Welcome to The Deep Dive. Today, we're tackling
something that really blends intricate mechanics
with some quite complex decision making. It's
the kind of puzzle, I think, that resonates whether
you're building a product, managing a team, or,
well, in this case, dealing with a broken bone.
We're diving into proximal humorous fractures,
often just called a broken shoulder. Indeed.
And it's an injury that really highlights how
something seemingly straightforward, like a simple
fall, can actually lead to surprisingly complex
challenges. Right. So for this Deep Dive, we've
looked at a range of expert sources, insights
from the Orthopedic Trauma Association, detailed
clinical reviews like stat pearls and ortho bullets,
bits from the bone school, and also a summary
document from the Stanford AVA lab. OK. And our
mission today is really to distill the essential
knowledge from all of that material. Why focus
on this specific injury? Well, partly because
it's remarkably common, isn't it, particularly
among older adults? Yes, very much so. And managing
it really seems to involve navigating complexity,
evaluating trade -offs, often under uncertainty,
and committing to what sounds like quite a demanding
recovery. These feel like universal themes. Absolutely.
By looking closely at the sort of anatomy of
the problem, how we classify its severity, the
nuanced choices around treatment, and the realities
of recovery and managing potential risks in a
specialist field like orthopedics, we definitely
find parallels. Parallels to strategic challenges
you might face in, well, any professional field
really. It's about understanding a specific intricate
system to gain perhaps broader insights into
problem solving and resilience. Right, okay.
Let's get into the mechanics of it then. When
we talk about a proximal humerus fracture, where
exactly are we focusing? What's the actual system
we need to understand here? Okay, let's start
with the basic structure, drawing on the descriptions
and sources like the OTA and stat pearls. Your
shoulder joint is... Well, it's a marvel of mobility,
really. Yeah. And at its core, you have three
bones. The clavicle, your collarbone, the scapula,
which is the shoulder blade, and the humerus,
your upper arm bone. OK. The proximal humerus
is simply the section of that humerus closest
to the shoulder joint. So essentially, the very
top of the arm bone. So the part that forms the
ball in the ball and socket joint of the shoulder.
Precisely. But this ball region, it's not just
one simple solid structure. To really understand
how it breaks, orthopedically, it's often viewed
as being made up of four functional parts. Four
parts? Yes. This way of thinking was really crystallized
by the surgeon Charles Near, whose classification
system we'll definitely come back to. These parts
are based on how the bone tends to fragment when
it's injured, often along weaker lines or areas
where key tendons attach. Four parts within just
the top of that one bone. That already sounds
more complex than just a simple break. What are
they? Well, based on the detailed descriptions
across our sources, stat pearls, ortho bullets,
they all cover this. These four key parts are...
Firstly, the articular segment. That's the rounded
smooth cartilage covered surface of the humeral
head itself. Right. The actual ball part that
moves against the socket on the shoulder blade.
The surface that allows that smooth movement.
Exactly. Then... Just below that articular surface,
you have the anatomic neck. Anatomic neck, okay.
This is basically the line where the original
growth plate was in childhood, separating the
head from the rest of the bone. Fractures right
along this line can be tricky because they're
very close to the blood supply feeding the humeral
head itself. Right, that sounds important. Okay,
anatomic neck. What's the third part? The third
is the surgical neck. This is located a bit further
down the bone, below those bony bones called
the tuberosities. We'll get to those next. Okay.
It's often described as the narrowest point or
perhaps the weakest structural zone of the upper
humerus. And this is a critically important area
because a very high percentage of proximal humerus
fractures happen right here through the surgical
neck, especially in things like falls onto an
outstretched arm. It's just a frequent point
of failure under stress. That makes sense, a
point of sort of mechanical vulnerability. Okay,
so we have the articular surface, the anatomic
neck, the surgical neck. What's the fourth part?
The fourth part, well, it actually refers to
two bony prominences or bumps located just below
the humeral head on the side of the bone. These
are the greater tuberosity and the lesser tuberosity.
Right. The greater tuberosity is on the outer
side of the shoulder, and it's the crucial attachment
point for three of the four rotator cuff muscles,
the supraspinatus, infraspinatus, and teres minor.
These muscles are absolutely vital for lifting
and rotating the arm outwards. The lesser tuberosity
is on the front of the bone, and that's where
the subscapularis muscle attaches, which helps
with inward rotation. So these tuberosities aren't
just bumps then, they're actually anchors for
the muscles that power our shoulder movement.
Precisely. They are completely integral to the
function and the stability of the joint. And
actually, The groove that runs between these
two tuberosities, that's called the occipital
groove. That's where the long head of the biceps
tendon runs. Okay. So when we talk about a proximal
humerus fracture, we're talking about a break
that affects one or more of these four functional
units. The head, the anatomic neck, the surgical
neck, or those tuberosities. And the nature of
the fracture, it depends on... which of these
parts break and, crucially, how they move relative
to each other. Absolutely. That's the crux of
it. The OTA source really highlights that the
pattern and the severity are highly variable.
It depends heavily on which parts are fractured
and, really importantly, the extent to which
these fractured segments have moved or, as we
say, displaced from their normal anatomical position.
Right. This displacement is absolutely key to
determining the stability of the fracture and,
ultimately, how it should be treated. That leads
us neatly into how these injuries actually happen.
You mentioned it's not just one type of event.
The sources point to quite a distinct pattern,
don't they? They do, yes. Staff pearls and ortho
bullets. Both really emphasize what's called
the classical bimodal distribution of these fractures.
Bimodal, meaning? It means the injury mechanism
and the type of patient affected tend to fall
into two pretty distinct peaks, or groups. Understanding
these patterns helps us understand the underlying
risk factors, and often the likely bone quality
involved. OK, let's explore these two groups.
What's the most common scenario then? Well, the
largest group, and this accounts for the clear
majority of these fractures, involves older adults,
typically people over the age of 65. Okay. In
this demographic, the injury is usually caused
by a low energy mechanism. Most commonly, it's
a simple fall from standing height. The classic
scenario is someone tripping, falling onto an
outstretched hand, or perhaps directly onto their
elbow or shoulder. And this is where bone density
comes into play, I assume. Exactly. Stat Pearls
explicitly notes that in this older population,
these fractures are very frequently fragility
fracture. Fragility fractures, meaning the bone
breaks easily. Precisely. It means the bone has
broken, not necessarily because the force was
immense, but because the bone quality itself
has been compromised, usually by osteoporosis
or osteopenia thinning of the bone. The bone
simply isn't strong enough to withstand even
a moderate force. And these fragility fractures
are a really significant contributor to the overall
healthcare burden associated with osteoporosis.
