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Humerus proximal fracture
Shoulder & Clavicle
AC separation
Biceps tendon rupture
Clavicle fracture
Humerus proximal fracture
Rotator cuff tear
Scapular fractures
Shoulder dislocations
SLAP tear
Sternoclavicular dislocation
Arm & Elbow
Compartment syndrome (anterior, lateral, deep - superficial posterior)
Coronoid process fracture
Elbow dislocations
Epicondylar fracture
Humeral shaft fracture
Intercondylar and condylar region fracture
Olecranon fracture
Radial head fracture (Mason I-IV)
Supracondylar fracture (pediatric and adult)
Triceps tendon rupture
Forearm, Wrist & Hand
Carpal bones fractures
Carpal dislocations and ligament injuries
Distal radius and ulna fracture
Fight bite (human bite over MCP)
Finger dislocations by joint
Finger open fractures - amputations
Forearm fractures
Hand and finger tendon and ligament injuries
Hand tendon injuries
Metacarpal fractures
Nail bed injuries
Phalangeal fractures
Tuft fracture
Spine
Cervical spine fracture (C1-C7)
Cord syndromes
Sacrum and coccyx fracture
Thoracic and lumbar spine fracture
Pelvis & Hip
Acetabular fractures
Hip dislocations
Pelvis fractures
Proximal femur fractures
Thigh & Knee
Distal femur fractures
Femoral shaft fractures
Knee dislocation
Knee ligament injuries
Patellar dislocation
Patellar fracture
Patellar tendon rupture
Pes anserine bursitis
Prepatellar bursitis
Quadriceps tendon rupture
Tibial plateau fracture
Tibial spine fracture
Tibial tubercle fracture
Leg & Shin
Achilles tendon rupture
Fibular shaft fracture
Proximal fibula fracture
Stress fracture (tibia-fibula)
Tibial and Fibular shaft fracture
Tibial shaft fracture
Toddler's fracture
Ankle
Ankle dislocation
Ankle fractures
Ankle sprain
Maisonneuve fracture (proximal fibula and syndesmosis)
Peroneal tendon dislocation or tear
Peroneal tendon tear or dislocation
Subtalar dislocation
Syndesmotic injury (high ankle sprain)
Foot
Calcaneus fracture
Cuboid fracture
Cuneiform fractures
Dancer's fracture (5th MT spiral shaft)
Jones fracture (5th MT base - metadiaphyseal junction)
Lisfranc injury (tarsometatarsal dislocation)
March fracture (metatarsal stress fracture)
Metatarsal fractures (1st-5th)
Navicular fracture
Plantar fascia rupture
Talus fracture
Tibialis posterior tendon dysfunction
Toe dislocations
Humerus proximal fracture
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Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
Approach to the Critical Patient
Immediate priorities
Proximal humerus fracture initial stabilization
▶
Airway risk with sedation needs
▶
NPO status uncertainty
Aspiration risk factors
Hemorrhage and shock screen
▶
High-energy mechanism trigger
Anticoagulant use trigger
Limb threat screen
▶
Cool hand
Absent radial pulse
Rapidly progressive neurologic deficit
Skin threat screen
▶
Tenting
Blanching
Impending open fracture features
Neurovascular and compartment risk
Distal perfusion and neurologic baseline
▶
Radial pulse
▶
Doppler signal if nonpalpable
Capillary refill
▶
Side-to-side comparison
Axillary nerve function
▶
Lateral deltoid sensation
Deltoid activation
Brachial plexus screen
▶
Median nerve motor and sensation
Ulnar nerve motor and sensation
Radial nerve motor and sensation
Compartments
▶
Escalate if pain out of proportion with tense swelling
Escalate if increasing analgesic requirement with worsening exam
Escalation triggers
Immediate orthopedics escalation
▶
Fracture-dislocation
Head-splitting fracture pattern concern
Open fracture
Persistent neurovascular deficit after immobilization
Threatened skin despite immobilization
Transfer triggers
▶
Vascular injury concern requiring CTA and vascular capability
Polytrauma with competing priorities
