Endgames Picture Quiz

Shoulder injury

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e3172 (Published 03 August 2012) Cite this as: BMJ 2012;345:e3172
  1. S S Jing, foundation year 2 trainee in trauma and orthopaedics ,
  2. S D S Newman, specialist trainee year 3 in trauma and orthopaedics ,
  3. D P S Baghla, consultant in trauma and orthopaedics
  1. 1Department of Trauma and Orthopaedic Surgery, Ealing Hospital, Southall UB1 3HW, UK
  1. Correspondence to: S S Jing shanshan.jing{at}gmail.com

A 57 year old right hand dominant woman presented to the emergency department with left shoulder pain one day after a low energy fall from standing height onto her outstretched arm. On clinical examination, she was haemodynamically stable with a swollen and bruised left shoulder. Palpation of the shoulder showed maximal tenderness over the proximal humerus, with global restriction of shoulder movement because of pain. No distal neurovascular deficit was noted. She was a non-smoker, had a body mass index of 28, and was otherwise fit and well with no risk factors for osteoporosis. Plain shoulder radiographs were obtained (figs 1 and 2).


Fig 1 Anterioposterior radiograph of left shoulder


Fig 2 Scapular Y view of the left shoulder joint


  • 1 What abnormality do the radiographs show?

  • 2 What further imaging should be considered?

  • 3 Which neurovascular structures are at risk?

  • 4 What are the options for managing this patient?


1 What abnormality do the radiographs show?

Short answer

The shoulder radiographs show a valgus impacted fracture of the left proximal humerus. It is multifragmentary, affecting the surgical neck, lesser tuberosity, and greater tuberosity.

Long answer

Radiographic evaluation is essential to allow diagnosis, fracture classification, and planning of treatment. Imaging of fractures of the proximal humerus should include three views: an anterioposterior, axillary, and scapular Y view. The shoulder radiographs show a displaced intra-articular fracture of the left proximal humerus. It is multifragmentary, involving the surgical neck and greater and lesser tuberosities. The humeral head articular fragment is rotated and impacted in a valgus position. This is unusual given the forces involved in the injury. More commonly, a two part fracture is sustained.

Proximal humerus fractures account for about 5% of all fractures.1 Most are caused by direct impact onto a shoulder, although they can occur through the transmission of force from a fall onto an outstretched hand as described here.1 Reduced protective responses may reflect poor physiological status in some patients. This may be why patients who sustain such fractures from direct impact on the shoulder tend to be frailer than those who sustain wrist fractures from an outstretched hand to break the fall.

Neer’s classification is widely used to describe fractures according to the number of displaced parts (humeral head, lesser tuberosity, greater tuberosity, and shaft; fig 3). Displacement of a part is defined by translation of more than 10 mm or angulation of more than 45°.2 This patient would be classified as having a four part fracture. Although commonly used, the classification has limitations. It has a low interobserver reliability.3 It also does not identify the valgus impacted four part fracture, which has a lower risk of bone necrosis after osteosynthesis than other four part fractures. The AO/ASIF (Arbeitsgemeinschaft für osteosynthesefragen/Association for the Study of Internal Fixation) classification is more comprehensive but consequently less easily used in clinical practice. It places more emphasis on the vascular supply of the articular segment of the proximal humerus.4


Fig 3 Neer’s classification of displaced proximal humeral fractures. Reproduced, with permission, from Murray and colleagues5

2 What further imaging should be considered?

Short answer

A modified axillary (Velpeau) view can be obtained in patients who are unable to abduct their arm because of pain.6 Computed tomography with three dimensional reconstruction is increasingly available; it can provide a better understanding of the fracture pattern if this is unclear with plain radiographs and can be used to plan operative procedures.

Long answer

A modified axillary (Velpeau) view can be obtained in patients who are unable to abduct their arm because of pain.6 While wearing a sling, the patient leans backwards 30° over the cassette, which is placed on a table. The x ray tube is placed above the shoulder and the beam projected vertically down through the shoulder onto the cassette.

The scapular Y view and axillary view are especially useful for detecting dislocations. On the scapular Y view, when the humeral head is in joint, the head sits in the glenoid fossa, with the acromion, coracoid process, and scapula blade radiating outwards to form a “Mercedes” sign. On the axillary view, when the shoulder is in joint, the humeral head can be seen to be in contact with the glenoid fossa. If the head is not where it is expected on these views then a dislocation is diagnosed.

Computed tomograms using bone windows and multiplanar reformatting (three dimensional reconstruction) are increasingly used to provide a better understanding of fractures and are useful in surgical planning. Three dimensional computed tomography enables an accurate assessment of the degree of subluxation and angulation of the humeral head, the extent of separation of the shaft from the head, and identification of the location of individual fracture fragments (fig 4).7


Fig 4 Computed tomography three dimensional reconstruction of the left shoulder

3 Which neurovascular structures are at risk?

Short answer

Neurovascular injuries often occur in proximal humeral fractures.8 Structures at risk are the axillary nerve, the brachial plexus, and the axillary artery, in that order of frequency.9 Nerve injuries are usually caused by traction, which produces neurapraxia and has a good prognosis. More rarely, a nerve is lacerated (neurotmesis), and this carries a poor prognosis.