The incidence of proximal humerus fractures is
cited as high as maybe 4 % to 6 % of all adult
fractures. And notably, there's a strong female
predominance, a reported 2 .1 female to male
ratio, which reflects the higher prevalence of
osteoporosis in women. So a very common issue
in older women, often acting as a sort of red
flag for underlying bone weakness. What about
the other group in this bimodal distribution?
The second peak involves younger, typically more
active patients. Now for them, it takes a much
higher energy trauma to cause a fracture in the
proximal humerus because their bone is generally
much stronger and denser. Examples of these high
energy mechanisms would be things like road traffic
collisions, falls from significant height, or
maybe high impact sports injuries. That's described
in the OTA and STAPROL sources. Right. These
injuries in younger patients are often more severe.
They might involve more comminution. That means
shattering of the bone. And they carry a higher
risk of associated injuries to the surrounding
soft tissues, nerves, or blood vessels, just
because of the sheer force involved. It's a stark
contrast, isn't it? A simple stumble for one
group versus a major impact for the other really
highlights different underlying vulnerabilities
or the external forces at play. So someone sustains
this injury? What are the immediate signs and
symptoms you'd expect to see? Well the clinical
presentation is usually quite dramatic and pretty
typical of a significant bone injury near a major
joint. Severe pain is almost always the primary
symptom localized right around the shoulder and
the upper arm and this pain is significantly
worse with any attempt at all to move the arm.
Swelling and bruising are also very common and
because of gravity The bruising can actually
be quite extensive. It might track downwards
over several days, sometimes appearing around
the elbow, or even further down in the forearm
or hand. That's mentioned in the OTA and unknown
19 sources. Patients will typically hold the
injured arm very close to their body, often supporting
it with the other hand, and report an inability
or just extreme reluctance to move it actively.
Sometimes they might describe a grating or grinding
sensation we call that crepitus if the fractured
bone ends are unstable and rubbing together.
And beyond just observing and asking about the
pain, a physical examination sounds absolutely
crucial to assess the full extent of the damage.
Oh, absolutely critical. A thorough physical
examination is indispensable. The clinician will
visually inspect the shoulder looking for any
obvious deformity, swelling, or that breathing
we mentioned. They'll gently palpate the area,
feel around to identify points of maximal tenderness,
and potentially feel for that crepitus. However,
a vital component of the examination, and this
is heavily emphasized in stepperals and ortho
-bullets, is the neurovascular assessment. Neurovascular,
checking nerves and blood vessels. Exactly. checking
the function of the nerves and the blood vessels
supplying the arm and hand. Why is that specific
check so important in a shoulder fracture compared
to, say, a broken wrist? It's because of the
very close proximity of major nerves and blood
vessels to the proximal humerus. particularly
around that surgical neck area where so many
fractures occur. The nerve most frequently at
risk in these injuries is the axillary nerve.
This nerve actually wraps around the surgical
neck of the humerus, and it supplies motor function
to the deltoid muscle, that's the big muscle
covering the shoulder, essential for lifting
the arm away from the body. It also supplies
sensation to the skin over the outer aspect of
the shoulder, sometimes called the regimental
badge area. So damage to that nerve could mean
real weakness in lifting the arm. Precisely.
A complete axillary nerve injury can result in
a noticeable weakness or even inability to abduct
to lift the arm sideways and often a patch of
numbness on that outer shoulder. Ortho Bullets
notes that axillary nerve palsy or weakness can
occur in quite a significant percentage of cases,
potentially up to 58%. based on some EMG studies,
although many of these might be temporary or
partial injuries, what we call neuropraxia. It's
also highlighted that the nerve is particularly
vulnerable during certain surgical approaches.
For instance, with lateral pin placement, if
doing pericucaneous fixation. Are blood vessels
also at risk then? Yes, though perhaps less commonly
injured than the axillary nerve, especially in
lower energy fractures. The axillary artery runs
close by and can potentially be damaged. particularly
in severely displaced fractures or fracture dislocations
or in those high -energy traumas. Scott Pearls
mentions arterial injury occurs in... perhaps
up to 5 % of cases. So it's absolutely crucial
to check the patient's pulses in the wrist and
hand and assess the color and temperature of
the limb to make sure there's adequate blood
flow. Although, as OrthoBullets points out, the
shoulder has quite good collateral circulation
alternative blood pathways. So relying solely
on pulses might sometimes miss a more subtle
vascular issue. Assessing motor function and
sensation for other major nerves like the radial
and musculocutaneous nerves is also part of a
thorough exam. So pain, bruising, swelling, potential
nerve, or even vascular compromise sounds quite
involved. How do clinicians then get a really
precise blueprint of the fracture pattern itself
to guide their decisions? Yeah, that's where
medical imaging becomes absolutely indispensable.
Radiographs or x -rays, as most people know them,
are the absolute cornerstone. They're the mandatory
initial step. Right. And our sources are very
specific about the views required to get a complete
picture. You need what's called a complete trauma
series of the shoulder. This isn't just one or
two quick pictures. A trauma series? What does
that typically include? Well, it involves several
views taken at different angles. The aim is to
get orthogonal, meaning 90 -degree perspectives,
which are essential for judging displacement
in multiple planes. You need to see it front
-on and side -on, essentially. OK. Q views usually
include, first, a true AP anteroposterior view,
sometimes called a grassy view. This is taken
with the patient rotated slightly so the x -ray
beam goes straight through the glenohumeral joint
space, showing it clearly without the scapula
overlapping. Gives you that front -on view of
the joint. Right. Second, a scapular Y view.
This is a lateral or side -on view. It's taken
with the patient positioned so the scapula is
seen on its side, and it looks a bit like the
letter Y. The humerus should normally sit right
in the center of that Y. This view is excellent
for assessing if the humeral head has shifted
forwards or backwards relative to the socket,
and it also helps rule out shoulder dislocations.
And a third view. Yes, usually an axillary lateral
view. This one is taken ideally with the arm
abducted, lifted slightly away from the body.
