Proximal Humerus Fracture

Proximal humerus off ended





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.  Rotator cuff


Supplies blood to tuberosities in fractures


Neer Classification 1970




Any fragment

- > 1cm displaced

- > 45o angulated


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


Avascular necrosis




Risk AVN


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

- posterior circumflex artery is sufficient

- risk increases with amount of displacement


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




FOOSH - mostly elderly patients with osteoporotic


Young patients - high energy MVA


Deforming Forces


2 part fracture

- pectoralis major displaces shaft medially

- head internally rotated by SSC


SNOH Fracture Displaced


Greater tuberosity fracture

- fragment pulled postero-superior

- combination of SS / IS / T minor


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


Lesser tuberosity fracture

- displaced medially by subscapularis


Lesser Tuberosity FractureLesser Tuberosity Fracture 2




AP / Scapula Lateral / Axillary lateral





- number of fracture fragements

- degree of displacement

- head splitting fracture

- is there sufficient bone in humeral head to consider ORIF?


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 




Minimally displaced

Elderly / low functioning patients




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


Complications of nonoperative treatment





- associated with AVN



Malunion OA


SNOH MalunionSNOH Malunion


TSR / consider resurfacing if significant deformity

- can be difficult surgery due to abnormal anatomy


Operative Management


1.  Two Part Fractures


A.  Surgical neck of humerus



- >1 cm displaced or > 45o angulation


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


ORIF with proximal humerus plate


B.  Displaced fractures of the greater tuberosity



- > 5 mm 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


GT displaced 1GT displaced 2GT displaced 3




Suture and repair over distal screw

Lateral plate




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


C. Lesser tuberosity fractures


Soft tissue washer and screw


LT ORIF Soft tissue washerORIF Proximal Humerus and LT ORIF




2.  Three and Four part fractures





IM nail


Reverse TSR


ORIF with plate


SNOH Plate




Young patient

Sufficient bone quality




Surgical technique


SNOH CT 4 Part YoungProximal Humeral Fracture 4 Part Head Splitting CTProximal humerus ORIF 1Proximal humerus ORIF 2


Set up

- GA, IV antibiotics, lazy beach chair

- mark anatomy

- ensure adequate flouroscopy images


Deltopectoral approach 

- cephalic usually taken laterally

- Hawkins Bell retractor/ blunt gelpies

- divide clavipectoral fascia to expose SSC

- release lateral edge of conjoint tendon

- place retractors deep to tendon

- release adhesions from undersurface of deltoid


Extensile approach

- release CA ligament

- release proximal pectoralis major

- can release anterior deltoid insertion from clavicle if needed (intra-osseous repair latera)



- protect musculocutaneous nerve under conjoint, minimal retraction

- protect the axillary nerve on inferior border of SSC medially


Identify structures

- identify and release biceps tendon

- identify and tag greater and lessor tuberosities with Mason Allen sutures

- remove hematoma

- reduce head onto shaft (head is displaced posteriorly)

- use elevator and lever it forward

- provisionally fix with 2 mm k wire

- check provisonal fixation with fluoroscopy


Apply plate 

- lateral to biceps with single cortical screw in oblique hole

- check fluoroscopy aain to avoid having plate too high

- keep head out of varus to avoid cutout

- long inferomedial screws / kickstand screws




Complications ORIF



- 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


B.  Intramedullary 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 / Reverse TSR






4 part fractures

Head splitting fractures


Proximal Humerus 4 Part Fracture In Elderly

Proximal Humerus Unreconstructable





SNOH Hemi 2SNOH Hemi 1




Must ensure tuberosities heal

ROM often poor / rarely > 90o




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




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


Shoulder Hemiarthoplasty TraumaShoulder Hemiarthroplasty Trauma 2


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