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Orthop Clin N Am 39 (2008) 393403

Classication and Imaging

of Proximal Humerus Fractures
Ben C. Robinson, MDa, George S. Athwal, MD, FRCSCb,
Joaquin Sanchez-Sotelo, MD, PhDc,
Damian M. Rispoli, MDa,d,*
Department of Orthopaedics, Wilford Hall Medical Center, 2200 Bergquist Drive,
Suite 1, Lackland AFB, TX 78236, USA
Hand and Upper Limb Centre, St Joesphs Health Care, University of Western Ontario, 268 Grosvenor Street,
London, Ontario, Canada, N6A 4L6
Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
F. Edward Hebert School of Medicine, Uniformed Services University, Bethesda, MD 20814, USA

Fractures of the proximal humerus represent CT currently available in most institutions allow
the second most common fracture type of the a much better understanding of complex fractures.
upper extremity and the third most common The ultimate goal of any classication scheme is
fracture in patients older than 65 years after hip to allow for determination of the best treatment of
and distal radius fractures [1]. In the past, surgical each individual fracture, and subsequently the
treatment has been estimated to be required in ability to compare ecacy of various treatment
20% of proximal humerus fractures. The indica- methods on a particular fracture. The most
tions for surgery continue to expand for several inuential early innovative concepts related to the
reasons, including a better understanding of the understanding of proximal humerus fractures were
multiple fracture patterns, higher patient expecta- introduced by Codman in 1934. Codman [2] classi-
tions, and improvements in internal xation ed proximal humeral fractures as occurring
techniques, hemiarthroplasty, tuberosity recon- between the humeral head, shaft, and lesser or
struction, and the selective use of modern reverse greater tuberosity (Fig. 1). Neer [3] was responsible
prosthesis designs. for the second major advancement in proximal
The decision to operate and the selection of the humerus fracture understanding by developing the
appropriate surgical modality for proximal hu- concepts of Codman and proposing a classication
merus fractures are largely based on the fracture system based on fracture pathoanatomy. Emphasis
pattern. Understanding the particular fracture on the vascularity of the proximal humerus led to
pattern in each case is complicated, however, a deeper understanding of fracture conguration
especially when poorly positioned radiographs are as related to perfusion of the articular segment.
the only available studies. Most well-accepted The AO (Arbeitsgemeinschaft fur Osteosynthese-
classication systems were developed based on fragen) classication highlights vascularity in their
radiographs complemented by intraoperative nd- classication system. Most existing classication
ings. Three-dimensional reconstructions based on systems focus on the anatomy of the fracture frag-
ments [3] or the anatomy of the fracture fragments
with a secondary focus on vascular anatomy [4].
* Corresponding author. Department of Orthopae-
dics, Wilford Hall Medical Center, Lackland AFB,
Some classications use newer imaging modalities
2200 Bergquist Drive, Suite 1, TX 78236. [5], such as CT, which has led to a greater level of in-
E-mail address: damian.rispoli@lackland.af.mil formation being available for decision making in the
(D.M. Rispoli). treatment of these fractures.
0030-5898/08/$ - see front matter. Published by Elsevier Inc.
doi:10.1016/j.ocl.2008.05.002 orthopedic.theclinics.com
394 ROBINSON et al

