Definition: Fractures occurring at or proximal to the surgical neck of the humerus


  • Cause of over 150,000 annual Emergency Department (ED) visits in the US
  • Most common fracture affecting the shoulder girdle in adults
    • 80% of all humeral fractures (Rockwood 1996)
    • 5% of all fractures presenting to the ED (Vachtsevanos 2014)
  • Commonly affects elderly women
    • Women account for 70% of cases
    • Second most common (after distal radius/ulna fractures) upper extremity fracture in patients age 65 yrs and older


  • Half of all proximal humerus fractures occur at home with a majority occurring after a fall on level ground
    • Older patients (60 yrs and older)
      • Low energy trauma, usually fall from a standing height
      • Fall onto an outstretched hand with extended elbow
    • Younger patients
      • High energy trauma, including fall from a height, motor vehicle accidents, sports or assaults
      • Direct blows to the arm

Physical Exam

  • Diffuse soft tissue swelling and ecchymosis
    • Swelling may be absent in obese patients
    • Loss of the normal convex contour of the shoulder
    • Presence of an anterior or posterior bulge may suggest a dislocation
  • Open fractures – rare, however usually present on the medial aspect of the upper arm adjacent to the axilla
  • Neurovascular Exam – the axillary nerve and artery are at highest risk of injury. Rarely the brachial artery and brachial plexus may be injured.
    • Sensation – assess for hypoesthesia over the lateral aspect of the proximal arm
    • Motor function – palpate the deltoid as the patient attempts to actively extend, abduct and flex the shoulder
    • Axillary Artery
      • Vascular injury more common in elderly patients
      • Assess radial pulse and capillary refill of affected arm with comparison to contralateral side
      • Assess for the presence of an expanding hematoma

Neer Classification:

  • Depends on number of fragments, degree of displacement and presence of dislocation
  • Based on four anatomical fracture segments:
    • Greater Tuberosity
    • Lesser Tuberosity
    • Head of Humerus (articular surface)
    • Humeral Shaft
  • Displaced Fracture: fracture with greater than 1 cm of displacement and less than 45 degrees of angulation from anatomic position (Carofino 2013)
    • One Part: Nondisplaced fracture, irrespective of number of fragments
    • Two Part: One segment is displaced, either the greater tuberosity, the lesser tuberosity or humeral head
    • Three Part: Displacement of one tuberosity and the surgical neck
    • Four Part: All four segments (both tuberosities, the articular surface, and the humeral shaft) displaced
      • Valgus Impacted Four-Part: head of humerus is rotated into valgus posture and driven down between the tuberosities
    • Criticism of Neer Classification:
      • Low inter- and intra- observer reliability
      • Definition of displacement arbitrarily defined by Neer at time of publication without evidentiary support
      • Unable to differentiate between the types of minimally displaced fractures
Proximal Humerus AO Classfication -

Proximal Humerus AO Classfication –

AO/OTA Classification

  • Based on fracture location and the presence of impaction, angulation, translation, comminution, or dislocation
  • Each fracture type is further subgrouped according to displacement, valgus or varus angulation of the humeral head, comminution and the presence and direction of glenohumeral joint dislocation
  • Type A: extra-articular, unifocal, associated with a single fracture line, lowest avascular necrosis (AVN) risk
    • A1: greater tuberosity fracture
    • A2: surgical neck fracture with metaphyseal impaction
    • A3: surgical neck fracture without metaphyseal impaction
  • Type B: extra-articular, bifocal, associate with two fracture lines, higher AVN risk
    • B1: surgical neck fracture with metaphyseal impaction and a displaced fracture of either the greater or lesser tuberosity
    • B2: nonimpacted surgical neck fracture with a displaced fracture of either the greater or lesser tuberosity
    • B3: surgical neck fracture with a displaced fracture of either the greater or the lesser tuberosity and glenohumeral dislocation
  • Type C: articular fracture, involving either the humeral head or anatomic neck, most severe, highest AVN risk
    • C1: Anatomic neck fracture with slight displacement
    • C2: Anatomic neck fracture with marked displacement
    • C3: Anatomic neck fracture with glenohumeral dislocation


  • Radiographs: AP, Scapula Y, and Axillary view
    • Additional Views:
      • Grashey view (true AP): AP Oblique view allowing for better evaluation of glenohumeral joint and position of humeral head in relation to the joint space
      • Modified Velpeau view: modification of axillary view for patients unable to abduct arm
  • CT Scan: generally not obtained in ED unless suggested by Orthopedics
    • Indications: evaluate extent of comminution, displacement of lesser and greater tuberosity fragments, assessment of humeral head and glenoid relationship

