Proximal humerus fractures (PHF) account for 5-6% of all adult fractures. There is increasing recognition given in regard to managing these fractures in the setting of elderly, low-energy falls as these events are contributing to the global impact of direct and indirect costs of osteoporosis and fragility fractures. Moreover, as the general population continues to age and an increasing percentage of these patients are being considered bone density compromised, the overall nonoperative and operative management of PHFs continue to receive considerable attention in the literature.
PHFs classically fall under a bimodal distribution by age and energy level. This bimodal pattern is very common and clinicians should recognize the high-energy (e.g. Motor vehicle accident in young patients) versus low-energy (e.g. elderly patient status post ground level fall) paradigm in various groups and fracture patterns.
PHFs most commonly occur in patients over 65 years of age. In the setting of osteoporosis or osteopenia, a low-energy fall resulting in a PHF is, by definition, a fragility fracture. Thus, patients sustaining these injuries (even without an official diagnosis via DEXA scan) should be considered to already be on the osteoporotic spectrum. Younger patients often present with these injuries following high-energy trauma such as MVAs.
PHFs most commonly occur in the elderly. The three most common osteoporotic (i.e. fragility) fractures include:
While high-energy mechanisms are more likely to result in associated soft tissue and/or neurovascular injuries, increasing age has been associated with more complex fracture types. The latter can include increasing degrees of comminution, displacement, and fracture/dislocation patterns. The overall incidence is reported at 4% to 6% with a 2:1 female to male ratio.
Proximal humeral anatomy includes four potential "parts". These parts were originally described by Neer and have been incorporated into his traditional classification scheme for PHFs. Proximal humerus anatomy includes:
Other osseous elements that are relevant to proximal humeral anatomy include the bicipital groove/intertubercular sulcus, medial calcar, and insertion sites for the deltoid, pectoralis major, and latissimus dorsi muscles .
The humeral head articulates with shallow glenoid fossa of the scapula which allows for complex dynamic range of motion in many different planes. The anatomical neck can be identified as the fused epiphyseal plate which is obliquely directed and lies proximal to greater and lesser tubercles. The greater tuberosity is given additional management considerations given the concerns regarding even minimal (3- to 5-mm or greater) displacement as this can lead to a significant compromise in patient outcomes following injury via impingement and rotator cuff dysfunction.
The intertubercular sulcus or groove separates the two tuberosities. The tendon of the long head of biceps brachii runs through this groove. Attached to the lips of the intertubercular sulcus are the tendons of the pectoralis major (lateral), latissimus dorsi (medial), and teres major (most medial/posterior). The most frequently fractured site of the humerus especially in elderly is the surgical neck which is an area of constriction distal to the tuberosities.
The deforming forces relevant to PHFs include:
Several neurovascular structures are at risk of injury depending on the pattern of injury. The most commonly injured nerve in PHFs is the axillary nerve. Arterial injury occurs at about a 5% incidence rate and has a higher likelihood in elderly patients. Two common scenarios relative to arterial artery injury at presentation include:
The posterior humeral circumflex artery is the main blood supply to the humeral head. The anterior humeral circumflex artery (AHCA) is known for its extensive arterial branching and anastomotic network it creates in the proximal humerus. Once traditionally thought of as the major blood supply to the proximal humerus, this theory has since been debunked. The AHCA does give off two main branches via the anterolateral ascending branch and the arcuate artery, with the latter serving as the major blood supply to the greater tuberosity.
A comprehensive history and physical examination should be performed in any and all patients. The elderly (>65 years old) often present status post a low-energy fall with the arm outstretched in an attempt to brace the fall. Younger patients often present following an MVA.
Most cases present in the acute setting. Pertinent questions include:
Inspection is assessing for signs of open fracture, ecchymosis that may extend to the chest, arm, and forearm. Crepitus and pain are often present over the fracture site. Loss of deltoid contour suggests concomitant dislocation of shoulder suggesting a higher-energy mechanism. The examiner should determine if any associated neurovascular injury is present. A comprehensive neurovascular examination should also be performed. Examiners should maintain a heightened clinical suspicion for associated nerve injury (most commonly a transient neuropraxia to the axillary nerve) especially in the setting of a fracture-dislocation pattern. Arterial compromise is much less common and can occur even in the setting of intact distal pulses palpated on exam secondary to extensive collateral blood supply.
Radiographic imaging should be obtained in all patients. Recommended views include mandatory orthoganol imaging:
CT scan aids in preoperative planning especially if the position of the humeral head or greater tuberosity is uncertain and intra-articular comminution. Furthermore, information obtained from the CT scan can help guide the ideal operative management when considering whether fixation versus reconstruction is most appropriate. MRI is rarely indicated however may be useful to identify associated rotator cuff injury
Neer’s Classification is based on the anatomic relationship of four segments: greater tuberosity, lesser tuberosity, articular surface, and shaft.
AO Classification arranges fractures into three main groups and additional subgroups based on fracture location, the status of the surgical neck, and the presence or absence of dislocation.
Initial management includes immobilization and pain control in the acute setting. Goals of management can then be determined whether non-operative versus operative.
Sling immobilization followed by gentle progressive rehabilitation is advocated in minimally displaced surgical and anatomic neck fractures. The acceptable amount of displacement with respect to an isolated greater tuberosity fracture remains debated. Recent literature has advocated for earlier surgical management in these isolated, two-part fracture pattern injuries.
Progressive physical therapy and rehabilitation protocols include early, gentle, shoulder pendulum exercises starting as early as 10 to 14 days following injury as dictated by the patient's symptoms.
