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Proximal humeral fracture

Dr Tom Foster and A.Prof Frank Gaillard ◉ ◈ et al.

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

On this page:

Article:

Epidemiology
Clinical presentation
Pathology
Radiographic features
Treatment and prognosis
Related articles
References

Images:

Cases and figures

Epidemiology

Proximal humeral fractures represent around 5% of all fractures ^?. They are most common in older populations and especially in those who are osteoporotic. As with other injuries, there is a bimodal distribution with a small peak amongst the young.

The majority of proximal humeral fractures occur in the elderly (mean age 65 years) with ~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.

Clinical presentation

Many older patients present following a relatively innocuous fall. Younger patients usually present following a high-trauma incident, e.g. a motor accident or fall from height. However, patients may present following a seizure, electrical shock or following direct trauma.

Pathology

Proximal humeral fractures usually result from a fall on an outstretched arm. Indirect forces transmitted through the proximal humerus and shoulder are the cause of most fractures. These forces may be compressive, tension, torsion or bending.

Radiographic features

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

Radiograph

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 (>1 cm 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 risk of malunion 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)

Quiz questions

References

Fractures

fracture
- terminology
  - fracture location
    - diaphyseal fracture
    - metaphyseal fracture
    - physeal fracture
      - Salter-Harris classification
        
        type I
        
        type II
        
        type III
        
        type IV
        
        type V
    - epiphyseal fracture
  - fracture types
  - fracture displacement
    - fracture translation
      - off-ended fracture
    - fracture angulation
    - fracture rotation
    - fracture length
      - distraction
      - impaction
      - shortening
- skull fractures
  - base of skull fractures
    - occipital condyle fracture
    - temporal bone fractures
      transsphenoidal basilar skull fracture
  - skull vault fractures
    - depressed skull fracture
    - ping pong skull fracture
- facial fractures
  - fractures involving a single facial buttress
    - alveolar process fractures
    - frontal sinus fracture
    - isolated zygomatic arch fractures
    - mandibular fracture
    - nasal bone fracture
    - orbital blow-out fracture
    - paranasal sinus fractures
  - complex fractures
- spinal fractures
  - classification (AO Spine classification systems)
    - cervical spine fracture classification systems
      - AO classification of upper cervical injuries
      - AO classification of subaxial injuries
      - Anderson and D'Alonzo classification (odontoid fracture)
      - Levine and Edwards classification (hangman fracture)
      - Roy-Camille classification (odontoid process fracture )
      - Allen and Ferguson classification (subaxial spine injuries)
      - subaxial cervical spine injury classification (SLIC)
    - thoracolumbar spinal fracture classification systems
    - three column concept of spinal fractures (Denis classification)
    - classification of sacral fractures
      - AO classification of sacral injuries
  - spinal fractures by region
    - cervical spine fractures
    - thoracic spine fractures
    - lumbar spine fractures
  - spinal fracture types
- rib fractures
  - flail chest
  - stove-in chest
- sternal fractures
- upper limb fractures
  - classification
  - upper limb fractures by region
    - shoulder
      - clavicular fracture
      - scapular fracture
        
        acromion fracture
        
        coracoid process fracture
        
        glenoid fracture
        
        Bankart lesion
        
        reverse Bankart lesion
      - humeral head fracture
        
        Hill-Sachs lesion
        
        reverse Hill-Sachs lesion
      - proximal humeral fracture
      - humeral neck fracture
    - arm
      - humeral shaft fracture
    - elbow
    - forearm
      - forearm fracture-dislocation
        
        Essex-Lopresti fracture-dislocation
        
        Galeazzi fracture-dislocation
        
        Monteggia fracture-dislocation
      - forearm fracture
        nightstick fracture
    - wrist
      - distal radial fracture
        
