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PROXIMAL HUMERUS FRACTURE ADULT

Introduction

Fracture Nomenclature for Proximal Humerus fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Proximal Humerus Fractures, the historical and specifically named fractures include no fracture eponyms.

Proximal humerus fractures are very common injuries that occur in a bimodal age distribution. In younger patients, these fractures typically occur secondary to high-energy trauma, such as from a car accident. Proximal humerus fractures are most prevalent in adults over 65 years—particularly women—and the mechanism of injury in this population is usually a low-energy fall that results in a fracture due to the presence of osteoporosis or osteopenia. These fragility fractures in older adults tend to create more complex fracture patterns than those seen in younger patients. Most proximal humerus fractures are nondisplaced or minimally displaced and can therefore be treated conservatively with sling immobilization followed by early, progressive rehabilitation. Surgery may be needed in displaced and more complex fractures, and several options are available.1-4

Definitions

  • A proximal humerus fracture is a disruption of the mechanical integrity of the proximal humerus.
  • A proximal humerus fracture produces a discontinuity in the proximal humeral contours that can be complete or incomplete.
  • A proximal humerus fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.5-7
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with immobilization with a sling and/or swathe. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typical unstable proximal humerus fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern1,8

  • Neer classification system
    • One-part fracture
      • Fracture line involves 1–4 parts.
      • None of the parts are displaced (i.e., <1 cm and <45°).
    • Two-part fracture
      • Fracture line involves 2–4 parts.
      • One of these parts (i.e., the greater tuberosity, lesser tuberosity, or articular segment at the anatomic or surgical neck) is displaced (i.e., >1 cm or >45°).
    • Three-part fracture
      • Fracture line involves 3–4 parts.
      • One tuberosity and the surgical neck fracture is displaced; the other tuberosity is attached and results in a rotational deformity.
    • Four-part fracture
      • Fracture line involves 4 parts.
      • All 4 parts (i.e., both tuberosities, the articular surface, and the humeral shaft) are displaced, and the articular portion is usually displaced laterally and out of contact with the glenoid.
      • These are typically more severe injuries with a higher risk for complications.

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the proximal humerus require antibiotics with surgical irrigation and wound debridement.5,9,10

R - Rotation

  • Proximal humerus fracture deformity can be caused by rotation of the proximal fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.
  • In three-part fractures, the nondisplaced tuberosity remains attached, which results in a rotational deformity.8

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angular deformity
  • Angulated: bent at the fracture site

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: ≥1 fracture lines defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted
  • Most proximal humerus fractures (80–85%) are either nondisplaced or minimally displaced and can be treated conservatively. Proximal humerus fractures that are displaced typically involve the surgical neck and may led to long-term functional impairments.3,4

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
  • Proximal humerus fractures can have fragment involvement at the glenohumeral joint.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to post-traumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised, and the risk of post-traumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Related Anatomy1,2,11

  • The shoulder is a complex that consists of four joints, with the acromioclavicular and glenohumeral joints being most important for movement. The acromioclavicular joint is a gliding joint formed by the articulation of the acromion and the clavicle. The glenohumeral joint is a ball-and-socket joint formed by the head of the proximal humerus and the glenoid fossa of the scapula.
    • The proximal humerus consists of an anatomic neck, the humeral head, the surgical neck, and the greater and lesser tuberosities. The anatomic neck represents the fused epiphyseal plate and lies proximal to the two tuberosities, while the surgical neck is located below the humeral head and is the weakest area of the humerus. The greater tuberosity is the anatomic footprint and insertion point for three of the four rotator cuff muscles, while the lesser tuberosity is the insertion point for the tendon of the subscapularis muscle.
    • The humeral head articulates with the shallow glenoid fossa of the scapula, and this articulation allows for complex and dynamic ROM in several planes, making the glenohumeral joint the most mobile of the body.
  • Key ligaments of the shoulder include the coracohumeral ligament, which attaches the greater tuberosity to the coracoid process of the scapula, and the superior, middle, and inferior glenohumeral ligaments. These three ligaments form the glenohumeral joint capsule that connects the glenoid fossa to the humerus.
  • Key muscles of the shoulder include the pectoralis major, latissimus dorsi, and teres major muscles, as well as the rotator cuff muscle complex, which is comprised of three muscles with tendons that insert onto the greater tuberosity (ie, supraspinatus, infraspinatus, and teres minor) and the large subscapularis tendon, which attaches to the lesser tuberosity.

