What is the initial management for a proximal humerus fracture in the emergency department?

Emergency Department Management of Proximal Humerus Fracture

Immediately immobilize the affected limb and administer regular paracetamol as first-line analgesia, obtain plain radiographs for diagnosis, and consider ultrasound-guided interfascial plane block for superior pain control while avoiding opioid-related complications. 1, 2

Initial Assessment and Diagnosis

Clinical Presentation

• Severe pain localized to the shoulder region with complete inability to move the upper arm is the hallmark presentation, typically occurring after a fall directly onto the shoulder or outstretched arm in elderly patients 3
• Examine for associated injuries including rotator cuff tears (high association with humeral head fractures), neurovascular compromise, and shoulder dislocation 1

Imaging Protocol

• Plain radiographs are the initial and definitive diagnostic study for proximal humerus fractures 1, 3
• CT without contrast is indicated only for complex fracture patterns requiring surgical planning, as it is superior to all other modalities in characterizing fracture planes and displacement 1
• MRI and ultrasound have no role in acute emergency department evaluation of proximal humerus fractures 1

Pain Management Strategy

First-Line Analgesia

• Administer regular paracetamol (acetaminophen) routinely unless contraindicated as the foundation of pain management 4, 5
• Avoid NSAIDs entirely due to high prevalence of renal dysfunction in the elderly population most commonly affected by these fractures 4

Opioid Use (When Necessary)

• Use opioids cautiously with reduced dosing, as approximately 40% of fracture patients have moderate renal dysfunction requiring dose adjustment 4
• Reduce both dose and frequency, particularly in elderly patients, until renal function is assessed 4
• Poor immediate pain control increases morbidity, so adequate analgesia is essential 6

Regional Anesthesia (Preferred Approach)

• The interfascial plane block (IPB) is an emerging ultrasound-guided technique that provides superior analgesia by targeting the fascial plane between the deltoid and subscapularis muscles 2
• Administer 20 mL of 7.5 mg/mL ropivacaine under ultrasound guidance, which achieves significant pain relief within 15 minutes 2
• IPB carries major advantages over traditional interscalene blocks: reduced risk of hemidiaphragmatic paresis, lower likelihood of motor blockade, and relatively easy to learn for clinicians familiar with ultrasound-guided techniques 2
• This technique reduces reliance on systemic opioids and facilitates immobilization or closed reduction without additional sedation 2

Immobilization

• Immobilize the limb immediately using a sling and swathe or shoulder immobilizer to minimize pain and prevent further injury 4
• Proper immobilization is critical before any imaging or definitive treatment planning 4

Disposition and Consultation

Orthopedic Consultation Criteria

• Consult orthopedics for fractures with multiple fragments and extensive displacement requiring surgical evaluation 3
• Most proximal humerus fractures (the vast majority) can be treated nonoperatively with good functional outcomes 7, 8, 9
• Surgical indications include significantly displaced fractures, 4-part fractures, head-split fractures, or fractures with underlying arthritic changes 9

Treatment Decision Framework

• Undisplaced or minimally displaced fractures: nonoperative management with immobilization and early rehabilitation 7, 8
• Displaced fractures in younger patients: consider surgical fixation with locking plates or other constructs 8, 9
• Comminuted 4-part fractures in elderly: may require arthroplasty consultation 9

Critical Pitfalls to Avoid

• Do not delay pain assessment and management, as early and effective analgesia is crucial and impacts morbidity 4, 6
• Do not prescribe NSAIDs without checking renal function first, as this population has extremely high rates of renal impairment 4
• Do not use standard opioid dosing in elderly patients without dose reduction, particularly in those with renal dysfunction 4
• Do not order CT, MRI, or ultrasound in the emergency department unless surgical planning is immediately needed, as plain radiographs are diagnostic 1
• Do not miss associated rotator cuff tears, which have high association with humeral head fractures, though these are typically addressed during surgical fixation if needed 1