaging
Neurovascular exam
Peripheral vascular assessment
▶
Radial and ulnar pulses bilaterally
▶
Capillary refill in fingers
Hand temperature and color compared to contralateral
Expanding axillary hematoma
▶
Pulsatile mass concern for pseudoaneurysm
Serial assessment every 15 to 30 minutes if concern
Peripheral nerve assessment
▶
Axillary nerve
▶
Sensation over lateral deltoid regimental badge area
Deltoid contraction against resistance
Radial nerve
▶
Wrist extension strength
Sensation dorsal first web space
Median and ulnar nerve
▶
Finger flexion and abduction strength
Sensation in hand median and ulnar distributions
Ipsilateral joint assessment
▶
Elbow range of motion and tenderness
▶
Associated radial head or coronoid fractures from fall
Wrist and hand for concurrent injuries
PITFALLS
Missed diagnoses
▶
Posterior fracture-dislocation missed on AP-only view
▶
Lightbulb sign on internal rotation AP
Axillary view or CT mandatory for all suspected cases
Axillary nerve injury under-documented
▶
Pre-reduction and post-reduction exam mandatory
5 to 30% incidence with proximal humerus fractures
Pathologic fracture missed in minimal trauma mechanism
▶
Low threshold for additional workup if malignancy history
Lytic lesion on imaging raises concern
Differential Diagnosis
Life-threatening and urgent diagnoses
Vascular injuries
▶
Axillary artery injury
▶
ICD-10 S45.001A
Absent pulse, expanding hematoma, cool hand
Brachial artery injury
▶
Associated with more distal fractures and humeral shaft
Vascular surgery emergency
Fracture-dislocation patterns
▶
Glenohumeral fracture-dislocation
▶
ICD-10 S40.011A anterior dislocation
Higher AVN risk than fracture alone
Head-split fracture
▶
ICD-10 S42.201A
Articular surface involvement requiring arthroplasty
Musculoskeletal mimics and associated injuries
Shoulder girdle fractures
▶
Clavicle fracture
▶
ICD-10 S42.009A midshaft most common
Tenderness over clavicle rather than proximal humerus
Scapula fracture
▶
ICD-10 S42.109A
High-energy mechanism, associated thoracic injuries
Greater tuberosity isolated fracture
▶
ICD-10 S42.251A
Minimally displaced often managed nonoperatively
Soft tissue injuries
▶
Acute traumatic rotator cuff tear
▶
ICD-10 S46.011A
May coexist with or mimic proximal humerus fracture
MRI required to diagnose if clinical concern after fracture healing
Acromioclavicular joint separation
▶
ICD-10 S43.101A
AC joint tenderness and step-off deformity
Shoulder dislocation without fracture
▶
ICD-10 S43.006A anterior most common
Radiograph series distinguishes from fracture-dislocation
Non-traumatic and pathologic causes
▶
Pathologic fracture through metastatic lesion
▶
ICD-10 M84.521A humerus
Breast, lung, renal, thyroid, myeloma as primary sites
Cervical radiculopathy
▶
ICD-10 M54.12
Referred shoulder pain without bony tenderness or mechanism
Humeral shaft fracture
▶
ICD-10 S42.301A
More distal pain and deformity, radial nerve at risk
Laboratory Tests
Routine laboratory assessment
Standard workup for elderly and comorbid patients
▶
Complete blood count
▶
Baseline hemoglobin if surgical candidate
Leukocytosis if open fracture concern
Basic metabolic panel
▶
Renal function for antibiotic and contrast dosing
Electrolytes if syncope preceded fall
Coagulation studies
▶
If on anticoagulants
Pre-surgical planning if operative candidate
Pathologic fracture workup
Metabolic bone disease labs
▶
Serum calcium and phosphate
▶
Hypercalcemia in malignancy
Elevated alkaline phosphatase in Paget disease or metastasis
Vitamin D level
▶
Deficiency prevalent in fragility fracture patients
Outpatient initiation of supplementation
PTH
▶
Primary hyperparathyroidism screen
Outpatient DEXA scan referral
Oncologic markers if pathologic fracture suspected
▶
CBC, CMP, ESR
▶
Anemia, hypercalcemia, elevated ESR in myeloma
Elevated alkaline phosphatase in bone metastases
SPEP and UPEP
▶
Myeloma paraprotein screen
Urine protein electrophoresis
PSA in males
▶
Prostate cancer as common bone metastasis source
Age-appropriate screening context
Pre-operative and perioperative labs
Surgical candidate evaluation
▶
Type and screen
▶
Significant hematoma or displaced fracture planned for ORIF
Reverse shoulder arthroplasty candidates
ECG
▶
Pre-operative cardiac screen in elderly patients
Syncope preceding fall evaluation
Glucose
▶
Diabetes perioperative management
Stress hyperglycemia
Diagnostic Tests
Scoring Systems
Neer classification system
▶
