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Proximal humeral fractures: Current concepts in classification, treatment and

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I. R. Murray,
A. K. Amin,
T. O. White,
C. M. Robinson
From the Edinburgh
Shoulder Clinic,
Edinburgh, United
Kingdom
„ I. R. Murray, BMedSci,
MRCSEd, Clinical Lecturer
The University of Edinburgh
„ A. K. Amin, FRCSEd(Orth),
Specialist Registrar
„ T. O. White, MD,
FRCSEd(Orth), Consultant
Orthopaedic Surgeon
„ C. M. Robinson, BMedSci,
FRCSEd(Orth), Consultant
Orthopaedic Surgeon
The Edinburgh Shoulder Clinic
The New Royal Infirmary of
Edinburgh, Old Dalkeith Road,
Edinburgh EH16 4SU, UK.
Correspondence should be sent
to Mr C. M. Robinson; e-mail:
c.mike.robinson@ed.ac.uk
©2011 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.93B1.
25702 $2.00
J Bone Joint Surg [Br]
2011;93-B:1-11.
VOL. 93-B, No. 1, JANUARY 2011
„ REVIEW ARTICLE
Proximal humeral fractures
CURRENT CONCEPTS IN CLASSIFICATION, TREATMENT AND
OUTCOMES
Most proximal humeral fractures are stable injuries of the ageing population, and can be
successfully treated non-operatively. The management of the smaller number of more
complex displaced fractures is more controversial and new fixation techniques have greatly
increased the range of fractures that may benefit from surgery.
This article explores current concepts in the classification and clinical aspects of these
injuries, reviewing the indications, innovations and outcomes for the most common
methods of treatment.
Fractures of the proximal humerus account for intimal tears, and resection with end-to-end
5% of injuries to the appendicular skeleton.1,2 anastomosis or grafting for more major lacera-
Most are stable, minimally-displaced osteo- tions,5 or embolisation for false aneurysms.
porotic fractures in the elderly, and are the result Most nerve injuries are direct injuries to the
of low-energy falls.3 Most patients with these brachial plexus or traction injuries to the axil-
injuries will regain a functional shoulder with- lary nerve, and are more likely in the presence
out operation. Surgery should only be consid- of a fracture-dislocation.6-8 Most injuries are
ered in approximately 20% of patients,4 either closed and are best treated non-operatively,
because they require better shoulder function or though early exploration may be beneficial in
because their fracture is more complex. An ever- younger individuals.9
expanding range of reconstructive options has
become available to treat these injuries, each Decision-making in treatment
with its advantages and disadvantages. There is a tendency to focus on the fracture con-
figuration when deciding upon the method of
Clinical assessment treatment. It is important to appreciate that in
Careful clinical assessment is required in each addition to the ‘personality’ of the fracture,
case to identify the rare, but serious, problems decision-making is also influenced by underlying
related to skin or neurovascular damage, which patient- and surgeon-related factors (Fig. 1).
warrant urgent investigation and treatment. Underlying patient factors. Most patients with
Open fractures of the proximal humerus are these injuries are elderly and have limited
rare, although severely displaced fractures may expectations from treatment. Operative treat-
produce skin tenting, causing pressure necrosis. ment is only rarely indicated in the very elderly
These fractures require treatment according to (aged > 85 years), those with cognitive impair-
standard open fracture guidelines. ment, a non-functional limb, or with severe
Vascular injuries are rare, but more likely in medical comorbidity. Poor outcomes and
the presence of a fracture-dislocation. Signs of increased risk of complications are associated
distal ischaemia may be absent, due to the rich with severe osteoporosis, smoking, drug and
collateral circulation, but a large expanding alcohol abuse, diabetes mellitus, rheumatoid
haematoma, pulsatile external bleeding, unex- arthritis, immunocompromise including ste-
plained hypotension, delayed anaemia and roid medication and concurrent neoplasm.10-12
associated nerve trunk or plexus injury should Underlying surgeon factors. The treating sur-
increase the level of suspicion. Digital subtrac- geon can influence outcome through both
tion angiography is the benchmark of assess- choice of treatment and technical exper-
ment, but Doppler assessment of the pulse and tise.11,13 There is substantial geographical vari-
single-injection angiography may be more ation in surgical expertise and operative
appropriate in the emergency setting. Vascular treatment.14 There is a limited but growing cul-
injuries can be treated with endarterectomy for ture of specialist tertiary referral, which should
1
2 I. R. MURRAY, A. K. AMIN, T. O. WHITE, C. M. ROBINSON

Non-operative
treatment Relative
(majority) indications
for non-
operative Relative
Patient treatment indications
factors for operative
Regardless of age Absolute
• Frail, elderly treatment
indications
• Co-morbidities for surgery
• Prior shoulder
problems (rare)
Young, active

Fracture Minimally
Benign fracture More severe fracture
‘personality’ displaced,
configuration configuration
stable fractures
Experience with
Inexperience SS
• Three- or four-part fracture-dislocations
with SS • True ‘head-splitting’ fractures
Regardless of
surgical expertise • Pathological fractures
Surgical • Open fractures
factors • Neurovascular injury

Non-operative Operative

Fig. 1

Flowchart depicting the way in which patient-, fracture- and surgery-related factors interact to influence treatment (SS, shoulder surgery).

be considered for more complex injuries, or if the treating
surgeon does not treat these fractures regularly.
Injury factors. There is no entirely satisfactory fracture clas-
sification to serve as a guide to modern treatment and pre-
dict outcome. The Neer classification4 (Fig. 2), although the
most widely used, has poor inter- and intra-observer reli-
ability.15 This anatomic system is based upon the degree of
involvement and displacement of the four major fracture
segments on plain radiographs, or at surgery. It does not
include some of the more recently described fracture types,
which may have a more favourable prognosis. These
include impacted-valgus fractures,10,12 varus fractures,16,17
the various subtypes of anterior and posterior fracture-
dislocations18,19 and those with partial articular involve-
ment due to a displaced tuberosity fragment bearing a piece
of the articular surface. Although refinements20,21 and
more detailed systems22,23 have been produced, none has
gained the level of acceptance of the Neer classification.4,24
Most fractures of the proximal humerus have a stable
configuration and heal functionally with non-operative
treatment.3,4 This treatment should be used for Neer one-
part fractures involving the humeral neck,25-28 one-part
greater or lesser tuberosity fractures29 and impacted two-
part fractures of the surgical neck with minimal angulation
of the humeral head.11 Neer two-, three- or four-part
fractures with less severe varus or valgus angulation of the
humeral head to the shaft (< 30° of displacement of the nor-
mal 130° head-shaft inclination), but with residual cortical
contact to the shaft, may also regain a good functional out-
come after non-operative treatment.12,17
The remaining 20% of fractures fall into three groups:
those in whom surgery is essential, those who may benefit
from a head-conserving reconstruction and those who
require a replacement of the humeral head. Surgery is man-
datory in less than 1% of fractures, and the indications for
surgery in the other two categories are relative rather than
absolute. Modern surgery for fractures of the proximal
humerus requires considerable expertise and the full arma-
mentarium of reconstructive implants, each with its advan-
tages, disadvantages and complications (Table I).
Fractures for which surgery is essential. Operative treatment
is mandatory for the rare situations in which there is either
an open fracture, an associated vascular injury, a true head-
splitting fracture, a pathological fracture, or a severe ipsi-
lateral injury to the shoulder girdle, most commonly the
‘floating shoulder’ produced by a scapular fracture. In these
circumstances, the feasibility of head-retaining reconstruc-
tion versus primary replacement arthroplasty dictates the
choice of procedure.
Fractures which may benefit from reduction and fixation. Reduc-
tion and fixation is usually performed with the aim of
improving the functional outcome as compared with non-
operative treatment. Physiologically younger and more
active patients usually have greater functional expectations

