Defined as fracture occurring at or proximal to the surgical neck It is the commonest fracture affecting the shoulder girdle in adults. Proximal humeral fracture 80% of all humeral fractures. In pts above the age of 65 years, proximal humeral fractures are the 2nd most frequent upper extremity fractures ANATOMY - The proximal humerus is retroverted 35 to 40 degrees relative to the epicondylar axis. Most common is fall onto outstretched upper extremity from a standing height, in older & osteoporotic woman. Younger pts present following high energy trauma with significant soft tissue injury. Less common with excessive shoulder abduction, direct trauma, electric shock and seizures r seizures

1. Presenter: Dr Darshan K S
II year orthopaedic resident
Moderator: Dr Shekar V
Associate professor of orthopaedics

2.  Defined as fracture occurring at or
proximal to surgical neck
 It is the commonest fracture affecting
shoulder girdle in adults.
 Proximal humeral fracture 80% of all
humeral fractures.
 In pts above the age of 65 years proximal
humeral fractures are the 2nd most frequent
upper extremity fractures.
DEFINITION

3. Anatomical
neck
Surgical neck

6. • The ascending branch of the
anterior circumflex humeral
artery has been considered to
provide most of the blood flow
to the articular segment.
• Several studies have shown
branches from PCHA to the
posteromedial head to be
equally important.
• Arcuate artery of Liang –
supplies Humeral head.
• If the medial calcar of the
humerus is spared by the
fracture, the vessel is spared.

7. ANATO
MY

8. Proximal humerus is
retroverted 35 to 40
degrees relative to
epicondylar axis.

9. Most common is fall onto outstretched upper
extremity from a standing height, in older &
osteoporotic woman.
Younger pts present following high energy
trauma with significant soft tissue injury.
Less common with excessive shoulder
abduction, direct trauma, electric shock and
seizures r seizures.

11. Four osseous segments in proximal
humerus are:
 Humeral head
 Lesser tuberosity
 Greater tuberosity
 Humeral shaft

12. ANATO
MY

13. Greater tuberosity is
displaced by
supraspinatus,
infraspinatus and teres
minor.
Lesser tuberosity is
displaced by
subscapularis.
Humeral shaft displaced by
pectoralis major.
Deltoid insertion
causes abduction of
proximal fragment.

14. THE PROXIMAL HUMERUS CAN
FRACTURE 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.

15. • The majority of proximal humeral
fracture occur as isolated injuries.
• In polytrauma pts, proximal humeral
fracture frequently exhibit comminution
extending into the humeral shaft.
• In the presence of fracture dislocations,
glenoid rim and neck fracture and
avulsion fracture of the coracoid may
occur.

16. AXILLARY NERVE (58%)
SUPRASCAPULAR NERVE (48%)
Combined neurologic lesions being
frequent.
Nerve Injuries associated
VASCULAR INJURY :
-5-6% of the cases are associated
with AXILLARY ARTERY injury.

17.  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.
ASSOCIATED SOFT TISSUE
INJURIES

18. ATTITUDE : Pts typically present with upper
extremity held closely to chest by
contralateral hand, pain, swelling &
tenderness.
Ecchymosis may or may not be.
Neurovascular exmn. is essential. Axillary
nerve and suprascapular nerve function.
It is assessed by presence of
sensation on lateral aspect of proximal arm
overlying deltoid.(REGIMENT BADGE
SIGN)

19. NEER CLASSIFICATION
AO/OTACLASSIFICATION

20. Most commonly used classification is
Neer’s classification.
Useful in guiding treatment.
Based on four part anatomy of proximal
humerus.

21. It is a Refinement of Codman’s
System,incorporates the concept of
displacement and vascular isolation
of the articular segment and relates
theanatomy and biomechanical
forces resulting in the displacement
of fragments to diagnosis and
treatment

22. 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.

25. INVESTIGATIONS
1. Radiograph
2. Computed tomography
3. Magnetic resonance imaging

26. GRASHEY’S VIEW.
Grashey view- Taken in neutral arm rotation
with torso rotated30 to 45 degrees

27.  NEER LATERAL Y VIEW
OF SHOULDER.
Neer view-Scapula is imaged perpendicular
to Grashey view.

28. AXILLARY VIEWOF SHOULDER.
Axillary view-Arm in neutral rotation
and abducted as much as possible, with
the patient. supine and X-ray beam
projected from axilla

30. CT of proximal humeral
fracture is helpful in
providing further
understanding of fracture
configuration.
Axial images can
confirm displacement of
the lesser and greater
tuberosity fragments in
the transverse plane.
LT
GT

31. Sagittal images help in
determining a flexion or extension
deformity of the proximal humerus
with regard to the shaft.
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
fracture extension.

33. NON OPERATIVE TREATMENT
OPERATIVE TREATMENT

35. Fracture stability can be
assessed both
radiographically and
clinically.
Radiographically, stable
fractures exhibit impaction or
interdigitation between bone
fragments

36. • Clinically, fracture stability may be
assessed by palpating the
proximal humerus just distal to
the acromion with one hand,
while rotating the arm at the
elbow with the other. If the
proximal humerus is felt to move
as a unit with the distal segment,
the fracture is considered stable
• Gilchrist or Velpeau
type shoulder
immobilizer used.

37. • GILCHRIST OR VELPEAU TYPE
SHOULDER IMMOBILIZER USED.

38. • At 2 weeks passive ROM exercises
of the shoulder.
• Duration of Immobilization should be
as short as possible, and as long as
necessary.
• Resistance exercises can generally
begin at 6 weeks.
• Isometric exercises may help
maintain strength during the first 6
weeks.

39. At 3 or 4 weeks
radiographs are taken
& gentle assistive
exercises (pulley
elevation, external
rotation with a stick,
extension with a stick)
are begun.
At 6 weeks, rapid
progression to terminal
stretches and light
resistive exercises is
started