Surgical capability mismatch for complex proximal humerus reconstruction
History
Injury context
Mechanism and energy
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Low-energy fall onto outstretched hand
▶
Fragility fracture context
Direct lateral shoulder impact
▶
Greater tuberosity involvement risk
High-energy MVC or fall from height
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Head-splitting and fracture-dislocation risk
Seizure or electrocution
▶
Posterior dislocation association
Timing and course
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Time since injury
Progressive swelling trajectory
Prior manipulation or reduction attempt
Function and baseline
▶
Hand dominance
Baseline shoulder function
Athletic overhead demands
Associated symptoms
▶
Numbness over lateral shoulder
▶
Axillary nerve concern
Hand numbness or weakness
▶
Brachial plexus concern
Neck pain
▶
Cervical spine injury co-risk
Bleeding and bone health
▶
Anticoagulants
Antiplatelets
Osteoporosis diagnosis
Chronic glucocorticoids
Prior shoulder surgery or hardware
Open injury risk
▶
Wound near shoulder
Contamination
Delay to presentation
Physical Exam
Shoulder and upper limb exam
Inspection and skin
▶
Deformity
Ecchymosis and swelling
Tenting or blanching
Abrasion or laceration near fracture site
Palpation and landmarks
▶
Proximal humerus tenderness
AC joint tenderness
Clavicle tenderness
Scapular spine tenderness
Motion and function
▶
Active shoulder motion limitation
Elbow range of motion
Wrist and hand range of motion
Neurovascular
▶
Axillary nerve
▶
Lateral deltoid sensation
Deltoid contraction
Radial nerve
▶
Wrist extension
Dorsal first web space sensation
Median nerve
▶
Thumb opposition
Index fingertip sensation
Ulnar nerve
▶
Finger abduction
Small fingertip sensation
Vascular
▶
Radial pulse
Ulnar pulse
Capillary refill
Joint above and below
▶
Cervical spine screen if mechanism warrants
Elbow tenderness and stability
Wrist tenderness
PITFALLS
Common misses
▶
Posterior shoulder dislocation with subtle deformity
▶
Limited external rotation clue
Axillary nerve neuropraxia documentation omission
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Pre and post immobilization neuro exam requirement
Concomitant rotator cuff tear in older patients
▶
Persistent weakness after pain control trigger
Differential Diagnosis
Shoulder region mimics and co-injuries
Fracture patterns and related conditions
▶
Glenohumeral dislocation without fracture
▶
Posterior dislocation
Anterior dislocation
Scapular fracture
▶
High-energy association
Clavicle fracture
AC joint injury
Rotator cuff tear
Brachial plexus injury
Axillary artery injury
Alternate diagnoses
▶
Cervical radiculopathy or cord injury
Septic arthritis
Pathologic fracture
▶
Malignancy concern
Coding targets
ICD-10 proximal humerus fracture
▶
S42.20 unspecified fracture of upper end of humerus
S42.21 surgical neck fracture of humerus
S42.24 greater tuberosity fracture of humerus
S42.29 other fracture of upper end of humerus
SNOMED CT concepts
▶
Proximal humerus fracture
Greater tuberosity fracture
Surgical neck fracture of humerus
Humeral head fracture
Shoulder fracture-dislocation
Laboratory Tests
When labs matter
Targeted labs only
▶
Planned procedural sedation
▶
Glucose if diabetes risk
Pregnancy test if applicable
Planned operative pathway
▶
CBC for anemia or bleeding concern
Electrolytes and creatinine for perioperative planning
Coagulation studies if anticoagulants or liver disease
Open fracture
▶
CBC for baseline
Lactate if systemic illness concern
Major trauma context
▶
Type and screen
Venous blood gas if shock concern
Interpretation pearls
▶
Normal labs do not exclude vascular injury
▶
Exam-driven escalation priority
