A 62-year-old female presented to the emergency department after falling down stairs and landing on her right arm. On examination, she had bruising just below her shoulder joint and was unable to move her arm due to pain. X-rays showed a linear fracture through the proximal humerus. The Neer classification system was used, which divides proximal humerus fractures into 1-4 parts based on displacement of fragments. Based on the classification, treatment options range from sling immobilization for nondisplaced fractures to surgery for displaced multi-part fractures. Prognosis depends on the fracture type and degree of displacement.
2. A 62yo female
present to the ED
after falling down
3 stairs and
landing on her
right arm. On
exam, there is
ecchymosis just
distal to the
glenohumeral
joint and, she
refuses to move
secondary to pain
3.
4. Linear lucency through proximal aspect of the humeral bone
Neer classification used to guide treatment and estimate the
prognosis
5. • Uses 4 segments
I: Greater tuberosity
II: Lesser tuberosity
III: Humeral head
IV: Humeral shaft
Also rates displacement
A fracture is displaced when there is more than 1 cm of
displacement and 45° of angulation of any one fragment
with respect to the others
6. • One-part fracture
• Nondisplaced
• Two-part fracture
• Involves any of the 4 parts and
includes 1 displaced fragment
• Three-part fracture
• Displaced fracture of the
surgical neck in addition to
either a displaced greater
tuberosity or lesser tuberosity
fracture
• Four-part fracture
• Displaced fractures of the
surgical neck and both
tuberosities
7. One-part fracture
Minimally displaced or nondisplaced fractures can be
managed conservatively with a sling and early range of
motion exercises
Two-part fractures
May reduce with glenohumeral reduction
Three-part fractures
Open reduction and internal fixation
Four-part fracture
Managed with hemiarthroplasty
8. One-part fracture
Excellent prognosis
Two- and three-part fractures
Prognosis depends on the displaced fragments and
associated early and late complications
Four-part fracture
Up to 90% result in avascular necrosis of the humeral head
9. History classically of direct trauma to arm or shoulder
or of axial loading transmitted through elbow
Although AP and axillary humerus and shoulder views
are mandatory, axillary view with Velpeau bandage
may be used to help obtain axillary
Proximal humeral fractures are associated with
neurovascular injuries, with the axillary nerve being
the most common
Most common displacement
Medial and anterior displacement of the shaft in
association with the fracture of the humeral neck
11. Marx J MD; Hockberger R MD; Walls R MD. Rosen’s
emergency medicine. 7th ed.
Simon R; Sherman S; Koenigsknecht S. Emergency
orthopedics: the extremities. 5th ed. McGraw Hill
Publishing.
Wheeless C R III MD. Wheeless textbook of
orthopedics. www.wheelessonline.com.
