Laboratory Studies

Routine preoperative laboratory studies for proximal humerus fractures include the following:

Complete blood count (CBC)
Basic metabolic panel
Coagulation studies
Type and cross-match

Imaging Studies

Radiographic evaluation is the most important diagnostic tool for proximal humerus fractures. Incorrect views or poor quality radiographs can lead to errors in prognosticating outcome and an inappropriate choice of treatment.

The initial series for evaluating a patient with a suspected proximal humerus fracture is the trauma series, which consists of anteroposterior (AP) and lateral views in the scapular plane and an axillary view.

The scapula sits obliquely to the chest wall. Therefore, to achieve a true AP view, the x-ray beam must be tilted approximately 40° to plane of the thorax. Similarly, in the lateral view, the x-ray beam will parallel the scapular spine when the body is tilted 40°. The axillary view can be obtained with the use of the Velpeau view, allowing the arm to stay within the sling. In this view, the patient is seated and tilted backwards approximately 45°.

Use the AP projection to assess fracture displacements of the surgical neck (varus or valgus), the greater tuberosity (superior displacement), and the lesser tuberosity (medial displacement). The glenohumeral joint should be clearly visible. If overlap is seen, suspect dislocation. The lateral view is helpful in assessing flexion or extension of the surgical neck and posterior displacement of the greater tuberosity fragment.

The axillary view helps to assess tuberosity fragments, with anteromedial displacement of the lesser tuberosity fragment and posterior displacement of the greater tuberosity fragment. This view is critical in assessing the greater tuberosity fragment, as superior displacement may be absent and the infraspinatus can be completely avulsed with a posteriorly displaced fragment. Furthermore, dislocation of the head can be defined clearly on this view.

Linear tomography can help to assess nonunions of the surgical neck. However, it has been supplanted by computed tomography (CT). In addition to surgical-neck assessment, CT can provide information on articular involvement in head-splitting fractures, impression fractures, chronic fracture-dislocations, and glenoid rim fractures.^[14]Tuberosity displacement can also be assessed.