between the dierent fragments have never been

clearly dened.
The six subgroups of the original classication,
designated by Roman numerals I through VI,
were changed in 1975. Neer [10] stated in his 2002
paper in the Journal of Shoulder and Elbow
Surgery that, the 4-segment classication is not
meant to be a numerical classication that is
oversimplied or patterned for easy roentgen clas-
sication, but rather is a concept or mental
picture of the actual pathomechanics and pathoa-
natomy of displaced humeral fractures and the
terminology to identify each category. In the
Fig. 1. Four segments of proximal humeral fractures. original study, radiographic assessment was
(Courtesy of D. M. Rispoli, MD, Lackland AFB, TX.)
performed using an anteroposterior radiograph
perpendicular to the scapular plane and a scapular
Classication systems Y view [3]. Subsequently, a three-view series was
recommended, including an axillary view [11,12].
Neer classication
Neers system of classication has been widely
In 1970, Neer [3] published his classication of used for close to 40 years and much has been
proximal humerus fractures. Traditional classi- published in the literature regarding it, including
cation schemes focused on the mechanism of its reliability and ecacy.
injury [6,7] or on the level of the fracture [8,9].
Neer noted that fracture level was of little assis-
AO classication
tance, as proximal humeral fractures frequently
involved multiple levels. Additionally, these classi- The AO classication system is also widely used
cation systems placed displaced and nondis- and accepted for fracture classication of the
placed fractures in similar categories. Neer based proximal humerus, especially in Europe (Fig. 3).
his pathoanatomic classication system (Fig. 2) This system was based on a study of 730 cases and-
on the study of the radiographic and intraopera- classies fractures into A, B, or C types, depending
tive anatomy of 300 displaced proximal humeral on whether the fractures are (A) extra-articular,
fractures and fracture-dislocations treated at his unifocal, with intact vascular supply; (B) extra-ar-
institution by closed reduction under anesthesia ticular, bifocal, with possible vascular compromise;
or surgery. His system is based on the presence or (C) articular, with a high likelihood of vascular
or absence of displacement of one or more of the compromise. Each type is then further divided
four major bony segments: the surgical neck, into groups and then subgroups depending on frac-
the anatomic neck, the greater tuberosity, and ture location, impaction, displacement, disloca-
the lesser tuberosity. By dividing the fractures in tion, angulation, or malalignment, resulting in
this manner the surgeon could focus on the multiple dierent possibilities [13].
deforming forces of the muscular attachments, In 1996, the Orthopaedic Trauma Association
the circulatory status of the fragments, and the adopted the original AO system developed by
continuity of the articular surface. Marsh and colleagues [4] with the goal of classify-
Displacement was dened as more than 1 cm ing fractures in a uniform and consistent man-
of separation or more than 45 degrees of angu- ner allowing for standardization of research
lation between fragments. The decision to dene and communication. This system was again
displacement by this criterion was based on an modied in 2007 in the hopes of further stimulat-
editorial suggestion and has been noted by Neer ing interest in a unied fracture classication
[10] to have been arbitrarily set. He further language resulting in improved patient care and
claried that it was not intended to dictate treat- clinical research. The advantages of a comprehen-
ment but simply to dene the minimal displace- sive system include providing a universal language
ment category (one part), aid in decision for fracture communication whereby clear deni-
making, and aid in standardization of future out- tions exist for various fracture types. Recognized
come studies [10]. The reference points for mea- diculties of this system are its complexity and
surements of displacement and angulation observer disagreement [4].

Fig. 2. The Neer classication of proximal humeral fractures. (Adapted from Neer CS. Four-segment classication
of proximal humeral fractures: purpose and reliable use. J Shoulder Elbow Surg 2002;11(4):391; with permission.)

Edelson CT classication system The authors describe the glenoid like an anvil on
which the proximal humerus fractures. Other
Edelson and colleagues [5] described a three-
recognized mechanisms of injury were a direct
dimensional (3-D) classication system of proxi-
impact to the proximal humerus or a fall with the
mal humerus fractures. The authors studied
arm in external rotation.
73 museum specimens selected from more than
Two-part fractures most often consisted of the
3200 specimens examined and 84 3-D CT recon-
head with the tuberosities attached and a fracture
structions from their own clinical cases. The
through the weaker metaphyseal bone of the
examined specimens were complicated fracture
surgical neck. Three-part fractures were the most
patterns correlating to Neer three- or four-part
common multipart fracture. They consisted of the
fractures. Five major fracture patterns were
head with the lesser tuberosity, the greater tuber-
identied: two-part, three-part, shield fractures
osity, and a surgical neck fracture. The superior
and their variants, isolated greater tuberosity, and
portion of the bicipital groove remained intact in
this fracture pattern; therefore, the authors sug-
The authors attributed most fractures of the
gested there was preservation of the major blood
proximal humerus to the position in which the
supply to the humeral head by way of the anterior
arm was held when trying to break a fall, namely
circumex vessels.
forward exion, abduction, and internal rotation.
396 ROBINSON et al

Fig. 3. The AO classication of proximal humeral fractures. (Data from Marsh JL, Slongo T, Agel J, et al. Fracture and
dislocation classication compendiumd2007. J Orthop Trauma 2007;21(Suppl 10):S1133.)

