Group II includes a displacement of the articular-segment at the anatomical neck without separation of one or both tuberosities (see Fig. 8.1). Although being rare this fracture configuration needs to be identified by strict anteroposterior radiographs of the shoulder in order to prevent malunion and vascular necrosis.
Group III characterizes fractures at the level of the surgical neck being displaced more than 1 cm or angulated more than 45°. Three variations of this fracture have been described in terms of an (A) impacted and angulated surgical neck fracture, (B) separated surgical neck fracture and (C) comminuted surgical neck fracture. In 1970 conservative treatment options have been described by Charles Neer for group III fractures, whereas today displaced surgical neck fractures mainly are treated operatively.
In summary Group II and III fractures are classified as two-part fractures (see Fig. 8.1).
Group IV includes fractures of the greater tuberosity and may occur as two-, three- and four-part fractures (see Fig. 8.1). Two-part fractures reveal an articular segment which remains in normal position to the humeral shaft. A minimally displaced fracture of the surgical neck may be present as well. Three-part fractures are characterized by an additional fracture of the surgical neck often appearing due to an application of force by the subscapularis tendon resulting in internal rotation position. In four-part fractures a further detachment of the humeral head is present (see Fig. 8.1). Closed reduction of group IV fractures led to high rates of unsuccessful results mainly due to malunion [8].
In group V fractures a displacement of the lesser tuberosity is present. The two-part fracture of this group is characterized by a displacement of the lesser tuberosity, in some cases associated with an undisplaced fracture of the surgical neck. In three part fractures the surgical neck appears dislocated leading to abduction and external rotation position of the articular segment due to the attachment of the supraspinatus and infraspinatus tendon. The four-part fracture additionally reveals retraction of both tuberosities (see Fig. 8.1). Again closed reduction of group V fractures resulted in a high incidence of unsuccessful outcome.
In group VI fractures caused by a dislocation of the proximal humerus are summed up. Antero-inferior and posterior dislocation may occur in two-, three- and four-part fractures (see Fig. 8.1). It has been stated that a posterior displacement in combination with damage of more than 20 % of articular cartilage predisposes for recurrent shoulder instability and may require a so-called McLaughlin procedure in terms of a transplantation of the subscapularis tendon [9]. Defects greater than 50 % of the articular cartilage may even require prosthetic treatment.
Hertel Classification
The Hertel classification is predicated on the article “Fractures of the proximal humerus in osteoporotic bone” published by Ralph Hertel in the Journal of Osteoporosis International in 2005. In this article the author reviewed effective treatment options for proximal humeral fractures in patients suffering from severe osteoporosis [10]. In this context based on the original drawings [11] of Codman et al. a descriptive fracture classification was introduced by Hertel (see Fig. 8.2). In contrast to Neer’s classification [2] based on the four segment theory, this classification is based on five fracture planes.
Fig. 8.2
Binary or “LEGO” descriptory system. The image illustrates the five basic fracture planes, resulting in 12 possible basic fractures: Six possible fractures devide the humerus into two fragments (figs. 1–6), five possible fractures devide the humerus into three fragments (figs. 7–11) and one single fracture devides the humerus into four fragments (fig. 12) (Reprinted with permission from Hertel [10])
In this context five questions have been released to identify the basic fracture planes:
1.
Is there a fracture between the greater tuberosity and the humeral head?
2.
Is there a fracture between the greater tuberosity and the humeral shaft?
3.
Is there a fracture between the lesser tuberosity and the humeral head?
4.
Is there a fracture between the lesser tuberosity and the humeral shaft?
5.
Is there a fracture between the lesser and the greater tuberosity?
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
