Proximal humeral fracture

Proximal humeral fractures are common upper extremity fractures, particularly in older patients, and can result in significant disability. 

Epidemiology

The majority of proximal humeral fractures occur in the elderly (mean age 65 years) with approximately 70% occurring in women, presumably due to the greater incidence of osteoporosis ¹. Most of these (90%) occur at home due to a fall, and in most cases they are an isolated injury ¹. 

Mechanism

Proximal humeral fractures usually result form a fall on an outstretched arm.

Radiographic features

Plain films are usually sufficient to characterise proximal humeral fractures, and thus to determine management. CT can be useful if adequate views cannot be obtained, or if fractures are unusual or other fractures (e.g. glenoid) are present ². Additionally, CT (and especially 3D surface shaded reconstructions) has been shown to improve inter-observer agreement on classification of proximal humeral fractures ⁴. 

Regardless of the imaging performed, the number of displaced fragments should be assessed, to enable appropriate classification of the fracture (Neer classification or AO classification are most commonly used).  

Plain film

The fracture is usually evident as a lucency and cortical breach with variable degrees of angulation, impaction and displacement. 

Reporting checklist

In addition to reporting the presence of a fracture it is important to assess and comment on a number of other features.

• fracture: it should be noted that in most instances a description of the fracture rather than a specific classification is sufficient, but the features required to classify the fracture should be included
  • location of fracture lines
  • displacement and angulation of each part (> 1cm and >45 degrees respectively is particularly important in the Neer classification
  • presence of involvement of the articular surface
• associated injuries
  • shoulder dislocation
  • acromioclavicular dislocation
  • scapular fracture
  • clavicle fracture
  • distal radial fracture (especially Colles fracture)

Treatment and prognosis

Management depends not only on the type of fracture, but also importantly on the functional status and living situation of the patient. For example, someone who lives alone may not be able to do so without the use of one arm. Having said this, in almost all cases undisplaced fractures are treated conservatively, whereas operative open reduction and internal fixation (with a variety of intramedullary nails, plates and screws and K-wires) is reserved for displaced fractures ¹. Hemi-arthroplasty is also an option especially for three and four part fractures, where the the risk of mal-union and avascular necrosis are high ¹. 

In general prognosis is good with the majority of fractures healing well with little functional loss. Poor prognostic factors include ¹:

• older age of patient
• displaced fracture 
• three and four part fractures (see Neer classification)
• type C fractures (AO classification)