Proximal Humerus Fracture

EpidemiologyProximal Humerus 4 Part Fracture



- third most common fracture after hip and distal radius




Neck shaft angle

- 130o


Head retroverted

- 20o relative to shaft


Anatomical neck

- junction of head and metaphysis


Surgical neck

- junction of diaphysis and metaphysis


Blood supply 


Gerber JBJS Am 1990 December

Anatomical cadaver study


1.  Anterior humeral circumflex


Major supply

- gives anterolateral branch

- runs in intertubercular groove lateral to biceps

- becomes arcuate artery

- supplies GT / LT / entire epiphysis


Nearly always disrupted in fractures


2.  Posterior Humeral circumflex


Small contribution posterior head

- allows head to survive with both tuberosities fractured


3.  RC

- supplies blood to tuberosities in fractures


Neer Classification 1970



-  any fragment > 1cm or > 45o


Number of displaced fragments

- 2 part (head/shaft, GT, LT)

- 3 part (head/shaft/GT, head/shaft/LT)

- 4 part (head/shaft/GT/LT)


Fracture / dislocation


Shoulder Fracture DislocationProximal Humerus Fracture DislocationShoulder Fracture Dislocation AnteriorPosterior Shoulder Fracture Dislocation


Head splitting fracture


SNOH Head Split CTProximal Humerus Head Split CT


Anatomical Neck Fracture


Humerus Anatomical Neck Fracture






In most fractures, arcuate artery is disrupted, but head survives

- posterior circumflex artery is sufficient

- increases with amount of displacement


Rates AVN


4 part fracture 30%


3 part fracture 15%


Hertel Radiographic criteria


Hertel et al J Should Elbow Surg 2004


2 criteria to predict ischaemia

A. Metaphyseal head extension < 8 mm

B. Medial hinge displaced > 2mm


97% positive predictive of ischaemia if both factors present





- mostly elderly patients with osteoporotic



- high energy MVA


Deforming Forces


2 part fracture

- P. major displaces shaft medially

- head internally rotated by SSC


SNOH Fracture Displaced


GT fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor


Displaced Greater Tuberosity Fracture APDisplaced Greater Tuberosity Fracture LateralShoulder CT Displaced GT Fracture


LT fracture

- medially by SSC


Lesser Tuberosity FractureLesser Tuberosity Fracture 2




AP / Scapula Lateral / Axillary lateral





- delineate no of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF / in elderly


Surgical Neck of Humerus CT 4 Part CoronalSurgical Neck of Humerus CT 4 Part SagittalSNOH CT 3 Parts


Associated Injuries


Axillary nerve 

- most commonly injured as close proximity 

- relatively fixed by posterior cord brachial plexus & deltoid


Axillary artery

- in young patient with high speed injury

- can have collateral circulation and pink hand




Non operative 



- undisplaced

- elderly




85% are undisplaced and do not require surgery




Sling for 2/52 then mobilise




Koval et al JBJS Am 1997

- 104 patients minimally displaced fracture as per Neer

- < 1cm displacement and <45o

- 90% no pain, 77% good or excellent result

- ROM approximately 90% of the other side

- 10% moderate pain and 10% poor result

- poor function and ROM associated with phyio started > 14 days after injury

- poor function associated with pre-existing cuff problems


Olerudet al JSES 2011

- RCT nonop v hemiarthroplasty for displaced 4 part

- 55 patients, average age 77

- 2 year follow up

- significant advantage of hemiarthroplasty


Operative Management


1.  2 Part Fractures





- >1 cm or > 45o


Displaced Proximal Humeral FractureSNOH Displaced 2 Part Fracture Axillary LateralSNOH Displaced 2 Part Fracture AP



- percutaneous wires / screws

- intra-osseous sutures

- proximal humeral nail

- locking plate


B.  GT 



- > 5mm displaced needs ORIF

- superior displacement will cause impingement

- up to 25% associated with cuff tear

- repair of cuff important step


Displaced Greater Tuberosity Fracture LateralCT Coronal Greater Tuberosity FractureCT GT Fracture Sagittal



- deltoid splitting approach

- young patient can ORIF with screw

- in elderly insert Mason Allen no 2 suture in cuff and tie over screw

- repair rotator cuff


 ORIF Greater Tuberosity FractureGreater tuberosity Tie over screw


Consequences Nonoperative Treatment


SNOH MalunionSNOH Malunion 2


C. LT Fractures


Soft tissue washer and screw


LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF




2.  3 & 4 Part fractures


A.  ORIF with plate


SNOH Plate



- need sufficient bone quality

- always attempt in young




Moonot et al JBJS Br 2007

- 32 patients with 3 or 4 part treated with Philos plate

- 31 of 32 united

- 27/32 (86%) excellent or satisfatory results

- 5/32 (16%) poor results

- 1 patient AVN and non union


Yang et al J Orthop Trauma 2010

- 64 patients treated with proximal humeral plate

- screw penetration into joint most common complication 5/64

- deep wound infection 2/64

- AVN 2/64

- 3 fixation failures requiring revision

- half good and half moderate shoulder scores, few excellent or poor

- all complications in 4 part fractures

- tuberosity malunion associated with poor outcome


B.  IM Nail




Agel et al J Should Elbow Surg 2004

- 20 patients treated with polaris nail

- 2 proximal failures requiring revision

- 5 delayed unions


C.  Hemiarthroplasty


Shoulder Trauma HemiarthroplastyShoulder Trauma Hemiarthroplasty



- unreconstructable

- elderly

- 4 part fractures

- head splitting fractures

- anatomical neck

- head impression > 40% articular surface


Proximal Humerus Unreconstructable



- only good ROM if tuberosities heal



- best to do in first three weeks

- whilst GT / LT still easy to mobilise




ROM often poor

- better if anatomical union tuberosities

- early ROM gives better results (<2/52)

