Advertisement

Anatomy and Classification of Proximal Humerus Fractures

  • John A. HinsonEmail author
Chapter

Abstract

Proximal humerus fractures are a common injury most often seen in elderly females with osteoporotic bone. The vast majority of these fractures are minimally displaced and amenable to nonoperative treatment. Appropriate surgical management is indicated in the remaining patients. Accurate diagnosis and classification of these fractures are the first steps in appropriate treatment. Authors have created a number of classification schemes with attempts made to link fracture type to treatment and prognosis. Knowledge of the bony anatomy, muscular attachments, and vascular supply of the humeral head has guided the creation of classification systems of these fractures. Dr. Charles Neer utilized this knowledge in the creation of his four-segment classification scheme. His system is the most widely used and studied in the current literature. An experienced surgeon with good imaging can use The Neer classification system to aid in diagnosis and help guide treatment of these fractures.

Keywords

Humeral Head Great Tuberosity Humeral Shaft Proximal Humerus Fracture Axillary Nerve 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettak C, editors. Skeletal trauma. 4th ed. Philadelphia: Saunders; 2009.Google Scholar
  2. 2.
    Rockwood CA, Matsen FA, Wirth MA, Lippitt SB, editors. The shoulder. 4th ed. Philadelphia: Saunders; 2009.Google Scholar
  3. 3.
    Krisitansen B, Barfod G, Bredsen J, et al. Epidemiology of proximal humeral fractures. Acta Orthop Scand. 1986;57:320–33.CrossRefGoogle Scholar
  4. 4.
    Itamura J, Dietrick T, Roidis N, et al. Analysis of the bicipital groove as a landmark for humeral head replacement. J Shoulder Elbow Surg. 2002;11:322–6.PubMedCrossRefGoogle Scholar
  5. 5.
    Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. J Bone Joint Surg. 1997;79B(5):857–65.CrossRefGoogle Scholar
  6. 6.
    Hill JA, Tkach L, Hendrix RW. A study of glenohumeral orientation in patients with anterior recurrent shoulder dislocations using computerized axial tomography. Orthop Rev. 1989;18(1):84–91.PubMedGoogle Scholar
  7. 7.
    Kronberg M, Brostrom LA, Soderlund V. Retroversion of the humeral head in the normal shoulder and its relationship to the normal range of motion. Clin Orthop. 1990;253:113–7.PubMedGoogle Scholar
  8. 8.
    Neer CS. Articular replacement for the humeral head. J Bone Joint Surg. 1955;37A:215–28.Google Scholar
  9. 9.
    Randelli M, Gambrioli PL. Glenohumeral osteotometry by computed tomography in normal and unstable shoulders. Clin Orthop. 1986;(208):151–6.Google Scholar
  10. 10.
    Hall MC, Rosser M. The structure of the upper end of the humerus, with reference to osteoporotic changes in senescence leading to fractures. Can Med Assoc J. 1963;88:290–4.PubMedPubMedCentralGoogle Scholar
  11. 11.
    Saitoh S, Nakatuchi Y. Osteoporosis of the proximal humerus: comparison of bone mineral density and mechanical strength of the proximal femur. J Shoulder Elbow Surg. 1993;2:78–84.PubMedCrossRefGoogle Scholar
  12. 12.
    Saitoh S, et al. Distribution of bone mineral density and bone strength of the proximal humerus. J Shoulder Elbow Surg. 1994;3:234–42.PubMedCrossRefGoogle Scholar
  13. 13.
    Laing PG. The arterial supply of the adult humerus. J Bone Joint Surg. 1956;28A:1105–16.Google Scholar
  14. 14.
    Gerber C, Schneeberger AG, Vinh TS. The arterial vascularization of the humeral head. An anatomic al study. J Bone Joint Surg. 1990;72(10):1486–94.PubMedGoogle Scholar
  15. 15.
    Brooks CH, Revell WJ, Heatley FW. Vascularity of the humeral head after proximal humerus fractures. An anatomical cadaver study. J Bone Joint Surg Br. 1993;75(1):132–6.PubMedGoogle Scholar
  16. 16.
    Coudane H, Fays J, De La Selle H, Nicoud C, Pilot L. Arteriography after complex fractures of the upper extremity of the humerus bone: a prospective study—preliminary results. J Shoulder Elbow Surg. 2000;9:548.Google Scholar
  17. 17.