Incidence

  • The overall incidence of proximal humerus fractures is 4–6%, and this figure is expected to continue increasing as the population grows older.1,12
  • Proximal humerus fractures are the second most common injuries of the upper extremity and the third most common fracture overall in the population older than 65 years.3
  • These injuries are most common in older individuals, and particularly women, who are 2–3 times more likely to experience a proximal humerus fracture than men.1,12

​

ICD-10 Codes

  • PROXIMAL HUMERUS FRACTURE - ADULT

    Diagnostic Guide Name

    PROXIMAL HUMERUS FRACTURE - ADULT

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PROXIMAL HUMERUS FRACTURE - ADULT    
    SURGICAL NECK - 2 PART    
    - DISPLACED S42.222_S42.221_ 
    - NONDISPLACED S42.225_S42.224_ 
    SURGICAL NECK - 3 PART S42.232_S42.231_ 
    SURGICAL NECK - 4 PART S42.242_S42.241_ 
    GREATER TUBEROSITY    
    - DISPLACED S42.252_S42.251_ 
    - NONDISPLACED S42.255_S42.254_ 
    LESSER TUBEROSITY    
    - DISPLACED S42.262_S42.261_ 
    - NONDISPLACED S42.265_S42.264_ 
    TORUS UPPER END OF HUMERUS S42.272_S42.271_ 
    OTHER FRACTURE UPPER END    
    - DISPLACED S42.292_S42.201_ 
    - NONDISPLACED S42.295_S42.294_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S42
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Clinical Presentation Photos and Related Diagrams
Proximal Humerus Fracture
  • Comminuted closed left proximal humerus fracture
    Comminuted closed left proximal humerus fracture
Symptoms
History of trauma
Fracture pain
Fracture deformity
Swelling, ecchymosis & tenderness
Abrasion
Typical History

