It is the commonest # affecting shoulder
girdle in adults.
Proximal humeral # account for almost 7%
of all # and 80% of all humeral #.
In pts above the age of 65 years proximal
humeral # are the 2nd most frequent upper
Shoulder has greatest range of motion of
any articulation in body.
It is due to shallow glenoid fossa that is
only 25% of humeral head.
Major contribution to stability is by soft
tissue composed of muscle, capsule, &
Proximal humerus is retroverted 35 to 40
degrees relative to epicondylar axis.
Four osseous segments in proximal
Greater tuberosity is
Lesser tuberosity is
Humeral shaft displaced
by pectoralis major.
causes abduction of
Most common is fall onto outstretched
upper extremity from a standing height, in
older & osteoporotic woman.
Younger pts present following high energy
Less common with excessive shoulder
abduction, direct trauma, electric shock or
The proximal humerus can # as a
consequence of 3 main loading modes:
Compressive loading of the glenoid onto
the humeral head.
Bending forces at the surgical neck.
Tension forces of the rotator cuff at the
greater & lesser tuberosities.
The majority of proximal humeral # occur
as isolated injuries.
In polytrauma pts, proximal humeral #
frequently exhibit comminution extending
into the humeral shaft.
In the presence of # dislocations, glenoid
rim and neck # and avulsion # of the
coracoid may occur.
The association of arterial injuries is rare and
is reported in the literature as isolated case
Electromyographic evidence of neurologic
injury can be present in as many as 67% of
proximal humeral #.
The most frequently affected nerves are the
axillary nerve (58%) & suprascapular nerve
(48%), with combined neurologic lesions
The association of rotator cuff tears has
been found to increase with age.
Full-thickness tears have been found in
only 6% of proximal humerus pts under 60
years of age compared to 30% in those pts
above 60 years of age.
Pts typically present with upper extremity
held closely to chest by contralateral hand,
pain, swelling & tenderness.
Ecchymosis may or may not be present.
Careful neurovascular exmn. is essential.
mainly for Axillary nerve function.
It is assessed by presence of sensation
on lateral aspect of proximal arm overlying
Most commonly used classification is
Useful in guiding treatment.
Based on four part anatomy of proximal
humerus : Humeral head, lesser & greater
tuberosities, proximal shaft.
Criteria for displacement
Greater than 1cm of seperation of a part or
Angulation of 45 degrees.
Osteonecrosis is most likely after displaced
four part fractures.
X ray AP view of
shoulder in plane of
CT of proximal humeral # is helpful in
providing further understanding of fracture
Axial images can confirm displacement of
the lesser and greater tuberosity
fragments in the transverse plane.
Coronal images give more detail about the
alignment of the humeral head &
assessment of comminution at the level of
the humeral calcar, the integrity of the
inferomedial hinge, and extent of
metaphyseal # extension.
Sagittal images help in determining a
flexion or extension deformity of the
proximal humerus with regard to the shaft.
Immobilization of the arm to the chest
using a simple collar and cuff sling
Gilchrist or Velpeau type shoulder
At 2 weeks passive ROM exercises of the
At 3 or 4 weeks
radiographs are taken &
gentle assistive exercises
(pulley elevation, external
rotation with a stick,
extension with a stick) are
At 6 weeks, rapid
progression to terminal
stretches and light resistive
exercises is started
Predictors for outcomes have been found
to be age factor.
Court-Brown et al. studied 131 two-part
surgical neck #.
At 1yr follow up pts able to return to
Non operative treatment yielded results
similar to those of surgical treatment even
in # with translation of 66% or more.
Court-Brown et al. further assessed non
operative treatment of four-part valgus-
impacted # in elderly patients.
Good or excellent results were achieved
in 81% of patients according to Neer’s
The treatment of displaced proximal humeral
# is complex & requires careful assessment
Pt factors (age & activity level)
Fracture-related factors (bone quality, fracture
pattern, degree of comminution, & vascular
The goal of treatment is a pain-free shoulder
with restoration of pre-injury function.
Good predictors of
of the humeral head of
Medial hinge disruption
of >2 mm
Ischemia of head:
The combination of
of the humeral head.
Medial hinge disruption
of >2 mm
Anatomic neck #
Radiographic criteria for perfusion of humeral head
Operative management is guided by
fracture pattern & cortical thickness.
Combined cortical thickness is the average
of medial & lateral cortical thickness.
A cortical thickness <4mm- sling,
osteosuture & hemiarthroplasty.
A cortical thickness >4mm- internal
proximal humeral fractures
that have at least 1 cm of
displacement between the
head and the shaft
or 5 mm of displacement of
the tuberosity fragment.
previous attempt(s) at
More than 6wks old #.
Four part comminuted #
Flatow et al. reported
tuberosity # had good
or excellent results
with osseous union.
78% of the pt had an
according to the
criteria of Neer et al.
in 2 or 3 part #.
greater tuberosity #
isolation or in conjunction
with a surgical neck #.
three and four-part proximal
four-part valgus impacted #
or true four part #.
severe osteopenia or
Comminution of the medial
portion of the calcar or
proximal part of the humeral
Two surgical approaches are commonly
used to perform open reduction and
internal fixation (ORIF).
These are the
Delto pectoral approach
AO type-B (bifocal)
AO type-C (anatomic neck)
Head splitting fractures
Impression fractures that
involve >40% of the articular
The plate should be positioned directly on
the middle of the lateral cortex and
approximately 8 mm distal to the superior
aspect of the greater tuberosity.
Humeral head preservation may be
possible with locked-plate fixation
supplemented with local bone graft or
The main indications for proximal humerus
interlocking IMIL nailing are displaced two-
part surgical neck # especially those with
extension into the humeral diaphysis, and
Three-part greater tuberosity fractures may
also be amenable to fixation with IM nailing
Four-part #, three-part # in
older pts with osteoporotic
That involve >40% of the
Active infection of the
shoulder joint and/or
Surrounding soft tissue
proximal anatomy is
medial to the humeral
neck and tie them
around the greater
A second set of
sutures can then be
passed into the lesser
tuberosity and tied.
Osteonecrosis: 3% to 14% of 3 part # , 4 to
14% of 4 part # & high rate in anatomical
Pin tract infection