Proximal humeral fractures in adults
- Rebecca Bassett, MD
Rebecca Bassett, MD
- Adjunct Clinical Assistant Professor
- University of North Carolina School of Medicine
Proximal humerus fractures occur most commonly in the elderly and their incidence is increasing. Fractures of the humerus can occur proximally, in the shaft (diaphysis), or distally. The majority of both proximal and midshaft humerus fractures are nondisplaced and can be treated conservatively (nonsurgically). Complex fracture patterns pose greater challenges for treatment.
Proximal fractures of the humerus will be reviewed here. Nonstress and stress fractures of the shaft of the humerus are discussed separately. (See "Midshaft humeral fractures in adults" and "Stress fractures of the humeral shaft".)
The humerus is the largest bone in the upper extremity. The proximal humerus articulates with the glenoid of the scapula to form the glenohumeral (shoulder) joint (figure 1 and figure 2 and figure 3). The muscles and tendons of the rotator cuff, the acromion, and ligamentous attachments, such as those between the coracoid process of the scapula and the acromion, both stabilize the glenohumeral articulation and provide for the shoulder’s wide range of motion. The distal humerus articulates with the radius and ulna at the elbow.
According to the Neer classification, the proximal humerus is divided into four sections: the anatomical neck, the surgical neck, the greater tuberosity, and the lesser tuberosity (figure 4) . (See 'Neer classification' below.)
●The anatomical neck consists of the widened articular surface of the humeral head.
- Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am 1970; 52:1077.
- Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg 2001; 10:421.
- Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand 2001; 72:365.
- Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res 2006; 442:87.
- Chu SP, Kelsey JL, Keegan TH, et al. Risk factors for proximal humerus fracture. Am J Epidemiol 2004; 160:360.
- Lee SH, Dargent-Molina P, Bréart G, EPIDOS Group. Epidemiologie de l'Osteoporose Study. Risk factors for fractures of the proximal humerus: results from the EPIDOS prospective study. J Bone Miner Res 2002; 17:817.
- Clement ND, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of proximal humeral fractures in the elderly: predictors of mortality and function. Bone Joint J 2014; 96-B:970.
- Perlmutter GS. Axillary nerve injury. Clin Orthop Relat Res 1999; :28.
- Robinson BC, Athwal GS, Sanchez-Sotelo J, Rispoli DM. Classification and imaging of proximal humerus fractures. Orthop Clin North Am 2008; 39:393.
- Foroohar A, Tosti R, Richmond JM, et al. Classification and treatment of proximal humerus fractures: inter-observer reliability and agreement across imaging modalities and experience. J Orthop Surg Res 2011; 6:38.
- Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. J Bone Joint Surg Am 1993; 75:1745.
- Fracture Management for Primary Care, Eiff P, Hatch R, Calmbach W. (Eds), Saunders, Philadelphia 2003.
- Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand 2003; 74:580.
- Tejwani NC, Liporace F, Walsh M, et al. Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg 2008; 17:216.
- Kristiansen B, Angermann P, Larsen TK. Functional results following fractures of the proximal humerus. A controlled clinical study comparing two periods of immobilization. Arch Orthop Trauma Surg 1989; 108:339.
- Misra A, Kapur R, Maffulli N. Complex proximal humeral fractures in adults--a systematic review of management. Injury 2001; 32:363.
- Lanting B, MacDermid J, Drosdowech D, Faber KJ. Proximal humeral fractures: a systematic review of treatment modalities. J Shoulder Elbow Surg 2008; 17:42.
- Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2015; 11:CD000434.
- Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg 2009; 18:612.
- Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br 2001; 83:799.
- Zyto K, Ahrengart L, Sperber A, Törnkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br 1997; 79:412.
- Rangan A, Handoll H, Brealey S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 2015; 313:1037.
- Lefevre-Colau MM, Babinet A, Fayad F, et al. Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. J Bone Joint Surg Am 2007; 89:2582.
- Hodgson SA, Mawson SJ, Stanley D. Rehabilitation after two-part fractures of the neck of the humerus. J Bone Joint Surg Br 2003; 85:419.
- Koval KJ, Gallagher MA, Marsicano JG, et al. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am 1997; 79:203.
- Hodgson S. Proximal humerus fracture rehabilitation. Clin Orthop Relat Res 2006; 442:131.
- Wilmanns C, Bonnaire F. Rotator cuff alterations resulting from humeral head fractures. Injury 2002; 33:781.
- Nanda R, Goodchild L, Gamble A, et al. Does the presence of a full-thickness rotator cuff tear influence outcome after proximal humeral fractures? J Trauma 2007; 62:1436.
- Gallo RA, Sciulli R, Daffner RH, et al. Defining the relationship between rotator cuff injury and proximal humerus fractures. Clin Orthop Relat Res 2007; 458:70.
- PERTINENT ANATOMY
- EPIDEMIOLOGY AND RISK FACTORS
- MECHANISM OF INJURY
- SYMPTOMS AND EXAMINATION FINDINGS
- RADIOGRAPHIC FINDINGS
- Fracture patterns
- - Neer classification
- INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
- INITIAL TREATMENT
- FOLLOW-UP CARE
- Duration of immobilization
- Subsequent visits
- RETURN TO SPORT OR WORK
- SUMMARY AND RECOMMENDATIONS