If the patient can manage it, shooting the x
-ray beam up from the armpit area. This view
is crucial for assessing displacement in the
axial plane. again, forward or backward movement,
and for seeing those tuberosities clearly in
profile. Now, if the patient can't lift their
arm due to pain or the injury itself, modified
axial views or other techniques might be needed.
That makes sense, getting multiple angles to
see the problem from all sides, like looking
at a complex structure from different viewpoints
before you decide how to fix it. What if those
standard x -rays aren't quite enough, if it looks
particularly complicated? Exactly. If the fracture
pattern is very complex, maybe shattered into
many pieces, or if there's a strong suspicion
that the break extends right into the joint surface
itself, what we call intra -articular involvement,
or simply if you need more detail for surgical
planning, then a CT scan, computed tomography,
is incredibly valuable. Stat pearls and orthobolates
both highlight its utility. A CT scan provides
detailed cross -sectional images, almost like
slices through the bone. It allows surgeons to
see precisely the number and position of all
the fragments, the degree of convolution, how
shattered it is, and the exact relationship of
the humeral head to the glenoid socket. This
is vital for planning how to fix it, whether
with pins, plates, or even a replacement. It's
particularly good for assessing the position
of those two porosities and the state of the
articular surface. And MRI, is that ever necessary
for these fracture? MRI, magnetic resonance imaging.
is less commonly used for assessing the bone
fracture itself. Its strength is really in evaluating
soft tissues. As the Orthobolus points out, an
MRI might be considered if there's a strong suspicion
of a significant associated soft tissue injury
that could really impact the treatment or the
outcome. For example, a complete tear of the
rotator cuff tendons, or perhaps significant
ligament damage, which might happen alongside
the fracture in those higher energy traumas.
Okay, so imaging gives us that detailed blueprint.
Then comes the task of actually classifying the
damage, which seems to be where orthopedic surgeons
translate all this complex image data into a
framework for making decisions. We mentioned
the near classification earlier. Let's dig into
that. How does it work, and why is this act of
classification so central to deciding the path
forward? Yeah, classification is absolutely fundamental
in orthopedic trauma. It does two main things.
It provides a common language so surgeons can
communicate effectively about specific injury
patterns, and it provides a framework for grouping
similar injuries together, which in turn helps
guide treatment algorithms and allows us to compare
outcomes in research studies. The near classification,
which is based on those four functional parts
we discussed earlier, the articular surface or
head, the greater tuberosity, the lesser tuberosity,
and the shaft or surgical neck region is arguably
the most widely used system for proximal humerus
fractures. And it classifies fractures based
purely on the number of these four primary parts
that are significantly displaced. So it's not
just about how many fracture lines you can see
on the x -ray, but specifically about how far
the main pieces have moved. That feels like a
key distinction. It is the key distinction. That's
the critical insight from near system. A fracture
line can exist, maybe multiple lines, but if
the pieces remain in relatively good alignment,
it's treated very differently than if they've
shifted significantly out of place. According
to StatPearls and OrthoBullets, a segment is
considered significantly displaced if it is moved
by more than one centimeter. or 10 millimeters,
or if it's angled by more than 45 degrees relative
to its normal anatomical position. Right. Those
are the specific thresholds used to determine
if a part counts towards the classification number.
Got it. Okay, so let's walk through the near
categories based on that displacement rule. How
does it start? Right. It starts simply. A one
-part fracture. This means there are fracture
lines present in the proximal humerus, potentially
separating multiple segments, but, and this is
the crucial bit, none of the four main parts,
head, tuberosity, shaft, are displaced by more
than that one centimeter or 45 degrees. So it's
key, multiple cracks don't automatically make
it a multi -part fracture in the Nair system
if the fragments are still essentially in place.
Orthobolus notes that these minimally displaced
fractures often technically two -part surgical
neck fractures, but with minimal shift, are actually
the most common type we see. So even if there
are breaks technically separating several areas,
if everything stays relatively put, it's classified
as a one -part. That's maybe a bit counterintuitive
at first. What's a two -part fracture then? A
two -part fracture means there are fracture lines
separating two or more segments, but only one
of those four major functional parts is significantly
displaced again, more than one centimeter or
45 degrees. Just one part moved significantly.
Yes. A very common example highlighted by ortho
bullets is a surgical neck fracture, where the
main shaft fragment is displaced upwards or angled.
but the humeral head and the tuberosities remain
together as a single unit and in reasonable alignment
relative to each other. Or, alternatively, maybe
the greater tuberosity alone is pulled off and
displaced, but the head and shaft remain aligned.
Okay, makes sense. And it just increases from
there. Exactly. A three -part fracture involves
fracture lines separating three or more segments,
and now two of the four primary parts are significantly
displaced relative to the others. Two parts out
of place. Yes. So a typical three -part fracture
might involve a fracture through the surgical
neck with significant displacement of both the
greater and lesser tuberosities relative to the
humeral head and shaft. or perhaps displacement
of just one tuberosity in the surgical neck fragment.
The point is, two of those four core units are
significantly out of alignment. Right. And finally,
the most severe in this system. That would be
the four -part fracture. This is the most complex
and generally unstable pattern classified by
NEAR. It means there are fracture lines separating
all four primary parts, the articular segment
head, the greater tuberosity, the lesser tuberosity,
and the shaft. And three of these four parts
are significantly displaced relative to each
other and the remaining segment. The blood supply
to the humeral head is often significantly compromised
in these injuries, which dramatically increases
the risk of the bone in the head dying off what
we call a vascular necrosis, or AVN. Okay. OrthoBullets
also mentions some specific patterns that are
particularly problematic, like fractures right
through the anatomic neck, which have a very
high risk of AVN, fracture dislocations, where
the humeral head is not only broken but also
completely out of the socket, and head split
fractures, where the articular surface itself
is actually shattered. These are often considered
within or alongside the four -part category due
to their severity and implications for treatment,
especially the risk to blood supply. So the NEAR
system provides a kind of shorthand, driven entirely
by displacement, for communicating the complexity
and the likely instability of the fracture. We
also saw mention of another system, the AOTA
classification. Is that widely used as well,
or is it more for specific purposes? Yes, the
AOATA system is another important classification,
and it's also referenced in StatPearls and OrthoBolix.
It's generally a more detailed and comprehensive
system than NEAR. It's actually part of a much
larger universal system. designed for classifying
all bone fractures throughout the body. It organizes
proximal humerus fractures into three main groups
labeled A, B, and C, based primarily on whether
the fracture is extra -articular, meaning it
doesn't involve the joint surface directly. Those
are the A types. Partially intraarticular, some
involvement of the joint surface, the B types.