THE JOURNAL OF BONE AND JOINT SURGERY

 PROXIMAL HUMERAL FRACTURES 3

One-part Two-part Three-part Four-part

fractures fractures fractures fractures

Anatomical
neck

Surgical
neck

}
Greater
tuberosity

Lesser
tuberosity

Anterior

Fracture
dislocation

Posterior

Head splitting Impression

fracture fracture

Fig. 2

Neer’s classification of proximal humeral fractures (modified from Neer CS 2nd. Displaced proximal humeral fractures.
I: classification and evaluation. J Bone Joint Surg [Am] 1970;52-A:1077-89).

from treatment and are therefore most often considered.
Surgery also aims to reduce the risk of complications
associated with non-operative treatment, including symp-
tomatic nonunion or malunion. Whether reduction and fix-
ation reduces the later risk of osteonecrosis of the humeral
head is unclear, although prosthetic replacement to treat
this complication is technically easier, and associated with a
better outcome, if the shoulder has initially been recon-
structed anatomically and the rotator cuff is functional.
In patients who are medically fit for surgery, it is the

VOL. 93-B, No. 1, JANUARY 2011

4 I. R. MURRAY, A. K. AMIN, T. O. WHITE, C. M. ROBINSON

Table I. Advantages, disadvantages and complications of techniques used to treat displaced proximal humeral fractures

Technique Advantages Disadvantages Complications

Non-operative treatment
Functionally as good as operative
treatment for many fractures, low risk of
infection and other operative
complications
Malunion inevitable:
Cuff dysfunction/stiffness
more likely
Later salvage surgery is more
difficult
Risk of nonunion increased
Nonunion, malunion,
osteonecrosis, rotator cuff tear,
subacromial impingement,
neurologic injury, osteoarthritis

Minimally invasive techniques
Reduced injury to soft-tissue envelope,
lower infection risk
Steep learning curve, risk of
axillary nerve/vascular injury,
less stable fixation
Nonunion, malunion, superficial
infection, deep infection,
avascular necrosis, subacromial
impingement, stiffness,
neurologic injury, movement of
fixation, osteoarthritis

Open reduction and plate fixation Anatomical fracture reduction is
possible:
Improved functional outcome
Later revision surgery easier
Most stable method of fixation in
multi-part fractures:
Rigid implants
Adjuvant bone grafting techniques
possible
Open surgical approach
required:
Increased risk of infection
Increased risk of
osteonecrosis
Top of plate may cause
mechanical impingement
Nonunion, malunion, superficial
infection, deep infection,
osteonecrosis, subacromial
impingement, tendinitis of
biceps, stiffness, neurologic
injury, fixation failure,
osteoarthritis

Intramedullary nailing
More stable fixation technique in osteo-
porotic bone, minimal dissection
required for insertion
Rotator cuff dysfunction after
antegrade insertion, poor results
in multipart fractures, high rate
of late metalwork removal
Nonunion, malunion, superficial
and deep infection, avascular
necrosis, fracture, stiffness,
neurologic injury, movement of
fixation, osteoarthritis

Hemiarthroplasty Risk of nonunion, osteonecrosis, and
symptomatic malunion removed
Low rate of re-operation
Poor functional outcome
Later arthroplasty complication
difficult to treat in the elderly
Superficial and deep infection,
rotator cuff tear or insufficiency,
subacromial impingement,
dislocation, heterotopic
ossification, reflex sympathetic
dystrophy, periprosthetic
fracture, loosening, greater
tuberosity pull-off, non-union

authors’ view that reduction and fixation should be con-
sidered for:
1. Two-part greater or lesser tuberosity fractures, or
three- and/or four-part fractures in which the greater tuber-
osity is displaced by more than 1 cm.
2. Fractures with a displaced fragment of the articular
surface of the humeral head attached to a displaced tuber-
osity fragment.
3. Unstable two-part surgical neck fractures in which
there is disengagement of the shaft from the humeral head,
due to displacement or extensive metaphyseal communition.
4. Two-, three- or four-part fractures in which there is
varus or valgus deformity of the humeral head to the
shaft by > 30° from the normal head shaft inclination
angle of 130°.
5. Three- or four-part anterior fracture-dislocations
caused by propagation of a posterior humeral head fracture
(‘Hill-Sachs lesion’30) and with retained soft-tissue
attachments to the humeral head at surgery (‘Type 1’ ante-
rior fracture-dislocation).
6. Three- or four-part posterior fracture-dislocations
caused by propagation of a fracture of the anterior humeral
head (‘reverse Hill-Sachs’) and with retained soft-tissue
attachments to the humeral head at surgery.
This form of surgery only provides patients with an oppor-
tunity to improve shoulder function over non-operative
treatment. Patients should be counselled that their post-oper-
ative rehabilitation may be long and arduous, and that their
compliance with rehabilitation will influence their outcome.
Fractures which may benefit most from primary replace-
ment of the humeral head. Despite the numerical increase
in fractures amenable to head-conserving treatment, there
is a minority of fractures in which reduction and fixation is
impractical or ill-advised. Replacement of the humeral
head is therefore usually reserved for fractures in which the
head is cleaved into two or more fragments and is unrecon-
structable (the true Neer ‘head-splitting’ fracture), those in
which the humeral head is found to be devoid of soft-tissue
attachments at surgery and therefore at high risk of
osteonecrosis,18,22,31 and multi-part fractures with delayed
presentation (> four weeks post-injury). This treatment
may also be selected for those with low-functional expecta-
tions, so as to avoid the requirement for re-operation which
might occur following unsuccessful reduction and fixation,
complicated by failure of fixation, nonunion or osteo-
necrosis. Delayed replacement of the humeral head has also
been used to treat complications following non-operative
and operative fracture management.32,33

