Imaging Studies

For the distal and diaphyseal humerus fractures, anteroposterior and lateral views of the humerus, as well as transthoracic and axillary views of the shoulder, should be adequate to visualize a fracture. CT scans are helpful if radiographs are unclear.

Proximal humerus fracture

The humeral head articulates with the scapular glenoid. The proximal humerus has 4 parts: articulating surface (anatomical neck), greater tuberosity, lesser tuberosity, and humeral shaft. The surgical neck is just distal to both tuberosities.

The minimum baseline studies for the evaluation of proximal humeral fractures must include a true anteroposterior (AP) view of the scapula and glenohumeral joint, an axillary view, and a lateral Y view of the scapula, evaluating the glenohumeral joint and proximal humerus in 3 perpendicular planes.^[6]

All greater tuberosity fractures should, at some point, have an ultrasound examination or an MRI to check the integrity of the rotator cuff.

Blood is supplied to the humeral head from branches off the axillary artery. Blood travels distally to proximally. Fractures of the anatomical neck may affect blood supply and result in avascular necrosis of the humeral head.

Classification

The Neer classification system is the commonly used terminology to describe proximal humerus fractures.^[4] (See the image below.)

Neer classification.

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If any of the 4 segments is separated by more than 1 cm from its neighbor or is angulated more than 45°, the fracture is said to be displaced.

One-part fractures are nondisplaced fractures or fractures with minimal displacement.
Two-part fractures are fractures in which only a single segment is displaced in relation to the other three.
Three-part fractures occur when two segments are displaced in relation to the other two parts. ^[25]
Four-part fractures exist when all the humeral segments are displaced.