Or fully intraarticular, crossing the joint surface
significantly, the C types. Right. And then within
each of those groups, there are numerous subgroups
that detail specific fracture patterns and the
level of convolution or shattering. Unknown19
mentions that a newer version from 2018 attempts
to integrate some of NEAR's concepts about displacement
while providing even greater descriptive power.
So, more detailed. Yes, much more granular. It's
often preferred in research settings because
it allows for very precise comparisons between
studies. And it's also very useful for detailed
preoperative planning, especially for the really
complex cases, as it allows for finer distinctions
in the fracture patterns. But perhaps for day
-to -day communication, NEAR is still very commonly
used because of its relative simplicity based
on that key concept of displacement. Okay, so
we've sort of dissected the anatomy, understood
the ways it breaks, and how those breaks are
classified based on displacement. Now comes the
really crucial, and it sounds like often challenging
phase, deciding on the actual treatment. This
seems less like a simple A or B choice and much
more like navigating a complex decision tree,
especially given all the variability and patience
in fracture patterns. It is indeed a complex
decision. This is where applying all that knowledge
to a very specific situation becomes paramount,
much like, as you say, strategic decision making
in other fields. And here's where it gets really
interesting and perhaps quite counterintuitive
for many people. Okay. The sources we looked
at consistently state that the majority of proximal
humerus fractures are actually treated successfully
without surgery. Really? That is surprising.
When you picture a broken shoulder, I think most
people instinctively assume surgery is needed.
It's a common assumption, but the data suggests
otherwise. Both the OTA and StatPearl site figures
suggesting that somewhere between 80 % and 85
% of these fractures can be managed non -operatively.
80 to 85 percent. Wow! So non -operative management
is the default path for most. For fractures that
are minimally displaced, and remember what minimally
displaced means in the Nair system, no part displaced
more than one centimeter or 45 degrees non -operative
management is generally the preferred approach.
Okay. This includes almost all one -part fractures,
even if there are multiple fracture lines visible,
and indeed many two -part surgical neck fractures
where the displacement is still within those
accepted limits. Even some displaced greater
tuberosity fractures might be managed non -operatively
initially. Although ortho bullets specifies that
displacement of the greater tuberosity by more
than about five millimeters is usually considered
unacceptable for non -operative treatment. Why
is that specific tuberosity displacement such
an issue? Because the rotator cuff muscles attach
there. If that fragment heals in a position that's
too high or too far back, it can physically block
the shoulder from moving properly. causing painful
impingement and significant loss of function,
especially lifting the arm. The muscles pull
it out of place. Right, makes sense. So if the
pieces are still in relatively good alignment,
the body is often capable of healing it itself
given the chance. Precisely. The goal of non
-operative treatment is simply to allow the bone
to heal naturally. in an acceptable position
while trying to maintain as much shoulder function
as possible throughout the process. It's essentially
a trust in the body's own biology. OK. This management
typically starts with a period of immobilization,
usually just for a few weeks, maybe two to three,
in a sling or a similar support like a shoulder
immobilizer. This is primarily for comfort during
the initial very painful phase, and also to provide
some protection for the healing tissues. Just
a few weeks of immobilization, not months of
being completely still then. Crucially, no. And
this is a really key point highlighted across
the sources. Prolonged, rigid immobilization
of the shoulder is actually detrimental. Why
is that? Because it inevitably leads to significant
stiffness. The shoulder capsule thickens and
contracts. potentially resulting in a frozen
shoulder or adhesive capsulitis, which could
be incredibly difficult to recover from. So the
non -operative protocol needs to transition relatively
quickly into a phase of progressive, supervised
physical therapy and rehabilitation. As early
as, say, 10 to 14 days after the injury, once
the very acute pain starts to settle, patients
are often encouraged to begin gentle range of
motion exercises such as pendulum exercises as
their pain allows. Pendulum exercises. That's
just letting the arm hang down and gently swinging
it. Exactly. Using gravity to create some gentle
movement at the shoulder joint without actively
using the muscles. This helps prevent the capsule
from seizing up. Okay. Then active assisted range
of motion where the patient uses their good hand
or a therapist helps to move the injured arm
typically begins around four to six weeks once
the initial pain is subsided further and there's
some early biological healing starting full active
range of motion using their own muscles and then
strengthening exercises follow on from that gradually
increasing in intensity as the bone continues
to heal and symptoms improve. It requires significant
patient buy -in though. Diligence is key. And
a good rehabilitation team is vital, as noted
in Unknown 19. Pain management throughout this
whole process is also absolutely critical to
allow participation in therapy. How long does
the bone itself take to heal? The bone itself
usually takes roughly three to four months to
achieve solid biological healing, or union, according
to the OTA. But, and this is important, regaining
full function, the movement and strength often
takes considerably longer. Okay, so non -operative
is the main path for most, focusing heavily on
early movement and diligent rehab. When is surgery
indicated then? When do clinicians decide that
the risks and costs of operating are actually
outweighed by the potential benefits? Surgery
is generally reserved for those fractures that
are significantly displaced beyond those near
thresholds or fractures that are inherently unstable
or ones that involve specific patterns that are
considered unlikely to heal well or restore adequate
function if they're just left in the sling. Right.
The decision is also very heavily influenced
by patient factors. We have to consider their
age, their overall health, their functional demands.
What do they need to be able to do with that
arm? Their general activity level, the quality
of their bone, Is it strong or osteoporotic?
And even things like their hand dominance. Okay.
For example, a young active person with a significantly
displaced three -part fracture is much more likely
to benefit from surgery aimed at restoring the
anatomy as perfectly as possible to give them
the best chance of optimal long -term function.
That might be different compared to, say, an
older, less active individual with lower functional
demands and perhaps poorer bone quality where
the risks of surgery might be higher and the
potential gains less critical for their lifestyle.
Makes sense. StatPearls and OrthoBullets outline
several main surgical options, each with its
own specific indications, advantages, and potential
drawbacks. Okay, let's try and walk through the
main surgical strategies then. It sounds like
there are different approaches for different
types of break or maybe different types of patient.