The typical patient is a 76-year-old woman with osteoporosis. The woman was walking to the bathroom in the middle of the night but did not turn on the light to avoid waking her husband. The darkness prevented her from seeing a large bag in front of her bed, which she tripped over while walking, landing on the ground with her right arm outstretched. The impact of the fall resulted in a fracture of the proximal humerus of her right shoulder. The next morning, she noticed that her shoulder had become swollen, tender, and painful, and her range of motion was significantly reduced, which led her to seek out treatment.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Proximal Humerus Fracture
  • CT of comminuted closed left proximal humerus fracture
    CT of comminuted closed left proximal humerus fracture
Treatment Options
Treatment Goals
  • When treating closed proximal humerus fractures, the treating surgeon has 4 basic goals:5,10
    1. A shoulder with a normal appearance. The X-ray may not need to be perfect, but the shoulder should have no obvious deformity (i.e., the shoulder looks normal!)
    2. Avoid shoulder stiffness by maintaining a normal functional ROM (i.e., the shoulder works!)
    3. The shoulder is not painful (i.e., the shoulder does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (i.e., the shoulder does not develop early post-traumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • Most proximal humeral fractures are nondisplaced or minimally displaced and can therefore be treated conservatively. Nonsurgical treatment is also indicated for most anatomic neck fractures and may be considered in patients with three- and four-part fractures who have poor baseline function or who are contraindicated for surgery.1,2
    • The acceptable amount of displacement in an isolated greater tuberosity fracture has not yet been established, and recent literature suggests that a surgical approach is likely best for these injuries.1
  • Conservative treatment for proximal humerus fractures usually involves short-term sling immobilization for 2–3 weeks, followed by early, progressive physical therapy that focuses on regaining shoulder ROM. Care must be taken to ensure that further displacement does not occur during the rehabilitation process.1-3
Operative
  • Surgical treatment of proximal humerus fractures must always be an individualized therapeutic decision.1,2  However, surgical proximal humerus fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple sling and swathe immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced proximal humerus fracture involving the glenohumeral joint.
    3. Open proximal humerus fractures. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Open reduction and internal fixation (ORIF)
    • Typically indicated for:
      • Greater tuberosity fractures with >3–5 mm displacement
      • Two-, three-, and four-part fractures in younger patients
      • Head-splitting fractures in younger patients.
    • Either an anterior or lateral approach can be used.
    • Fixation devices include:
      • Heavy nonabsorbable sutures
      • Isolated screws
      • Locking plates
  • Closed reduction and percutaneous pinning (CRPP)
    • Typically Indicated for:
      • Two-part surgical neck fractures
      • Three-part surgical neck fractures and valgus-impacted four-part fractures if there is good bone quality, minimal metaphyseal comminution, and an intact medial calcar
  • Intramedullary nailing
    • Typically indicated for:
      • Surgical neck fractures and three-part greater tuberosity fractures in younger patients
      • Combined proximal humerus and humeral shaft fractures
    • A superior deltoid-splitting approach is usually recommended.
  • Arthroplasty
    • Hemiarthroplasty
      • Typically indicated for:
        • Younger patients with complex fracture-dislocations
        • Fractures involving head-splitting components that may not be amenable to ORIF
      • An anterior approach is typically recommended.
    • Reverse total shoulder arthroplasty
      • Typically indicated for:
        • Older patients, who tend to have pre-existing or concomitant rotator cuff disruption, with fractured tuberosities that cannot be reconstructed
        • Older patients with poor bone quality and fracture-dislocations
      • An anterior approach with an anterolateral deltoid split is usually recommended.
Treatment Photos and Diagrams
Left Adult Proximal Humerus Fracture Treatment
  • ORIF of comminuted closed left proximal humerus fracture
    ORIF of comminuted closed left proximal humerus fracture
  • Completed ORIF of comminuted closed left proximal humerus fracture
    Completed ORIF of comminuted closed left proximal humerus fracture

Post-treatment Management

  • The care and precautions related to immobilization devices for the proximal humerus fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with a properly fitting sling, reassurance, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Fractures that require internal fixation can usually be mobilized after 2 to 4 weeks.
  • For conservatively managed proximal humerus fractures, progressive physical therapy can begin as early as 10 days after the injury—so long as the patient’s symptoms are manageable—and should include early, gentle exercises that aim to regain shoulder ROM, such as pendulum exercises.1
  • Rehabilitation after ORIF should include early passive ROM exercises, active ROM and progressive resistance exercises, and an advanced stretching and strengthening exercise program. Prolonged immobilization should be avoided to reduce the risk for stiffness.
CPT Codes for Treatment Options