The shield fracture was a progression of the radiographs has yielded low interobserver reliabil-
three-part fracture and occurred when the head ity [1420]. In an attempt to increase reliability CT
segment was further driven down and back. The has been added as an adjunct to radiographs
shield was dened as the section of bone circling the with varied results [14,17,2124]. Castagno and
head composed of the greater and lesser tuberosi- colleagues [21] and Guix and colleagues [24] found
ties and held together by the bicipital groove. The CT benecial; Bernstein and colleagues [14] and
shield fracture pattern involved the superior Sjoden and colleagues [23] noted no additional
bicipital groove and the lesser tuberosity, with the benet. Even the inclusion of 3-D CT imaging
shield fragment itself usually being comminuted. did not improve reliability [17,22]. The experience
Isolated fractures of the greater tuberosity were of the surgeon has been shown to improve reliabil-
more commonly on the posterolateral aspect of the ity in two studies [12,22] and not to alter reliability
greater tuberosity and did not extend into the in one [17]. Reduction of the classication com-
bicipital groove. plexity has not been shown to improve reliability
The nal category was fracture-dislocations, [12,14], whereas formal training and a structured
with anterior dislocation mechanisms occurring protocol have been shown to improve reliability
with external rotation and posterior disloca- [15,24]. Siebenrock and Gerber [19] evaluated
tions with internal rotation. The fracture com- the Neer and AO/American Society for Internal
ponent mirrored the patterns seen in fractures Fixation systems showing similar concerns for
without associated dislocations. both systems.
Using the 3-D classication system, interob-
Evaluation of current classication systems
server reproducibility was 0.69. The authors con-
Evaluation of the classication systems for cluded that using a 3-D versus a two-dimensional
fractures of the proximal humerus with plain system of classication to guide treatment

options was signicantly better and it had the

potential to modify and improve surgical
procedures [5] to include less destructive
approaches and more anatomic reconstruction.
Limitations of the classication system were
secondary to limitations of 3-D technology,
especially in recreating fractures that were mini-
mally displaced or severely comminuted, and
lack of rapid reconstruction and ease of acquisi-
tion. The CT classication has not gained wide-
spread use.
Many concerns regarding the current classi-
cation systems have been expressed in the
literature. None have evaluated Dr. Neers clas-
sication system in the manner it was designed (ie,
using operative ndings correlated with radio-
graphs to arrive at the nal classication) [10].
The Neer classication system has received sup-
port from surgeons by its use in clinical studies,
practice, and the orthopaedic literature [25].

Imaging studies
Bone density assessment
Fig. 4. Combined cortical thickness. (From Tingart MJ,
Critical evaluation of the radiographic and Apreleva M, von Stechow D, et al. The cortical thickness
clinical parameters to determine physiologic age of the proximal humerus diaphysis predicts bone mineral
is more appropriate than decisions based on density of the proximal jumerus. J Bone Joint Surg Br
chronologic age. One part of the decision-making 2003;85:6117; with permission.)
process on the treatment of proximal humerus
fractures is based on bone qualitydspecically
Radiographic evaluation of vascularity
the presence or absence of osteoporosis. Bone
mineral density can be roughly determined by Another consideration in the radiographic
radiographic evaluation and can have a consider- classication of proximal humeral fractures is
able eect on treatment options [26]. Tingart and the vascularity of the humeral head. Avascular
colleagues [27] identied a reliable and repro- necrosis is a known sequelae of proximal humeral
ducible predictor of bone mineral density of the fractures and has been reported at rates of 21% to
proximal humerus. They compared the cortical 75% [30,31]. Fracture nonunion and tuberosity
thickness of the proximal humeral diaphysis with reabsorption may also be inuenced by fracture
the bone mineral density of the proximal vascularity. The vascularity of the humeral head
humerus. They noted that a cortical thickness segment in conjunction with the state of the artic-
(dened as the sum of the cortical thickness of ular surface and other mitigating patient factors
the medial and lateral cortex of the proximal help to determine optimum treatment. The vascu-
humerus) less than 4 mm was highly predictive larity of the proximal humerus has been well
of low bone mineral density (Fig. 4). The critical studied by dierent groups (Fig. 5) [3236]. The
evaluation of plain radiographs has been reported vascular supply of the humeral head is presumed
as a better predictor of osteopenia than simple damaged in four-part fractures unless the medial
age-based criteria [28]. Additionally the radio- aspect of the fracture line lies below the articular
graphic images must be evaluated for the presence surface, preserving some of the medial capsular
of an intact medial buttress because this has vessels. Hertel and colleagues [37] devised a series
been theorized to be important in strength of x- of criteria that could be predictive of humeral
ation, especially regarding current locking plate head ischemia after fracture (Fig. 6). They viewed
technology [29]. the tuberosities as intercalated segments between
398 ROBINSON et al

Fig. 5. The vascularity of the proximal humerus. (Courtesy of D. M. Rispoli, MD, Lackland AFB, TX.)

the head and the shaft instead of the classic view anatomic neck and a fracture below the tuberosi-
in which the tuberosities were protuberances of ties at the surgical neck; however, the tuberosities
the metaphysis. Specic fracture combinations did not have a fracture between them. Additional
were associated with impaired head perfusion. elements, such as length of the posteromedial
Fractures that were predictive of ischemia were metaphyseal extension (!8 mm associated with
those of the anatomic neck, four-part displaced, vascular compromise) and the integrity of the me-
and all three-part fractures congurations except dial hinge, were also key in predicting vascular
one. The exception three-part fracture that main- disruption. They noted that the degree of displace-
tained perfusion involved a fracture at the ment of the four components was less important

Fig. 6. Hertel radiographic criteria. (Redrawn from Hertal R, Hempng A, Stiehler M, et al. Predictors of humeral head
ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg 2004;13:429; with permission.)

than the key elements they noted. Certain dis- The true AP view is shot with the beam angled
placed fractures, notably the valgus impacted frac- 45 degrees from the sagittal plane (perpendicular
tures, have been theorized to cause less destruction to the axis of the scapula). This view projects
of the proximal humeral blood supply theoretically clearly the articular surface of the humeral head
because of preservation of the medial hinge and and the joint space from the glenoid fossa. This
subsequently the posteromedial vasculature [38]. view is also a good image for evaluation of the
Tamai and colleagues [39] suggested that the tuberosities (Fig. 7) [41].
orientation of the articular surface is important The axillary view is shot with the shoulder
in predicting humeral head vascularity. The abducted ideally between 70 and 90 degrees and
absence of displacement or medial displacement the beam directed cephalad with the cassette
of the humeral head with respect to the humeral positioned at the superior aspect of the shoulder.
shaft was predictive of maintained vascularity to It is the best view to image for dislocations and
the humeral head. the presence of humeral head compression frac-
tures, glenoid fractures, and fractures of the lesser
tuberosity (Fig. 8).
Radiographs If the patient is unable to tolerate the axillary
In his landmark publication, Neer [3] suggested view because of pain, a Velpeau axillary view can
that determination of fracture conguration could be substituted (see Fig. 8) [41,42]. The patient re-
be done using true anteroposterior (AP) and mains in the shoulder sling and is leaned obliquely
scapular Y radiographs. Over the years, others backward approximately 30 to 45 degrees over the
suggested the need for an additional radiographic cassette. The beam is then directed caudally,
view, the axillary lateral [11,12,14,15, orthogonal to the cassette. It is benecial for the
4042]. The axillary radiograph best shows surgeon or a trained member of their sta to assist
displacement of the lesser and greater tubero- with positioning the arm for accurate imaging
sities and splits and dislocations of the humeral with the axillary view. The axillary view is the
head. most frequently omitted image and is a common
A trauma series of radiographs represents the reason for missed dislocations and fractures
minimum requirement in the evaluation of prox- [4244]. With careful positioning of the arm into
imal humerus fractures. This series consists of abduction by the physician, the axillary view can
a true anteroposterior view of the scapula and nearly always be obtained [3,10].
glenohumeral joint, an axillary view, and a lateral The scapular Y view is shot posteroanterior
Y view of the scapula. The trauma series evaluates with the beam angled 40 degrees from the coronal
the glenohumeral joint and proximal humerus in plane and is at a right angle from the true AP
three perpendicular planes. view. The lateral Y radiograph projects the

Fig. 7. True anteroposterior radiograph. (Courtesy of D. M. Rispoli, MD, Lackland AFB, TX.)
400 ROBINSON et al

Fig. 8. Valpeau axillary radiograph and axillary radiograph. (Courtesy of D. M. Rispoli, MD, Lackland AFB, TX.)

contour of the scapula as the letter Y with the reduced position lying at the center of the arms of
forks of the Y being the body of the scapula in the the Y. In dislocations, the head is seen anterior or
downward direction, and the upward forks as posterior to the center of the Y (Fig. 9).
the coracoid anteriorly, and the spine and the Other radiographic projections are useful for
acromion posteriorly. The glenoid is seen at the specic fracture types, such as humeral head
center of the Y with the humeral head in its indentations (so-called Hill-Sachs and reverse

Fig. 9. Scapular Y radiograph. (Courtesy of D. M. Rispoli, MD, Lackland AFB, TX.)