INR target for regional anesthesia decisions per local protocol
▶
Anesthesia involvement trigger
Diagnostic Tests
Scoring Systems
Neer classification
▶
Neer parts definition
▶
Part displacement threshold
▶
Greater than 1 cm separation
Greater than 45 degrees angulation
One-part fracture
▶
No segment meeting displacement threshold
Two-part fracture
▶
One displaced segment
Three-part fracture
▶
Two displaced segments with head still articulating
Four-part fracture
▶
Three displaced segments with head segment involved
Clinical implications
▶
One-part typical nonoperative pathway
Multi-part higher avascular necrosis risk
AO OTA proximal humerus classification
▶
Extra-articular unifocal
Extra-articular bifocal
Articular
Surgical planning communication tool
Radiographs
Required views
▶
Shoulder series
▶
AP in scapular plane
Scapular Y
Axillary view
▶
Velpeau axillary view option if abduction limited
Include joint above and below when shaft extension suspected
▶
Humerus AP and lateral
Elbow views if pain or swelling
Key interpretation targets
▶
Fracture location
▶
Surgical neck
Anatomic neck
Greater tuberosity
Lesser tuberosity
Displacement and angulation
▶
Neer displacement thresholds
Dislocation
▶
Glenohumeral alignment
Greater tuberosity displacement
▶
Less than 5 mm typical nonoperative
Greater than 5 mm operative consideration due to impingement risk
Varus angulation and medial calcar comminution
▶
Instability and malunion risk
Post-reduction imaging
▶
Mandatory after any manipulation
Neurovascular exam documentation paired with post films
MRI
Indications
▶
Occult fracture with high suspicion and negative radiographs
Rotator cuff tear suspicion affecting management
Persistent pain and weakness after initial immobilization period
Contraindications and limitations
▶
Non MRI compatible implants
Acute pain limiting positioning
Diagnostic performance considerations
▶
High sensitivity for marrow edema and occult fracture patterns
Soft tissue injury delineation
CT
Indications
▶
Complex fracture morphology for surgical planning
Head-splitting pattern concern
Fracture-dislocation characterization
Intra-articular extension uncertainty
Protocol considerations
▶
Thin-slice shoulder CT with 3D reconstructions when surgical planning needed
Vascular imaging pathway
▶
CTA upper extremity if hard signs of vascular injury
▶
Expanding hematoma
Absent pulses with ischemic signs
Bruit or thrill
Disposition
Site of care and follow-up
Copy
Discharge criteria
▶
Hemodynamically stable
Pain controlled with oral regimen
Neurovascularly intact after immobilization
No threatened skin
Reliable follow-up within timeframe
Admission criteria
▶
Uncontrolled pain despite ED optimization
Neurovascular compromise
Open fracture
Fracture-dislocation
Unsafe discharge supports
Polytrauma
Orthopedics follow-up timing
▶
Minimally displaced fracture
▶
3 to 7 days
Displaced fracture or greater tuberosity involvement
▶
24 to 72 hours
Post reduction fracture-dislocation
▶
Next day or within 48 hours
Activity restrictions
▶
Sling immobilization
No lifting with affected arm
Elbow wrist hand range of motion encouraged
Treatment
Immediate life-saving interventions
Limb threat actions
▶
If pulseless or ischemic hand, immediate reduction attempt if dislocated and rapid ortho and vascular escalation
▶
Immobilization after reduction with repeat vascular exam
If open fracture, antibiotics and tetanus pathway before prolonged imaging when feasible
Constriction relief
▶
Ring removal
Tight clothing and jewelry removal
Pain control and antiemesis
▶
Multimodal approach
Avoid oversedation in elderly
Immobilization and Splinting
Upper extremity immobilization selection
▶
Sling and swathe
▶
Standard for proximal humerus fractures
Coaptation splint