Four-segment classification based on displacement
▶
Articular surface (head), greater tuberosity, lesser tuberosity, shaft
A segment is a part only if displaced > 1 cm or angulated > 45 degrees
Neer 1-part (minimally displaced)
▶
Approximately 85% of all proximal humerus fractures
Nonoperative management standard
Neer 2-part fractures
▶
Surgical neck most common 2-part type
Greater tuberosity 2-part often managed nonoperatively if < 5 mm displacement
Neer 3-part and 4-part fractures
▶
Increasing surgical consideration
Higher AVN risk with 4-part fractures
Interobserver reliability limitation
▶
Kappa values reported as low to moderate
CT improves but does not eliminate disagreement
AO/OTA classification
▶
Focuses on vascularity of the humeral head
▶
Type A: intact blood supply
Type B: possible blood supply compromise
Type C: likely blood supply compromise and high AVN risk
Used for surgical planning and prognosis
▶
Type C corresponds to highest AVN rates
Guides arthroplasty vs fixation decision
PROFHER trial evidence
▶
RCT comparing surgery vs nonoperative for displaced proximal humerus fractures
▶
Patients aged 16 years or older, JAMA 2015
No significant benefit of surgery for 2-part or 3-part fractures in patients >= 60 years
NITEP trial confirmation
▶
Open-label RCT, PLoS Medicine 2023
Locking plate or hemiarthroplasty vs nonoperative for 3-4 part fractures
No difference in functional outcomes, higher complications in surgical groups
MRI
MRI shoulder indications
▶
Not routinely required acutely
▶
Plain radiograph and CT sufficient for acute fracture characterization
MRI deferred to outpatient setting
Subacute and post-healing indications
▶
Suspected concomitant rotator cuff tear after fracture healing
AVN surveillance in high-risk fracture patterns
MRI arthrogram consideration
▶
Labral pathology if instability concern after healing
Superior labrum and biceps anchor assessment
MRI technical considerations
▶
Contraindications
▶
Non-MRI-compatible implants after surgical fixation
Patient cooperation required
Sequence selection
▶
PD fat sat for rotator cuff and soft tissue
STIR for bone marrow edema and occult fracture
Coronal and axial planes most informative
CT
CT shoulder indications
▶
Complex or displaced fractures
▶
Better characterization of fracture pattern and fragment count than plain films
ACR Appropriateness Criteria: CT optimal for delineating proximal humeral fracture patterns (2024 update)
Pre-operative planning
▶
3D reconstructions for surgical approach decision
Fragment size and rotation assessment
Suspected fracture-dislocation
▶
Posterior fracture-dislocation evaluation
Head-split pattern identification
Pathologic fracture characterization
▶
Cortical destruction pattern
Soft tissue mass assessment
CT angiography
▶
Vascular injury suspected
▶
Absent or diminished distal pulse
Expanding axillary hematoma
Axillary artery injury diagnosis
▶
Intimal injury, pseudoaneurysm, or occlusion
Sensitivity and specificity approach 100% for significant vessel injury
CT technique
▶
Without contrast for fracture characterization
▶
1 mm axial slices with reformats
3D reconstruction improves interobserver reliability
Radiation dose consideration
▶
Appropriate use criteria guidance
Avoid in pregnancy unless clinically essential
Ultrasound
Point-of-care ultrasound POCUS
▶
Fracture identification at bedside
▶
Cortical disruption visible as step-off
Effusion in glenohumeral joint
Hematoma assessment
▶
Axillary hematoma size and characteristics
Serial assessment for expansion
Axillary vessel assessment
▶
Doppler for axillary artery flow
Not a substitute for CTA if vascular injury suspected
Musculoskeletal ultrasound
▶
Rotator cuff assessment
▶
Supraspinatus and infraspinatus tendon integrity
Operator dependent sensitivity
Guided procedures
▶
Glenohumeral joint aspiration if hemarthrosis causing pain
Nerve block guidance for interscalene or supraclavicular block
Limitations
▶
Plain radiograph mandatory first-line imaging
▶
POCUS supplements but does not replace standard imaging
Cannot reliably characterize fragment count or displacement
Disposition
Discharge criteria
Copy
Outpatient management criteria
▶
Minimally displaced 1-part fracture (Neer 1-part)
▶
Displacement < 1 cm and angulation < 45 degrees
Accounts for approximately 85% of proximal humerus fractures
Intact neurovascular exam
▶
Normal pulses, capillary refill, sensation, and motor function
Documented pre-discharge assessment