Avascular Necrosis of Humeral Head

  • Ascending branch of the anterior circumflex humeral artery (ACHA) is the primary source of vascular supply
    • Disrupted by fractures through the anatomic neck
  • Posterior circumflex humeral artery (PCHA) provides perfusion through the posteromedial proximal humeral metaphysis and becomes predominant source of vascular supply when ACHA is disrupted
    • Certain fracture patterns are high risk for disruption of PCHA and therefore ischemia of humeral head:
      • Distal metaphyseal extension of the head fragment < 8mm
      • Disruption of medial hinge between the humeral head and shaft


  • Nonoperative Management:
    • Nondisplaced or minimally displaced fractures
      • 85% of proximal humerus fractures (Quillen 2004)
      • Immobilization with a cuff, sling or shoulder immobilizer
        • Close Orthopedic follow-up to confirm acceptable alignment and fracture stability
      • Early Range of Motion exercise: decreases the risk of developing adhesive capsulitis
        • Active range of motion exercises of wrist and hand within 2 weeks of injury
    • Displaced fractures: Orthopedic consultation for evaluation and operative planning.
      • Non-operative management typically considered in elderly patients with minimal functional demands, patients not fit for surgery
      • Complications: malunion, subacromial impingement, osteoarthritis and rotator cuff deficiency
  • Operative Management
    • The use of operative treatment in displaced fractures is increasing, due to concern for improved functional outcome. However, in the literature, no clear benefit has been found.
      • PROFHER Trial: in patients with displaced fractures involving the surgical neck, no significant difference in clinical outcome in patients treated operatively versus non-operatively (Handoll 2015)
      • Cochrane Review: no significant difference in patient functional outcome at 1 year. Those who underwent operative treatment required additional surgical intervention. (Handoll 2012)
    • Selection of surgical approach depends on: classification, involvement of tuberosity or surgical neck, patient age and expected level of activity.
      • Closed Reduction and Percutaneous Pinning (CRPP)
        • Indications: 2- and 3- part surgical neck fractures
        • Complications: fixation failure, intra-articular pin migration, axially nerve injury
        • Contraindications: head-split fractures, fracture-dislocations, complex fractures in the elderly
      • Open Reduction and Internal Fixation (ORIF)
        • Indications: Neer 2-, 3- and 4- part fractures with rotation greater than 45 degrees or displacement greater than 5mm (or 1 cm, depending on source), Head splitting fractures in younger patients (Part of humeral head dislocates and the unfractured part remains attached to the shaft)
        • Preferred in younger patients due to good bone quality and joint preservation
        • Complications: impingement, screw penetration, screw cutout and fixation loss.
      • Hemiarthoplasty
        • Previously the gold standard for treatment of complex fractures
          • Satisfactory pain relief but inconsistent functional outcome (Kontakis 2008)
        • Indications:
          • Displaced 4- part fractures and fracture-dislocations at high risk for osteonecrosis
          • Fractures with inadequate reduction or fixation, fractures with vascular compromise
        • Complications: infection, dislocation, intraoperative or periprosthetic fractures and rotator cuff dysfunction
      • Reverse Total Shoulder Arthroplasty
        • Indications: Alternative treatment for displaced 4-part fractures and nonreconstructible tuberosities
        • Procedure of choice in patients over 70 with complex fractures (Boyle 2013)
  •  Prognosis: Overall prognosis is good. Poor prognosis is associated with: older age, presence of displacement, 3- and 4- Part Neer fractures, Type C AO Fractures

Take Home Points

  • Proximal humerus fractures commonly occur in patients over age 65 (especially women) secondary to a fall on an outstretched had
  • The presence of displacement, defined as fractures with greater than 1 cm of displacement and less than 45 degrees of angulation, often determines operative versus non-operative management plan
  • The most common injury pattern (Neer One-part fracture) is treated with sling, early range of motion exercises and Orthopedic follow-up


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Boyle M., et al. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. JShoulder Elbow Surg 2013 Jan;22(1):32-7. PMID: 22652065

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Handoll H., et al. The ProFHER trial – a pragmatic multicenter randomized controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of Humerus in adults. Health Technol Assess. 2015 Mar;19(24):1-280. PMID: 25822598

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Quillen D et al. Acute Shoulder Injuries. Am Fam Physician. 2004; 70(10): 1947-1954. PMID: 15571061.

Rockwood CA. Jr, Green DP, Bucholz RW, Heckman JD. Fractures in Adults. 4th ed. Philadelphia, Pa: Lippincott-Raven; 1996.

Vachtsevanos L., et al. Management of proximal humerus fractures in adults. World J Orthop. 2014 Nov 18;5(5):685-93. PMID: 25405098