▶
If extension into humeral shaft with instability
Posterior long arm
▶
If concomitant elbow injury suspected
Immobilization principles
▶
Comfort position
▶
Slight elbow flexion
Arm supported to reduce traction pain
Swelling phase
▶
Avoid circumferential casting
Reassessment
▶
Neurovascular exam after immobilization
Skin checks for pressure points
Reduction
Indications for urgent reduction
▶
Fracture-dislocation
Neurovascular compromise
Threatened skin
Analgesia and anesthesia options
▶
Non-opioid analgesia
▶
Acetaminophen PO 1000 mg q6h
▶
Maximum 4000 mg per day
Ibuprofen PO 400 mg q6h
▶
Maximum 2400 mg per day
Opioid analgesia
▶
Hydromorphone IV 0.2 mg to 0.5 mg q5 to 10 min PRN
▶
Titrate to pain and respiratory status
Fentanyl IV 25 mcg to 50 mcg q5 min PRN
▶
Titrate to effect
Regional anesthesia
▶
Interscalene block when expertise available
▶
Phrenic nerve palsy risk
Procedural sedation
▶
Ketamine IV 0.5 mg per kg to 1 mg per kg
▶
Repeat 0.25 mg per kg to 0.5 mg per kg q5 to 10 min PRN
▶
Airway readiness and continuous monitoring
Propofol IV 0.5 mg per kg to 1 mg per kg
▶
Repeat 0.25 mg per kg to 0.5 mg per kg q1 to 3 min PRN
▶
Hypotension risk in elderly
Technique principles
▶
Gentle traction and countertraction
Deformity exaggeration when fragments locked
Reverse mechanism for dislocation pattern when clear
Avoid repeated forceful attempts
Post reduction requirements
▶
Immediate neurovascular recheck
Post reduction radiographs
Immobilization in stable position
Failed reduction pathway
▶
Persistent neurovascular deficit triggers immediate escalation
Irreducible dislocation triggers urgent orthopedics
Worsening pain with tense swelling triggers compartment concern escalation
Open fracture medications and timing
Antibiotics
▶
Cefazolin IV 2 g q8h
▶
First dose within 60 minutes of presentation when open suspected
If severe beta-lactam allergy, clindamycin IV 900 mg q8h
▶
MRSA risk consideration per local protocol
If heavy contamination or farm injury, add gentamicin IV 5 mg per kg daily
▶
Renal function dosing adjustment
Tetanus prophylaxis
▶
Unknown or incomplete immunization
▶
Tdap or Td
Tetanus immune globulin 250 units IM
Up to date immunization with dirty wound and last booster over 5 years
▶
Tdap or Td booster
Wound care
▶
Sterile saline moistened dressing
Avoid deep probing in ED
Orthopedics urgent washout pathway
DVT prophylaxis when relevant
Typical isolated upper extremity fracture
▶
Routine pharmacologic prophylaxis not standard
Elevated risk scenarios
▶
Prolonged immobilization with major comorbidity
Polytrauma
Operative admission
Prior VTE
Alignment with local protocol
▶
Medicine or surgery service decision ownership
Special Populations
Pregnancy
Maternal and fetal considerations
▶
Left lateral positioning if symptomatic hypotension
Analgesia selection
▶
Acetaminophen preferred first-line
NSAID avoidance in later pregnancy per obstetric guidance
Imaging considerations
▶
Radiographs acceptable with shielding when appropriate
CT risk-benefit when vascular injury concern
Obstetric involvement triggers
▶
Abdominal trauma
Vaginal bleeding
Contractions
Geriatric
Fragility fracture pathway
▶
Low-energy fall mechanism common
Osteoporosis evaluation referral
Higher delirium risk with opioids
Treatment trends and evidence
▶
More than 80 percent minimally displaced and treated nonsurgically
▶
AAOS educational summary
Operative vs nonoperative outcomes uncertainty in displaced fractures
▶
PROFHER trial no difference at 2 years for selected displaced fractures
Disposition considerations
▶
Admission threshold lower with poor supports
PT OT needs
Fall risk mitigation plan
Pediatrics
Remodeling potential
▶
Younger children tolerate greater angulation and displacement