Hill-Sachs lesions) or glenoid rim fractures, but The Didiee view is an excellent radiographic
are not needed in most cases. The West Point view for visualization of the anterior inferior
axillary lateral view was initially described by glenoid rim; it is shot with the patient prone and
Rokous and colleagues [45] and provides tangen- the cassette under the shoulder. The forearm is
tial imaging of the anterior glenoid rim. This ra- positioned posterior to the trunk and the arm is
diograph is shot with the patient prone with the placed parallel to the top of the table with a 3-in
injured shoulder raised 7 to 8 cm above the table, pad under the elbow. The dorsum of the hand is
the head and neck turned away. The cassette is placed on the iliac crest with the thumb pointing
positioned at the superior aspect of the shoulder upward. In this position the tube is directly lateral
and the beam is centered at the axilla, 25 degrees to the glenohumeral joint, and the radiograph is
inferiorly and 25 degrees medially. shot with the beam angled 45 degrees [41].
The apical-oblique view is shot with the
scapula at against the cassette while the patient CT
is sitting. The x-ray beam is aimed 45 degrees from CT has enhanced tremendously our ability to
the coronal plane and 45 degrees caudally, per- image and understand complex proximal humerus
pendicular to the cassette and centered on the fractures. Modern locking-plate technology
coracoid. The purpose of this radiograph is to allows successful internal xation of complex
view for posterolateral impression fractures of the fracture patterns treated in the past with hemi-
humeral head and anterior glenoid rim fractures arthroplasty; CT represents an invaluable tool
[41]. in the preoperative planning and execution of
The internal rotation view allows for better internal xation for these complex fractures. The
visualization of the lesser tuberosity. This view value of CT evaluation has been shown in
may be used in follow-up of a proximal humeral multiple studies [21,4648]. Most authors recom-
fracture. The internal rotation view is shot mend the systematic use of CT scans for preoper-
with the patient supine. A sandbag is positioned ative planning, especially for fractures including
under the elbow placing the humerus horizontal the greater or lesser tuberosities, humeral head im-
from the top of the table. The arm is abducted and paction, head splitting, or any other fracture with
internally rotated 45 degrees with the forearm intra-articular fragments [10,1416,20,35,37]. The
lying across the trunk. The beam is rotated most commonly found occult fractures include
15 degrees caudally and is centered over the lesser tuberosity fractures, head splitting, and pos-
humeral head [41]. terolateral compression fractures of the humeral
The tangential view is shot with the elbow head [47].
exed to 90 degrees, the dorsum of the hand
positioned posteriorly to the trunk in the region of MRI
the upper lumbar spine, and the thumb pointing
upward. The x-ray tube is positioned posterior, Berger and colleagues [49] published several
lateral, and inferior to the elbow with the cassette case reports of proximal humerus fractures de-
placed superiorly to the adducted arm [41]. tected using MRI while investigating for rotator
The Hill-Sachs radiograph is an AP radio- cu pathologies. These fractures were radiograph-
graph taken with the humerus in internal rotation ically occult or showed only subtle abnormalities
revealing posterolateral head impaction fractures overlooked on initial reading. Berger concluded
[41]. that MRI can be a useful diagnostic tool in assess-
The Stryker notch view is used to evaluate for ing osseous abnormalities about the proximal
Hill-Sachs lesions in dislocations and fracture humerus potentially leading to improved patient
dislocations of the glenohumeral joint. Hall and evaluation and treatment. In general, MRI is
colleagues [41] rst reported a radiograph devel- rarely used in the standard preoperative imaging
oped by Stryker called the Stryker notch view. protocol of proximal humerus fractures.
For this radiograph, the patient lies supine with
the cassette positioned under the shoulder. The
palm of the aected shoulder is placed on
the head with the ngers pointed posteriorly and The evaluation and treatment of proximal
the elbow pointing straight superiorly. The beam humerus fractures has evolved substantially over
is tilted 10 degrees toward the head and is centered the last few decades. The indications for surgery
over the coracoid. have continued to expand reecting the increased
402 ROBINSON et al

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