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AUTHOR INFORMATION
| Section 1 of 11   |
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| Author: Daniel Corboy, MD, Clinical Instructor, Department of Emergency Medicine, Harvard University Medical School, Massachusetts General Hospital Coauthor(s): D Daniel Rotenberg, MD, Consulting Surgeon, Department of Orthopedic Surgery, Western Orthopedics and Sports Medicine |
| Daniel Corboy, MD, is a member of the following medical societies:
Massachusetts Medical Society |
| Editor(s): Michelle Ervin, MD, Chair, Department of Emergency Medicine, Howard University Hospital; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine;
Eric Legome, MD, Residency Director, Assistant Professor of Emergency Medicine, Department of Emergency Medicine New York University, New York University Hospital, Bellevue Hospital Center, Manhattan VA;
John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School;
and Scott H Plantz, MD, FAAEM, Research Director, Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine |
Disclosure
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INTRODUCTION
| Section 2 of 11   |
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Background: Humerus fractures, particularly fractures of the proximal humerus, are encountered commonly in the ED. Rarely do these injuries represent surgical emergencies; however, the emergency physician must recognize which fractures require urgent, versus emergent, orthopedic referral.
Pathophysiology: Humerus fractures typically are caused by direct trauma to the arm or shoulder or axial loading transmitted through the elbow. Attachments from pectoralis major, deltoid, and rotator cuff muscles influence the degree of displacement of proximal humerus fractures. Frequency:
- In the US: Humerus fractures represent 4-5% of all fractures.
Age: Fracture patterns are similar across all ages, though older persons are more prone to fracture because of osteoporosis.
History: - Most patients convey blunt trauma to the arm or shoulder or axial loading through the elbow. Typical history involves a fall on an outstretched, abducted arm.
- Pathologic fractures of the humerus may occur with minimal trauma. Suspect these in patients with the following history:
- Cancer metastatic to bone
- Decreased range of motion (ROM)
Physical: - Pain occurs with palpation or movement of shoulder or elbow.
- Ecchymosis and edema usually are present.
- Perform a careful neurovascular exam. Radial nerve injury following humerus shaft fractures is relatively common.
Causes: - A humerus fracture in a child with an inconsistent injury mechanism should raise suspicion for abuse and trigger a legal and social service investigation.
- Fractures that occur spontaneously, without apparent injury, suggest pathologic fracture. Causes include cancer metastatic to the bone, Paget disease, and bone cyst.
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DIFFERENTIALS
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Dislocations, Shoulder
Fractures, Clavicle
Fractures, Elbow
Fractures, Scapular
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Imaging Studies:
- Anteroposterior and lateral views of the humerus, as well as transthoracic and axillary views of the shoulder, should be adequate to visualize a fracture.
- Proximal humerus fracture
- Proximal humerus has 4 parts: articulating surface, greater tuberosity, lesser tuberosity, and humeral shaft.
- Neer classification system describes how many of these parts are fractured, displaced, and/or angulated (not just fractured).
- Operative treatment decisions are based primarily on the number of segments involved and degree of displacement. Most fractures are displaced minimally and treated conservatively. Three- and 4-part fractures often need operative repair.
- Humerus shaft fracture may be transverse, oblique, or spiral.
- CT scan or MRI occasionally may be required.
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TREATMENT
| Section 6 of 11 |
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Prehospital Care: Immobilize the fracture. Emergency Department Care: - Minimize patient movement and provide adequate analgesia to make patient comfortable in the ED.
- Proximal humerus fracture: Sling and swathe application is primary treatment in ED.
- It is best stabilized using a coaptation splint.
- Wrap splinting material snugly from axilla to nape of neck, creating a stirrup around elbow.
- Fracture reduction is unnecessary because maintaining a reduction is difficult once achieved.
- Because of the shoulder's ability to compensate, 30-40° of angulation is acceptable.
Consultations: - Most isolated proximal and diaphyseal humeral fractures can be managed by an orthopedist in an outpatient setting. Even patients with fractures that may eventually require surgery generally may be discharged with early follow-up care if fracture is otherwise uncomplicated.
- Open fractures represent a surgical emergency; obtain an immediate orthopedic consult.
- Penetrating trauma requires particular neurovascular scrutiny.
- Glenohumeral dislocation in conjunction with a proximal humerus fracture requires orthopedic evaluation.
- Floating elbow (an ipsilateral humerus and forearm fracture) requires operative repair.
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MEDICATION
| Section 7 of 11 |
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Drugs used to treat fractures are generally NSAIDs, analgesics, and anxiolytics.
Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs) -- These agents are used most commonly for the relief of mild to moderately severe pain. Effects of NSAIDs in the treatment of pain tend to be patient specific, yet ibuprofen is usually DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen. Drug Name
| Ibuprofen (Ibuprin, Advil, Motrin) -- Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, which inhibits prostaglandin synthesis. | | Adult Dose | 200-400 mg PO q4-6h prn; not to exceed 3.2 g/d |
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| Pediatric Dose | 6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency; high risk of bleeding |
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| Interactions | Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
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Drug Name
| Ketoprofen (Oruvail, Orudis, Actron) -- Used for relief of mild to moderately severe pain and inflammation.
Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease.
Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.| Adult Dose | 25-50 mg PO q6-8h prn; not to exceed 300 mg/d |
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| Pediatric Dose | 3 months to 14 years: 0.1–1 mg/kg PO q6-8h
>12 years: Administer as in adults| Contraindications | Documented hypersensitivity |
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| Interactions | Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in coagulation abnormalities or during anticoagulant therapy |
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Drug Name
| Naproxen (Anaprox, Naprelan, Naprosyn) -- Relieves mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, which decreases prostaglandin synthesis. |
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| Adult Dose | 500 mg PO followed by 250 mg q6-8h; not to exceed 1.25 g/d |
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| Pediatric Dose | <2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d| Contraindications | Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency |
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| Interactions | Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |
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Drug Name
| Flurbiprofen (Ansaid) -- Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis. |
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| Adult Dose | 200-300 mg/d PO divided bid/qid |
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| Pediatric Dose | Not established |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity; may decrease effects of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT in patients taking anticoagulants—monitor PT closely and instruct patients to watch for signs of bleeding; may increase risk of methotrexate toxicity; may increase phenytoin levels |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug |
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Drug Category: Analgesics -- Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and aids physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.Drug Name
| Acetaminophen (Tylenol, Panadol, aspirin-free Anacin) -- DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs and in those with upper GI disease or taking oral anticoagulants. |
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| Adult Dose | 325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg q4h; not to exceed 5 doses/d| Contraindications | Documented hypersensitivity; known G-6-P deficiency |
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| Interactions | Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity |
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| Pregnancy |
B - Usually safe but benefits must outweigh the risks.
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| Precautions | Hepatotoxicity possible in chronic alcoholics following various dose levels; severe or recurrent pain or high or continued fever may indicate a serious illness; APAP is contained in many OTC products and combined use with these products may result in cumulative APAP doses exceeding recommended maximum dose |
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Drug Name
| Acetaminophen and codeine (Tylenol #3) -- Drug combination indicated for treatment of mild to moderately severe pain. |
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| Adult Dose | 30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 12 tab/d |
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| Pediatric Dose | 0.5-1 mg/kg/dose based on codeine content PO q4-6h; 10-15 mg/kg/dose based on acetaminophen content; not to exceed 2.6 g/d of acetaminophen |
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| Contraindications | Documented hypersensitivity |
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| Interactions | CNS depressants or tricyclic antidepressants increase toxicity |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction |
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Drug Name
| Hydrocodone bitartrate and acetaminophen (Vicodin ES) -- Drug combination indicated for relief of moderately severe to severe pain. |
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| Adult Dose | 1-2 tab/cap PO q4-6h prn |
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| Pediatric Dose | <12 years: 10-15 mg/kg/dose acetaminophen PO q4-6h prn; not to exceed 2.6 g/d of acetaminophen
>12 years: 750 mg acetaminophen q4h; single dose not to exceed 10 mg of hydrocodone bitartrate; not to exceed 5 doses/d| Contraindications | Documented hypersensitivity; high-altitude cerebral edema; elevated intracranial pressure |
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| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants may increase toxicity |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Tablets contain metabisulfite which may cause hypersensitivity; caution in patients dependent on opiates since this substitution may result in acute opiate-withdrawal symptoms; caution in severe renal or hepatic dysfunction |
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Drug Name
| Oxycodone and acetaminophen (Percocet) -- Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients. |
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| Adult Dose | 1-2 tab/cap PO q4-6h prn |
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| Pediatric Dose | 0.05-0.15 mg/kg/dose oxycodone PO q4-6h prn; not to exceed 5 mg/dose of oxycodone |
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| Contraindications | Documented hypersensitivity |
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| Interactions | Phenothiazines may decrease analgesic effects; CNS depressants or tricyclic antidepressants increase toxicity |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Duration of action may increase in the elderly; be aware of total daily dose of acetaminophen patient is receiving; do not exceed 4000 mg/24h of acetaminophen; higher doses may cause liver toxicity |
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Drug Name
| Morphine sulfate (Duramorph, Astramorph, MS Contin) -- DOC for narcotic analgesia because of its reliable and predictable effects, safety, and ease of reversibility with naloxone.
Morphine sulfate administered IV may be dosed in a number of ways and commonly is titrated until desired effect obtained.| Adult Dose | Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of dose| Pediatric Dose | Neonates: 0.05-0.2 mg/kg IV/IM/SC prn
Children: 0.1-0.2 mg/kg dose q2-4h prn| Contraindications | Documented hypersensitivity; hypotension; potentially compromised airway in which establishing rapid airway control would be difficult |
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| Interactions | Phenothiazines may antagonize analgesic effects; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects |
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| Pregnancy |
C - Safety for use during pregnancy has not been established.