        Chauffeur fracture
        
        Colles fracture
        
        Smith fracture
        
        Barton fracture
        
        reverse Barton fracture
      - distal ulnar fracture
        ulnar styloid fracture
    - carpal bones
      - scaphoid fracture
        
        scaphoid non-union
        scaphoid non-union advanced collapse
        
        humpback deformity
      - lunate fracture
        
        perilunate fracture-dislocation
        
        lunate dislocation
      - capitate fracture
      - triquetral fracture
      - pisiform fracture
      - hamate fracture
        hook of hamate fracture
      - trapezoid fracture
      - trapezium fracture
    - hand
- lower limb fractures
  - classification by region
    - pelvis
      - Judet and Letournel classification (acetabular fracture)
      - Young and Burgess classification of pelvic ring fractures
    - hip
    - femoral
      - Winquist classification (femoral shaft fracture)
    - knee
      - Schatzker classification (tibial plateau fracture)
      - Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)
    - tibia/fibula
      - Watson-Jones classification (tibial tuberosity avulsion fracture)
    - ankle
      - Lauge-Hansen classification (ankle injury)
      - Danis-Weber classification (ankle fracture)
    - foot
      - Berndt and Harty classification (osteochondral lesions of the talus)
      - Sanders CT classification (calcaneal fracture)
      - Hawkins classification (talar neck fracture)
      - Myerson classification (Lisfranc injury)
      - Nunley-Vertullo classification (Lisfranc injury)
  - pelvis and lower limb fractures by region
    - pelvic fracture
    - sacral fracture
      - sacral insufficiency fractures
        Honda sign
    - coccygeal fracture
    - hip
      - acetabular fracture
      - femoral head fracture
      - femoral neck fracture
        
        subcapital fracture
        
        transcervical fracture
        
        basicervical fracture
      - trochanteric fracture
        
        pertrochanteric fracture
        
        intertrochanteric fracture
        
        subtrochanteric fracture
    - thigh
      - mid-shaft fracture
      - bisphosphonate-related fracture
    - knee
      - avulsion fractures
        
        Segond fracture
        
        reverse Segond fracture
        
        anterior cruciate ligament avulsion fracture
        
        posterior cruciate ligament avulsion fracture
        
        arcuate complex avulsion fracture (arcuate sign)
        
        biceps femoris avulsion fracture
        
        iliotibial band avulsion fracture
        
        semimembranosus tendon avulsion fracture
        
        Stieda fracture (MCL avulsion fracture)
      - patellar fracture
      - tibial plateau fracture
    - leg
      - tibial tuberosity avulsion fracture
      - tibial shaft fracture
      - fibular shaft fracture
      - Maisonneuve fracture
    - ankle
      - bimalleolar fracture
      - trimalleolar fracture
      - triplane fracture
      - Tillaux fracture
      - Bosworth fracture
      - pilon fracture
      - Wagstaffe-Le Fort fracture
    - foot
      - tarsal bones
        
        Chopart fracture
        
        calcaneal fracture
        
        lover's fracture
        
        calcaneal tuberosity avulsion fracture
        
        talus fracture
        
        talar body fractures
        
        talar dome osteochondral fracture
        
        posterior talar process fracture
        
        lateral talar process fracture
        
        talar neck fracture
        aviator fracture
        
        talar head fracture
        
        navicular fracture
        
        medial cuneiform fracture
        
        intermediate cuneiform fracture
        
        lateral cuneiform fracture
        
        cuboid fracture
        nutcracker fracture
      - metatarsal bones
        
        general
        
        march fracture
        
        Lisfranc fracture-dislocation
        
        5th metatarsal fracture
        
        stress fracture of the 5th metatarsal
        
        Jones fracture
        
        pseudo-Jones fracture
        
        avulsion fracture of the proximal 5th metatarsal
      - phalanges

Article information

rID: 18277

System: Musculoskeletal, Trauma

Tag: humerus, fractures

Synonyms or Alternate Spellings:

Proximal humeral fractures

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Cases and figures

Case 1Case 1

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Case 2Case 2

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Case 3Case 3

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Case 4Case 4

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Case 5Case 5

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Case 6Case 6

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Case 7Case 7

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Case 8 - surgical neck of humerus fractureCase 8 - surgical neck of humerus fracture

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Case 9Case 9

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Case 10Case 10

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Case 11Case 11

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Case 12: with dislocation and arterial dissectionCase 12: with dislocation and arterial dissection

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Case 13 Case 13

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