THE JOURNAL OF BONE AND JOINT SURGERY

 PROXIMAL HUMERAL FRACTURES
Fig. 3a Fig. 3b
Radiographs showing a) a three-part fracture of the proximal humerus
with medial and inferior displacement of the head. The head fragment
was raised with an elevator, automatically reducing the greater tuberos-
ity fragment and b) Kirschner-wires and cannulated screws were used to
complete the reconstruction (reprinted with permission from Resch H,
Povacz P, Frohlich R, Wambacher M. Percutaneous fixation of three- and
four-part fractures of the proximal humerus. J Bone Joint Surg [Br]
1997;79-B:295-300).
Planning treatment
Where surgical intervention is appropriate, most patients
can be treated on a semi-elective basis within the first week
after injury. Computed tomography with three-dimensional
reconstruction (3D-CT) makes it much easier to under-
stand the fracture pattern, and plan the operative pro-
cedures. In particular 3D-CT enables an accurate
assessment of the degree of subluxation and angulation of
the humeral head, the extent of separation of the shaft from
the head, the degree of separation of any marginal frag-
ments of tuberosity and the presence of any marginal frag-
ments of the articular surface attached to the tuberosities.
Treatment methods
Non-operative treatment
In most cases non-operative management is used because the
configuration of the fracture is stable and it is likely to heal
with a good outcome.
Technique and results. Pain control is often challenging,
particularly in the first week after injury, as adequate splin-
tage of the fracture is not possible. Many patients find
sleeping in a chair most comfortable as the pain is usually
aggravated by lying flat. Oral analgesia, hot or cold com-
presses and a sling should be used.34 Hospital admission
may be required because of an inability to cope at home.
Hanging casts offer no advantage and may distract the frac-
ture, predisposing to nonunion.35,36 Prolonged immobilisa-
tion is of no value,37 and functional recovery is better when
physiotherapy commences early.35,37,38
The majority of elderly patients with stable and mini-
mally displaced fractures will have a satisfactory outcome
after non-operative treatment, if the three major complica-
tions of nonunion, symptomatic malunion and osteo-
VOL. 93-B, No. 1, JANUARY 2011
5
necrosis are avoided.27,39 Conservative treatment of
displaced and multi-part fractures is more controversial,
but may be more appropriate in the very elderly,
cognitively-impaired or debilitated and alcoholic patients.
Although some authors have documented good overall out-
comes,28,39,40 it is generally accepted that the risk of non-
union, symptomatic malunion and osteonecrosis is higher
in this group. Secondary salvage surgery is also likely to be
more complex, and the anticipated outcome is likely to be
worse than after primary operative treatment.41
Humeral head conserving techniques
Closed/minimally invasive reduction and percutaneous fixa-
tion. Closed and minimally invasive techniques have poten-
tial advantages over more invasive techniques in improving
cosmesis and reducing blood loss, post-operative pain and
the risk of infection. Unimpacted two-, three- and four-part
fractures in which the shaft has translated or separated
from the head fragment and impacted valgus fractures are
most amenable to these techniques, whereas fracture-
dislocations are not suitable.
Technique and results. Reduction is achieved using closed
manipulation and instruments or pins to ‘joystick’ frag-
ments into position guided by fluoroscopy. Fixation is
achieved by passing end-threaded Kirschner (K-) wires or
cannulated screws across the major fracture fragments
(Fig. 3).42 Where bone quality is poor a ‘humerus block’
can be inserted percutaneously to link the wires and
improve stability.43
Satisfactory results have been reported using closed or
minimally invasive reduction and percutaneous pin or
screw fixation.43,44 However, these procedures have a pro-
tracted learning curve and carry substantial rates of compli-
cations including failure of fixation, malunion, nonunion
and osteonecrosis.
Open reduction and internal fixation (ORIF). Recent innova-
tions in surgical approach, techniques of reduction,
implants and the use of bone graft or substitutes have
greatly increased the range of fractures of the proximal
humerus which are amenable to fixation.
Surgical approach. The extensile anterior deltopectoral
approach45 remains the benchmark procedure. However,
the limited access which this provides posteriorly may
compromise the surgeon’s ability to reconstruct multi-part
fractures, where the greater tuberosity is markedly dis-
placed, and in posterior fracture-dislocations. This has led
to the extended deltoid-splitting approach, using either a
straight lateral46 or a shoulder strap47 incision. This pro-
vides better access for reconstruction, provided the ante-
rior terminal branch of the axillary nerve is identified and
protected throughout the procedure. The ‘surgical win-
dow’ above the nerve allows access for reduction and
stabilisation of the fracture, whereas the window below
allows access to the humeral shaft and creates a safe area
for insertion of screws into the lower part of the plate.
Although concerns regarding the risk of intra-operative
6 I. R. MURRAY, A. K. AMIN, T. O. WHITE, C. M. ROBINSON
Fig. 4
Radiograph showing the humeral locking
plate; a large metaphyseal void was left fol-
lowing disimpaction and reduction, which
was filled with femoral head allograft (arrows)
prior to application of the locking plate.
injury to the axillary nerve and late deltoid pull-off have
been expressed, these complications have not been
encountered in practice,18,47 with cadaver studies also sug-
gesting that the nerve is protected.48,49
Fracture reduction. In order to achieve this, a clear under-
standing of the anatomy of the more complex fracture
patterns is essential. This is aided greatly by the use of pre-
operative 3D-CT. If the humeral head is dislocated it must be
reduced and stabilised along with any fracture involving the
articular surface. Varus and valgus deformities of the head
can then be corrected using K-wires, elevators or osteotomes
inserted eccentrically into the humeral head and used as joy-
sticks. Particular attention should be paid to complete
correction of varus deformity, to prevent instability and re-
displacement.50,51 Anatomical reduction can then be
achieved by correcting the translation of the shaft under the
head, and then correcting any residual rotational deformity.
Adjuvant fracture stabilisation. In three- and four-part
impacted valgus fractures, after reduction there is usually a
substantial defect in the metaphysis which should be filled