Adequate pain control with oral medications
▶
Able to manage with sling immobilization
Home support available
Reliable orthopedic follow-up arranged
▶
Within 7 to 10 days
Repeat radiographs at 1 to 2 weeks for interval displacement check
Admission indications
Criteria requiring admission
▶
Neurovascular compromise
▶
Absent or diminished pulse
Progressive neurologic deficit
Open fracture
▶
IV antibiotics and urgent operative washout
Orthopedic surgery admission
Fracture-dislocation requiring reduction or surgery
▶
Urgent orthopedic consultation
Operating room availability
Polytrauma
▶
Trauma team admission
Associated thoracic or abdominal injuries
Inability to manage at home
▶
Lives alone with inadequate pain control
Functional dependence without home support
Suspected pathologic fracture requiring workup
▶
Oncology or internal medicine consultation
Further imaging including bone scan or PET CT
Orthopedic consultation triggers
Urgent orthopedic consultation
▶
Displaced or unstable fractures (Neer 2-, 3-, or 4-part)
▶
Surgical candidacy assessment
Decision between ORIF and arthroplasty
Fracture-dislocations
▶
Closed vs open reduction decision
AVN risk counseling
Open fractures
▶
Emergent washout within 6 hours
IV antibiotic coverage
Neurovascular injury
▶
Joint vascular surgery consultation
Timing of fixation and revascularization
Young active patients with displaced fractures
▶
Higher threshold for fixation than elderly
ORIF preferred over arthroplasty
Transfer criteria
Transfer indications
▶
Vascular injury requiring operative repair beyond local capability
▶
Transfer to vascular surgery center
Time sensitive revascularization
Complex 4-part fracture requiring reverse shoulder arthroplasty
▶
Subspecialty center with shoulder arthroplasty expertise
Preoperative imaging sent with transfer
Treatment
Acute pain management
Analgesia options
▶
Acetaminophen
▶
1 g PO or IV every 6 hours
First-line for all patients without contraindication
NSAIDs
▶
Ibuprofen 400 to 600 mg PO every 6 to 8 hours with food
Short-term use acceptable; long-term NSAIDs debated for fracture healing
Opioids for breakthrough pain
▶
Hydromorphone 0.5 to 1 mg IV or SC every 4 hours PRN
Oral oxycodone 5 to 10 mg every 4 to 6 hours short course
Regional anesthesia
▶
Interscalene brachial plexus block superior analgesia
Supraclavicular block as alternative
Reduces opioid requirements and facilitates early mobilization
Nonoperative management
Sling immobilization
▶
Standard sling or sling and swathe
▶
Worn for 3 to 6 weeks depending on fracture type
Elbow, wrist, and hand kept mobile from day 1
Coaptation splint for surgical neck fractures with angulation
▶
Sugar tong splint for selected unstable patterns
Orthopedic guidance on splinting decision
Rehabilitation protocol
▶
Weeks 0 to 3: sling immobilization and pendulum exercises
▶
Gravity-assisted gentle circumduction
Elbow, wrist, and hand range of motion
Weeks 3 to 6: active-assisted shoulder range of motion
▶
Pulley and wand exercises
No active abduction until callus forms
After 6 weeks: active range of motion and progressive strengthening
▶
Resistance exercises introduced gradually
Full recovery average 6 to 8 months
Monitoring for displacement
▶
Repeat radiographs at 1 to 2 weeks
▶
AP and scapular Y views
Interval displacement changes surgical threshold
Serial follow-up at 2, 6, and 12 weeks
▶
Healing and rehabilitation progression assessment
CT if radiographs inconclusive about healing
Open fracture management
IV antibiotics
▶
Cefazolin 2 g IV within 1 hour of recognition
▶
Add metronidazole 500 mg IV every 8 hours for contaminated wounds
Cover gram-positive and gram-negative organisms
Penicillin allergy
▶
Clindamycin 600 mg IV every 8 hours plus gentamicin 5 mg/kg IV daily
Infectious disease consultation for complex allergy patterns
Wound management
▶
Saline-soaked sterile dressing
▶
Do not reduce exposed bone in ED
Tetanus prophylaxis per immunization status
Urgent operative washout within 6 hours
▶
Gustilo-Anderson classification guides debridement extent
Orthopedic surgery responsible for classification and management
Surgical management overview
ORIF with locking plate
▶
Preferred for displaced 2- and 3-part fractures in younger patients
▶
Proximal humerus locking plate systems
Minimizes AVN risk with careful technique
Complications
▶
Screw cutout into glenohumeral joint
AVN of humeral head 6 to 16% after ORIF
Intramedullary nailing
▶
