1. The patient is a 58-year-old Thai woman who fell and injured her left shoulder 3 days ago. 2. Physical examination revealed tenderness and mild swelling of the left shoulder with limited range of motion due to pain. 3. X-rays of the left shoulder showed a fracture of the proximal humerus. The document describes a case of a 58-year-old Thai woman who presented with a fractured left shoulder after a fall. Physical examination and x-rays confirmed a fracture of the proximal humerus. Non-displaced fractures can be treated conservatively while displaced fractures require orthopedic referral.

1. Extern conference
BY NITHIT SEMSAWAT
PI 5422054

2. ผู้ป่วยหญิงไทยคู่อายุ 58 ปี
ภูมิลาเนา อาเภอเมือง จังหวัด นครราชสีมา
สิทธิประกันสุขภาพถ้วนหน้า
Chief complaint
ล้มไหล่ซ้ายกระแทกพื้น 3 วัน PTA

3. Primary survey
• A : can talk , no cervical spine tenderness , full
ROM of neck
• B : equal breath sound , no adventitious sound,
CCT neg
• C : BP 119 / 76 mmhg , PR 98/min , RR 20 / min
, T 36 C , no visible site of active bleeding.
• D : E4V5M6, pupil 3 mm RTLBE
• E : No External wound

4. Secondary survey
• A : no drug allergy
• M : no current medication
• P : no underlying disease
• L : last meal 4 hr PTA
• E : 3 day PTA ลื่นหกล้มไหล่ซายกระแทกพื้น เจ็บแขนซ้าย
ยกแขนได้เล็กน้อยเนื่องจากปวด บวมเล็กน้อย ไม่มีแผลด้าน
นอก ไม่มีอาการชาทีไหล่ ไม่มีเลือดออก ไม่มีอาการเจ็บบริเวณ
อื่น ไม่สลบ ขยับข้อมือได้ปกติ

5. Physical examination
• Vital signs : BP 119 / 76 mmHg , PR 98/min , RR
20 / min , T 36 C
• General appearance : A Thai women good
consciousness, well co operative
• HEENT : not pale, no jaundice
• Lung : clear , equal breath sound both
• CVS : normal s1s2, no murmur
• Abdomen : soft not tender
• Neuro : E4V5M6 , orientated to time place person

6. Extremieties : Left shoulder
• Tenderness, mild swelling,
limited ROM due to pain,
no deformity, no
ecchymosis at left
shoulder , no numbness
at deltoid area
• Brachial pulses 2+
• Radial pulse 2+
• No wrist drop

7. Investigation : Film left shoulder AP, Transcapular

8. Diagnosis
CFX left humeral neck

9. Management
• On Arm sling
• F/U 2 wk + Film left shoulder AP, Transcapular
• Home medication
– Paracetamol [500] 1 tab oral prn for pain q 6 hr
– Tramol [50] 1*3 oral prn for pain

10. Fracture Proximal
Humerus

11. Outlines
• Epidemiology and risk factors
• Signs and symptoms
• Physical Examination
• Radiographic findings
• Neer classification
• Indication for referral
• Follow-up care
• Return to sport or work

12. Epidemiology and risk factors
• Incidence 4-5 % of all fractures
• Incidence increases with age
– > 70 % occurring in Pt. > 60 yr.
• 3-4 times more common in females
• Risk factors
– Frequent falls
– Low bone density

13. Signs and symptoms
• Shoulder pain that increases with shoulder
movement
• Swelling and ecchymosis
• Shoulder deformities

14. Physical Examination
• No specific examination tests for diagnosis
• Typically have focal tenderness at proximal
humerus
• Neurovasucular injury
– Axillary nerve
• Deltoid m. weakness
• Decrease sensation of mid-deltoid region
– Suprascapular nerve
• Supraspinatous and infraspinatous m. weakness
• Vasucular injury
– Circumflex artery

19. Radiographic findings
• Film shoulder AP , transcapular
• CT with three dimensional reconstructions
[if Plain film can’t diagnostic]

20. Film shoulder AP

21. Film Transcapular view

22. Fracture patterns : Neer classification
• Non – displace VS Displaced
1. Displaced > 1 cm
2. Angulation > 45 degrees
• Fracture classified
– One-part Fracture
– Two-part Fracture
– Three-part Fracture
– Four-part Fracture
Displaced
Non-Displaced
Displaced

26. Indication for referral
• 80 % are non-displace or minimally displace
– Can conservative at primary care clinicians
• Displaced [2-4 part fractures]: need surgery
– Refer to orthopedic surgeon for evaluation
- Osteosynthesis - Percutaneous pinning
- ORIF - Hemiarthroplasty
• Emergency referral
– all nerve and vascular injuries
– Fracture dislocation

27. Initial treatment
• Immobilization
– Standard sling : impact fracture
– Collar and cuff sling
• Reduction of minimally displaced fragments
– Swathes : use in shoulder unstable
• Pain control
• Ice : reduce pain and swelling
• Pain control medication
• Close reduction of fracture fragments is not
recommended
– Because several muscles have insertions on the proximal
humerus

28. Follow-up care
• Total healing is typically 6-12 wks
• Early callus formation usually occurs a 4-6 wks
• Duration of immobilization
– 1-2 wks initiated ROM exercises

29. Follow-up care: Reevaluation
• 7-14 days Reevaluation for significant
displacement
• If pain is well controlled and no displacement
fragments
– Pendulum exercises : decrease loss of shoulder
motion
– Isometric strengthening exercises for the biceps
and triceps

30. Pendulum exercises
Isometric strengthening
exercises

31. Follow-up care : Subsequent visits
• 2 - 4 wks after surgery
– Encourage to discontinue their sling
– Passive range of motion exercise of the elbow and
shoulder : Twice daily
• Pendulum exercise
• Wall climbing exercise
• Consult PT for passive ROM if necessary
• Serial follow up q 2-4 wks for evaluation and
improve range of motion

32. Wall climbing exercise

33. Follow-up care : Complications
• Loss of shoulder mobility : most common
• Neurovascular injury
– Circumflex artery
– Axillary or suprascapular nerve
– Rotator cuff tear [if dislocation of humeral head ]
• Osteonecrosis of Humeral head [uncommon]

34. Return to sport or work
• Work : 3 wks after proximal humerus fracture
– Not full use of the affected arm
– 8-12 wks if jobs includes two-handed labor
• Sports
– Adequate range of motion
– Strength as well as stable callus formation on
radiographs

35. Take home message
• Non displace fracture
– Conservative
– Early ROM exercise
• Displace fracture
– Refer to orthopedic surgeon for evaluation