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Complications

Post-treatment Management

  • The care and precautions related to immobilization devices for the proximal humerus fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with a properly fitting sling, reassurance, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Fractures that require internal fixation can usually be mobilized after 2 to 4 weeks.
  • For conservatively managed proximal humerus fractures, progressive physical therapy can begin as early as 10 days after the injury—so long as the patient’s symptoms are manageable—and should include early, gentle exercises that aim to regain shoulder ROM, such as pendulum exercises.1
  • Rehabilitation after ORIF should include early passive ROM exercises, active ROM and progressive resistance exercises, and an advanced stretching and strengthening exercise program. Prolonged immobilization should be avoided to reduce the risk for stiffness.
Outcomes
  • Overall, successful outcomes have been documented in 80–85% of proximal humerus fractures that are treated conservatively. Positive outcomes following nonsurgical treatment are most likely to occur in minimally displaced surgical neck fractures and greater tuberosity fractures that are displaced <3 mm.1
  • Displaced proximal humerus fractures are typically associated with long-term functional impairments.3
  • Nonsurgical treatment has been found to be at least as efficacious as surgery, particularly for proximal humerus fractures with minimal displacement.2
    • In one randomized controlled trial of patients with displaced proximal humeral fractures of the surgical neck, no significant differences were found in patient-reported clinical outcomes between surgery and nonsurgical treatment within 2 years after the injury.4
    • A Cochrane review of randomized controlled trials evaluating proximal humerus fractures found a lack of evidence to show that surgical interventions produced consistently better outcomes than nonsurgical treatment.13
Key Educational Points
  • For displaced proximal humerus fractures that require surgery, no surgical approach is yet regarded as the gold standard.3
  • As the general population continues to age and thus a greater proportion of patients with compromised bone density experiences proximal humerus fractures, more attention will continue to be paid to both the conservative and surgical management of these injuries.1
  • Surgeons must explain to patients that no treatment can produce an outcome that equates to pre-injury functional levels, regardless of how successful the intervention is.14
  • Although most proximal humerus fractures can be managed conservatively, the rate of surgical intervention—mainly ORIF and humeral head replacement—for these injuries is steadily rising.4
  • Recommended imaging views include the true anteroposterior view, scapular Y view, and axillary lateral view. The “West Point axillary view,” which provides a tangential view of the anteroinferior rim of the glenoid rim, may also be considered.1
  • Computerized tomography (CT) scanning may assist with preoperative planning or to guide the ideal surgical approach, especially if there is uncertainty about the position of the humeral head or greater tuberosity.1
  • Magnetic resonance imaging - MRI without contrast is rarely needed, but may be helpful for identifying concomitant rotator cuff injury.1
References

Cited Articles

  1. Pencle, FJ and Varacallo, M.Proximal Humerus Fracture. In: StatPearls. Treasure Island (FL):2021. PMID: 29262220
  2. Kancherla, VK, Singh, A and Anakwenze, OA. Management of Acute Proximal Humeral Fractures. J Am Acad Orthop Surg 2017;25(1):42-52. PMID: 28002214
  3. Nho, SJ, Brophy, RH, Barker, JU, et al. Innovations in the management of displaced proximal humerus fractures. J Am Acad Orthop Surg 2007;15(1):12-26. PMID: 17213379
  4. Rangan, A, Handoll, H, Brealey, S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 2015;313(10):1037-47. PMID: 25756440
  5. Cheah, AE and Yao, J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-22. PMID: 27113910
  6. Nesbitt, KS, Failla, JM and Les, C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29(6):1128-38. PMID: 15576227
  7. Walenkamp, MM, Vos, LM, Strackee, SD, et al. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4(4):307-16. PMID: 26649263
  8. Carofino, BC and Leopold, SS. Classifications in brief: the Neer classification for proximal humerus fractures. Clin Orthop Relat Res 2013;471(1):39-43. PMID: 22752734
  9. Ketonis, C, Dwyer, J and Ilyas, AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12(2):119-126. PMID: 28344521
  10. Meals, C and Meals, R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021-31. PMID: 23618458
  11. Attum, B and Thompson, JH. Humerus Fractures Overview. In: StatPearls. Treasure Island (FL):2021. PMID: 29489190
  12. Rouleau, DM, Mutch, J and Laflamme, GY. Surgical Treatment of Displaced Greater Tuberosity Fractures of the Humerus. J Am Acad Orthop Surg 2016;24(1):46-56. PMID: 26700632
  13. Handoll, HH, Ollivere, BJ and Rollins, KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev 2012;12:CD000434. PMID: 23235575
  14. Lambert, SM. Ischaemia, healing and outcomes in proximal humeral fractures. EFORT Open Rev 2018;3(5):304-315. PMID: 29951270
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