Neer classification of proximal humeral fractures
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The Neer classification of proximal humeral fractures is probably the most frequently used system along with the AO classification of proximal humeral fractures. The terminology and factors which influence the classification are essential for the utility of radiology reports of proximal humeral fractures.
The two main components of the classification are the number of fracture parts and the displacement 1,4-6.
The Neer system divides the proximal humerus into four parts and considers not the fracture line, but the displacement as being significant in terms of classification.
The four parts are:
- humeral head
- greater tuberosity
- lesser tuberosity
- humeral shaft
Displacement is on a per-part basis. A fracture part is considered displaced if angulation exceeds 45°, or if the fracture is displaced by more than 1 cm 1.
The simplest displaced fracture which is possible, therefore, is a two-part fracture. A minimally displaced fracture, even one that includes multiple fracture lines, however, merely constitutes a type I, one-part fracture.
The Neer classification has been variably adapted by multiple authors. The classification consists of four major groupings, based on the number of displaced parts. Neer added a fifth group 9 more recently.
- fracture lines involves 1 to 4 parts
- none of the parts are displaced (i.e. <1 cm and <45°)
These non-displaced or minimally displaced fractures account for ~70-80% of all proximal humeral fractures and are almost always treated conservatively 6,7.
- fracture lines involves 2 to 4 parts
- one part is displaced (i.e. >1 cm or >45°)
Four possible types of two-part fractures exist (one for each part):
- surgical neck: most common
- greater tuberosity
- frequently seen in the setting of anterior shoulder dislocation 8
- a lower threshold of displacement (>5 mm) has been proposed 8
- anatomical neck
- lesser tuberosity: uncommon
These fractures account for approximately 20% of proximal humeral fractures 6.
- fracture lines involves 3 or 4 parts
- two parts are displaced (i.e. >1 cm or >45°)
Two three-part fracture patterns are encountered 7:
- greater tuberosity and shaft are displaced with respect to the lesser tuberosity and articular surface which remain together
- most common three-part pattern
- lesser tuberosity and shaft are displaced with respect to the greater tuberosity and articular surface which remain together
These fractures account for approximately 5% of proximal humeral fractures 6.
- fracture lines involves all 4 parts
- three parts are displaced (i.e. >1 cm or >45°) with respect to the 4th
These fractures are uncommon (<1% of proximal humeral fractures) 6.
This pattern has poor non-operative results, and as the articular surface is no longer attached to any parts of the humerus which are attached to soft tissues. This pattern has a high incidence of osteonecrosis 7.
These fractures require operative management.
Valgus impacted four-part fracture
This type of four-part fracture is considered its own category and has a different prognosis than typical four-part fractures 9.
- 1. Kilcoyne R, Shuman W, Matsen F, Morris M, Rockwood C. The Neer Classification of Displaced Proximal Humeral Fractures: Spectrum of Findings on Plain Radiographs and CT Scans. AJR Am J Roentgenol. 1990;154(5):1029-33. doi:10.2214/ajr.154.5.2108538 - Pubmed
- 2. Kristiansen B, Andersen U, Olsen C, Varmarken J. The Neer Classification of Fractures of the Proximal Humerus. An Assessment of Interobserver Variation. Skeletal Radiol. 1988;17(6):420-2. doi:10.1007/BF00361661 - Pubmed
- 3. Brorson S, Bagger J, Sylvest A, Hrobjartsson A. Diagnosing Displaced Four-Part Fractures of the Proximal Humerus: A Review of Observer Studies. Int Orthop. 2009;33(2):323-7. doi:10.1007/s00264-008-0591-2 - Pubmed
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- 5. Neer C. Displaced Proximal Humeral Fractures. II. Treatment of Three-Part and Four-Part Displacement. J Bone Joint Surg Am. 1970;52(6):1090-103. - Pubmed
- 6. Yingze Zhang. Clinical Epidemiology of Orthopedic Trauma. (2012) ISBN: 9783131660411 - Google Books
- 7. Joseph P. Iannotti, Gerald R. Williams (Jr.). Disorders of the Shoulder: Diagnosis and Management (2 Volume Set). (2006) ISBN: 0781756782 - Google Books
- 8. Koval, Kenneth J.. Shoulder Fractures: The Practical Guide to Management. (2005) ISBN: 1588903109 - Google Books
- 9. Neer C. Four-Segment Classification of Proximal Humeral Fractures: Purpose and Reliable Use. J Shoulder Elbow Surg. 2002;11(4):389-400. doi:10.1067/mse.2002.124346 - Pubmed