- rarely > 90o


SNOH Hemi 1SNOH Hemi 2


Atuna et al J Should Elbow Surg 2008

- 57 patients with 5 year follow up

- average age 66

- active forward elevation 100o

- 16% moderate or severe pain


Caiet al Orthopedics 2012

- RCT of ORIF v hemiarthroplasty in 4 part fractures elderly

- 32 patients, average age 72 years

- 2 year follow up

- minor advantages in pain relief and ROM with shoulder hemiarthroplasty


D.  Reverse total shoulder



- elderly patient

- poor cuff

- poor chance of tuberosity healing



- reverse has more serious complications (i.e. dislocation)

- techically more difficult to do

- results are not outstanding




Gallinet et al J Orthopaedics and Traumatology

- 21 patients hemiarthroplasty, 19 in reverse group

- forward flexion (90o v 60o) and abduction (90o v 53o) better in reverse

- rotation better in hemiarthroplasty


ORIF Locking Plate


SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CT


Proximal Humerus 4 Part Head Splitting ORIF APProximal Humeral 4 Part Head Splitting ORIF Lateral




Set up

- GA, IV ABx, lazy beach chair

- mark anatomy

- II (patient either in middle of radiolucent table or remove lateral aspect shoulder table) 


Deltopectoral approach 

- cephalic usually taken lateral

- take part of pec major off to facilitate exposure

- Hawkins Bell retractor (shoulder charnley retractor) / non pointed double gelpies 

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractor deep to tendon



- protect MCN under conjoint, minimal retraction

- find and protect the axillary nerve on inferior border of SSC, sweep finger inferiorly


Deep dissection

- clear sup deltoid bursa

- must elevate deltoid from head

- place a homan retractor over head to elevate deltoid


Identify structures

- remove callous

- reduce head onto shaft

- head is displaced posteriorly

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check for head splitting fractures


Find tuberosities

- secure with Mason Allen

- no 5 non absorbable


Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check II now to avoid having plate too high

- must not leave head in varus





- to prevent cutout must have head out of varus

- long inferomedial screws / kickstand screws

- similar concepts to NOF (don't want screws high in the head)


Closure over drain



- sling 6/52 with pendulars

- ROM 6/52





- uncommon

- associated with AVN






SNOH Malunion



- medial support very important

- must avoid varus malreduction


Plate impingement

- need to ensure place plate low on the head


Screw perforation of humeral head

- most common complication



- fortunately uncommon


Shoulder AVN Post ORIFShoulder AVN Post ORIF Lateral




Vascular Injury


Axillary / MCN / Brachial Plexus



- from signficant deformity

- TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy




Proximal Humerus 4 Part Fracture In Elderly


Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2TSR Post OA





Preoperative template

- often missing proximal neck

- x-ray of other side for reference

- template size, attempt to judge height


Set up

- need to be able to extend humerus to insert stem

- arm over side

- lazy beachchair

- head firmly secured on ring

- 500ml saline back between shoulder blades


Deltopectoral approach


Remove and tag tuberosities

- identify AXN first

- Mason Allen sutures, 2 in each

- often useful to debulk tuberosities


Remove and size anatomical neck

- identify diameter and thickness

- remove bone graft from head for tuberosity fixation


Ream humerus

- trial stem

- important to assess height

- trial with arm hanging to replicate weight

- will usually need to leave stem proud from fracture

- should be able to anatomically restore tuberosities


Need retroversion of 30o

- most prosthesis (i.e. Depuy Global Shoulder system) have an anterior fin

- position to the bicipital groove

- the prosthesis will be retroverted 30o


Need drill holes in humeral shaft 

- medial 2 for LT sutures

- lateral 2 for GT sutues

- anterior 2 to pass through both

- no 2 fibre wire

- keep them gliding as the cement sets


Cement with low viscosity Abx cement

- cement restrictor

- nil pressurisation or will fracture


Place on head with 12/14 taper


Repair tuberosities

- use any bone graft available

- 2 x additional sutures through anterior fin

- 1 x additional suture through medial hole


Biceps tenodesis


Close over drain, rehab as above




Malunion / Non union tuberosities



- increased in women

- increased with initial malposition

- excessive height or retroversion of humeral head



- 4-50%


Heterotropic ossification

- 10%


Glenoid degeneration

- 8% at 3 years


Prosthetic loosening

- 3-6%


Nerve injury




- 1-2%



- need realistic goals

- aim to achieve function at shoulder height