Older adolescents lower remodeling capacity
Growth plate concerns
▶
Salter-Harris patterns
Gentle technique if reduction needed
Nonaccidental trauma consideration
▶
Inconsistent history
Additional injuries
Background
Epidemiology
Incidence and demographics
▶
Incidence 89.3 per 100000 women per year and 28.2 per 100000 men per year in one population study
Overall incidence about 110 per 100000 population per year in a large database analysis
Women disproportionately affected among age 65 years and older
Second most common upper extremity fracture after distal radius
Mechanism patterns
▶
Low-energy falls predominant in older adults
High-energy trauma more common in younger patients
Pathophysiology
Anatomy and deforming forces
▶
Rotator cuff pulls tuberosity fragments
▶
Supraspinatus greater tuberosity superior displacement
Subscapularis lesser tuberosity medial displacement
Varus collapse mechanism
▶
Medial calcar comminution instability
Complications mechanisms
▶
Avascular necrosis risk
▶
Disruption of humeral head blood supply with multi-part patterns
Stiffness risk
▶
Prolonged immobilization and pain-limited motion
Malunion and nonunion risk
▶
Varus malunion in unstable patterns
Therapeutic Considerations
Nonoperative rationale
▶
Minimally displaced fractures have good outcomes with sling and early motion
Early pendulum and assisted motion reduces stiffness risk
Operative rationale
▶
Articular congruity and tuberosity position preserve shoulder mechanics
Greater tuberosity displacement over 5 mm associated with impingement and loss of abduction and external rotation
Indications categories
▶
Absolute surgical indications described in expert guidance
▶
Dislocated humeral head
Head-splitting fracture
Greater tuberosity displaced superiorly or posteriorly
Significant varus angulation with medial pillar instability
Evidence framing
▶
PROFHER randomized trial
▶
No functional outcome difference at 2 years in selected displaced fractures randomized to operative vs nonoperative
Patient Discharge Instructions
Copy discharge instructions
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Proximal humerus fracture discharge plan
▶
Sling and swathe
▶
Wear continuously except hygiene and exercises as instructed
Elevation
▶
Hand above heart when resting
Ice
▶
15 to 20 minutes every 2 to 3 hours for 48 hours
Pain control
▶
Acetaminophen as directed on label
Ibuprofen as directed on label if safe for you
Opioid only if prescribed
Mobility
▶
Finger wrist elbow motion several times daily
No lifting or pushing with injured arm
Return to ED now
▶
Increasing pain not controlled
New numbness or weakness
Cool pale or blue hand
Increasing tight swelling
Splint or sling causing skin pressure injury
Fever or wound drainage
Follow-up
▶
Orthopedics appointment within recommended timeframe from discharge paperwork
Repeat x-ray timing per orthopedics plan
References
Evidence-based sources
Source set
▶
Neer classification displacement thresholds greater than 1 cm separation or 45 degrees angulation
▶
PMC review of Neer classification
Epidemiology rates
▶
Female incidence 89.3 per 100000 per year and male incidence 28.2 per 100000 per year in one study
Overall incidence about 110 per 100000 per year in a large database analysis
Nonoperative prevalence
▶
More than 80 percent minimally displaced and treated nonsurgically in AAOS educational material
Greater tuberosity operative threshold
▶
Displacement greater than 5 mm operative consideration and less than 5 mm typical nonoperative in Orthobullets summary
Operative vs nonoperative outcomes
▶
PROFHER trial summary in OTA curriculum document
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Orthopedic Injuries
Humerus proximal fracture