Exactly. It's all about tailoring the solution
to the specific problem and also to the capabilities
of the system, meaning the patient's bone quality,
their overall health, their ability to participate
in rehab, and so on. One option is closed reduction
and percutaneous pinning, CRPP. Closed reduction,
meaning no big cut. That's right. It involves
manipulating the bone fragments back into a better
alignment without making a large surgical incision,
closed reduction, and then holding them in that
position using metal pins or sometimes wires
which are inserted through small poke holes in
the skin, percutaneous pinning. Okay. When would
that be used? It's often considered for certain
two -parter or maybe some three -part surgical
neck fractures, or occasionally specific four
-part fractures, particularly in patients who
have good quality bone where the fragments can
be manipulated back into place relatively easily
and are expected to hold with just pins. What
are the sort of pros and cons of that approach?
Well, the main advantage is that it's less invasive
than open surgery. That potentially means a quicker
initial recovery, less disruption to the blood
supply. Right. But the fixation isn't as mechanically
strong or rigid as using plates and screws. OrthoBullets
notes that CRPP can have higher rates of certain
complications, like pin -side infections or loss
of reduction, meaning the bone slipping out of
place again after surgery compared to other methods.
And as we discussed earlier, the axillary nerve
is definitely at risk, particularly with pins
placed from the lateral or outer side. OK. What
about using plates and screws? That sounds like
a much more rigid way to hold everything together.
It is. That's open reduction and internal fixation,
or IF. This is a more direct approach. It involves
making a surgical incision, exposing the fracture
site, open reduction, carefully putting the bone
fragments back together like a jigsaw puzzle
under direct vision, and then fixing them firmly
in place using anatomically pre -contoured metal
plates and screws. Okay. This is often indicated
for displays two, three, and particularly some
four -part fractures, especially those displaced
surgical neck fractures and significantly displaced
tuberosity fractures. Remember those needing
to be pulled back down if displaced more than
five millimeter. It's often the preferred method
in younger patients where restoring the precise
anatomy is considered critical for optimal long
-term function. Unknown 19 mentions it's typically
aimed at younger patients or those where the
fragments are distinct and manageable enough
to piece back together. Are there specific technical
challenges with using plates and screws in this
particular bone, the humerus? Yes, absolutely.
Especially given that many of these fractures,
the low -energy ones, occur in older patients
who often have osteoporotic bone. Meaning the
bone is soft? Exactly. Soft and sometimes quite
brittle, which doesn't provide a very strong
grip for the screws. Orthobolus goes into significant
detail on this. A key challenge is providing
adequate support on the inner or medial side
of the humerus. Why is that side so important?
Because without good support there, the humeral
head has a tendency to collapse or shift downwards
and inwards into what we call a varus position,
especially if the bone is shattered underneath,
combinated. This varus collapse is a common failure
mechanism. Right. So surgeons use specific techniques
to try and prevent this. They might place a specific
screw, called a calcar screw, upwards into a
denser area of bone on that medial side. Or sometimes,
particularly in severe convolution, they might
even use a piece of donor bone, often a strut
graft taken from the patient's fibula, lower
leg bone, and place it alongside the plate to
act as a buttress, providing that crucial medial
support. Wow, using bone from the leg. Yes, it
can provide excellent mechanical support. Even
with these techniques, screw cutout, where the
screws lose their grip in the soft bone of the
humeral head and pull out, remains a significant
and relatively common complication after locking
plate fixation. It's reported in maybe up to
14 % of cases in some series. Careful plate positioning
is also essential to avoid irritating or damaging
nearby structures, like the rotator cuff tendons
or blood vessels. It really sounds like a technically
demanding surgery, particularly when dealing
with weaker bone. What about the option of using
a rod inside the bone instead? Yes, that's intramedullary
nailing. This involves inserting a specially
designed metal rod down the hollow central canal,
the medullary cavity of the humerus. This rod
crosses the fracture site. Screws are then inserted
through the bone and into the nail both above
and below the fracture to lock the fragments
in the nail together and control rotation. Okay,
when is nailing used? It's typically used for
certain fractures of the surgical neck or perhaps
some specific two or three part fractures. It's
often considered in younger patients with good
bone quality or sometimes when there's also a
fracture further down the humeral shaft that
needs fixing as well, the nail can potentially
address both. What are the pros and cons of nailing
compared to, say, pleating? Well, ortho bullets
suggest IMN can potentially have favorable healing
rates and might allow for slightly earlier range
of motion compared to plates in some cases, as
it acts more like an internal splint, a load
sharing device. However, a potential downside
is the insertion point for the nail. Where does
it go in? It usually has to be inserted through
the very top of the humerus, which often requires
making a split in or going through part of the
rotator cuff tendons, usually the supraspinatus.
This necessary violation of the rotator cuff
can sometimes lead to persistent shoulder pain
or impingement symptoms after surgery. There
are also risks to nerves, particularly the axillary
and radial nerves, with the placement of the
locking screws used to secure the nail. Okay,
so different trade -offs again. Now what about
the most significant intervention, replacing
the joint entirely? Right, that's arthroplasty,
or shoulder replacement. This is generally considered
for the most severe fracture patterns where the
bone fragments are deemed unlikely to heal reliably,
perhaps where the articular surface itself is
badly damaged or split, or, crucially, where
the blood supply to the humeral head is thought
to be significantly compromised, leading to a
very high risk of that avascular necrosis, AVN,
the bone dying off. It also sometimes uses a
salvage procedure if other surgical attempts,
like ORIF, have failed. Arthroplasty is generally
chosen more frequently for older patients, especially
those with poorer bone quality, or perhaps those
who already had significant shoulder arthritis
or rotator cuff problems even before the fracture.