Treatment & Management

Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970 Sep. 52 (6):1077-89. [QxMD MEDLINE Link].
Dimakopoulos P, Potamitis N, Lambiris E. Hemiarthroplasty in the treatment of comminuted intraarticular fractures of the proximal humerus. Clin Orthop Relat Res. 1997 Aug. (341):7-11. [QxMD MEDLINE Link].
Hartsock LA, Estes WJ, Murray CA, Friedman RJ. Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am. 1998 Jul. 29 (3):467-75. [QxMD MEDLINE Link].
Bigliani LU, McCluskey GM 3rd. Prosthetic replacement in acute fractures of the proximal humerus. Semin Arthroplasty. 1990 Oct. 1 (2):129-37. [QxMD MEDLINE Link].
Bastian JD, Hertel R. Initial post-fracture humeral head ischemia does not predict development of necrosis. J Shoulder Elbow Surg. 2008 Jan-Feb. 17 (1):2-8. [QxMD MEDLINE Link].
Fjalestad T, Hole MØ, Blücher J, Hovden IA, Stiris MG, Strømsøe K. Rotator cuff tears in proximal humeral fractures: an MRI cohort study in 76 patients. Arch Orthop Trauma Surg. 2010 May. 130 (5):575-81. [QxMD MEDLINE Link].
Monga P, Verma R, Sharma VK. Closed reduction and external fixation for displaced proximal humeral fractures. J Orthop Surg (Hong Kong). 2009 Aug. 17 (2):142-5. [QxMD MEDLINE Link].
Yang H, Li Z, Zhou F, Wang D, Zhong B. A prospective clinical study of proximal humerus fractures treated with a locking proximal humerus plate. J Orthop Trauma. 2011 Jan. 25 (1):11-7. [QxMD MEDLINE Link].
Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011 Jul. 20 (5):747-55. [QxMD MEDLINE Link].
Hatzidakis AM, Shevlin MJ, Fenton DL, Curran-Everett D, Nowinski RJ, Fehringer EV. Angular-stable locked intramedullary nailing of two-part surgical neck fractures of the proximal part of the humerus. A multicenter retrospective observational study. J Bone Joint Surg Am. 2011 Dec 7. 93 (23):2172-9. [QxMD MEDLINE Link]. [Full Text].
Südkamp N, Bayer J, Hepp P, Voigt C, Oestern H, Kääb M, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. Results of a prospective, multicenter, observational study. J Bone Joint Surg Am. 2009 Jun. 91 (6):1320-8. [QxMD MEDLINE Link]. [Full Text].
Bahrs C, Rolauffs B, Dietz K, Eingartner C, Weise K. Clinical and radiological evaluation of minimally displaced proximal humeral fractures. Arch Orthop Trauma Surg. 2010 May. 130 (5):673-9. [QxMD MEDLINE Link].
Lenarz C, Shishani Y, McCrum C, Nowinski RJ, Edwards TB, Gobezie R. Is reverse shoulder arthroplasty appropriate for the treatment of fractures in the older patient? Early observations. Clin Orthop Relat Res. 2011 Dec. 469 (12):3324-31. [QxMD MEDLINE Link]. [Full Text].
Edelson G, Safuri H, Salami J, Vigder F, Militianu D. Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg. 2008 May-Jun. 17 (3):399-409. [QxMD MEDLINE Link].
McLean AS, Price N, Graves S, Hatton A, Taylor FJ. Nationwide trends in management of proximal humeral fractures: an analysis of 77,966 cases from 2008 to 2017. J Shoulder Elbow Surg. 2019 Nov. 28 (11):2072-2078. [QxMD MEDLINE Link].
Klug A, Gramlich Y, Wincheringer D, Schmidt-Horlohé K, Hoffmann R. Trends in surgical management of proximal humeral fractures in adults: a nationwide study of records in Germany from 2007 to 2016. Arch Orthop Trauma Surg. 2019 Dec. 139 (12):1713-1721. [QxMD MEDLINE Link].
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 Jul-Aug. 18 (4):612-21. [QxMD MEDLINE Link].
Torrens C, Corrales M, Vilà G, Santana F, Cáceres E. Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma. 2011 Oct. 25 (10):581-7. [QxMD MEDLINE Link].
Iyengar JJ, Devcic Z, Sproul RC, Feeley BT. Nonoperative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma. 2011 Oct. 25 (10):612-7. [QxMD MEDLINE Link].
Iacobellis C, Serafini D, Aldegheri R. PHN for treatment of proximal humerus fractures: evaluation of 80 cases. Chir Organi Mov. 2009 Sep. 93 (2):47-56. [QxMD MEDLINE Link].
Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009 Mar. 23 (3):163-72. [QxMD MEDLINE Link].
Bhayana H, Chouhan DK, Aggarwal S, Prakash M, Patel S, Arora C, et al. Outcomes of plate osteosynthesis for displaced 3-part and 4-part proximal humerus fractures with deltopectoral vs. deltoid split approach. Eur J Trauma Emerg Surg. 2021 Jul 31. [QxMD MEDLINE Link].
Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial approach for fractures of the proximal humerus. J Orthop Trauma. 2008 Feb. 22 (2):132-7. [QxMD MEDLINE Link].
Hettrich CM, Neviaser A, Beamer BS, Paul O, Helfet DL, Lorich DG. Locked plating of the proximal humerus using an endosteal implant. J Orthop Trauma. 2012 Apr. 26 (4):212-5. [QxMD MEDLINE Link]. [Full Text].
Egol KA, Sugi MT, Ong CC, Montero N, Davidovitch R, Zuckerman JD. Fracture site augmentation with calcium phosphate cement reduces screw penetration after open reduction-internal fixation of proximal humeral fractures. J Shoulder Elbow Surg. 2012 Jun. 21 (6):741-8. [QxMD MEDLINE Link]. [Full Text].
Rogers D, Raad M, Srikumaran U, Shafiq B. Proximal Humerus Fracture-Open Reduction Internal Fixation With an Expandable Intramedullary Nitinol Scaffold. J Orthop Trauma. 2021 Aug 1. 35 (Suppl 2):S1-S2. [QxMD MEDLINE Link].
Ponce BA, Williams JF, Watson SL, Perez JL, Hudson PW, Scott JH, et al. Adoption of Intramedullary Nail Fixation for Proximal Humerus Fractures: Assessment of Surgical Efficiency and Complications. J Surg Orthop Adv. 2019 Summer. 28 (2):121-126. [QxMD MEDLINE Link].
Handoll H, Brealey S, Rangan A, Keding A, Corbacho B, Jefferson L, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess. 2015 Mar. 19 (24):1-280. [QxMD MEDLINE Link].
Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015 Mar 10. 313 (10):1037-47. [QxMD MEDLINE Link]. [Full Text].
Panagopoulos GN, Pugliese M, Leonidou A, Butt F, Jaibaji M, Megaloikonomos PD, et al. Acute versus Delayed Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures: A Consecutive Cohort Study. J Shoulder Elbow Surg. 2021 Aug 13. [QxMD MEDLINE Link].
Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014 Oct. 23 (10):1419-26. [QxMD MEDLINE Link].
Ross M, Hope B, Stokes A, Peters SE, McLeod I, Duke PF. Reverse shoulder arthroplasty for the treatment of three-part and four-part proximal humeral fractures in the elderly. J Shoulder Elbow Surg. 2015 Feb. 24 (2):215-22. [QxMD MEDLINE Link].
Shannon SF, Wagner ER, Houdek MT, Cross WW 3rd, Sánchez-Sotelo J. Reverse shoulder arthroplasty for proximal humeral fractures: outcomes comparing primary reverse arthroplasty for fracture versus reverse arthroplasty after failed osteosynthesis. J Shoulder Elbow Surg. 2016 Oct. 25 (10):1655-60. [QxMD MEDLINE Link].
Luciani P, Farinelli L, Procaccini R, Verducci C, Gigante A. Primary reverse shoulder arthroplasty for acute proximal humerus fractures: A 5-year long term retrospective study of elderly patients. Injury. 2019 Nov. 50 (11):1974-1977. [QxMD MEDLINE Link].
Lopiz Y, Alcobía-Díaz B, Galán-Olleros M, García-Fernández C, Picado AL, Marco F. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2019 Dec. 28 (12):2259-2271. [QxMD MEDLINE Link].
Boyle MJ, Youn SM, Frampton CM, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elbow Surg. 2013 Jan. 22 (1):32-7. [QxMD MEDLINE Link]. [Full Text].
Liu K, Liu PC, Liu R, Wu X. Advantage of minimally invasive lateral approach relative to conventional deltopectoral approach for treatment of proximal humerus fractures. Med Sci Monit. 2015 Feb 15. 21:496-504. [QxMD MEDLINE Link]. [Full Text].
Rossi LA, Guillermina BM, Buljubasich M, Atala N, Tanoira I, Bongiovanni S, et al. Cemented vs Uncemented Reverse Shoulder Arthroplasty for Acute Proximal Humeral Fractures. J Shoulder Elbow Surg. 2021 Aug 3. [QxMD MEDLINE Link].

