Pucker Up – An arm injury with a twist!

On a cold winter night, a 20-year-old female comes into the ED with left arm pain. She was ice skating with friends and fell, striking her arm on the ice. Her only injury is to the left shoulder, and you observe this on her exam:

Image 1: Physical examination findings 

Image 1: Physical examination findings 

She is tender over the ecchymotic area, and she refuses to move the shoulder. The AP radiograph demonstrates the following:

Image 2: AP radiograph of the left shoulder

Image 2: AP radiograph of the left shoulder

What’s the diagnosis and management?

Angulated surgical neck humerus fracture requiring reduction and immobilization.

Following closed reduction, you see the following:

Image 3: Exam findings following closed reduction

Image 3: Exam findings following closed reduction

What does this finding indicate? What is the treatment?

The skin puckering and bruising are indicative of skin entrapment. This occurs as a result of the fractured bone poking through the deltoid muscle. If left unreduced, it can lead to skin necrosis and conversion of the closed fracture into an open fracture. This manifestation has been reported in peer-reviewed literature five times: four instances that required operative intervention to resolve the entrapment, and one reported occurrence was successfully reduced in the ED.

In our case, with procedural sedation, traction allowed reduction and resolution of skin puckering. X-rays confirm reduction and, after overnight observation, the patient is discharged home with out-patient Orthopedic follow-up.

Brief overview of humerus fractures

Humerus fractures are initially classified as proximal, mid-shaft, or distal fractures. They are often further classified as 2-, 3-, or 4-part fractures based on the Neer classification system.

Image 4: Neer's Classification of humerus fractures. Figure created by https://www.shoulderdoc.co.uk/article/1457

Image 4: Neer's Classification of humerus fractures. Figure created by https://www.shoulderdoc.co.uk/article/1457

Most proximal humerus fractures are minimally displaced and may be managed nonoperatively with sling immobilization and early ROM since many proximal humerus fractures occur in elderly patients. Operative management is more likely to be pursued in younger patients with good bone quality, and Orthopedic consultation should be obtained in these cases.

Appropriate imaging of proximal humerus fractures includes three views of the shoulder (AP, scapular Y, and axillary lateral). CT scan may be useful for operative planning. MRI is rarely indicated.

Proximal humerus fractures typically require only sling immobilization. However, familiarity with the coaptation splint is important as a method of immobilization for mid-shaft humerus fractures.

Image 5: Coaptation splint

Image 5: Coaptation splint

Don’t forget a thorough upper extremity neurological exam, including sensation throughout the arm, and motor function at the elbow, wrist, and hand, as some fractures may affect neurovascular bundles (mid-shaft fractures are associated with radial nerve injury, and surgical neck fractures can involve the brachial plexus).

Take home message 

If the skin is bruised or puckered over the fracture, the skin may be trapped in the fracture. This can be reduced in the ED, but Orthopedics should be consulted for this rare and potentially surgical case. Many proximal and mid-shaft humerus fractures can be immobilized and referred for Orthopedic follow-up, but knowledge of fracture classification systems is helpful in determining the urgency of Orthopedic consultation and providing anticipatory guidance to the patient.

Faculty Reviewer: Dr. Jeff Feden


Allen, Deborha. “Proximal Humerus Fractures.” Orthobullets. Online. 7 June 2016. http://www.orthobullets.com/trauma/1015/proximal-humerus-fractures.

Alshryda, S., Odak, S., & Patel, A. (2008). Skin Puckering as a Sign of Humeral Neck Fracture. The Annals of The Royal College of Surgeons of England, 90(8), 692–693.

Chisolm-straker, M., & Cherkas, D. (2016). Clinical Communications: Adults. Journal of Emergency Medicine, 45(3), 341–344.

Davarinos, N., Ellanti, P., Khan Bhambro, K. S., & Keogh, P. (2011). Skin puckering an uncommon sign of underlying humeral neck fracture: A case report. Irish Journal of Medical Science, 180(3), 731–733.

Jindal, N., Gupta, P., Gupta, R. K., Kumar, A., & Jindal, A. (2013). Pucker sign in proximal humeral fractures: Implications on management. Strategies in Trauma and Limb Reconstruction, 8(2), 123–126. http://doi.org/10.1007/s11751-013-0162-y

Minneapolis Orthopedics. “Treatment.” A Patient’s Guide to Adult Humerus Shaft Fractures. Online. 26 June 2016. http://www.mplsortho.com/conditions-treatments/ecategory/47/etopic/4e9a2e8d8583ef20c2f7a72ebfa65420/.

 “Proximal Humerus Fracture Classifications.” Shoulder Doc. https://www.shoulderdoc.co.uk/article/1457

 Tintinalli J, Stapczynski J, et. al. “Shoulder and Humerus Injuries.” Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. McGraw-Hill Education, 8th Edition, 2016.