with autograft bone, allograft or bone substitutes, in order
to assist healing and reduce the risk of re-displacement. The
early results of these techniques have been encourag-
ing.16,52,53 Structural autograft or allograft may also be
used as a ‘strut’ to improve the stability of fractures in
which the humeral head is displaced into varus, or if there
is instability due to loss of the posteromedial calcar,16,54
and also as a space-filler in anterior and posterior fracture-
dislocations, where there is a Hill-Sachs defect.55
Fixation of fracture. Cloverleaf, buttress and simple semi-
tubular plate fixation have been extensively used in the
past, but have been superseded by site-specific locking
plates, which provide more secure fixation in osteoporotic
bone (Fig. 4).56-59 Both fixed (mono-axial) and poly-axial
plates are now available.60,61 It is important for these to be
positioned below the apex of the greater tuberosity to pre-
vent later impingement. None of the screws placed in the
humeral head should penetrate the articular surface. In
fractures in which the humeral head is displaced into varus,
it is essential to insert locking screws in a low position in the
head along the area of the calcar. These screws are under
compression rather than tension and act to buttress the area
of bony instability in the deficient postero-inferior cal-
car.16,54,62 The function of the plate is only to connect the
head to the shaft, and independent fixation of any separate
fragments of tuberosity, using cancellous screws or osteo-
suturing techniques, is essential to prevent early tuberosity
‘pull off’.
Results of treatment. Objective comparison of the latest
results of the newer techniques with other techniques is
impractical due to a lack of clinical trials in this area.63 The
functional results for both conventional and locking plates
are satisfactory with a relatively low rate of the major com-
plications of osteonecrosis, nonunion and malunion.64-67
Recent series reporting higher rates of fixation failure and
screw cut-out have highlighted the importance of achieving
a stable reduction in varus displaced fractures.68 The
increased use of structural bone grafts and calcar-
supporting screws to enhance stability may improve the
results from this form of surgery. However, the learning
curve is steep and complications are common.
Closed or open intramedullary nailing. The concept of stat-
ically locked intramedullary nailing is based on preserving
the periosteal blood supply by achieving reduction of frac-
ture and fixation without substantial damage to the soft-
tissue envelope. Antegrade insertion places the entry point
close to the rotator cuff and may lead to pain and stiffness
of the shoulder and dysfunction of the rotator cuff. For this
reason, many surgeons are reticent to use this technique in
younger patients. The current ideal indication would be an
elderly patient with a displaced two-part surgical neck frac-
ture (Fig. 5),69-71 despite the reduced options for fixation
within the humeral head compared with plate fixation.
Three- and four-part fracture configurations are difficult to
treat using this technique.
Results of treatment. Evaluation of the published results
suggest that this technique can be used satisfactorily for
two-part fractures but it is associated with variable results
in three- and four-part fractures.72-74 Satisfactory func-
tional results have been reported in case series for both
locked and unlocked nails.75-77 However, substantial rates
of rotator cuff dysfunction requiring secondary nail
removal and high rates of fixation failure and malunion,
especially for more unstable two- and multipart fractures,
have resulted in a high rate of revision surgery.72
Replacement of the humeral head
Neer popularised the use of humeral head replacement to
treat acute fractures in the 1970s because of the high
rates of osteonecrosis and nonunion associated with
THE JOURNAL OF BONE AND JOINT SURGERY
 PROXIMAL HUMERAL FRACTURES
Fig. 5
Radiograph showing locked
intramedullary nailing for a com-
minuted surgical neck fracture in
an older patient.
complex three- and four-part fractures.4,78 The improved
results achieved by head-conserving reconstructive tech-
niques recently have reduced the requirement for this
technique.
Technique and results. Hemiarthroplasty is generally pre-
ferred to total shoulder replacement in acute fractures, and
aims to restore the anatomical relationship of the humeral
head to the tuberosities and shaft, by achieving proper com-
ponent height, off-set and version (Fig. 6). Modular
implants are now available that are specifically designed to
treat these fractures. They have jigs for judging insertion,
porous coating, and fenestrations to encourage tuberosity
healing. In view of the poor potential for osseous integra-
tion in these osteoporotic fractures, cemented implants are
generally used. The high rate of tuberosity pull-off and non-
union has generated renewed interest in enhanced suturing
techniques to promote tuberosity healing.79.80
The reported outcomes following primary replacement
of the humeral head for fractures are varied.81-84 Although
satisfactory prosthetic survival rates with a low rate of revi-
sion have been reported, few studies have been able to rep-
licate the good functional results reported by Neer.78,85A
good functional outcome can be anticipated for younger
individuals if the tuberosities heal and the rotator cuff is
functional. The results are poorer in elderly patients, partic-
ularly if they have a neurological deficit, a post-operative
complication requiring re-operation, or an eccentrically
located prosthesis with retracted tuberosities.86,87
VOL. 93-B, No. 1, JANUARY 2011
7
Fig. 6
Radiograph showing conventional hemiarthro-
plasty used for a non-reconstructable fracture. In
this case the tuberosities healed and a satisfactory
result was achieved.
The poor outcomes associated with traditional replace-
ment of the humeral head have led to the extended use of
the reverse shoulder arthroplasty, which had previously
been used to treat rotator cuff arthropathy (Fig. 7). The
joint lateralisation dictates that an intact cuff is not
required and healing of the tuberosities is therefore less
important. The provisional results of this technique in
acute fractures have been encouraging.83,84 However,
larger studies are required to properly assess the outcome.
In addition to the risks associated with conventional
replacement of the humeral head, reverse shoulder arthro-
plasty may also be complicated by the development of
notching of the scapular neck, early loosening and
acromial stress fracture.
Complications of proximal humeral fractures