Alternative fixation for surgical neck fractures
▶
Rotator cuff impingement risk from nail entry
Selected cases in younger patients
Hemiarthroplasty
▶
Declining use in favor of reverse shoulder arthroplasty
▶
Historically used for 4-part fractures
Unpredictable functional outcomes
Reverse shoulder arthroplasty RSA
▶
Increasingly preferred for complex 3- and 4-part fractures in elderly patients
▶
Superior functional outcomes vs hemiarthroplasty in RCTs
Deltoid-driven mechanism compensates for rotator cuff absence
RSA indications
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4-part fractures in patients over 65 years
3-part fractures with poor bone quality
Failed ORIF or nonoperative treatment
Osteoporosis and fall prevention
Bone health optimization
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Calcium supplementation
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1200 mg elemental calcium daily in divided doses
Dietary calcium preferred where possible
Vitamin D supplementation
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800 to 1000 IU vitamin D daily
Higher doses if deficiency confirmed on serum level
Bisphosphonate therapy
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Initiate or optimize after fracture healing
Alendronate 70 mg PO weekly or zoledronic acid 5 mg IV annually
Not initiated acutely in ED; outpatient follow-up
Fall risk reduction
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Medication review
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Deprescribe or reduce sedatives, anticholinergics, antihypertensives
Pharmacist consultation for polypharmacy
Physiotherapy referral
▶
Balance and gait training
Home safety assessment
Special Populations
Pregnancy
Pregnancy considerations
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Mechanism context
▶
Fall from standing height most common
Balance changes in third trimester increase fall risk
Imaging approach
▶
Plain radiograph with abdominal shielding when indicated
CT shoulder only when plain films insufficient and clinical need high
MRI without gadolinium preferred over CT if advanced imaging needed
Analgesia in pregnancy
▶
Acetaminophen 1 g PO every 6 hours safe all trimesters
NSAIDs avoid after 20 weeks gestation due to fetal renal and ductus arteriosus effects
Short-course opioids only if pain refractory to acetaminophen
Regional anesthesia considerations
▶
Interscalene block with obstetric anesthesia guidance
Systemic local anesthetic toxicity risk modified by pregnancy physiology
Surgical management
▶
Defer elective surgery to postpartum if possible
Emergency surgery with obstetric and anesthesia team involvement
Fetal monitoring when viable gestation
Geriatric
Geriatric-specific considerations
▶
Fracture epidemiology
▶
Most proximal humerus fractures occur in patients over 65 years
Incidence 73 per 100,000 person-years increasing with osteoporosis prevalence
Female-to-male ratio approximately 3 to 1
Fracture complexity in elderly
▶
Osteoporotic bone increases multi-fragment fracture risk
Higher Neer 3- and 4-part fracture rates
AVN risk increased with displaced and comminuted patterns
Treatment decision nuance
▶
PROFHER and NITEP trials: no benefit of surgery over nonoperative for most displaced fractures in patients >= 60 years
Nonoperative management with early rehabilitation strongly supported
RSA preferred over ORIF when arthroplasty is chosen
Medication management
▶
Renal dose adjustment for all renally cleared medications
Avoid NSAIDs if eGFR < 30 ml/min/1.73m2
Opioid caution with falls risk and delirium
Delirium prevention
▶
Pain control reduces delirium risk
Avoid benzodiazepines and anticholinergics
Early mobilization and orientation strategies
Disposition planning
▶
Home support assessment mandatory
Occupational therapy and physiotherapy involvement
Osteoporosis management referral as fragility fracture
Pediatrics
Pediatric proximal humerus fractures
▶
Fracture patterns differ from adults
▶
Physeal fractures (Salter-Harris) in skeletally immature patients
Salter-Harris type II most common
Remodeling potential high in younger children
Mechanism differences
▶
High-energy trauma more common in adolescents
Non-accidental trauma consideration in infants and toddlers
Classification
▶
Neer classification applies to skeletally mature adolescents
Physeal fractures use Salter-Harris classification
Treatment principles
▶
Significant remodeling potential under age 12
