Slide 129 — Proximal humerus fracture

Clean FRCS notes with inline figures

Proximal humerus fracture

•Appearance of ossification centres

•Head 3months

•GT 1 yr

•LT 3 yr

•Fusion

•GT-Head-LT 6yo

•To shaft 18yo

Classification

•SH

Neer classification for physeal plate fracture

Type / group	Definition / note
I	<5mm displacement
II	<1/3 shaft width
III	1/3-2/3 shaft width

•IV >2/3 shaft width

Deforming force:

•Proximal cuff

•Distal deltoid and pec major

•Unacceptable alignment

•Neer III/IV

•Angulation

•<7yo: 75deg

•7-12yo: 60deg

•>12yo: 45deg

Management

•Rule out NAI

•CR maneuver: 90 flexion, 90 abd + ER

•<12 yo – shoulder spica cast

•>12 yo – pinning or swathe/shoulder immobilizer

Evidence

•A recent systematic review of over 550 cases by Pahlavan (J children orthopedics 2011): children over 13yo may benefit from anatomic reduction and fixation due to poorer outcomes with conservative mx

•Flexible IM nail vs percutaneous pinning (2011)

•Percutaneous pinning more complications but shorter surgical time and less blood loss

Direct Q&A

Q1 How is Proximal humerus fracture classified here?

•I - <5mm displacement

•II - <1/3 shaft width

•III – 1/3-2/3 shaft width

•IV >2/3 shaft width

Q2 How is Proximal humerus fracture managed?

Rule out NAI

•CR maneuver: 90 flexion, 90 abd + ER

•<12 yo – shoulder spica cast

•>12 yo – pinning or swathe/shoulder immobilizer

Q3 What evidence or study finding is cited for Proximal humerus fracture?

•Flexible IM nail vs percutaneous pinning (2011)

Percutaneous pinning more complications but shorter surgical time and less blood loss

Raw speaker-note hierarchy audit

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Proximal humerus fracture
2	0	None	None	0	Appearance of ossification centres
3	0	None	None	0	Head 3months
4	0	None	None	0	GT 1 yr
5	0	None	None	0	LT 3 yr
6	0	None	None	0	Fusion
7	0	None	None	0	GT-Head-LT 6yo
8	0	None	None	0	To shaft 18yo
9	0	None	None	0	Classification
10	0	None	None	0	SH
11	0	None	None	0	Neer classification for physeal plate fracture
12	1	457200	0	1	I - <5mm displacement
13	1	457200	0	1	II - <1/3 shaft width
14	1	457200	0	1	III – 1/3-2/3 shaft width
15	1	457200	0	1	IV >2/3 shaft width
16	0	None	None	0	Deforming force:
17	0	171450	-171450	1	Proximal cuff
18	0	171450	-171450	1	Distal deltoid and pec major
19	0	None	None	0	Unacceptable alignment
20	0	None	None	0	Neer III/IV
21	0	None	None	0	Angulation
22	0	171450	-171450	1	<7yo: 75deg
23	0	171450	-171450	1	7-12yo: 60deg
24	0	171450	-171450	1	>12yo: 45deg
25	0	None	None	0	Mx:
26	0	None	None	0	Rule out NAI
27	0	None	None	0	CR maneuver: 90 flexion, 90 abd + ER
28	0	None	None	0	<12 yo – shoulder spica cast
29	0	None	None	0	>12 yo – pinning or swathe/shoulder immobilizer
30	0	None	None	0	Evidence
31	0	None	None	0	A recent systematic review of over 550 cases by Pahlavan (J children orthopedics 2011): children over 13yo may benefit from anatomic reduction and fixation due to poorer outcomes with conservative mx
32	0	None	None	0	Flexible IM nail vs percutaneous pinning (2011)
33	0	None	None	0	Percutaneous pinning more complications but shorter surgical time and less blood loss

lvl

marL

indent

logical

original note line

None

Proximal humerus fracture

None

Appearance of ossification centres

None

Head 3months

None

GT 1 yr

None

LT 3 yr

None

Fusion

None

GT-Head-LT 6yo

None

To shaft 18yo

None

Classification

None

Neer classification for physeal plate fracture

457200

I - <5mm displacement

457200

II - <1/3 shaft width

457200

III – 1/3-2/3 shaft width

457200

IV >2/3 shaft width

None

Deforming force:

171450

-171450

Proximal cuff

171450

-171450

Distal deltoid and pec major

None

Unacceptable alignment

None

Neer III/IV

None

Angulation

171450

-171450

<7yo: 75deg

171450

-171450

7-12yo: 60deg

171450

-171450

>12yo: 45deg

None

Mx:

None

Rule out NAI

None

CR maneuver: 90 flexion, 90 abd + ER

None

<12 yo – shoulder spica cast

None

>12 yo – pinning or swathe/shoulder immobilizer

None

Evidence

None

A recent systematic review of over 550 cases by Pahlavan (J children orthopedics 2011): children over 13yo may benefit from anatomic reduction and fixation due to poorer outcomes with conservative mx

None

Flexible IM nail vs percutaneous pinning (2011)

None

Percutaneous pinning more complications but shorter surgical time and less blood loss

Improved semantic hierarchy used for the study notes

#	semantic level	section?	rewritten line
1	0		Proximal humerus fracture
2	1		Appearance of ossification centres
3	1		Head 3months
4	1		GT 1 yr
5	1		LT 3 yr
6	1		Fusion
7	1		GT-Head-LT 6yo
8	1		To shaft 18yo
9	0	yes	Classification
10	1		SH
11	0	yes	Neer classification for physeal plate fracture
12	1		I - <5mm displacement
13	1		II - <1/3 shaft width
14	1		III – 1/3-2/3 shaft width
15	1		IV >2/3 shaft width
16	0	yes	Deforming force:
17	1		Proximal cuff
18	1		Distal deltoid and pec major
19	1		Unacceptable alignment
20	1		Neer III/IV
21	1		Angulation
22	1		<7yo: 75deg
23	1		7-12yo: 60deg
24	1		>12yo: 45deg
25	0	yes	Management
26	1		Rule out NAI
27	1		CR maneuver: 90 flexion, 90 abd + ER
28	1		<12 yo – shoulder spica cast
29	1		>12 yo – pinning or swathe/shoulder immobilizer
30	0	yes	Evidence
31	1		A recent systematic review of over 550 cases by Pahlavan (J children orthopedics 2011): children over 13yo may benefit from anatomic reduction and fixation due to poorer outcomes with conservative mx
32	1		Flexible IM nail vs percutaneous pinning (2011)
33	1		Percutaneous pinning more complications but shorter surgical time and less blood loss

semantic level

section?

rewritten line

Proximal humerus fracture

Appearance of ossification centres

Head 3months

GT 1 yr

LT 3 yr

Fusion

GT-Head-LT 6yo

To shaft 18yo

yes

Classification

yes

Neer classification for physeal plate fracture

I - <5mm displacement

II - <1/3 shaft width

III – 1/3-2/3 shaft width

IV >2/3 shaft width

yes

Deforming force:

Proximal cuff

Distal deltoid and pec major

Unacceptable alignment

Neer III/IV

Angulation

<7yo: 75deg

7-12yo: 60deg

>12yo: 45deg

yes

Management

Rule out NAI

CR maneuver: 90 flexion, 90 abd + ER

<12 yo – shoulder spica cast

>12 yo – pinning or swathe/shoulder immobilizer

yes

Evidence

A recent systematic review of over 550 cases by Pahlavan (J children orthopedics 2011): children over 13yo may benefit from anatomic reduction and fixation due to poorer outcomes with conservative mx

Flexible IM nail vs percutaneous pinning (2011)

Percutaneous pinning more complications but shorter surgical time and less blood loss

129. Proximal humerus fracture

Clean FRCS notes with inline figures

Proximal humerus fracture

Classification

Neer classification for physeal plate fracture

Deforming force:

Management

Evidence

Direct Q&A

Rule out NAI

Percutaneous pinning more complications but shorter surgical time and less blood loss

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes