Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Fracture, Humerus, Proximal


Related Terms

  • Broken Arm
  • Broken Shoulder
  • Shoulder Fracture-dislocation

Differential Diagnosis

Specialists

  • Neurologist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Factors Influencing Duration

Duration depends upon severity of the injury, whether the dominant or non-dominant shoulder is affected, type of treatment, response to treatment, and complications.

Medical Codes

ICD-9-CM:
812 - Fracture of Humerus
812.0 - Closed Fracture of Upper End of Humerus
812.00 - Closed Fracture of Unspecified Part of Upper End of Humerus; Closed Fracture of Humerus, Proximal End, Shoulder
812.01 - Closed Fracture of Surgical Neck of Humerus
812.02 - Closed Fracture of Anatomical Neck of Humerus
812.03 - Closed Fracture of Greater Tuberosity of Humerus
812.09 - Other Closed Fractures of Upper End of Humerus; Head; Upper Epiphysis
812.1 - Open Fracture of Upper End of Humerus
812.10 - Open Fracture of Upper End of Humerus, Unspecified Part
812.11 - Open Fracture of Surgical Neck of Humerus
812.12 - Open Fracture of Anatomical Neck of Humerus
812.13 - Open Fracture of Greater Tuberosity of Humerus
812.19 - Other Open Facture of Upper End of Humerus
812.2 - Closed Fracture of Unspecified Part of Humerus
812.20 - Closed Fracture of Unspecified Part of Humerus
812.3 - Open Fracture of Shaft or Unspecified Part of Humerus
812.30 - Open Fracture of Unspecified Part of Humerus

Overview

© Reed Group
A fracture of the upper (proximal) end of the humerus, the long bone of the upper arm, is a frequent type of shoulder fracture. The humerus is a relatively thick bone with a large, round, smooth head that articulates at its upper end (proximally) with the shoulder blade (scapula) to form the shoulder joint and articulates at its lower end (distally) with the elbow. The shoulder joint consists of the hemispherical "ball" of the humeral head, the concave "socket" of the glenoid cavity of the scapula, and a group of 4 muscles (supraspinatus, infraspinatus, teres minor, subscapularis) that form the rotator cuff.

The most common mechanism of injury in a proximal humerus fracture is trauma to the arm or shoulder, such as occurs with a fall onto an outstretched hand. Fractures of the proximal humerus usually involve the humeral shaft, surgical neck, or the sites of muscle attachment (greater or lesser tuberosities). Fractured bones may remain in alignment (nondisplaced fracture) or fragments may separate and become misaligned (displaced fracture). The majority of proximal humerus fractures are nondisplaced and may be treated nonsurgically. Displaced fractures most commonly involve the surgical neck of the humerus. The degree of fracture displacement is dependent upon the direction of pull of the muscles that attach to the tuberosities. Greater tuberosity fractures account for 15% of proximal humerus fractures, and are associated with anterior shoulder dislocations one-third of the time (Norris).

Additional damage to the joint capsule, ligaments of the acromioclavicular (AC) joint, and the rotator cuff muscles and tendons may occur at the time of bone fracture. Shoulder dislocation may occur with proximal humeral fracture (fracture-dislocation). On occasion, the bone may break spontaneously (pathologic fracture) due to underlying weakness from osteoporosis, cancer, or a bone cyst.

Incidence and Prevalence: Proximal humerus fractures account for 5% of all fractures (Frankle). Incidence increases with age. Proximal humerus fracture is a major cause of morbidity in individuals age 65 and older (Frankle).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Athletes and older individuals, particularly post-menopausal women with osteoporosis, are at greater risk of sustaining proximal humerus fractures. Among younger individuals, high-impact sports activity is a frequent cause. Proximal humerus fractures are twice as common in women as in men, largely due to the increased incidence of osteoporosis in women (Guttman; Frankle). In addition to falls, proximal humerus fractures occur with increased frequency in individuals who are involved in motor vehicle or skiing accidents.

Source: Medical Disability Advisor



Diagnosis

History: Most individuals report a history of trauma to the arm or shoulder. Individuals may complain of pain, swelling, and the inability to lift the affected arm without assistance. A detailed history of the mechanism of injury will aid diagnosis Seizure and electrical shock can be associated with posterior shoulder dislocation, so it is important to ask specifically about these. A complete medical history including other medical conditions and medications being taken should be obtained.

Physical exam: Swelling (edema) and bruising (ecchymosis) may be evident on the arm, around the shoulder and chest wall. The full extent of ecchymosis may not be visible until 24 to 48 hours after injury. If the fracture is displaced, there may be an obvious deformity of the arm, and muscle spasms may be present. Upon examination, the individual is usually unable to lift the arm without assistance.

Thorough neurologic testing of the muscles of the forearm, wrist, and hand should be performed to determine if nerve injury has occurred. Loss of sensation in the lateral deltoid muscle suggests damage to the axillary nerve, a common site of injury in proximal humeral fractures. Radial nerve injury, indicated by inability to extend the wrist, is common with humerus fractures. The physician will examine for signs of numbness (paresthesia) or weakness in the muscles of the affected arm. Electromyography (EMG) may need to be performed if nerve injury is suspected. Radial and ulnar pulses of the affected arm should be checked as a weak or absent pulse could indicate vascular injury.

Tests: Plain x-rays in a trauma series (anteroposterior [AP], lateral views in scapular plane, and axillary views) show most fractures of the humerus and define extent and type of injury. Axillary views allow assessment of tuberosity fragments and dislocation of the head of the humerus. CT scans may be necessary to check for a fracture-dislocation. CT scans made also be needed to see if the is damage to the humeral head or glenoid.

Source: Medical Disability Advisor



Treatment

The goals of treatment are to control pain with nonsteroidal anti-inflammatory drugs (NSAIDs), analgesics, and/or narcotic pain medication during the recovery period and to restore function of the injured arm. The majority of proximal humerus fractures are nondisplaced and do not occur within the joint (intra-articular). To treat a nondisplaced humerus fracture, the arm is placed in a sling or shoulder immobilizer.

Proximal humerus fractures from a fall onto an outstretched hand result in a greater degree of fracture displacement than occurs from direct impact to the shoulder. Displaced fractures that involve the joint (articular fractures) and fractures with neurovascular injuries require surgery. Left untreated, these types of fractures usually result in significant physical limitations. Surgical approaches will differ depending on the degree of bone separation, location, presence of osteoporosis, and whether the bone has broken into several pieces (comminuted fracture). Surgical treatment may be closed reduction with percutaneous fixation, open reduction with internal fixation (ORIF), or humeral head replacement (shoulder reconstruction, shoulder hemiarthroplasty). ORIF may involve the insertion of wires, pins, screws, or an intramedullary rod or nail to realign fracture fragments. This procedure is more commonly used in younger individuals. Prosthetic shoulder replacement may be necessary for comminuted three- and four-part fractures, fractures that split the humeral head and in older persons. Regardless of the surgical method chosen, the bone fragments will be stabilized. The rotator cuff may need to be reconstructed if the fracture occurred near the attachments.

Source: Medical Disability Advisor



Prognosis

Most humerus shaft fractures require a year for complete recovery (Frankl). The prognosis will depend on the individual's age, overall health status, adherence to rehabilitation, and stability of the fracture if surgery is performed. Patient compliance, medical comorbidities and time between injury and treatment may affect outcome.

Source: Medical Disability Advisor



Rehabilitation

The goals of rehabilitation following a proximal humerus fracture are first to decrease pain and then to return the individual to full function with a pain-free shoulder. These goals may be achieved by emphasizing the restoration of full range of motion and strength to the upper extremity, while working toward independence in all activities of daily living. The therapist monitors the individual for neural and tendon integrity as healing and rehabilitation progress.

Rehabilitation is related to the location and type of fracture, as well as to the length of immobilization. Protocols for rehabilitation must be based upon stability of the fracture and whether fracture management was operative or nonoperative. If the fracture was managed surgically, the surgeon may recommend specific rehabilitation guidelines. In almost all cases, early return to passive range of motion results in a more functional recovery (Burton). Following operative treatment, exercises to restore passive range of motion are typically initiated within the first 2 days (Gutteman). When immobilized in a sling (nonoperative treatment), therapy is usually begun within 1 week after the injury (Burton; Gutteman). For cases requiring a humeral head replacement, rehabilitation therapy will generally follow the shoulder arthroplasty recommendations.

Local cold application may be beneficial for controlling pain and edema (Salter). Depending on the stability of the fracture, range of motion exercises of the adjacent joints may be started immediately and progressed to strengthening exercises as indicated (Hodgson; Bucholz). Unless contraindicated, the therapist should promote exercise and activities for the hand, wrist, and elbow to prevent loss of motion, strength, and dexterity. The therapist will progress the individual to activities that emphasize function, including endurance and coordination exercises, as shoulder range of motion and strength increase. The amount and intensity of therapy required will be determined somewhat by the pre-injury occupational and leisure activities that the individual wishes to resume.

Bone healing may occur within 6 to 12 weeks; however, bone strength and the ability of the humerus to sustain a heavy load may take up a year to return (Chapman). Once bone healing has occurred, the individual may resume full activities of daily living. It is important to instruct the individual not to overload the fracture site until the bone has regained its full strength. The treating physician should guide the resumption of heavy work and sports.

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistFracture, Humerus, Proximal
Physical or Occupational TherapistUp to 16 visits within 8 weeks
Surgical
SpecialistFracture, Humerus, Proximal
Physical or Occupational TherapistUp to 12 visits within 6 weeks
Note on Nonsurgical Guidelines: Rehabilitation may not begin until tissue healing, about 6 to 8 weeks after the fracture.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Early rehabilitation is very important. A humerus fracture that is immobilized for a long period may result in inability to move the shoulder (adhesive capsulitis). This may require lengthy rehabilitation or surgery to release adhesions. Ongoing shoulder weakness may follow healing. Proximal humerus fracture may result in malunion or non-union of bone fragments, particularly if the fracture involved the greater tuberosity. Injuries to the brachial plexus and nerves (axillary, suprascapular, musculocutaneous, radial) occur in up to 50% of proximal humerus fractures and 8% of these result in permanent loss of muscle strength. Risk of nerve injury is increased in individuals who sustain a fracture to the surgical neck of the humerus, suffer dislocation, and in the elderly. Most vascular injuries occur in individuals older than 50 years of age. Injury to the proximal humeral blood supply (ascending branch of anterior circumflex humeral artery) can lead to avascular necrosis (AVN), which occurs in 14% of three-part fractures, and in 34% of four-part humeral fractures (Frankle). AVN is common in fractures of the surgical neck of the humerus and may require total joint replacement (arthroplasty).

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Following a fracture, ice packs and a place to rest may be required. Breaks from job activities may be necessary every 2 hours or as pain and swelling dictate. Lifting and carrying activities may need to be reduced or temporarily eliminated. The individual may need to take narcotic or other medication for pain. Company policy on medication usage should be reviewed to determine if pain medication use is compatible with job safety and function.

Individuals with fractures requiring surgery and/or fractures involving the dominant arm will require longer periods of work restrictions. A fracture that involves the head of the humerus may prevent a return to heavy work or work that requires overhead use of the arm for that side of the body. Prosthetic replacement is generally not compatible with heavy work.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Did individual report a fall or direct blow to the shoulder? Was mechanism of injury determined?
  • Does individual complain of pain and swelling?
  • Does individual report inability to lift the arm without assistance?
  • Were x-rays (with anteroposterior [AP], lateral, and oblique views) of the shoulder taken?
  • Was diagnosis of fractured proximal humerus confirmed?
  • Was CT scan performed to determine presence of shoulder dislocation? Were neurovascular injuries identified?
  • Does individual have underlying comorbid illness that could contribute to fracture complexity or influence healing?

Regarding treatment:

  • Was the fracture a nondisplaced fracture or a displaced fracture?
  • If individual experienced a displaced fracture, was surgical realignment done?
  • If open reduction was required, did any complications occur post-surgically?
  • What class of medication was required to relieve pain (analgesics, NSAIDS, narcotics)?
  • Was physical therapy recommended for this individual?
  • Was individual compliant with all the treatment recommendations (rest, ice, physical therapy)?

Regarding prognosis:

  • In the case of a displaced fracture, was there joint, nerve, or tissue damage requiring significant time for recovery? Was there associated joint dislocation?
  • Did complications such as malunion, non-union, avascular necrosis, adhesive capsulitis, or neurovascular injury occur?
  • Has physical therapy been completed as recommended? Would additional therapy benefit the individual?
  • Did adequate time elapse for full recovery?
  • Is pain medication or pain-induced sleep deprivation causing cognitive impairment or inappropriate sleepiness during work hours?

Source: Medical Disability Advisor



References

Cited

Bucholz, Robert, and James D. Heckman. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins, 2005.

Burton, D., and A. Walters. "Management of proximal humerus fractures." Current Orthopaedics 20 (2006): 222-223.

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Frankle, Mark, and Raymond Long. "Proximal Humerus Fractures." eMedicine. Eds. Jegan Krishnan, et al. 20 Feb. 2002. Medscape. 22 Dec. 2008 <http://emedicine.medscape.com/article/1261320-overview>.

Gutteman, Dan, et al., eds. "Section M: Injuries of the Promximal Humerus (1. Injuries of the Proximal Humerus in Adults)." DeLee and Drez's Orthopaedic Sports Medicine. 2 ed. Saunders Elsevier, 2003.

Guttmann, Dan, Chang-Hyuk Choi, and Frances Cuomo. "Injuries of the Proximal Humerus." DeLee and Drez's Orthopaedic Sports Medicine. Eds. Jesse DeLee and David Drez. 2nd ed. 2 vols. Philadelphia: W.B. Saunders, 2003. 1096-1118. MD Consult. Elsevier, Inc. 8 Sep. 2008 <http://home.mdconsult.com/das/book/42853711-2/view/1103?sid=294763628>.

Hodgson, S. A., S. J. Mawson, and D. Stanley. "Rehabilitation after Two-part Fractures of the Neck of the Humerus." Journal of Bone and Joint Surgery 85 3 (2003): 419-422. National Center for Biotechnology Information. National Library of Medicine. 8 Sep. 2008 <PMID: 12729121>.

Norris, Tom R., and Andrew Green. "Proximal Humeral Fractures and Glenohumeral Dislocations." Skeletal Trauma: Basic Science, Management, and Reconstruction. Eds. Bruce. D. Browner, et al. 3rd ed. 2 vols. Philadelphia: Elsevier, Inc., 2003. 1512-1624. MD Consult. Elsevier, Inc. 8 Sep. 2008 <http://home.mdconsult.com/das/book/42853711-2/view/1217?sid=294763628>.

Salter, Robert, ed. Textbook of Disorders and Injuries of the Musculoskeletal System. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 1999.

Source: Medical Disability Advisor






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