Closed reduction and sling for most physeal fractures
ORIF or percutaneous pinning for unstable displaced fractures in older adolescents
Analgesia in children
▶
Acetaminophen 15 mg/kg PO or IV every 6 hours
Ibuprofen 10 mg/kg PO every 6 to 8 hours (max 40 mg/kg/day)
Intranasal fentanyl 1.5 mcg/kg for acute severe pain
Safeguarding considerations
▶
Non-accidental injury in infants with fractures inconsistent with developmental stage
Child protection referral if mechanism implausible
Skeletal survey if abuse suspected
Background
Epidemiology
Incidence and demographics
▶
Approximately 6% of all adult fractures
▶
Third most common fracture in the elderly after hip and distal radius
Incidence 73 per 100,000 person-years
Age and sex distribution
▶
Most common in patients over 65 years
Female predominance 71 to 94% in major trials
Bimodal distribution: elderly low-energy and younger high-energy
Mechanism distribution
▶
85% low-energy falls from standing height in elderly
High-energy trauma in younger patients from sports and MVA
Seizure-associated fractures with posterior dislocation pattern
Fracture pattern prevalence
▶
85% are minimally displaced 1-part fractures managed nonoperatively
▶
Displacement < 1 cm and angulation < 45 degrees
Excellent prognosis with conservative care
15% are displaced 2-, 3-, or 4-part fractures
▶
Require orthopedic consultation
Surgery-vs-conservative debate ongoing
Pathophysiology
Fracture mechanisms
▶
Axial load through outstretched hand
▶
Force transmitted proximally through elbow and humerus
Torque at surgical neck produces fracture
Direct impact
▶
Lateral or posterior impact on shoulder
Greater tuberosity isolated fractures from rotator cuff avulsion
Osteoporotic bone failure
▶
Reduced cortical thickness and trabecular density
Low-energy mechanism sufficient for fracture
Anatomy of fracture segments
▶
Four-segment anatomy (Neer)
▶
Articular head: supplied by anterior circumflex humeral artery arcuate branch
Greater tuberosity: supraspinatus and infraspinatus attachment
Lesser tuberosity: subscapularis attachment
Shaft: deltoid insertion
Avascular necrosis mechanism
▶
Disruption of anterior circumflex humeral artery
Intraosseous blood supply from calcar region also important
4-part fractures have highest AVN rate 13 to 34%
Neurovascular anatomy at risk
▶
Axillary artery
▶
Runs from lateral border of first rib to lower border of teres major
Anterior circumflex humeral artery branch at risk with proximal fractures
Axillary nerve
▶
Exits quadrilateral space at inferior capsule
At risk with inferior humeral head displacement
Most commonly injured nerve with proximal humerus fractures
Therapeutic Considerations
Nonoperative vs operative decision framework
▶
Neer 1-part and selected 2-part fractures
▶
Nonoperative management standard of care
Excellent outcomes with rehabilitation
PROFHER and NITEP trial implications
▶
No functional outcome benefit of surgery for most displaced fractures in older patients
Higher surgical complication and reoperation rates
Shift toward nonoperative approach for elderly with 2- and 3-part fractures
Surgical indications that remain valid
▶
Open fractures
Neurovascular compromise
Head-split fractures
Selected fracture-dislocations
Young active patients with significant displacement
AVN risk and arthroplasty selection
▶
Risk stratification
▶
4-part fractures: 13 to 34% AVN risk
Medial calcar integrity predicts lower AVN risk even in 3- and 4-part patterns
AO Type C fractures: highest risk
RSA vs hemiarthroplasty
▶
RSA superior functional outcomes in RCTs for elderly patients
RSA complications include instability and implant loosening
Hemiarthroplasty outcomes depend on tuberosity healing which is unpredictable
Regional anesthesia integration
▶
Interscalene or supraclavicular block
▶
Effective acute pain management in ED
Reduces systemic opioid exposure
Enables earlier rehabilitation initiation
Multimodal analgesia principle
▶
Acetaminophen plus NSAIDs plus regional block
Opioid-sparing approach reduces adverse effects
Patient Discharge Instructions
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Proximal humerus fracture home care
▶
Wear your sling at all times except for exercises
▶
Remove sling only when doing prescribed exercises
Sleep with sling on or in a recliner for comfort
Ice wrapped in cloth to shoulder for 20 minutes several times daily
▶
Do not apply ice directly to skin
Continue for the first 48 to 72 hours
Keep your elbow, wrist, and fingers moving
▶
Bend and straighten your elbow 10 times hourly
Open and close your fist and move your wrist gently
Pendulum exercises if instructed by your doctor
▶
Lean forward and let arm hang, gently swing in small circles
Stop if pain is severe
Medications
▶
Take acetaminophen and anti-inflammatories as prescribed
▶
Do not exceed 4 g of acetaminophen per day
Take anti-inflammatories with food
If prescribed opioid pain medication
▶
Take only as needed for severe pain
Do not drive or operate machinery
Do not take with alcohol
Activity restrictions
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Do not lift anything with the injured arm
▶
No reaching above shoulder height
No pushing or pulling with the affected arm
Expect bruising extending to your chest and arm
▶
This is normal and expected within 24 to 48 hours
Bruising does not indicate worsening injury
Recovery is gradual
▶
Even minimally displaced fractures take 6 to 8 months for full recovery
Do not rush return to activity
Follow-up
▶
Orthopedic appointment within 7 to 10 days
▶
Bring all imaging from the emergency department
Repeat x-rays will be done at follow-up
Osteoporosis evaluation recommended
▶
Ask your family doctor about a bone density scan DEXA
Calcium and vitamin D supplements recommended
Return to emergency department immediately if
▶
Increasing numbness, tingling, or weakness in hand or fingers
Hand becomes cold, pale, or blue or purple in color
Worsening pain not controlled by medications
Fever over 38.5 degrees Celsius
Redness, warmth, or drainage from any wound
Inability to move fingers
References
Guidelines and key sources
Clinical practice guidelines
▶
ACR Appropriateness Criteria Acute Shoulder Pain 2024 Update
▶
Laur O et al., Journal of the American College of Radiology 2025
CT optimal for delineating proximal humeral fracture patterns
American Family Physician acute shoulder injuries review 2023
▶
Simon LM, Nguyen V, Ezinwa NM
Comprehensive nonoperative and operative guidance
Cochrane Review interventions for treating proximal humeral fractures in adults 2022
▶
Handoll HH et al., Cochrane Database of Systematic Reviews
Synthesis of surgical vs nonoperative evidence
Landmark trials
PROFHER trial
▶
Rangan A et al., JAMA 2015
▶
Surgical vs nonsurgical treatment of displaced proximal humerus fractures
No significant benefit of surgery over nonoperative treatment in patients >= 60 years
Higher complication and reoperation rates in surgical group
▶
Shifted practice toward nonoperative management in elderly
NITEP trial
▶
Launonen AP et al., PLoS Medicine 2023
▶
Locking plate or hemiarthroplasty vs nonoperative for 3-4 part fractures
Confirms PROFHER findings with no functional outcome benefit of surgery
Open-label randomized trial
Classification and imaging evidence
Neer classification reliability
▶
Sumrein BO et al., Journal of Shoulder and Elbow Surgery 2018
▶
Intraobserver and interobserver reliability evaluation
Poor to moderate kappa values for Neer classification
Berkes MB et al., Journal of Bone and Joint Surgery American Volume 2014
▶
3D CT improves intraobserver and interobserver reliability
3D CT recommended for preoperative planning
Dauwe J et al., European Journal of Trauma and Emergency Surgery 2022
▶
Advanced CT visualization improves classification accuracy for orthopaedic surgeons and residents
Vascular injury references
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Ng AJ et al., Annals of Vascular Surgery 2016
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Axillary artery injury associated with proximal humeral fractures
Long-term vascular, orthopedic, and neurologic outcomes review
Zuckerman JD et al., Clinical Orthopaedics and Related Research 1984
▶
Axillary artery injury as complication of proximal humeral fractures
Case reports and literature review
ICD-10 and coding references
Relevant ICD-10 codes
▶
S42.201A closed proximal humerus fracture unspecified
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S42.251A greater tuberosity fracture
S42.301A humeral shaft fracture for differential
M84.521A pathologic fracture humerus
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S43.006A glenohumeral dislocation
S45.001A axillary artery injury
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
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Management Protocols
Humerus Fracture (Proximal)