Proximal humeral fractures

Introduction

Proximal humeral fractures are frequently seen after falls in the elderly, or after high energy trauma in younger people

Anatomy

The proximal humerus comprises four "parts" (corresponding to the growth centers): the head, the shaft and the greater and lesser tuberosities. Fracture lines typically separate these parts, giving rise to recognizable patterns. These patterns are the basis of the Neer /Codman classification.

Pathogeneis

Proximal humerus fractures result from direct trauma; the pull of the rotator cuff can also avulse a bony fragment.

Natural History

Non-displaced fractures usually do well. Multi-part fractures, often with associated injuries, usually lead to imperfect results

Patient History and Physical Findings

Imaging and Diagnostic Studies

It is critical that adequate x-rays are obtained. The trauma series of AP/Y/Axillary views are mandatory.

CT scanning was shown to not be very helpful.

Differential Diagnosis

The diagnosis of a fracture should be readily made from plain radiographs. The tricky issue is determining displacement and, in turn, where the fragments lie. Also, the soft tissue injury (cuff, labrum, articular surface) must be defined. For that MRI is helpful.

Treatment

Non operative treatment is best for non displaced fractures.

Displaced fractures need either ORIF or replacement. Percutaneous

Pearls and Pitfalls

Don’t miss a fracture dislocation

Document the status of the axillary nerve

Don’t miss a cuff tear that needs fixing

A displaced Greater Tuberosity fragment may lead to true impingement

Postoperative Care

Include immediate postoperative care and rehabilitation

Outcome

Include functional and prosthetic survivorship data as applicable

Complications

Include overview of complications

Selected References

Insert selected references and landmark articles