    Jakob RP, Miniaci A, Anson PS, Jaberg H, Osterwalder A, Ganz R. Four-part valgus impacted fractures of the proximal humerus. J Bone Joint Surg Br. 1991;73:295–8.PubMedGoogle Scholar
  18. 18.
    Lee CK, Hansen HR. Post-traumatic avascular necrosis of the humeral head in displaced proximal humerus fractures. J Trauma. 1981;21:788–91.PubMedCrossRefGoogle Scholar
  19. 19.
    Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg. 2002;84:1919–25.PubMedGoogle Scholar
  20. 20.
    Esser RD. Treatment of three- and four-part fractures of the proximal humerus with a modified cloverleaf plate. J Orthop Trauma. 1994;8:15–22.PubMedCrossRefGoogle Scholar
  21. 21.
    Esser RD. Open reduction and internal fixation of three- and four-part fractures of the proximal humerus. Clin Orthop Relat Res. 1994;299:244–51.PubMedGoogle Scholar
  22. 22.
    Edelson G, Saruri H, Salami J, Vigder F, Militianu D. Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg. 2008;17:399–409.PubMedCrossRefGoogle Scholar
  23. 23.
    Hawkins RJ, Bell RH, Gurr K. The three-part fracture of the proximal part of the humerus. Operative treatment. J Bone Joint Surg. 1986;68:1410–4.PubMedGoogle Scholar
  24. 24.
    Nayak NK, Schickendantz MS, Regan WD, Hawkins RJ. Operative treatment of nonunion of surgical neck fractures of the humerus. Clin Orthop Relat Res. 1995;313:200–5.PubMedGoogle Scholar
  25. 25.
    Wanner GA, Wanner-Schmid E, Romero J, Hersche O, von Smekal A, Trentz O, Ertel W. Internal fixation of displaced proximal humeral fractures with two one-third tubular plates. J Trauma. 2003;54:536–44.PubMedCrossRefGoogle Scholar
  26. 26.
    Hintermann B, Trouillier HH, Schafer D. Rigid internal fixation of fractures of the proximal humerus in older patients. J Bone Joint Surg Br. 2000;82:1107–12.PubMedCrossRefGoogle Scholar
  27. 27.
    Moda SK, Chadha NS, Sangwan SS, Khurana DK, Dahiya AS, Siwach RC. Open reduction and internal fixation of proximal humeral fractures and fracture-dislocations. J Bone Joint Surg Br. 1990;72:1050–2.PubMedGoogle Scholar
  28. 28.
    Neer CS. Displaced proximal humeral fractures. Part II. Treatment of three-part and four-part displacement. J Bone Joint Surg. 1970;52:1090–103.PubMedGoogle Scholar
  29. 29.
    Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG. Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg. 2010;92:943–8.PubMedCrossRefGoogle Scholar
  30. 30.
    Gardener E. Innervation of the shoulder joint. Anat Rec. 1948;102:1–18.CrossRefGoogle Scholar
  31. 31.
    Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humerus fractures. J Shoulder Elbow Surg. 2001;10:421–7.PubMedCrossRefGoogle Scholar
  32. 32.
    Bono CM, Grossman MG, Hochwald N, Tornetta III P. Radial and axillary nerves. Anatomic considerations in humerus fixation. Clin Orthop Relat Res. 2000;373:259–64.PubMedCrossRefGoogle Scholar
  33. 33.
    Visser CP, Tavy DL, Coene LN, Brand R. Electromyographic findings in shoulder dislocations and fractures of the proximal humerus: comparison with clinical neurological examination. Clin Neurol Neurosurg. 1999;101:86–91.PubMedCrossRefGoogle Scholar
  34. 34.
    Flatow EL, Bigliani LU, April EW. An anatomic study of the musculocutaneous nerve and its relationship to the coracoid process. Clin Orthop Relat Res. 1989;244:166–71.PubMedGoogle Scholar
  35. 35.
    Levine WN, Marra G, Bigliani LU, editors. Fractures of the shoulder girdle. New York: Marcel Dekker; 2003.Google Scholar
  36. 36.
    Kelly JP. Fractures complicating electroconvulsive therapy and chronic epilepsy. J Bone Joint Surg. 1954;36B:70–9.Google Scholar
  37. 37.
    Gruson KI, Ruchelsman DE, Tejwani NC. Isolated tuberosity fractures of the proximal humerus: current concepts. Injury. 2008;39:284–98.PubMedCrossRefGoogle Scholar
  38. 38.
    Green A, Izzi Jr J. Isolated fractures of the greater tuberosity of the proximal humerus. J Shoulder Elbow Surg. 2003;12:641–9.PubMedCrossRefGoogle Scholar
  39. 39.
    Brunner A, Honigmann P, Treumann T, Babst R. The impact of stereo-visualization of three-dimensional CT datasets on the inter- and intraobserver reliability of the AO/OTA and Neer classifications in the assessment of fractures of the proximal humerus. J Bone Joint Surg Br. 2009;91-B:766–71.CrossRefGoogle Scholar
