Acute Shoulder Pain After a Fall
Author: Kayla Prokopakis, DO
Peer-reviewer and editor: Alex Tomesch, MD
An 80-year-old female tripped over her cat at home. This caused her to fall, hitting her right shoulder on the counter on the way to the floor. She is complaining of right shoulder pain and denies hitting her head or LOC. X-rays obtained in the Emergency Department are shown below.
Image 1. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 18281
What is your diagnosis?
Proximal humerus fracture.
- Pearl: Proximal humerus fractures most commonly occur in the elderly, and are usually after a fall. In most cases they are an isolated injury [1].
What is the common classification system used to describe this fracture?
The Neer classification. This classification system describes the proximal humerus into 4 “parts” (the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft). A “part” is displaced if it exceeds >45 degrees of angulation or is displaced by more than 1 cm. If none of the parts meet the criteria of being displaced, it is called a one-part fracture. Any other piece that is displaced adds to the number. Fractures can be one, two, three, or four part [2,3].
- Pearl: 50% of all proximal humerus fractures are one part, meaning they are nondisplaced [4,5].
What physical exam findings are expected?
Patients usually have pain, swelling and tenderness around the shoulder. ROM is significantly limited and the patient will hold the arm in adduction [6].
What is the imaging modality of choice in the ED?
Plain film imaging is usually sufficient to characterize the fracture. Images should include AP, lateral and axillary views. This will be used to confirm that the shoulder is not dislocated as well.
- Pearl: CT imaging may be useful if severely comminuted or if the provider cannot definitively determine if the shoulder is dislocated [6,7,8].
What is your treatment? When do you consult orthopedics?
Most proximal humerus fractures can be treated conservatively [9]. Patients may be treated with a sling and swath, analgesics and outpatient orthopedic vs primary care sports medicine referral [6]. The more parts, the greater possibility that surgical management may be needed. Fractures that involve the articular surface, are fracture-dislocations, have extensive displacement or have neurovascular compromise need orthopedic consultation from the emergency department [6].
- Pearl: Poor prognostic factors include older age, displaced fracture, and three or four part fractures [1].
References
[1] Court-Brown CM, McQueen MM, Tornetta P. Trauma. Lippincott Williams & Wilkins. (2005) ISBN:0781750962.
[2 Kilcoyne RF, Shuman WP, Matsen FA 3rd, Morris M, Rockwood CA. The Neer classification of displaced proximal humeral fractures: spectrum of findings on plain radiographs and CT scans. AJR Am J Roentgenol. 1990;154(5):1029-1033. doi:10.2214/ajr.154.5.2108538.PMID: 2108538.
[3] Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-1089.PMID: 5455339.
[4] Chu SP, Kelsey JL, Keegan TH, et al. Risk factors for proximal humerus fracture. Am J Epidemiol. 2004;160(4):360-367. doi:10.1093/aje/kwh224.PMID: 15286021.
[5] Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand. 2003;74(5):580-585. doi:10.1080/00016470310017992. PMID: 14620980.PMID: 14620980.
[6] Stapczynski, JS, Tintinalli, JE. Shoulder and Humerus Injuries.. In Tintinalli's emergency medicine: A comprehensive study guide, 8th Edition. New York, NY: McGraw-Hill Education; 2016: 1839-1842.
[7] Castagno AA, Shuman WP, Kilcoyne RF, Haynor DR, Morris ME, Matsen FA. Complex fractures of the proximal humerus: role of CT in treatment. Radiology. 1987;165(3):759-762. doi:10.1148/radiology.165.3.3685356. PMID: 3685356.
[8] Bhandari M. Evidence-Based Orthopedics. Wiley-Blackwell. (2012) ISBN:1405184760.
[9] Launonen AP, Sumrein BO, Lepola V. Treatment of proximal humerus fractures in the elderly. Duodecim. 2017;133(4):353-358.PMID: 29205983.
