1.1 Epidemiology

Proximal humeral fractures are common and are mainly the result of low-energy injuries in the elderly population. Most fractures of the proximal humerus are nondisplaced or minimally displaced and can be treated successfully by nonoperative treatment, only 10–20% of the fractures require surgery [1]. Fracture of the proximal humerus is the third most common fracture in the whole body, accounting for 4–10% of all fractures [1]. The annual incidence is reported between 31 and 250 per 100,000 in adults, and the incidence is rising steadily as the elderly population increases.

1.2 Special characteristics

Proximal humeral fractures in patients with osteoporosis are challenging problems. A systematic review [2] of nonoperative treatment in elderly patients with proximal humeral fractures demonstrated high rates of healing and good functional outcomes. Nonoperative treatment of displaced fractures avoids implant-related problems that are common following surgical treatment. However, consistently satisfactory results cannot always be expected with nonoperative treatment [3–5]. Locking plates with angular stable screws provide more stability in osteoporosis but the complication rate remains high [6].

2.1 Case history and physical examination

A detailed history should include the patient′s age, activity level, and the mechanism of the injury. Most proximal humeral fractures occur in elderly patients with a fall from standing height onto an outstretched arm [1], and osteoporosis plays an important role with increasing incidence in the elderly female population. Proximal humeral fractures in young patients usually occur with high-energy trauma. They suffer more severe soft-tissue injury and multifragmentary fractures. Seizure or electric shock may also result in proximal humeral fractures with or without a dislocation.

A complete physical examination should assess the entire upper extremity and focus on other areas to exclude other injuries, including the neck and spine. Swelling and bruising may spread to dependent areas; severe swelling may occasionally be associated with vascular injury. Although open fractures are rare, severe closed fractures may cause severe tenting and pressure necrosis of the skin. Deformity of the shoulder joint may not be visible and obvious deformity suggests a dislocation. Restricted range of motion should be distinguished from rotator cuff injuries. The motor and sensory function of the axillary nerve should always be evaluated and if dislocation is present, assess the function of the brachial plexus and evaluate the wrist pulses.

2.2 Imaging

Plain x-rays are the best basic method to evaluate proximal humeral fractures. Trauma series x-rays in three views should be obtained, which include a true AP and lateral view of the shoulder joint along with an axillary view ( Fig 6.2.1-1a–d ). The standard axillary view (with the arm abducted to about 90°) is impossible because of pain and the risk of further displacement of the fracture ( Fig 6.2.1-1e–f ). Therefore, a modified axillary view (Velpeau view) can be obtained without excessive shoulder abduction ( Fig 6.2.1-1g ).

A computed tomographic (CT) scan provides important additional information for evaluating complex proximal humeral fractures. Coronal, sagittal, and 3-D reconstructions provide further details of the fracture lines, the glenoid, and humeral head ( Fig 6.2.1-2 ).

4.1 AO/OTA Fracture and Dislocation Classification

The severity of the proximal humeral fracture increases from A1 to C3, so the AO/OTA Fracture and Dislocation Classification can direct treatment and is also prognostic for the vascular supply of the humeral head and outcome ( Fig 6.2.1-5 ).

4.2 Neer classification

In 1970, Neer [6] proposed a classification system based upon the anatomical parts of the proximal humerus and their displacement from each other. Malposition of > 1 cm and angulation > 45° is considered as displacement. The Neer classification is a widely used classification for proximal humeral fractures.

4.3 LEGO classification

Hertel et al [9] developed the LEGO classification system. This classification emphasizes the location of the fracture line between each of the four parts of the proximal humerus and different combinations based upon the number of parts that are fractured.

6.1 Timing of surgery

Proximal humeral fractures rarely require immediate surgery and there are few studies on how timing of surgery affects clinical outcomes. Satisfactory results can be expected in delayed cases [10], but in comparative studies [10, 11] early surgical intervention seems to produce better functional outcomes, regardless of treatment provided.

6.2 Implant selection

The choice of implants for proximal humeral fractures should be based upon the personality of the injury including fracture characteristics, patient features, and the soft tissues. The function of the rotator cuff is also an important factor. Threaded K-wires are mainly used in immature patients with open physeal plates, whereas sutures, tension band, or screws can be utilized in 2-part tuberosity fractures with good bone quality. Locking plates are widely used in displaced fractures but plate-related complications and bone quality should be taken into account. If a closed reduction can be obtained and maintained during surgery, minimal invasive technique such as percutaneous fixation, minimally invasive plate osteosynthesis (MIPO) technique, or intramedullary (IM) nailing can be performed to minimize further disruption of the blood supply at the fracture site. Arthroplasty may be indicated for complex fractures or fracture dislocations with osteoporotic bone in the elderly. However, union of the greater tuberosity fragment(s) is unpredictable after surgery [12] and may give poor function. Reverse total shoulder arthroplasty has gained more interest in the past decade. Comparative studies [12, 13] show that reverse arthroplasty provides more predictable and higher functional outcomes than hemiarthroplasty alone but concerns about the longevity of these implants remain.

6.3 Operating room set-up

After disinfecting the entire arm and shoulder from the neck to the fingertips, the hand and forearm are covered in a waterproof stockinette. A U drape is applied with the split facing the axilla. The apex of the U is on the lateral chest wall and the two tails are stuck down anterior and posterior to meet at the root of the neck ( Fig 6.2.1-6 ). The image intensifier also needs to be draped.

The surgeon stands facing the patient′s shoulder, adjacent to the operating table and the axilla, or he positions himself between the patient and the abducted arm facing the axilla. The assistant can stand behind the patient′s shoulder. The operating room personnel set up between the two surgeons. The image intensifier display screen is placed in full view of the surgical team and the radiographer ( Fig 6.2.1-7 ).