01Approach to the Critical Patient/attcp48

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

02History/hx75

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)

03Physical Exam/exam56

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

04Differential Diagnosis/ddx45

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

05Laboratory Tests/lt40

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

06Diagnostic Tests/dt98

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

07Disposition/dispo55

Discharge criteria

›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

08Treatment/t93

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

›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

›Calcium supplementation

›1200 mg elemental calcium daily in divided doses

›Dietary calcium preferred where possible

›Vitamin D supplementation

›800 to 1000 IU vitamin D daily

›Higher doses if deficiency confirmed on serum level

›Bisphosphonate therapy

›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

›Medication review

›Deprescribe or reduce sedatives, anticholinergics, antihypertensives

›Pharmacist consultation for polypharmacy

›Physiotherapy referral

›Balance and gait training

›Home safety assessment

09Special Populations/sp67

Pregnancy

›Pregnancy considerations

›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

10Background/b78

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

11Patient Discharge Instructions/pdi45

copy discharge instructions

›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

›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

12References/r44

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

Evidence & Review