Media Gallery

of 0

Author

Mark A Frankle, MD Adult Reconstruction and Arthritis Orthopaedic Surgeon, Florida Orthopaedic Institute

Mark A Frankle, MD is a member of the following medical societies: American Medical Association, Florida Orthopaedic Society, Shoulder and Elbow Society of Australia, American Shoulder and Elbow Surgeons, American Academy of Orthopaedic Surgeons, American College of Surgeons, American Medical Association

Disclosure: Received consulting fee from DJO for consulting; Received royalty from DJO for other.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Pekka A Mooar, MD Professor, Department of Orthopedic Surgery, Temple University School of Medicine

Pekka A Mooar, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Mohit N Gilotra, MD, MS, FAAOS, FAOA Associate Professor, Department of Orthopaedics, Shoulder and Elbow Service, Associate Residency Program Director, Co-Director of Resident Research, University of Maryland School of Medicine; Chief of Orthopaedics, VA Maryland Healthcare

Mohit N Gilotra, MD, MS, FAAOS, FAOA is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Shoulder and Elbow Surgeons, Maryland Orthopaedic Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Tigon<br/>Serve(d) as a speaker or a member of a speakers bureau for: Arthrex<br/>Received research grant from: Orthofix.

Additional Contributors

Jegan Krishnan, MBBS, FRACS, PhD Professor, Chair, Department of Orthopedic Surgery, Flinders University of South Australia; Senior Clinical Director of Orthopedic Surgery, Repatriation General Hospital; Private Practice, Orthopaedics SA, Flinders Private Hospital

Jegan Krishnan, MBBS, FRACS, PhD is a member of the following medical societies: Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Matthew Teusink, MD, and Raymond Long, MD, FRCSC, are gratefully acknowledged for contributions made to this article.