In general, nonoperative management alone has demonstrated an approximately 80% to 85% success rate when analyzing all types of PHFs. Nonoperative management is most successful in the following:
Operative management consists of several different options including closed reduction and percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), intramedullary nailing (IMN), hemiarthroplasty and total shoulder arthroplasty (reverse TSA or standard/anatomic TSA).
AC joint conditions
All patients should be informed regarding the risks, benefits, and alternatives to all nonoperative and operative treatment options. While most patients improve and return to baseline function following either type of management pathway, persistent disability and loss of function remain common issues of concern. Each PHF should be treated on a case-by-case basis and should factor in the patient's age, hand dominance, functional status, social situation, medical comorbidities, and the overall goals and expectations during and after the recovery process.
Isolated extremity trauma is the next potential target in specialty fields like orthopedic surgery as, in general, the diagnosis, treatment, and rehabilitation clinical care pathways are being given increasing attention in the literature as potential targets for alternative payment models, bundled payment care initiatives, and healthcare cost containment strategies. Thus, healthcare providers, clinicians, and institutions have been previously encouraged to implement a "big data versus little data" management mindset to apply notable trends, risk factors, and potential treatment variables that have been previously identified across large sample sizes and database literature reports and subsequently applying these potential "at-risk" variables in a customized fashion across all institutions. This ensures that the healthcare systems worldwide mitigate the risk of falling into a "one size fits all" treatment strategy for patients in all areas of the world.
PHFs are commonly managed nonoperatively although referral to an orthopedic surgeon should be considered in all of these injuries given the wide variation in treatment strategies. Active and open communication should be considered standard of care as discussions between the nursing staff, therapists, physicians, and surgeons is required to ensure an ideal outcome for all patients being managed with these injuries. Finally, follow-up with a bone density specialist should be ensured when patients present with a PHF in the setting of a low-energy injury as these presentations are considered to be, by definition, an instant diagnosis of bone mineral density compromise.
Level of evidence: II-III
|||Court-Brown CM,Caesar B, Epidemiology of adult fractures: A review. Injury. 2006 Aug; [PubMed PMID: 16814787]|
|||Donnally III CJ,Varacallo M, Fracture, Compression 2018 Jan; [PubMed PMID: 28846351]|
|||Aiyer A,Varacallo M,Boateng H,Reid SJ, Humeral Shaft Fracture with Ipsilateral Anterior Shoulder Dislocation and Posterior Elbow Dislocation: A Case Report and Review of the Literature. JBJS case connector. 2014 Sep 10; [PubMed PMID: 29252297]|
|||Kim SH,Szabo RM,Marder RA, Epidemiology of humerus fractures in the United States: nationwide emergency department sample, 2008. Arthritis care [PubMed PMID: 22162357]|
|||Varacallo MA,Fox EJ, Osteoporosis and its complications. The Medical clinics of North America. 2014 Jul; [PubMed PMID: 24994054]|
|||Varacallo MA,Fox EJ,Paul EM,Hassenbein SE,Warlow PM, Patients' response toward an automated orthopedic osteoporosis intervention program. Geriatric orthopaedic surgery [PubMed PMID: 24319621]|
|||Porter JL,Varacallo M, Osteoporosis 2018 Jan; [PubMed PMID: 28722930]|
|||Varacallo M,Pizzutillo P, Osteoporosis, Spinal Cord Injury 2018 Jan; [PubMed PMID: 30252365]|
|||Varacallo M,Pizzutillo P, Osteopenia 2018 Jan; [PubMed PMID: 29763053]|
|||Court-Brown CM,Duckworth AD,Clement ND,McQueen MM, Fractures in older adults. A view of the future? Injury. 2018 Dec; [PubMed PMID: 30526922]|
|||Schumaier A,Grawe B, Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatric orthopaedic surgery [PubMed PMID: 29399372]|
|||Court-Brown CM,Bugler KE,Clement ND,Duckworth AD,McQueen MM, The epidemiology of open fractures in adults. A 15-year review. Injury. 2012 Jun; [PubMed PMID: 22204774]|
|||Displaced proximal humeral fractures. I. Classification and evaluation., Neer CS 2nd,, The Journal of bone and joint surgery. American volume, 1970 Sep [PubMed PMID: 5455339]|
|||Mostafa E,Varacallo M, Anatomy, Shoulder and Upper Limb, Humerus 2018 Jan; [PubMed PMID: 30521242]|
|||Eovaldi BJ,Varacallo M, Anatomy, Shoulder and Upper Limb, Shoulder Muscles 2018 Jan; [PubMed PMID: 30521257]|
|||Maruvada S,Varacallo M, Anatomy, Rotator Cuff 2018 Jan; [PubMed PMID: 28722874]|
|||Varacallo M,Mair SD, Biceps Tendon Dislocation and Instability 2018 Jan; [PubMed PMID: 30475566]|
|||Jeno SH,Varacallo M, Anatomy, Back, Latissimus Dorsi 2018 Jan; [PubMed PMID: 28846224]|
|||Tiwana MS,Varacallo M, Anatomy, Shoulder and Upper Limb, Biceps Muscle 2018 Jan; [PubMed PMID: 30137823]|
|||Varacallo M,Mair SD, Bicipital Tendonitis 2018 Jan; [PubMed PMID: 30422594]|
|||Hettrich CM,Boraiah S,Dyke JP,Neviaser A,Helfet DL,Lorich DG, Quantitative assessment of the vascularity of the proximal part of the humerus. The Journal of bone and joint surgery. American volume. 2010 Apr [PubMed PMID: 20360519]|
|||Varacallo M,Mair SD, Rotator Cuff Syndrome . 2018 Jan [PubMed PMID: 30285401]|
|||Nickerson M,Varacallo M, Swimmers Shoulder . 2018 Jan [PubMed PMID: 29262079]|