Complications may occur as an inevitable consequence of
the original injury, or as a result of errors in treatment.
Osteonecrosis, nonunion, and malunion of the tuberosities
causing rotator cuff dysfunction are the most common
complications, and a satisfactory outcome is generally
achieved if they are avoided.
Osteonecrosis. Osteonecrosis may be an inevitable compli-
cation of an injury which damages the blood supply of the
humeral head, and is thus more common in multi-part frac-
tures and fracture-dislocations. It may also be the result of
poor operative technique, with excessive manipulation of
the fracture and stripping of soft tissues.
8 I. R. MURRAY, A. K. AMIN, T. O. WHITE, C. M. ROBINSON
Fig. 7
Radiograph showing how the shoulder joint centre of
rotation is lateralised with reverse shoulder arthroplasty,
relying less on the integrity of the rotator cuff.
The pathophysiology is poorly understood as osteo-
necrosis does not necessarily develop, even if the head is
denuded of blood supply,31,88,89 whereas some cases occur
after relatively innocuous injury. It presents with pain, stiff-
ness and loss of function, typically after a latent period of sat-
isfactory function. Radiologically, the changes vary from
patchy and segmental sclerosis of the head to complete
resorption and collapse and MRI is useful in the evaluation of
the extent and severity. Osteonecrosis may be relatively
asymptomatic and amenable to non-operative treatment.90
Core decompression can help in patients with early radio-
logical changes,91 but most patients have symptomatic
advanced collapse requiring replacement of the humeral
head.92 If there are reciprocal glenoid changes, a conventional
total joint replacement may be more successful,93 and if there
is a severe associated malunion of the tuberosities or cuff tear,
reverse shoulder arthroplasty may be a better option.
Osteonecrosis may also occur in one or both tuberosities
after fracture, regardless of the viability of the humeral
head. The patient usually has debilitating shoulder pain and
loss of function, with signs of rotator cuff weakness and
dysfunction. At present, there is no known treatment for
this complication.
Nonunion. Head-shaft nonunion is a rare but debilitating
complication.94 There are usually associated identifiable
patient-, fracture- or treatment-related risk factors.
Patient factors include osteoporosis, existing inflamma-
tory or degenerative joint disease of the shoulder, poor
physiological state, medical comorbidities and drug treat-
ment, smoking and alcohol abuse.95-98 The fractures most
at risk are those with no residual cortical contact between
the humeral head and shaft, and those with marked com-
minution.94 Complete disruption of the periosteal sleeve
leads to instability and soft-tissue interposition may
inhibit callus formation.99 Hanging casts, which distract
the fracture, overzealous shoulder mobilisation,78 poor
surgical technique with extensive soft-tissue stripping, and
mechanically unstable fracture reduction and fixation
may also cause nonunion. Patients complain of severe
pain, stiffness and loss of function, and there is usually
‘pseudoparalysis’ of the deltoid, rotator cuff, and
periscapular muscles, and a flail arm. Radiologically, there
is resorption and fracture line widening, often with mas-
sive bone resorption.
CT can be used to confirm the nonunion and assess the
feasibility of reconstruction. If ORIF has been performed
as a primary treatment, infection should be excluded by
culture of an ultrasound-guided aspirate.100 All medically
fit patients should be offered reconstruction if the pain is
debilitating. Nonunion may be treated either by ORIF and
bone grafting, or replacement of the humeral head. The
decision as to which form of treatment is most appropri-
ate is individualised, but absence of infection, osteo-
arthrosis and osteonecrosis, adequate humeral bone
stock, and lack of severe malunion of the tuberosities are
mandatory for ORIF.
Malunion. Some degree of malunion is inevitable in dis-
placed fractures of the proximal humerus treated non-
operatively. Head-shaft and head-tuberosity malunion are
both common, and usually well-tolerated in older
patients. However, in younger patients, debilitating symp-
toms may be produced by a head-tuberosity malunion
causing defunctioning, impingement or tears of the rota-
tor cuff tendons. It is important to determine the cause of
the symptoms by careful clinical examination as post-
operative shoulder stiffness, dysfunction of the acromio-
clavicular joint, tendinopathy of the biceps and complex
regional pain syndromes may all contribute to symptoms.
If infection is suspected, joint aspiration and bacterio-
logical examination is warranted. The complex anatomy
of a malunion is best appreciated using 3D CT reconstruc-
tion. Symptoms may be improved by an osteotomy and
correction of the deformity, or more commonly by
replacement of the humeral head.
Post-traumatic shoulder stiffness. Although capsular con-
tracture is the main cause of refractory stiffness, there may be
other factors including malunion of the fracture, complex
regional pain syndrome, thoracic outlet syndrome, impinge-
ment of implants, and rotator cuff dysfunction from
impingement or tears. The initial treatment is non-operative
with rehabilitation in an attempt to regain movement of the
THE JOURNAL OF BONE AND JOINT SURGERY
 PROXIMAL HUMERAL FRACTURES
shoulder using stretching exercises. Although distension
arthrography is useful in stretching the capsule in idiopathic
adhesive capsulitis, it is the authors’ experience that the pro-
cedure is less effective in the post-traumatic shoulder. In
patients with refractory post-traumatic stiffness without
malunion, treatment by manipulation under anaesthesia and
by arthroscopic arthrolysis often helps.
Infection. Infection is relatively rare after fractures of the
proximal humerus, even after ORIF, because of the rich
vascularity and good soft-tissue cover.101,102 However,
most infections associated with these fractures follow
operative intervention. Superficial infections are common
and invariably resolve with antibiotic therapy, whereas
deep infections may occur early, or be delayed. Early sep-
sis with a stable implant should be treated with debride-
ment and prolonged antibiotic therapy. Removal of
the implant may be required to eradicate infection.
Deep infection can occur several years after arthroplasty
and may result from a transient bacteraemia caused by a
range of organisms.103 The removal of metalwork, debri-
dement, the insertion of a spacer, and parenteral antibiotic
therapy should form the basis of treatment. Eventual re-
implantation can be achieved if the organism can be
eradicated.103,104
Complications unique to arthroplasty. Rotator cuff dys-
function from early tuberosity redisplacement or non-
union is the major complication resulting in
unsatisfactory outcome following replacement of the
humeral head. Many patients are also unable to comply
with an aggressive rehabilitation program after surgery,
and this may result in symptomatic peri-articular adhe-
sions and capsulitis. Other complications associated with
arthroplasty include instability, dislocation, prosthetic
loosening, late infection and peri-prosthetic fracture.
Most elderly patients do not survive long enough to
develop these complications; those who do should be
treated according to the same protocols used for primary
arthroplasty for degenerative joint disease.105-107
Conclusion
The majority of fractures of the proximal humerus are
stable injuries in the elderly and can be successfully treated
non-operatively. The challenge for the future is to select
those patients who are going to be at increased risk of
developing complications or a poor functional result after
non-operative treatment. Well-designed trials will be
required to evaluate whether the outcome in these patients
is improved by operation. Current systems serve the sur-
geon poorly in both classifying these fractures and
evaluating their outcome after treatment. More robust and
reliable systems are required to enable more objective com-
parison of different methods of treatment in future studies.
For the present, it is the authors’ belief that the treatment of
most fractures of the proximal humerus should be individ-
ualised, and based upon an assessment of the personality of
that particular fracture.
VOL. 93-B, No. 1, JANUARY 2011
9
Supplementary material
Tables summarising published results with the use of
non-operative treatment, plate fixation, intramedul-
lary nailing and humeral head replacement in fractures of
the proximal humerus are available with the electronic ver-
sion of this article on our website at www.jbjs.org.uk
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
References
1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury
2006;37:691-7.
2. Lind T, Krøner K, Jensen J. The epidemiology of fractures of the proximal humerus.
Arch Orthop Trauma Surg 1989;108:285-7.
3. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral
fractures. Acta Orthop Scand 2001;72:365-71.
4. Neer CS 2nd. Displaced proximal humeral fractures. I: classification and evaluation.
J Bone Joint Surg [Am] 1970;52-A:1077-89.
5. Modi CS, Nnene CO, Godsiff SP, Esler CN. Axillary artery injury secondary to dis-
placed proximal humeral fractures: a report of two cases. J Orthop Surg (Hong Kong)
2008;16:243-6.
6. de Laat EA, Visser CP, Coene LN, Pahlplatz PV, Tavy DL. Nerve lesions in primary
shoulder dislocations and humeral neck fractures: a prospective clinical and EMG
study. J Bone Joint Surg [Br] 1994;76-B:381-3.
7. Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral frac-
tures. J Shoulder Elbow Surg 2001;10:421-7.
8. Visser CP, Tavy DL, Coene LN, Brand R. Electromyographic findings in shoulder
dislocations and fractures of the proximal humerus: comparison with clinical neuro-
logical examination. Clin Neurol Neurosurg 1999;101:86-91.
9. Fox M, Lambert S, Birch R. The terrible triad of the shoulder. J Bone Joint Surg [Br]
2009;91-B(Suppl 1):13.
10. Robinson CM, Page RS. Severely impacted valgus proximal humeral fractures:
results of operative treatment. J Bone Joint Surg [Am] 2003;85-A:1647-55.
11. Court-Brown CM, Garg A, McQueen MM. The translated two-part fracture of the
proximal humerus: epidemiology and outcome in the older patient. J Bone Joint Surg
[Br] 2001;83-B:799-804.
12. Court-Brown CM, Cattermole H, McQueen MM. Impacted valgus fractures (B1.1)
of the proximal humerus: the results of non-operative treatment. J Bone Joint Surg
[Br] 2002;84-B:504-8.
13. Zyto K, Ahrengart L, Sperbert A, Törnkvist H. Treatment of displaced proximal
humeral fractures in elderly patients. J Bone Joint Surg [Br] 1997;79-B:412-17.
14. Sporer SM, Weinstein JN, Koval KJ. The geographic incidence and treatment
variation of common fractures of elderly patients. J Am Acad Orthop Surg
2006;14:246-55.
15. Sidor ML, Zuckerman JD, Lyon T, et al. The Neer classification system for proxi-
mal humeral fractures: an assessment of interobserver reliability and intraobserver
reproducibility. J Bone Joint Surg [Am] 1993;75-A:1745-50.
16. Robinson CM, Wylie JR, Ray AG, et al. Proximal humeral fractures with a severe
varus deformity treated by fixation with a locking plate. J Bone Joint Surg [Br]
2010;92-B:672-8.
17. Court-Brown CM, McQueen MM. The impacted varus (A2.2) proximal humeral
fracture: prediction of outcome and results of nonoperative treatment in 99 patients.
Acta Orthop Scand 2004;75:736-40.
18. Robinson CM, Khan LA, Akhtar MA. Treatment of anterior fracture-dislocations of
the proximal humerus by open reduction and internal fixation. J Bone Joint Surg [Br]
2006;88-B:502-8.
19. Robinson CM, Akhtar A, Mitchell M, Beavis C. Complex posterior fracture-dislo-
cation of the shoulder: epidemiology, injury patterns, and results of operative treat-
ment. J Bone Joint Surg [Am] 2007;89-A:1454-66.
20. Flatow E. Fractures of the proximal humerus. In: Bucholz RW, Heckman JD, eds.
Rockwood and Green’s fractures in adults. Fifth edition. Philadelphia: Lippincott Wil-
liams & Wilkins, 2001:997-1040.
21. Edelson G, Kelly I, Vigder F, Reis ND. A three-dimensional classification for frac-
tures of the proximal humerus. J Bone Joint Surg [Br] 2004;86-B:413-25.
22. Hertel R, Hempfing A, Steihler M, Leunig M. Predictors of humeral head ischemia
after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg
2004;13:427-33.
23. Müller M, Nazarian S, Koch P, Schatzker J. The comprehensive classification of
fractures of long bones. New York: Springer, 1990.
10 I. R. MURRAY, A. K. AMIN, T. O. WHITE, C. M. ROBINSON
24. Neer CS 2nd. Four-segment classification of proximal humeral fractures: purpose
and reliable use. J Shoulder Elbow Surg 2002;11:389-400.
25. Gaebler C, McQueen MM, Court-Brown CM. Minimally displaced proximal
humeral fractures: epidemiology and outcome in 507 cases. Acta Orthop Scand
2003;74:580-5.
26. Keser S, Bólükbasi S, Bayer A, et al. Proximal humeral fractures with minimal dis-
placement treated conservatively. Int Orthop 2004;28:231-4.
27. Tejwani NC, Liporace F, Walsh M, et al. Functional outcome following one-part
proximal humeral fractures: a prospective study. J Shoulder Elbow Surg 2008;17:216-19.
28. Bahrs C, Rolauffs B, Dietz K, Eingartner C, Weise K. Clinical and radiological
evaluation of minimally displaced proximal humeral fractures. Arch Orthop Trauma
Surg 2010;130:673-9.
29. Platzer P, Kutscha-Lissberg F, Lehr S, Vecsei V, Gaebler C. The influence of dis-
placement on shoulder function in patients with minimally displaced fractures of the
greater tuberosity. Injury 2005;36:1185-9.
30. Hill HA, Sachs MI. The grooved defect of the humeral head: a frequently unrecog-
nized complication of dislocations of the shoulder joint. Radiology 1940;35:690-700.
31. Bastian JD, Hertel R. Initial post-fracture humeral head ischemia does not predict
development of necrosis. J Shoulder Elbow Surg 2008;17:2-8.
32. Antuña SA, Sperling JW, Sánchez-Sotelo J, Cofield RH. Shoulder arthroplasty
for proximal humeral nonunions. J Shoulder Elbow Surg 2002;11:114-21.
33. Boileau P, Trojani C, Walch G, et al. Shoulder arthroplasty for the treatment of the
sequelae of fractures of the proximal humerus. J Shoulder Elbow Surg 2001;10:299-308.
34. DePalma AF, Cautilli RA. Fractures of the upper end of the humerus. Clin Orthop
1961;20:73-93.
35. Leyshon RL. Closed treatment of fractures of the proximal humerus. Acta Orthop
Scand 1984;55:48-51.
36. Rasmussen S, Hvass I, Dalsgaard J, Christensen BS, Holstad E. Displaced
proximal humeral fractures: results of conservative treatment. Injury 1992;23:41-3.
37. Koval KJ, Gallagher MA, Marsicano JG, et al. Functional outcome after mini-
mally displaced fractures of the proximal part of the humerus. J Bone Joint Surg [Am]
1997;79-A:203-7.
38. Kristiansen B, Angermann P, Larsen TK. Functional results following fractures of
the proximal humerus: a controlled clinical study comparing two periods of immobili-
zation. Arch Orthop Trauma Surg 1989;108:339-41.
39. Poeze M, Lenssen AF, Van Empel JM, Verbruggen JP. Conservative manage-
ment of proximal humeral fractures: can poor functional outcome be related to stan-
dard transscapular radiographic evaluation? J Shoulder Elbow Surg 2010;19:273-81.
40. Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after non-
operative management of fractures of the proximal humerus. J Shoulder Elbow Surg
2009;18:612-21.
41. Bosch U, Skutek M, Fremerey RW, Tscherne H. Outcome after primary and sec-
ondary hemiarthroplasty in elderly patients with fractures of the proximal humerus. J
Shoulder Elbow Surg 1998;7:479-84.
42. Kamineni S, Ankem H, Sanghavi S. Anatomical considerations for percutaneous
proximal humeral fracture fixation. Injury 2004;35:1133-6.
43. Resch H, Hübner C, Schwaiger R. Minimally invasive reduction and osteosynthe-
sis of articular fractures of the humeral head. Injury 2001;32(Suppl 1):25-32.
44. Dimakopoulos P, Panagopoulos A, Kasimatis G. Transosseous suture fixation of
proximal humeral fractures: surgical technique. J Bone Joint Surg [Am] 2007;89-
A:1700-9.
45. Neer CS 2nd, Watson KC, Stanton FJ. Recent experience in total shoulder replace-
ment. J Bone Joint Surg [Am] 1982;64-A:319-37.
46. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. The anterolateral acromial
approach for fractures of the proximal humerus. J Orthop Trauma 2008;22:132-7.
47. Robinson CM, Khan L, Akhtar A, Whittaker R. The extended deltoid-splitting
approach to the proximal humerus. J Orthop Trauma 2007;21:657-62.
48. Gardner MJ, Griffith MH, Dines JS, et al. The extended anterolateral acromial
approach allows minimally invasive access to the proximal humerus. Clin Orthop
2005;434:123-9.
49. Khan LA, Robinson CM, Will E, Whittaker R. Assessment of axillary nerve func-
tion and functional outcome after fixation of complex proximal humeral fractures
using the extended deltoid-splitting approach. Injury 2009;40:181-5.
50. Lee CW, Shin SJ. Prognostic factors for unstable proximal humeral fractures treated
with locking-plate fixation. J Shoulder Elbow Surg 2009;18:83-8.
51. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open
reduction and locked plate fixation of proximal humeral fractures. J Bone Joint Surg
[Am] 2008;90-A:233-40.
52. Gerber C, Werner CM, Vienne P. Internal fixation of complex fractures of the prox-
imal humerus. J Bone Joint Surg [Br] 2004;86-B:848-55.
53. Russo R, Visconti V, Lombardi LV, Ciccarelli M, Giudice G. The block-bridge sys-
tem: a new concept and surgical technique to reconstruct articular surfaces and
tuberosities in complex proximal humeral fractures. J Shoulder Elbow Surg
2008;17:29-36.
54. Gardner MJ, Boraiah S, Helfet DL, Lorich DG. Indirect medial reduction and strut
support of proximal humerus fractures using an endosteal implant. J Orthop Trauma
2008;22:195-200.
55. Robinson CM, Aderinto J. Posterior shoulder dislocations and fracture-disloca-
tions. J Bone Joint Surg [Am] 2005;87-A:639-50.
56. Björkenheim JM, Pajarinen J, Savolainen V. Internal fixation of proximal
humeral fractures with a locking compression plate: a retrospective evaluation of 72
patients followed for a minimum of 1 year. Acta Orthop Scand 2004;75:741-5.
57. Fankhauser F, Boldin C, Schippinger G, Haunschmid C, Szyszkowitz R. A new lock-
ing plate for unstable fractures of the proximal humerus. Clin Orthop 2005;430:176-81.
58. Koukakis A, Apostolou CD, Taneja T, Korres DS, Amini A. Fixation of proximal
humerus fractures using the PHILOS plate: early experience. Clin Orthop
2006;442:115-20.
59. Moonot P, Ashwood N, Hamlet M. Early results for treatment of three- and four-
part fractures of the proximal humerus using the PHILOS plate system. J Bone Joint
Surg [Br] 2007;89-B:1206-9.
60. Walsh S, Reindle R, Harvey E, et al. Biomechanical comparison of a unique locking
plate versus a standard plate for internal fixation of proximal humerus fractures in a
cadaveric model. Clin Biomech (Bristol, Avon) 2006;21:1027-31.
61. Weinstein DM, Bratton DR, Ciccone WJ 2nd, Elias JJ. Locking plates improve
torsional resistance in the stabilization of three-part proximal humeral fractures. J
Shoulder Elbow Surg 2006;15:239-43.
62. Gardner MJ, Weil Y, Barker JU, et al. The importance of medial support in locked
plating of proximal humerus fractures. J Orthop Trauma 2007;21:185-91.
63. Handoll HH, Gibson JN, Madhok R. Interventions for treating proximal humeral
fractures in adults. Cochrane Database Syst Rev 2003;4:CD000434.
64. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal
humeral fractures with use of the locking proximal humerus plate: results of a prospec-
tive, multicenter, observational study. J Bone Joint Surg [Am] 2009;91-A:1320-8.
65. Brunner F, Sommer C, Bahrs C, et al. Open reduction and internal fixation of prox-
imal humerus fractures using a proximal humeral locked plate: a prospective multi-
center analysis. J Orthop Trauma 2009;23:163-72.
66. Bigorre N, Talha A, Cronier P, et al. A prospective study of a new locking plate for
proximal humeral fracture. Injury 2009;40:192-6.
67. Meier RA, Messmer P, Regazzoni P, Rothfischer W, Gross T. Unexpected high
