Summary Proximal humerus fractures are common fractures often seen in older patients with osteoporotic bone following a ground-level fall on an outstretched arm. Diagnosis is made with orthogonal radiographs of the shoulder. Treatment with sling immobilization is indicated for minimally displaced fractures with surgical fixation versus arthroplasty indicated in more complex and displaced fractures. Epidemiology Incidence common login to view 2 more bullets two-part surgical neck fractures are most common Demographics 2:1 female to male ratio increasing age associated with more complex fracture types Anatomic location may occur at the surgical neck, anatomic neck, greater tuberosity, and lesser tuberosity login to view 1 more bullet Risk factors osteoporosis diabetes epilepsy female gender Etiology Pathophysiology mechanism login to view 5 more bullets pathoanatomy login to view 8 more bullets Associated conditions nerve injury login to view 1 more bullet arterial injury login to view 2 more bullets Anatomy Osteology anatomic neck login to view 1 more bullet surgical neck login to view 2 more bullets average neck-shaft angle is 135 degrees Muscles pectoralis major displaces shaft anteriorly and medially deltoid displaces proximal fragment laterally supraspinatus, infraspinatus, and teres minor externally rotate greater tuberosity subscapularis internally rotates articular segment or lesser tuberosity Ligaments Coracohumeral ligament login to view 1 more bullet SGHL login to view 1 more bullet MGHL login to view 1 more bullet IGHL login to view 1 more bullet Blood Supply anterior humeral circumflex artery login to view 4 more bullets posterior humeral circumflex artery login to view 1 more bullet Classification AO/OTA organizes fractures into 3 main groups and additional subgroups based on login to view 3 more bullets Neer classification based on anatomic relationship of 4 segments login to view 4 more bullets considered a separate part if login to view 2 more bullets Neer Classification Minimally displaced Two-part Three-part Four-part Anatomical neck Surgical Neck Greater Tuberosity Lesser Tuberosity Fracture-Dislocation Head Split Presentation Symptoms pain and swelling decreased motion Physical exam inspection login to view 1 more bullet neurovascular exam login to view 3 more bullets examine for concomitant chest wall injuries Imaging Radiographs recommended views login to view 12 more bullets CT scan indications login to view 4 more bullets MRI indications login to view 2 more bullets Treatment Nonoperative sling immobilization followed by progressive rehabilitation login to view 16 more bullets Operative closed reduction percutaneous pinning (CRPP) login to view 7 more bullets ORIF login to view 10 more bullets Intramedullary nailing login to view 6 more bullets Arthroplasty login to view 17 more bullets Treatment by Fracture Type Two-part fractures Surgical Neck Most common fx pattern Deforming forces: 1) pectoralis pulls shaft anterior and medial2) head and attached tuberosities stay neutral Nonoperative Closed reduction often possible Sling Operative -indications controversial -technique --- CRPP --- Plate fixation --- IM nail Greater tuberosity Often missed Deforming forces: GT pulled superior and posterior by SS, IS, and TM Can only accept minimal displacement (<5mm) or else it will block ER and ABD Nonoperative indicated for GT displaced < 5 mm Operative indicated for GT displacement > 5 mm - isolated screw fixation only in young with good bone stock - non-absorbable suture technique for osteoporotic bone (avoid hardware due to impingement) -tension band wiring Lesser tuberosity Assume posterior dislocation until proven otherwise Nonoperative Minimally or non-displaced Operative ORIF if large fragment excision with RCR if small Anatomic neck Rare Nonoperative Minimally or non-displaced Operative ORIF in young ORIF v. hemiarthroplasty v. reverse total shoulder arthroplasty in elderly Three-part fracture Surgical neck and GT Subscap will internally rotate articular segment Often associated with longitudinal RCT Nonoperative if: Minimally displaced (GT<5 mm; articular segment <1 cm and <45 degrees) Poor surgical candidate Operative: Young patient - percutaneous pinning (good results, protect axillary nerve) - IM fixation (violates cuff) - locking plate (poor results with high rate of AVN, impingement, infection, and malunion) Elderly patient - hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty Surgical neck and LT Unopposed pull of posterior cuff musculature leads articular surface to point anterior Often associated with longitudinal RCT Trend towards nonoperative management given high complications with ORIF Young patient - percutaneous pinning (good results, protect axillary nerve) - IM fixation (violates cuff) - locking plate (poor results with high rate of AVN, impingement, infection, and malunion) Elderly patient - hemiarthroplasty with RCR or tuberosity repair vs. reverse total shoulder arthroplasty Four-Part Fracture Valgus impacted fracture Radiographically will see alignment between medial shaft and head segments Low rate of AVN if posteromedial component intact thus preserving intraosseous blood supply Surgical technique 1. raise articular surface and fill defects 2. repair tuberosities 4-part with head-splitting fracture Characterized by high risk of AVN (21-75%) Deforming forces:1) shaft pulled medially by pectoralis Young patient - ORIF vs. hemiarthroplasty (hemiarthroplasty favored for non-reconstructible articular surface, severe head split, extruded anatomic neck fracture) Elderly patient - hemiarthroplasty v. reverse total shoulder arthroplasty Techniques Sling immobilization followed by progressive rehabilitation technique login to view 1 more bullet CRPP (closed reduction percutaneous pinning) approach login to view 1 more bullet technique login to view 3 more bullets complications login to view 5 more bullets ORIF approach login to view 3 more bullets technique login to view 10 more bullets postoperative Rehabilitation login to view 6 more bullets Intramedullary nailing approach login to view 1 more bullet technique login to view 3 more bullets complications login to view 5 more bullets Hemiarthroplasty approach login to view 1 more bullet technique for fractures login to view 6 more bullets Reverse shoulder arthroplasty approach login to view 2 more bullets technique for fractures login to view 4 more bullets Complications Screw cut-out incidence login to view 1 more bullet Avascular necrosis risk factors login to view 3 more bullets Nerve injury incidence login to view 7 more bullets Malunion usually varus apex-anterior or malunion of GT results inferior if converting from varus malunited fracture to TSA login to view 1 more bullet Nonunion most common after two-part surgical neck fracture treatment of chronic nonunion/malunion in the elderly should include arthroplasty lesser tuberosity nonunion leads to weakness with lift-off testing greater tuberosity nonunion after arthroplasty leads to lack of external rotation and, to a lesser degree, active shoulder elevation greatest risk factors for nonunion are age and smoking Rotator cuff injuries and dysfunction Long head of biceps tendon injuries also at risk with anterior pin in CRPP Missed posterior dislocation consider in all patients with lesser tuberosity fracture Adhesive capsulitis and scar tissue Posttraumatic arthritis Infection