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| Precautions | Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate |
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Drug Category: Anxiolytics -- Patients with painful injuries usually experience significant anxiety. Anxiolytics allow a smaller analgesic dose to achieve same effect.Drug Name
| Lorazepam (Ativan) -- Sedative hypnotic in benzodiazepine class with short onset of effect and relatively long half-life. By increasing action of GABA, a major inhibitory neurotransmitter, may depress all levels of CNS, including limbic and reticular formation.
Excellent for sedating patients for >24 h.
Monitor patient's BP after administering dose and adjust as necessary.| Adult Dose | Initial dose: 2 mg total or 0.044 mg/kg IV, whichever is smaller
For greater lack of recall: 0.05 mg/kg IV; not to exceed 4 mg/dose| Pediatric Dose | 0.05 - 0.1 mg/kg IV slowly over 2-5 min; may repeat dose of 0.05 mg/kg IV slowly |
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| Contraindications | Documented hypersensitivity; preexisting CNS depression; hypotension; narrow-angle glaucoma |
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| Interactions | Alcohol, phenothiazines, barbiturates, and MAOIs increase toxicity |
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| Pregnancy |
D - Unsafe in pregnancy
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| Precautions | Caution in renal or hepatic impairment, myasthenia gravis, organic brain syndrome, or Parkinson disease |
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FOLLOW-UP
| Section 8 of 11 |
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Further Inpatient Care:
- These require extensive irrigation.
- Administer prophylactic antibiotics, such as cephalexin and gentamicin.
Further Outpatient Care:
- Proximal humerus fracture
- Displaced 3- or 4-part fractures frequently require surgical fixation.
- Perform open reduction and internal fixation in young patients.
- Perform humeral arthroplasty in older patients.
- For nonsurgical fractures, continue sling for comfort and institute early ROM exercises.
- Schedule initial follow-up visit within 1 week.
- Most humerus shaft fractures are treated nonoperatively with an expected union rate of 90-100%, though surgical fixation, either by intramedullary nailing or plating, is necessary if the fracture is segmental or the vasculature is compromised.
- Use coaptation splint until immediate postfracture pain has subsided, usually within 3-7 days. Then place patient in a functional brace.
- An orthopedic surgeon best addresses decisions regarding alignment, rotation, and progression to union.
In/Out Patient Meds:
- As with all fractures, provide adequate outpatient analgesia especially during first few days. Narcotic analgesia may be appropriate.
Complications:
- Nerve transection is rare.
- Transient neurapraxia from stretching is more common.
- Complete return to function is the norm.
- Multiple segment fractures are most common.
- Avascular necrosis is seen in fractures through surgical neck of humerus.
Prognosis:
- Proximal humeral fractures
- Complete union is expected at 6-8 weeks.
- Older patients often exhibit functional decrease in shoulder ROM.
- These fractures have a high rate of union.
- Residual angulation is well tolerated because of compensation by shoulder and elbow ROM.
Patient Education:
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MISCELLANEOUS
| Section 9 of 11 |
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Medical/Legal Pitfalls:
- Failure to assess and document radial nerve function in humerus shaft fracture
- Failure to recognize a glenohumeral dislocation associated with a proximal humerus fracture. This may increase risk of avascular necrosis of humeral head.
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PICTURES
| Section 10 of 11 |
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BIBLIOGRAPHY
| Section 11 of 11 |
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Byrd RG, Byrd RP Jr, Roy TM: Axillary artery injuries after proximal fracture of the humerus. Am J Emerg Med 1998 Mar; 16(2): 154-6[Medline].
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Keller A: The management of gunshot fractures of the humerus. Injury 1995 Mar; 26(2): 93-6[Medline].
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McKee MD, Jupiter JB: A contemporary approach to the management of complex fractures of the distal humerus and their sequelae. Hand Clin 1994 Aug; 10(3): 479-94[Medline].
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Minkowitz B, Busch MT: Supracondylar humerus fractures. Current trends and controversies. Orthop Clin North Am 1994 Oct; 25(4): 581-94[Medline].
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Niall DM, O'Mahony J, McElwain JP: Plating of humeral shaft fractures--has the pendulum swung back? Injury 2004 Jun; 35(6): 580-6[Medline].
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Rosen P: Emergency Medicine. 2nd ed. Mosby-Year Book, Incorporated; 1988: 735-758.
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Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ: Proximal humeral fractures. Management techniques and expected results. Clin Orthop 1993 Jul; (292): 13-25[Medline].
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Tintinalli J, Ruiz E, Krome R: Emergency Medicine. 4th ed. McGraw Hill Text; 1996: 1242-1244.
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Wilkins KE: Supracondylar fractures: what's new? J Pediatr Orthop B 1997 Apr; 6(2): 110-6[Medline].
Fractures, Humerus excerpt |
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