  40. 40.
    Kocher T. Beiträge zur Kenntnis einiger Praktisch Wichtiger Frakturformen. Basel: Carl Sallmann; 1896.Google Scholar
  41. 41.
    Codman EA. The shoulder: rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa. Boston: Thomas Todd; 1934.Google Scholar
  42. 42.
    Watson-Jones R. Fracture of the neck of the humerus. In: Fractures and other bone and joint injuries. Baltimore: Williams and Wilkens; 1940. p. 289–97.Google Scholar
  43. 43.
    Dehne E. Fractures at the upper end of the humerus. Surg Clin North Am. 1945;25:28–47.Google Scholar
  44. 44.
    Neer CS. Displaced proximal humeral fractures. Part I. Classification and evaluation. J Bone Joint Surg. 1970;52(6):1077–89.PubMedGoogle Scholar
  45. 45.
    Knight RA, Mayne JA. Comminuted fractures and fracture-dislocations involving the articular surface of the humeral head. J Bone Joint Surg. 1957;39:1343–55.PubMedGoogle Scholar
  46. 46.
    De Anquin CE, De Anquin CA. Prosthetic replacement in the treatment of serious fractures of the proximal humerus. In: Bayley I, Kessel L, editors. Shoulder surgery. Berlin: Springer; 1982. p. 207–17.CrossRefGoogle Scholar
  47. 47.
    DePalma AF, Cautilli RA. Fractures of the upper end of the humerus. Clin Orthop Relat Res. 1961;20:73–93.Google Scholar
  48. 48.
    Muller ME, et al. The comprehensive classification of fractures of long bones. Berlin: Springer; 1990.CrossRefGoogle Scholar
  49. 49.
    Siebenrock KA, Gerber C. The reproducibility of classification fractures of the proximal end of the humerus. J Bone Joint Surg. 1993;75(12):1751–5.PubMedGoogle Scholar
  50. 50.
    Sukthankar AV, Leonello DT, Hertel RW, Ding GS, Sandow MJ. A comprehensive classification of proximal humeral fractures: HGLS system. J Shoulder Elbow Surg. 2013;22:e1–6.PubMedCrossRefGoogle Scholar
  51. 51.
    Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13:427–33.PubMedCrossRefGoogle Scholar
  52. 52.
    Neer CS. Four-segment classification of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg. 2002;11(4):389–400.PubMedCrossRefGoogle Scholar
  53. 53.
    Bucholz RW, Heckman JD, Tornetta P, Koval KJ, Wirth MA, editors. Rockwood and Green’s fractures in adults. 6th ed. Philadelphia: Lippincott; 2005.Google Scholar
  54. 54.
    Tamai K, Ishige N, Kuroda S, Ohno W, Itoh H, Hashiguchi H, Iizawa N, Mikasa M. Four-segment classification of proximal humeral fractures revisited: a multicenter study on 509 cases. J Shoulder Elbow Surg. 2009;18:845–50.PubMedCrossRefGoogle Scholar
  55. 55.
    Kristiansen B, et al. The Neer classification of fractures of the proximal humerus. An assessment of interobserver variation. Skeletal Radiol. 1988;17(6):420–2.PubMedCrossRefGoogle Scholar
  56. 56.
    Sidor ML, et al. The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg. 1993;75(12):1745–50.PubMedGoogle Scholar
  57. 57.
    Bernstein J, et al. Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs. J Bone Joint Surg. 1996;78A:1371–5.Google Scholar
  58. 58.
    Sjoden GO, et al. Poor reproducibility of classification of proximal humeral fractures. Additional CT of minor value. Acta Orthop Scand. 1997;69(3):239–42.CrossRefGoogle Scholar
  59. 59.
    Sallay PI, Pedowitz RA, Mallon WJ, Vandemark RM, Dalton JD, Speer KP. Reliability and reproducibility of radiographic interpretation of proximal humeral fracture pathoanatomy. J Shoulder Elbow Surg. 1997;6:60–9.PubMedCrossRefGoogle Scholar
  60. 60.
    Shrader MW, Sanchez-Sotelo J, Sperling JW, Rowland CM, Cofield RH. Understanding proximal humerus fractures: image analysis, classification, and treatment. J Shoulder Elbow Surg. 2005;14:497–505.PubMedCrossRefGoogle Scholar
  61. 61.
    Brorson S, Hrόbjartsson A. Training improves agreement among doctors using the Neer system for proximal humeral fractures in a systematic review. J Clin Epidemiol. 2008;61:7–16.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2015

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryGeorgia Regents UniversityAugustaUSA

Personalised recommendations