The sources describe two main types used for
fracture. OK, what are they? The first is hemiarthroplasty,
hemi meaning half. This involves replacing only
the humeral side of the joint. The ball is replaced
with a metal prosthesis. The socket side, the
glenoid on the shoulder blade, is left as it
is. This might be used in slightly younger patients,
maybe those aged 40 to 65, with certain fracture
patterns where the head isn't salvageable, but
the rotator cuff is still functional. Or it's
also an option in older patients with severely
shattered anatomic neck fractures, or four -part
fractures, as described in sat pearls and ortho
bullets. What's the main challenge with heme
arthroplasty for fractures? A really critical
challenge is getting those tuberosity fragments,
remember, where the rotator cuff muscles attach
to heal correctly onto the middle prosthesis
and in the right position. This is technically
demanding. If the tuberosities don't heal properly
or heal in the wrong place, then the rotator
cuff function is compromised, which can significantly
limit movement, particularly the ability to rotate
the arm outwards. Okay. And the other... type
of replacement, the one that sounds like it's
becoming more common. Yes, that's the reverse
total shoulder arthroplasty, RSA. This is being
used increasingly, particularly in older, perhaps
less functionally demanding patients with complex
fractures. It's called reverse because it fundamentally
alters the shoulder's normal biomechanics. In
a standard shoulder replacement, you replace
the ball with a metal ball and the socket with
a plastic socket. In an RSA, you actually put
the ball component onto the shoulder blade side
on the glenoid socket, and you put a socket component
onto the top of the humeral bone. It flips the
joint around. Exactly. It effectively reverses
the ball and socket. The clever thing about this
design is that it allows the large deltoid muscle
on the outside of the shoulder to become the
primary elevator of the arm, effectively bypassing
the need for a functional rotator cuff. Ah, I
see. So it's indicated in elderly patients with
very complex fractures, especially four -part
fractures, those where the tuberosities are shattered
beyond repair, non -reconstructable, those with
very poor bone stock making fixation difficult,
or importantly, those who already had large irreparable
rotator cuff tears before they even broke. their
shoulder. So the RSA is chosen when the normal
engine for lifting the arm the rotator cuff is
damaged or can't be relied upon and it essentially
leverages a different engine the deltoid muscle
to do the work. That's a very good way to think
about it, yes. It shifts the joint's center of
rotation downwards and inwards, which tensions
the deltoid muscle fibers more effectively, allowing
them to lift the arm even without a working rotator
cuff. Interesting. OrthoBullets notes that even
when doing an RSA for fracture, attempting to
repair the greater tuberosity fragment back to
the prosthesis is still generally recommended
if possible, as it seems to improve the overall
range of motion, particularly rotation. Okay.
stat pearls adds an interesting observation.
RSA performed as a primary procedure for a bad
fracture or perhaps after failed non -operative
management might actually yield better functional
outcomes than RSA performed as a salvage procedure
after a failed attempt at ORIF with plates and
screws. Why might that be? The thinking is perhaps
there's less scarring and damage to the surrounding
muscles and tissues in the non -operative group
compared to those who've had a previous complex
open surgery that didn't succeed. It's really
clear there's no single best treatment then.
It's all about carefully matching the intervention
to the specific patient, the specific fracture
pattern, and the predicted likelihood of success
with the different methods, considering all those
risks and benefits. Which brings us to the journey
after the initial treatment, the road to recovery.
This sounds like it's probably a marathon, not
a sprint. Absolutely. That's a very apt description.
Whether treated nonoperatively with just a sling
or operatively with complex metalwork, recovery
from a proximal humerus fracture is often a lengthy
and demanding process for the patient. Right.
While the bone itself might achieve biological
union, as we said, in maybe three to four months,
according to the OTA, regaining full or even
near full pain -free range of motion, strength,
and functional independence takes significantly
longer, often six months to a year and sometimes
even more. That's a really substantial commitment
of time and effort. What makes the recovery so
particularly challenging with this injury? Well,
several factors contribute. Pain is often prolonged,
especially in the early stages, and managing
it effectively is key to enabling refabilitation.
Stiffness is a major, major hurdle. Stiffness?
Yes. The shoulder joint is notoriously prone
to developing adhesive capsulitis, that frozen
shoulder, after almost any significant injury
or period of immobilization. And this can happen
regardless of whether it was treated non -operatively
or operatively. Regaining strength in the shoulder
and arm muscles, which weaken very rapidly with
disuse, requires dedicated, consistent effort
over many months. And unknown 19 also highlights
something important. The significant emotional
and psychological impact these injuries can have.
How so? Think about the loss of independence.
the inability to perform simple daily tasks like
dressing or cooking, the persistent pain, and
sometimes the frustratingly slow pace of recovery.
This can understandably lead to frustration,
anxiety, and sometimes even depression, which
in turn can impact motivation for rehab. So that
diligent physical therapy we talked about earlier
isn't just recommended. It sounds absolutely
essential. It is absolutely non -negotiable.
You simply won't get the best possible outcome
without it. A structured progressive rehabilitation
program guided by a physiotherapist is the cornerstone
of recovery, whether the fracture was treated
with a sling or with the most complex surgery.
OrthoBullets describes a typical multi -phase
program, starting with those gentle, often passive
or pendulum range of motion exercises very early
on, progressing carefully to active assisted
and then full active range of motion as healing
allows and pain settles. And finally, incorporating
progressive strengthening exercises for the rotator
cuff, deltoid, and scapular stabilizing muscles,
along with more advanced functional exercises
relevant to the patient's goals. Without this
commitment to physical therapy, significant stiffness
and lasting limitations in movement are almost
guaranteed. This is stressed across all the main
sources, the OTA or the bullets unknown 19. What
are the potential long -term outcomes then, even
assuming successful treatment and good rehab?
Are there often lingering issues people should
be aware of? While most patients will certainly
see significant improvement over time, it is
important to manage expectations realistically.
Full restoration back to exactly the pre -injury
level of function isn't always achieved, particularly
with the more complex fracture patterns, or often
in older patients. The OTA mentions that persistent
stiffness, perhaps not regaining the last few
degrees of motion, some degree of ongoing soreness
or pain, particularly with certain activities
or weather changes, and maybe not quite regaining
the original level of strength, these are not
uncommon long -term outcomes. The shoulder might
just feel and move a bit differently than it
did before the injury, even years later. And
beyond just those lingering symptoms, what about
actual complications that can arise, either during
healing or later on? We touched on some earlier,
like nerve injury or infection. Yes. Unfortunately,
complications can occur with both non -operative
and operative management, and they can obviously
significantly impact the final outcome, sometimes
requiring further intervention. Drawing from
the information in StatPearls, OrthoBullets,
and Unknown19, the potential complications include
quite a range. Non -union. This is where the
bone simply fails to heal completely. Orthobolus
states, this is perhaps most common after two
-part surgical neck fractures, and risk factors
include being older, being a smoker, and significant
displacement initially. Melunian, this means
the bone does heal, but it heals in a poor or
abnormal position, maybe with significant angulation
or displacement remaining. A malunited greater
tuberosity fragment, for instance, healing too
high, is a classic cause of chronic pain and
impingement of the rotator cuff tendons when
lifting the arm of vascular necrosis, AVN. I
mentioned this. The blood supply to the humeral
head gets disrupted by the fracture lines, causing
the bone tissue in the head to die. This can
lead to the head collapsing or fragmenting over
time, causing pain and arthritis. It's a significant
risk, particularly in those four -part fractures
and anatomic neck fractures, precisely because
the fracture lines run through areas critical
for blood supply. Stiffness Adhesive Capsulitis,
that frozen shoulder we discussed, a significant
loss of range of motion due to scarring and thickening
of the joint capsule. This is a risk in almost
any significant shoulder injury or surgery, but
particularly common after fractures due to the
initial trauma and necessary periods of immobilization.