complication rate following internal fixation of unstable proximal humerus fractures
with an angled blade plate. J Orthop Trauma 2006;20:253-60.
68. Charalambous CP, Siddique I, Valluripalli K, et al. Proximal humeral internal
locking system (PHILOS) for the treatment of proximal humeral fractures. Arch Orthop
Trauma Surg 2007;127:205-10.
69. Bernard J, Charalambides C, Aderinto J, Mok D. Early failure of intramedullary
nailing for proximal humeral fractures. Injury 2000;31:789-92.
70. Lin J, Hou SM. Locked-nail treatment of humeral surgical neck nonunion. J Trauma
2003;54:530-5.
71. Rajasekhar C, Ray PS, Bhamra MS. Fixation of proximal humeral fractures with
the Polarus nail. J Shoulder Elbow Surg 2001;10:7-10.
72. Adedapo AO, Ikpeme JO. The results of internal fixation of three- and four-part
proximal humeral fractures with the Polarus nail. Injury 2001;32:115-21.
73. Agel J, Jones CB, Sanzone AG, Camuso M, Henley MB. Treatment of proximal
humeral fractures with Polarus nail fixation. J Shoulder Elbow Surg 2004;13:191-5.
74. Lin J, Hou SM, Hang YS. Locked nailing for displaced surgical neck fractures of the
humerus. J Trauma 1998;45:1051-7.
75. Park JY, An JW, Oh JH. Open intramedullary nailing with tension band and locking
sutures for proximal humeral fracture: hot air balloon technique. J Shoulder Elbow
Surg 2006;15:594-601.
76. Iacobellis C, Serafini D, Aldegheri R. PHN for treatment of proximal humerus
fractures: evaluation of 80 cases. Chir Organi Mov 2009;93:47-56.
77. Russo R, Cautiero F, Lombardi LV, Visconti V. Telegraph antegrade nailing in the
treatment of humeral fractures with rotator interval split technique. Chir Organi Mov
2009;93(Suppl 1):7-14.
78. Neer CS 2nd. Displaced proximal humeral fractures. II: treatment of three-part and
four-part displacement. J Bone Joint Surg [Am] 1970;52-A:1090-103.
79. Abu-Rajab RB, Stansfield BW, Nunn T, Nicol AC, Kelly IG. Re-attachment of the
tuberosities of the humerus following hemiarthroplasty for four-part fracture. J Bone
Joint Surg [Br] 2006;88-B:1539-44.
80. Krause FG, Huebschle L, Hertel R. Reattachment of the tuberosities with cable
wires and bone graft in hemiarthroplasties done for proximal humeral fractures with
cable wire and bone graft: 58 patients with a 22-month minimum follow-up. J Orthop
Trauma 2007;21:682-6.
THE JOURNAL OF BONE AND JOINT SURGERY
 PROXIMAL HUMERAL FRACTURES
81. Antuña SA, Sperling JW, Cofield RH. Shoulder hemiarthroplasty for acute frac-
tures of the proximal humerus: a minimum five-year follow-up. J Shoulder Elbow Surg
2008;17:202-9.
82. Yang SH, Wang J, Xu WH, et al. Shoulder hemiarthroplasty for the treatment of
complex proximal humeral fractures. Chin J Traumatol 2009;12:14-17.
83. Grassi FA, Murena L, Valli F, Albeiro R. Six-year experience with the Delta III
reverse shoulder prosthesis. J Orthop Surg (Hong Kong) 2009;17:151-6.
84. Klein M, Juschka M, Hinkenjann B, Scherger B, Ostermann PA. Treatment of
comminuted fractures of the proximal humerus in elderly patients with the Delta III
reverse shoulder prosthesis. J Orthop Trauma 2008;22:698-704.
85. Hawkins RJ, Switlyk P. Acute prosthetic replacement for severe fractures of the
proximal humerus. Clin Orthop 1993;289;156-60.
86. Boileau P, Krishnan SG, Tinsi L, et al. Tuberosity malposition and migration: rea-
sons for poor outcomes after hemiarthroplasty for displaced fractures of the proximal
humerus. J Shoulder Elbow Surg 2002;11:401-12.
87. Kralinger F, Schwaiger R, Wambacher M, et al. Outcome after primary hemiar-
throplasty for fracture of the head of the humerus: a retrospective multicentre study
of 167 patients. J Bone Joint Surg [Br] 2004;86-B:217-19.
88. Jaberg H, Warner JJ, Jakob RP. Percutaneous stabilization of unstable fractures
of the humerus. J Bone Joint Surg [Am] 1992;74-A:508-15.
89. Gerber C, Lambert SM, Hoogewoud HM. Absence of avascular necrosis of the
humeral head after post-traumatic rupture of the anterior and posterior humeral cir-
cumflex arteries: a case report. J Bone Joint Surg [Am] 1996;78-A:1256-9.
90. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti RK. Open reduction
and internal fixation of three and four-part fractures of the proximal part of the
humerus. J Bone Joint Surg [Am] 2002;84-A:1919-25.
91. Mont MA, Maar DC, Urquhart MW, Lennox D, Hungerford DS. Avascular necro-
sis of the humeal head treated by core decompression: a retrospective review. J Bone
Joint Surg [Br] 1993;75-B:785-8.
92. Gerber C, Hersche O, Berberat C. The clinical relevance of posttraumatic avascu-
lar necrosis of the humeral head. J Shoulder Elbow Surg 1998;7:586-90.
VOL. 93-B, No. 1, JANUARY 2011
View publication stats
11
93. Doetsch AM, Faber J, Lynnerup N, et al. The effect of calcium and vitamin D3
supplementation on the healing of the proximal humerus fracture: a randomized pla-
cebo-controlled study. Calcif Tissue Int 2004;75:183-8.
94. Court-Brown CM, McQueen MM. Nonunions of the proximal humerus: their prev-
alence and functional outcome. J Trauma 2008;64:1517-21.
95. Healy WL, Jupiter JB, Kristiansen TK, White RR. Nonunion of the proximal
humerus: a review of 25 cases. J Orthop Trauma 1990;4:424-31.
96. Scheck M. Surgical treatment of nonunions of the surgical neck of the humerus. Clin
Orthop 1982;167:255-9.
97. Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin Orthop
2004;419:46-50.
98. Rooney PJ, Cockshott WP. Pseudarthrosis following proximal humeral fractures: a
possible mechanism. Skeletal Radiol 1986;15:21-4.
99. Galatz LM, Iannotti JP. Management of surgical neck nonunions. Orthop Clin North
Am 2000;31:51-61.
100. Dines DM, Warren RF, Altchek DW, Moeckel B. Posttraumatic changes of the
proximal humerus: malunion, nonunion, and osteonecrosis: treatment with modular
hemiarthroplasty or total shoulder arthroplasty. J Shoulder Elbow Surg 1993;2:11-21.
101. Connor PM, Flatow EL. Complication of internal fixation of proximal humeral frac-
tures. Instr Course Lect 1997;46:25-37.
102. Johansson O. Complications and failures of surgery in various fractures of the
humerus. Acta Chir Scand 1961;120:469-78.
103. Coste JS, Reig S, Trojani C, et al. The management of infection in arthroplasty of
the shoulder. J Bone Joint Surg [Br] 2004;86-B:65-9.
104. Sperling JW, Kozak TK, Hanssen AD, Cofield RH. Infection after shoulder arthro-
plasty. Clin Orthop 2001;382:206-16.
105. Brown TD, Bigliani LU. Complications with humeral head replacement. Orthop Clin
North Am 2000;31:77-90.
106. Plausinis D, Kwon YW, Zuckerman JD. Complications of humeral head replace-
ment for proximal humeral fractures. Instr Course Lect 2005;54:371-80.
107. Wirth MA, Rockwood CA Jr. Complications of shoulder arthroplasty. Clin Orthop
1994;307:47-69.