Any injured patient needs comprehensive and systematic assessment (eg, ATLS approach) to identify and treat life- and limb-threatening conditions. Pain, swelling, deformity, and/or open wound help to localize injuries. Any such signs and symptoms involving the shoulder region require an additional focused evaluation to assess distal pulses, motor and sensation, as well as active and passive shoulder motion. The possibility of a scapular, cervical spine, or other upper extremity injury must be considered.
In addition to fracture morphology, optimal treatment of proximal humeral fractures depends on several other factors which need to be evaluated:
- Bone quality (eg, osteoporosis, comminution)
- Blood supply to the humeral head
- Preexisting condition of the rotator cuff
- Patient’s demands and comorbidities
After the patient’s clinical status has been established and stabilized, x-ray examination of the injured shoulder is mandatory. A trauma x-ray series should be performed. This consists of a true AP view, an axillary lateral view, and a scapular Y view. At least two perpendicular x-rays (true AP and a scapular Y view) are necessary to identify the fracture type. A “true AP x-ray” of the shoulder is made with the central ray tangential to the glenoid surface. A scapular Y view is made with the central ray perpendicular to the glenoid. A transthoracic lateral view is obsolete nowadays.
CT scans are not necessary for all proximal humerus fractures, especially if minimally displaced. They can be very helpful for assessing complex injuries, particularly involving the humeral head, or with significant comminution. CT scans aid assessment of:
- Fracture morphology (including the number of fragments)
- Bone stock of the tuberosities and humeral head fragment
- Degree of comminution
- Size of fixable fragments
- Length of posteromedial metaphyseal extension