Okay. Nerve injury. While some nerve issues might
be present right from the initial injury, nerve
damage can also occur during surgery or sometimes
nerve function doesn't recover fully. The axillary
nerve is the most commonly affected. Radial and
musculocutaneous nerve injuries are less common,
but certainly possible. Hardware complications.
These are specific to operative treatment involving
plates, screws, pins, or nails. Examples include
that screw cut out from the bone, especially
with plates in poor quality osteoporotic bone.
Hardware can also loosen over time, break, or
sometimes just become prominent or irritating,
requiring removal later on. Infection. Always
a risk with any surgery, though thankfully relatively
low with modern techniques, it can be devastating
if it occurs, often requiring further operations.
Post -traumatic arthritis. Arthritis can develop
in the shoulder joint over time, sometimes years
later, especially if the original fracture involved
the articular surface, or if there was a malunion
or AVN that altered the joint mechanics. And
these complications, particularly things like
painful non -union, Malunion, AVN, or severe
stiffness can sometimes necessitate further surgery
down the line. Often, this might involve converting
to a salvage shoulder replacement, particularly
in older individuals, if the pain dysfunction
are severe enough. It really highlights that
fixing the initial break is just the very beginning,
isn't it? Managing the whole biological and mechanical
environment to get successful healing and good
long -term function is incredibly complex. It
also underscores the need for expertise right
at the start. diagnosis. What else could potentially
cause similar symptoms that might be mistaken
for a proximal humerus fracture initially? That's
a critical point for clinicians. Yes, being able
to distinguish a fracture from other potential
sources of severe shoulder pain and dysfunction
is step one. StatProls provides quite an extensive
list of these differential diagnoses that must
be considered. It's a bit like ensuring you're
diagnosing the correct root cause of a business
problem before you jump to proposing a solution.
Right. What sorts of things are on that list?
What else could it be? Well, it's quite broad,
as you might imagine. It certainly encompasses
other traumatic injuries right around the shoulder
complex. Things like dislocations of the main
shoulder joint itself, which can actually occur
with fractures, complicating things further,
or fractures of the clavicle. the collarbone,
or the scapula, the shoulder blade. But it also
includes a wide range of non -bony injuries and
conditions that can cause significant shoulder
pain. Rotator cuff pathology. This is a big one.
It includes acute tears, maybe partial or full
-thickness tears caused by the same trauma that
might have caused a fracture. Or it could be
chronic issues like tendonitis or impingement
syndromes where the tendons are getting pinched.
Degenerative conditions, things like pre -existing
or developing glenohumeral arthritis, just wear
and tear of the joint surface, or even avascular
necrosis, AVN, occurring independently of any
recent trauma. Capsular issues. Adhesive capsulitis,
that frozen shoulder again. Sometimes the onset
can be relatively sudden, making it difficult
to differentiate from the stiffness following
a fracture initially, although the history of
injury is usually different. Biceps, tendon problems,
things like inflammation, tendonitis, or even
ruptures of the long head of the biceps tendon
where it runs near the shoulder joint, acromioclavicular
joint issues, the joint at the top of the shoulder
where the collarbone meets the shoulder blade.
Things like AC joint separation from a fall or
just arthritis in that joint. Shoulder instability.
Patients might have recurrent dislocations or
just a general feeling of looseness called multi
-directional instability. And then less common,
but still possible, are neurovascular issues
presenting primarily as pain. Things like nerve
entrapments, perhaps superscapular neuropathy,
affecting the rotator cuff muscles, or thoracic
outlet syndrome affecting nerves and vessels
as they leave the neck. Or, very rarely, vascular
events like subclavian artery thrombosis. So
quite a significant overlap in potential symptoms,
then, really requiring a systematic approach
to diagnosis using the patient's history, the
physical exam findings, and then targeted imaging
to confirm. Precisely. A thorough evaluation
is absolutely essential to pinpoint the exact
name the nature of the injury or the condition
causing the symptoms. This is why self -diagnosis
for severe shoulder pain is really risky. And
getting an expert clinical assessment is paramount.
And as Stat Pearls notes, optimal management
requires more than just understanding the injury
itself. It requires tailoring the treatment plan
very carefully to the individual patient, considering
their age, their functional status, their hand
dominance, their overall health, and any other
medical problems, even their social situation
and support network, and crucially, personal
goals and expectations for recovery. It has to
be a holistic assessment, not just focusing narrowly
on the broken bone. This comprehensive approach
to managing these injuries, especially when you
consider how common they are in our aging population,
feels like it must pose a significant challenge
for healthcare systems more broadly. Are the
sources touching upon how the system is grappling
with this, particularly perhaps the cost aspect?
They are, yes. And this is a point with significant
implications that go beyond just this specific
injury. The StatPearl source in particular highlights
that proximal humerus fractures, precisely because
they are common, and the treatment, especially
surgical treatment and rehab, can be costly,
are increasingly becoming a focus of health care
cost containment strategies and alternative payment
models. Cost containment and alternative payment
models. What does that actually mean in practice?
What means that health care systems and the organizations
that pay for care, like insurers or government
bodies, are actively looking for ways to manage
the total costs associated with treating these
injuries more efficiently and predictably. Right.