Treatment & Management

Crean TE, Nallamothu SV. Distal Humerus Fractures. 2019 Jan. [QxMD MEDLINE Link]. [Full Text].
Kontakis G, Koutras C, Tosounidis T, Giannoudis P. Early management of proximal humeral fractures with hemiarthroplasty: a systematic review. J Bone Joint Surg Br. 2008 Nov. 90(11):1407-13. [QxMD MEDLINE Link].
Cheung EV, Sperling JW. Management of proximal humeral nonunions and malunions. Orthop Clin North Am. 2008 Oct. 39(4):475-82, vii. [QxMD MEDLINE Link].
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].
Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005 Dec. 87(12):1647-52. [QxMD MEDLINE Link].
Robinson BC, Athwal GS, Sanchez-Sotelo J, Rispoli DM. Classification and imaging of proximal humerus fractures. Orthop Clin North Am. 2008 Oct. 39(4):393-403, v. [QxMD MEDLINE Link].
Claessen FM, Peters RM, Verbeek DO, Helfet DL, Ring D. Factors associated with radial nerve palsy after operative treatment of diaphyseal humeral shaft fractures. J Shoulder Elbow Surg. 2015 Sep 2. [QxMD MEDLINE Link].
Warner JP, Costouros JG, Gerber C. Fractures of the proximal humerus. Bucholz RW, Heckman JD, Brown CC, eds. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2006. Vol 1: 1161-1205.
Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, et al. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018 Aug. 27 (8):1526-1534. [QxMD MEDLINE Link].
Launonen AP, Sumrein BO, Reito A, Lepola V, Paloneva J, Jonsson KB, et al. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019 Jul. 16 (7):e1002855. [QxMD MEDLINE Link]. [Full Text].
Brorson S, Alispahic N, Bahrs C, Joeris A, Steinitz A, Audigé L. Complications after non-surgical management of proximal humeral fractures: a systematic review of terms and definitions. BMC Musculoskelet Disord. 2019 Feb 23. 20 (1):91. [QxMD MEDLINE Link]. [Full Text].
Brukner P. Stress fractures of the upper limb. Sports Med. 1998 Dec. 26(6):415-24. [QxMD MEDLINE Link].
Ogawa K, Yoshida A. Throwing fracture of the humeral shaft. An analysis of 90 patients. Am J Sports Med. 1998 Mar-Apr. 26(2):242-6. [QxMD MEDLINE Link].
Pehlivan O, Kiral A, Akmaz I, Solakoglu C, Arpacioglu O, Kaplan H. Humeral shaft fractures secondary to throwing. Orthopedics. 2003 Nov. 26(11):1139-41. [QxMD MEDLINE Link].
Grawe B, Le T, Lee T, Wyrick J. Open Reduction and Internal Fixation (ORIF) of Complex 3- and 4-Part Fractures of the Proximal Humerus: Does Age Really Matter?. Geriatr Orthop Surg Rehabil. 2012 Mar. 3(1):27-32. [QxMD MEDLINE Link]. [Full Text].
Pedrazzoni M, Abbate B, Verzicco I, Pedrazzini A, Benatti M, Cervellin G. Humeral fractures due to low-energy trauma: an epidemiological survey in patients referred to a large emergency department in Northern Italy. Arch Osteoporos. 2015. 10:228. [QxMD MEDLINE Link].
Anglen JO, Archdeacon MT, Cannada LK, Herscovici D Jr. Avoiding complications in the treatment of humeral fractures. J Bone Joint Surg Am. 2008 Jul. 90(7):1580-9. [QxMD MEDLINE Link].
Amir S, Jannis S, Daniel R. Distal humerus fractures: a review of current therapy concepts. Curr Rev Musculoskelet Med. 2016 Jun. 9 (2):199-206. [QxMD MEDLINE Link].
Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil. 2018. 9:2151458517750516. [QxMD MEDLINE Link].
Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006 Aug. 37(8):691-7. [QxMD MEDLINE Link].
Brown CC, McQueen MM, Tornetta III P. Orthopedic Surgery Essentials: Trauma. Philadelphia, Pa: Lippincott Williams and Wilkins; 2006. 89-114.
Baron AA, Barrett JA, Karagas MR. The epidemiology of peripheral fractures. Bone. 1996. 18:209S-13S.
Mckee MD. Fractures of the shaft of the humerus. Bucholz RW, Heckman JD, Brown CC, eds. Rockwood and Green's Fractures in Adults. 6th ed. Philadelphia, Pa: Lippincott Williams and Wilkins; 2006. Vol 1: 1117-1159.
Siddiqui YS, Khan AQ, Sherwani M. Pathological Fractures in Primary Non-Hodgkin's Lymphoma of the Bone: A Case Series with Review of the Literature. J Clin Diagn Res. 2013 Mar. 7(3):513-7. [QxMD MEDLINE Link]. [Full Text].
Barco R, Barrientos I, Encinas C, Antuña SA. Minimally invasive poly-axial screw plating for three-part fractures of the proximal humerus. Injury. 2012 Dec. 43 Suppl 2:S7-S11. [QxMD MEDLINE Link].
Urda A, González A, Colino A, Lópiz Y, García-Fernández C, Marco F. Management of displaced surgical neck fractures of the humerus: health related quality of life, functional and radiographic results. Injury. 2012 Dec. 43 Suppl 2:S12-9. [QxMD MEDLINE Link].
Park MJ, Ho CA, Larson AN. AAOS Appropriate Use Criteria: Management of Pediatric Supracondylar Humerus Fractures. J Am Acad Orthop Surg. 2015 Sep 16. [QxMD MEDLINE Link]. [Full Text].
Byrd RG, Byrd RP Jr, Roy TM. Axillary artery injuries after proximal fracture of the humerus. Am J Emerg Med. 1998 Mar. 16(2):154-6. [QxMD MEDLINE Link].
Keller A. The management of gunshot fractures of the humerus. Injury. 1995 Mar. 26(2):93-6. [QxMD MEDLINE Link].
McKee MD, Jupiter JB. A contemporary approach to the management of complex fractures of the distal humerus and their sequelae. Hand Clin. 1994 Aug. 10(3):479-94. [QxMD MEDLINE Link].
Minkowitz B, Busch MT. Supracondylar humerus fractures. Current trends and controversies. Orthop Clin North Am. 1994 Oct. 25(4):581-94. [QxMD MEDLINE Link].
Niall DM, O'Mahony J, McElwain JP. Plating of humeral shaft fractures--has the pendulum swung back?. Injury. 2004 Jun. 35(6):580-6. [QxMD MEDLINE Link].
Rosen P. Emergency Medicine. 6th ed. Mosby-Year Book, Incorporated; 2006. 647-69.
Szyszkowitz R, Seggl W, Schleifer P, Cundy PJ. Proximal humeral fractures. Management techniques and expected results. Clin Orthop Relat Res. 1993 Jul. 13-25. [QxMD MEDLINE Link].
Tintinalli J, Ruiz E, Krome R. Emergency Medicine. 4th ed. McGraw Hill Text; 1996. 1242-1244.
Wilkins KE. Supracondylar fractures: what's new?. J Pediatr Orthop B. 1997 Apr. 6(2):110-6. [QxMD MEDLINE Link].

Media Gallery

Diaphyseal humerus fracture.
Neer classification.

of 2

Author

Adarsh K Srivastava, MD Staff Physician, Department of Emergency Medicine/Internal Medicine, Allegheny General Hospital

Adarsh K Srivastava, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew A Aronson, MD, FACEP Vice President, Physician Practices, Bravo Health Advanced Care Center; Consulting Staff, Department of Emergency Medicine, Taylor Hospital

Andrew A Aronson, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society of Hospital Medicine

Disclosure: Nothing to disclose.

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.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Acknowledgements

Michelle Ervin, MD Chair, Department of Emergency Medicine, Howard University Hospital

Michelle Ervin, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, National Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.