Long answer

The assessment of any limb injury should include an evaluation of the distal neurovascular status. Proximal humerus fractures are often associated with neurovascular injuries.8 The axillary nerve is the most commonly injured nerve owing to its close proximity to the surgical neck of the humerus. An assessment of axillary nerve sensory and motor function should be made at the initial examination. Sensory function can be tested through assessment of light touch over the superolateral aspect of the shoulder (regimental badge area). Motor assessment is potentially more difficult because of pain. However, where possible, after appropriate analgesia the deltoid muscle should be palpated and the patient asked to initiate shoulder abduction—contraction of the muscle indicates intact axillary nerve function. Injury to other branches of the brachial plexus is possible, and a full assessment of upper limb neurology should be completed. Most axillary nerve injuries are caused by stretch, which results in neurapraxia or axonotmesis. More rarely the nerve may be lacerated (neurotmesis), and this has a worse prognosis. If nerve function has not returned within three weeks of injury, electrophysiological testing should be performed to determine the nature of the nerve injury. If clinical or electrophysiological improvement has not occurred after three months the nerve should be explored.

Injury to the axillary artery is uncommon, but elderly patients have a greater risk than younger ones.10 Absent or reduced peripheral pulses are suggestive of injury, but a grossly ischaemic limb does not usually occur because of a good collateral vasculature. Palpable pulses are present in 27% of axillary artery injuries as a result of scapular collateral circulation.11 If vascular injury is suspected, an angiogram and the involvement of a vascular surgeon are required urgently.

4 What are the options for managing this patient?

Short answer

Management options are non-operative (sling, analgesia, and a graded rehabilitation programme) or operative (open reduction and internal fixation, or (hemi)arthroplasty). Most proximal humeral fractures are not seriously displaced and can be managed non-operatively, particularly in elderly patients. Operative management should be considered in this case because the patient is physiologically young and active with a complex injury pattern. Operative management carries a small risk of infection and nerve injury, but non-operative management may result in malunion and greater joint stiffness.

Long answer

Fracture management in any patient can be complex. Considerations other than the configuration of the fracture that are related to the patient (comorbidities) or surgeon (familiarity with shoulder surgery) influence the ultimate management decision. The management of proximal fractures of the humerus can present a particular challenge when there is underlying osteoporosis, potentially avascular fragments, or marked comminution. Fixation of osteoporotic bone is challenging and has a failure rate of 10-25%.12

In general, non-displaced fractures of the proximal humeral can be treated non-operatively with a reasonable clinical outcome.13 14 Increasingly, displaced fractures, particularly in elderly patients, are also being managed non-operatively. Absolute indications for surgery include open fractures, head splitting fractures, three or four part fracture dislocations, and neurovascular injury. Relative indications for surgery include the patient being younger and more active with more severe fracture configurations. Functional outcomes for many fracture patterns are identical whether treated operatively or non-operatively. One study estimated that only 1% of fractures of the proximal humerus mandate operative intervention, and that surgery is relatively indicated in a further 19%.5

Indications for non-operative management include the patient being elderly, less severe fracture patterns, previous shoulder pathology, and the surgeon’s lack of familiarity with shoulder surgery.2 Non-operative management involves initial rest in a sling or collar and cuff, analgesia, and a graded rehabilitation programme. The best available evidence for rehabilitation suggests the need for advice, exercise, and limited mobilisation of joints.15 A typical regimen would include the use of a sling combined with pendular, shoulder girdle, and scapula setting exercises during the first three weeks. Gentle isometric exercises should be introduced over the following three weeks before progressing to a full range of motion exercises at six weeks. Elbow, hand, and wrist range of motion exercises should be encouraged from day one.

The goals of surgery are to create a functional glenohumeral joint. This can be achieved by attempting open reduction and internal fixation using various techniques, including plate osteosynthesis, interosseous sutures, wires, screws, staples, or intramedullary devices. The choice of technique depends on the fracture pattern and the familiarity of the surgeon with a particular method of fixation. If osteosynthesis is not achievable then a (hemi)arthroplasty may be performed to replace the humeral head and reconstitute the joint.16

Both non-operative and operative management have potential complications. Non-operative management may be associated with stiffness, malunion, non-union, avascular necrosis, subacromial impingement, and osteoarthritis. The complications of surgery depend partly on the type of fixation used but include stiffness, infection, neurological injury, malunion, non-union, avascular necrosis, subacromial impingement, rotator cuff injury, and osteoarthritis. If an arthroplasty is performed rather than osteosynthesis, further risks include dislocation, periprosthetic fracture, and implant loosening.

Patient outcome

Our patient underwent open reduction and internal fixation of her fracture with a locking plate and screws (fig 5). No postoperative complications were encountered. Her left arm was placed in a sling for three weeks with pendular movements and shoulder strengthening exercises from day one. She progressed through a graded physiotherapy programme and by six months had achieved a functional level of movement, with active abduction and elevation to 100°, external rotation to 30°, and internal rotation to L3.


Fig 5 Postoperative anterioposterior radiograph after open reduction and internal fixation with a proximal humerus locking plate


Cite this as: BMJ 2012;344:e3172


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent obtained.