This includes initiatives like bundled payments,
where a single predetermined payment is made
to cover all the services related to a specific
episode of care, say, from the initial fracture
diagnosis right through several months of recovery
and rehabilitation, rather than paying for each
individual doctor visit, x -ray, surgery, therapy
session separately. Oh, I see. The idea is this
encourages hospitals and all the providers involved
to coordinate care more effectively, reduce unnecessary
variations, and control the overall cost of that
episode. There's also a growing emphasis on standardizing
diagnosis, treatment, and rehabilitation pathways
based on the best available evidence and outcomes
data. Standardizing care pathways. Does that
risk creating a sort of one -size -fits -all
approach, given how much variability there seems
to be in these fractures and, as you said, in
the patients themselves? That's exactly the tension,
isn't it? Yeah. And StatPearls explicitly cautions
against adopting a rigid one -size -fits -all
strategy. The goal, ideally, is not to eliminate
individualized care based on clinical judgment
and patient needs, but rather it's about using
big data. aggregating information from large
patient populations, analyzing outcomes from
different treatments in different groups through
research studies to identify best practices,
understand risk factors better, and determine
which treatments tend to be most effective and
cost effective for different patient profiles
and fracture types. This population -level knowledge
should then inform what they call customized
application at the level of the hospital or clinic
and ultimately at the individual patient level.
So, using the big -picture data to help refine
individual treatment decisions, rather than dictating
them rigidly from the top down. Exactly. It's
about establishing evidence -based guidelines
and protocols that can guide decision -making
and reduce unwarranted variation, while still
allowing clinicians the flexibility to exercise
their judgment and incorporate patient preferences.
But achieving this effectively requires really
strong active communication and collaboration
among the entire healthcare team. The whole team.
Yes, the orthopedic surgeons, the anesthetists,
nurses, physical therapists, occupational therapists,
perhaps geriatricians for older patients, social
workers, case managers, everyone involved needs
to work together to ensure the patient receives
coordinated, efficient, and effective care right
from the moment of injury through their long
-term recovery. It's a systemic challenge that
really requires a team -based solution. And just
going back to those low -energy fractures in
older patients, StatPearls also notes that the
fracture itself is effectively a diagnosis of
compromised bone density, doesn't it? Yes, that's
a crucial point highlighted in the Pearls section
of that source. For any older adult who sustains
a proximal humerus fracture from a simple fall
or minimal trauma, assessing and addressing their
underlying bone health, specifically looking
for osteoporosis, is really non -negotiable.
Because that fracture acts as a sentinel event.
It's a major warning sign indicating that the
patient is at significantly high risk for suffering
other fragility fractures in the future, particularly
devastating ones like hip fractures or vertebral
fractures in the spine or wrist fractures. Right.
So ensuring these patients receive appropriate
follow -up, which usually involves bone density
testing, like a decasis scan, and then management,
which might include lifestyle advice, calcium
and vitamin D supplementation, and potentially
specific osteoporosis medications. That's a key
part of providing comprehensive care. It's not
just about fixing the immediate break. That connects
back really powerfully to prevention then, doesn't
it? If poor bone quality and falls are the major
factors driving the most common type of proximal
humerus fracture, then surely addressing those
upstream issues has to be critical. Absolutely.
And Unknown 19 provides some specific prevention
strategies that resonate broadly with the idea
of risk management. management. For older adults,
fall prevention is paramount. What does that
involve? It involves several things. Identifying
and modifying potential environmental hazards
in their home, things like securing loose rugs,
improving lighting, installing grab bars or handrails
in bathrooms and on stairs. It also involves
reviewing their medications, as some can cause
dizziness or unsteadiness. Ensuring they have
appropriate, well -fitting footwear is important
too. And crucially, incorporating regular balance
and strength training exercises into their routine
can significantly reduce fall risk. For athletes
or perhaps people involved in high impact activities
or contact sports, using appropriate protective
gear like shoulder pads where relevant is key.
And for everyone, really, particularly as we
age, focusing on overall bone health is vital.
That means ensuring adequate dietary intake or
supplementation of calcium and vitamin D, avoiding
smoking, limiting alcohol intake, and engaging
in regular weight -bearing physical activity,
things like walking, jogging, dancing, stair
climbing, which helps stimulate bone density
and also maintain muscle strength, which further
supports balance and reduces fall risk. This
entire journey we've discussed from, you know,
really understanding the intricate anatomy of
the brake and classifying its severity to then
navigating those complex treatment decisions
with all their inherent risks and trade -offs
and then committing to what sounds like an often
arduous road of recovery while managing potential
complications, it truly does mirror challenges
we often face in many professional domains, doesn't
it? It really does. That need to deeply understand
a complex system before intervening. the need
to classify problems effectively to help guide
action, the need to weigh different potential
solutions based on evidence, but also considering
the specific context and the individual system
you're dealing with, the need to anticipate and
manage inherent risks, and ultimately the need
to embrace a resilient, often team -based approach
to achieve the desired outcome. Whether you're
talking about healthcare, engineering, finance,
or business strategy, these core principles seem
remarkably consistent. Well, we hope this deep
dive has given you a much clearer picture of
proximal humerus fractures, perhaps revealing
some of the layers of complexity beneath what
might initially seem like just a straightforward
broken bone. Yes. From the subtle yet critical
points of anatomy, the distinct patterns of injury
depending on age and mechanism, the classification
systems that help structure our decision -making
around displacement, the important nuances and
trade -offs between non -operative care and the
various operative strategies, right through to
the demanding but absolutely vital process of
rehabilitation and being aware of the potential
hurdles of complications, understanding these
different facets really provides a robust framework
for thinking about this injury. And it all stems
directly from the comprehensive source material
we've been exploring today, the Orthopedic Trauma
Association guidelines, those detailed reviews
and stat pearls and ortho bullets, insights from
the bone school and the Stanford AVA lab summary
document. So our thanks to the experts and authors
behind all of those valuable resources. Indeed.
They provide the foundational knowledge that's
absolutely necessary to navigate what is often
a very complex clinical challenge. If you found
this deep dive insightful, perhaps because it
helped you understand complexity through a slightly
different lens today, please do consider leaving
us a rating and maybe sharing it with someone
in your network who you think might also benefit.
And finally, perhaps consider this provocative
thought. building on that increasing prevalence
of these injuries, especially in older adults.
Given the clear interception of an aging global
population, the rising incidence of osteoporosis,
and the significant functional implications in
healthcare costs associated with proximal humerus
fractures is the healthcare system currently
doing enough to shift its focus from primarily
treating these injuries after they happen to
more effectively preventing them on a true population
scale. What systemic changes might be needed
to really manage this growing fragility fracture
epidemic proactively rather than reactively?
A question with some very broad implications
indeed. Something to think about. Until next
time on The Deep Dive.