Summary

Proximal Humerus Fractures (PHF) are the third most common osteoporotic fracture (after hip and wrist), affecting elderly females typically after a fall from standing height. The Neer Classification defines severity based on the displacement of 4 key segments (Head, Shaft, Greater Tuberosity, Lesser Tuberosity). The management of PHF has been controversial. Historically, displaced fractures were plated widely. However, the landmark PROFHER Trial (2015) demonstrated that for the majority of displaced fractures in the elderly, surgical fixation offers no functional benefit over conservative care. Currently, surgery is reserved for fracture-dislocations, head-splitting patterns, or high-demand young patients. For complex 4-part fractures in the elderly, Reverse Shoulder Arthroplasty (RSA) has superseded Hemiarthroplasty as the gold standard. [1,2,3]

Key Facts

• Most Common Nerve Injury: Axillary Nerve. Supplies the Deltoid. Test sensation over the "Regimental Badge" patch.
• Most Common Vessel Injury: Axillary Artery (in elderly with atherosclerosis).
• Neer's "Part": A segment is only a "part" if it is displaced >1cm or angulated >45 degrees.
• Ecchymosis: Massive chest wall bruising (Hennequin's ecchymosis) is normal and expected 24-48h later.

Clinical Pearls

"Treat the Patient, Not the X-Ray": A 75-year-old with a comminuted Neer 3-part fracture often heals with a painless, functional shoulder (albeit stiff) using a sling. Plating this "bag of bones" risks screw cutout, infection, and re-operation for no functional gain. (PROFHER).

"Beware the Lightbulb": Posterior dislocations are missed in 50% of initial presentations. The arm is locked in Internal Rotation. On the AP X-ray, the head looks like a lightbulb (loss of the normal walking stick profile). You MUST get an Axillary View.

"The Cuff is King (or was)": Hemiarthroplasty fails because relies on healing of the tuberosities (Rotator Cuff) to function. In osteoporosis, these tuberosities disappear or non-unite. RSA works because it ignores the cuff and uses the Deltoid instead.

Based on Displacement (>1cm or >45 deg).

• One-Part: No displacement. (80% of all PHFs). Stable.
• Two-Part: One segment displaced (usually Surgical Neck or GT).
• Three-Part: Surgical Neck + GT displaced. Head rotated.
• Four-Part: Everything displaced. Head isolated (AVN risk 100%).
• Valgus Impacted: A variant of 4-part where the head is jammed into the shaft. Blood supply OFTEN PRESERVED. Do not replace - Fix.

              PROXIMAL HUMERUS FRACTURE
                       ↓
             DISLOCATED? OPEN? SPLIT HEAD?
             ┌─────────┴─────────┐
            YES                  NO
             ↓                   ↓
        URGENT SURGERY       DISPLACED? (>1cm)
       (Reduction/Washout)   ┌───┴────┐
                            NO       YES
                           (1-part)   ↓
                            ↓        PATIENT AGE/DEMAND?
                           SLING     ┌────────┴───────┐
                          (PROFHER) <65 (Active)    >65 (Low Demand)
                                     ↓                ↓
                                   SURGERY          SLING
                                 (Plate/Nail)      (PROFHER)
                                                      ↓
                                                FAILS/SEVERE PAIN?
                                                  → REVERSE ARTHROPLASTY

1. Conservative (Non-Operative)

• Indication: 85% of cases. 1-Part fractures. Displaced fractures in elderly/low demand (per PROFHER).
• Protocol:
  • Collar and Cuff Sling: Gravity helps reduce the fracture.
  • Sleep: Upright (sitting) for 2 weeks to reduce pain.
  • Phase 1 (0-2 weeks): Pendulums only.
  • Phase 2 (2-6 weeks): Active assistive.
  • Phase 3 (6+ weeks): Strengthening.
• Outcome: High rate of stiffness ("Frozen Shoulder"), but functionally acceptable for ADLs.

2. Surgical Fixation (ORIF)

• Indication: 2/3-part fractures in Young/Physiological Active patients. GT Avulsions blocking abduction.
• Implant: PHILOS Plate (Proximal Humeral Internal Locking System).
• Technique: Deltopectoral approach. Screws lock into head. Sutures capture the cuff.
• Complication: Screw Cut-out (15%). If the head collapses, the rigid screws penetrate the joint, destroying the glenoid.

3. Hemiarthroplasty (Half Replacement)

• Indication: Rarely used now. Head-split in young patient.
• Failure: Depends on tuberosity healing. High failure rate.

4. Reverse Shoulder Arthroplasty (RSA)

• Indication: 4-Part fractures in Elderly (>70). Comminuted fractures with cuff pathology.
• Biomechanics: Rotator Cuff is removed/irrelevant. The Deltoid becomes the sole elevator.
• Outcome: Reliable elevation to 90-120 degrees. Low pain. Low re-operation rate. Gold Standard for severe fractures in elderly.

The PROFHER Trial (Rangan et al. JAMA 2015)

• Design: Multicentre RCT (UK). Surgery vs Sling for displaced surgical neck fractures in adults.
• Results: No significant difference in Oxford Shoulder Score (OSS) at 2 years.
• Conclusion: Routine surgery for displaced PHF is not supported.
• Criticism: Excluded head-splits and dislocations. Critics say it included "too many 2-part fractures" which heal well anyway. However, it effectively stopped the trend of plating every grandmother's shoulder.

What has happened?

You have broken the top of the arm bone, just below the shoulder ball. It is common in osteoporosis.

Do I need an operation?

We usually try to NOT operate. A major study called PROFHER showed that in people of your age, surgery (putting a metal plate in) does not give you a better shoulder than letting it smile heal, but it DOES add risks of infection and nerve damage.

The Plan

1. Sling: Wear it for 2-3 weeks.
2. Move: Start "Pendulum" exercises (swinging arm gently) immediately to stop it freezing.
3. Purple Arm: Tomorrow, your whole arm and chest will turn black/purple. This is normal bruising sinking with gravity.

What if it doesn't heal?

It almost always heals (unites). If it heals in a crooked position but you can move it without pain, that is a success. If it is very painful later, we can replace the joint (Reverse Shoulder Replacement), but this is rarely needed.

Q1: What are Hertel's Criteria for AVN? A: Anatomical predictors of ischemia:

1. Metaphyseal extension (calcar) <8mm.
2. Disrupted medial hinge.
3. Basic fracture pattern (Anatomical neck/4-part). If calcar <8mm AND hinge disrupted -> 97% risk of AVN.

Q2: Describe the principle of Reverse Shoulder Arthroplasty. A: It reverses the anatomy (Glenoid Sphere, Humeral Cup). It medialises the center of rotation and lengthens the lever arm of the Deltoid. This recruits more Deltoid fibers (Anterior/Posterior) to become elevators, allowing the arm to lift without a functional supraspinatus (rotator cuff).

Q3: Why is the Axillary view so important? A: (1) It confirms the head is located (not posteriorly dislocated), which can be missed on AP. (2) It shows the position of the tuberosities (GT/LT) relative to the head.

(End of Topic)