Proximal Humerus 1
Only 20% require operative care
Two patient groups: 1. Young, high energy, good bone
2. Old, low energy, weak bone
The basic question…
Should the joint be preserved by undertaking some sort of reduction
and then fixation, or should the joint be replaced?
The Basic Issues:
If one considers internal fixation, the issues are:
· What internal fixation should I use?
· How good are the results?
· What is the likelihood of AVN (whether I fix it or not?)
· If AVN were to occur, how significant would that be?
If one considers hemiarthroplasty, the issues are:
· What are the short-term results of hemiarthroplasty?
· If I put this into a young patient, how long will it last?
· If my internal fixation fails, what are the results of salvaging it with a hemiarthroplasty
The first fundamental problem with the
literature on proximal humerus fractures…
Do we really know what we are treating when we describe
the treatment of proximal humerus fractures?
The Neer Classification
Þ Neer C.S., Displaced Proximal Humeral Fractures: I. Classification and Evaluation. Journal of Bone and Joint Surgery, 52A: 1077-1089. 1970
· 300 displaced proximal humeral fractures and fracture-dislocations between 1953 and 1967
· Ages 22 to 89, mean of 55.6.
· Closed reduction under anesthesia in 162
· Open reduction in 75
· Prosthetic replacement in 63
· Head removal in 5
Until this time, proximal humerus fractures were described based on mechanism of injury and level of the fracture. Neer recognizes Codman’s description of the four major segments that seem to be involved: the head, the lesser tuberosity, the greater tuberosity, and the shaft. His classification is based “not on the level of the fracture nor on the mechanism of injury, but on the presence or absence of displacement of one or more of the four major segments. Since all minimally displaced fractures pose analogous problems in treatment and prognosis, it seems logical that they be grouped together, regardless of the number of fracture lines.”
I: Minimum displacement
II: Articular segment displaced (anatomic neck)
III: Shaft displacement
IV: Greater tuberosity displacement
V: Lesser tuberosity displacement
VI: Fracture dislocation
Displacement: greater than 1 cm or 45o angulation.
Described as minimally displaced, 2, 3, 4-part, and articular surface fractures.
AVN is not originally a big issue in Neer’s description.
The Neer Classification – Reliable and Reproducible?
Þ Siebenrock K.A., Gerber C., The reproducibility of classification of fractures of the proximal end of the humerus, Journal of Bone and Joint Surgery, 75A: 1751-1755, Dec 1993.
· 95 radiographs classified by the Neer and the AO classification
· 5 orthopaedic surgeons with special interest in shoulder
· Neer: inter-observer reliability – Kappa .40
· AO: inter-observer reliability – Kappa .53
“We concluded that neither the Neer nor the AO classification of fractures of the proximal end of the humerus is sufficiently reproducible to allow meaningful comparison of similarly classified fractures in different studies.”
Þ Sidor M.L., Zuckerman J.D., Lyon T., Koval K., Cuomo F., Shoenberg N., The Neer classification system for proximal humeral fractures. An assessment of interobserver reliability and intraobserver reproducibility. Journal of Bone and Joint Surgery, 75A: 1745-1450, Dec 1993
· 50 radiographs
· orthopaedic shoulder specialist, orthopaedic traumatologist, skeletal radiologist, R2 and R5
· inter-observer reliability – Kappa .48 for first viewing, .52 for second viewing
· intra-observer reliability – Kappa .66 (ranging from .83 (shoulder specialist) to .50 (radiologist))
Is there currently a reproducible, reliable way to describe proximal humerus fractures?
The recognized but unaddressed issue of bone quality…..
What internal fixation