This is an enhanced PDF from The Journal of Bone and Joint Surgery

The PDF of the article you requested follows this cover page.

Displaced Proximal Humeral Fractures: PART I. CLASSIFICATION

AND EVALUATION
CHARLES S. NEER, II
J Bone Joint Surg Am. 1970;52:1077-1089.

This information is current as of March 30, 2009

Reprints and Permissions

Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
Permissions] link.

Publisher Information

The Journal of Bone and Joint Surgery

20 Pickering Street, Needham, MA 02492-3157
www.jbjs.org

The
Bone

Journal

of

Joint

Surgery

and
Ai,wricaii

VOLUME

52-A,

No.

(5

SEPT1MBER

Displaced

Proximal
I.

PA1T
BY
Front

th

and

S.

York

_Vew

ANI)

NEER,

of Orthopaulic

Th

Humeral

CLAss1FIcTlox

(HAItLES

Deparliiient

( a iversity,

1/oluine

11,

M.1).t,

Surgery,

)dost
treatment.

proxint1
hunera1
fractures
It is oIll\ the occasional

demands

sl)ecial

adequate

to

guidelines
not onl

for treatment.
adequate
for

correlating

the

This
sorting

roentgen

appearance

A study
-as made
fracture-di1ocations,

under
anesthesia
or
Presbyterian
Medical
patients

ranged

ears.

and

in

and

fracture
major

the
between

in

replacement

made
segments

before
were

surgically

were

categories

became

Traditional

treatment
charted.

correlated

the

Head
York,
161

to

that
but

jjioxinial
treated

Orthopaedic
19i3
and

has beeti found

also helpful
in

years
and
anesthesia

under

humeral

head

appearance.

was

in Existing

fractures
reduction

on

five

35.6
open

occasions

As

relationships

those

of

the

of

averaged
in 162,

Roentgenograms

patients.

roentgen

hunleral
by closed

Hospital-Colunbia1967.
The ages

studied
and the precise
findings
and photographs

according

tlirtt

fractures.

eighty-nine
the

classification

classifications

distinct

of

the

of

the

treated

anatomical

evolved.

Classifications

to the

lesser tuberosity,
the greater
produces
a lesion
that
can

or a suijical-neck

New

lork
s-ears

sixty-three

the

cotI(Ivative

Simj)1(

Method

of

were
Operative

with

evident,

to

fiacture-dislocatioti

level

of the

fracture

are

of

little

depicting
the type
of displaced
fracture
because
two
levels
were
involved
(Fig.
1). As Codman
observed,
fractures
at the humeral
neck
one,
two,
or three
of the four major
segments
from the rest: the segments

are the head,

the
both
tuberosities

of fresh

reductioti

15,16,17

(enter,

in

separate

fracture

Nethe

closed

Deficiencies

assistance
frequently

type

removal

with

(oluinbia

llv(li(al

yet
existing
classificatiotis
are
into portray
the specific
fracture
under
literature
and difficulty
in establishing

years

consisted

Surgeons-,

and

at

twenty-two

seventy-five,

prosthetic

satisfactorily
fracture
or

the anatomy
of 300 disphtcd
selected
at random
from those

surgery
Center

from

Treatment.

reduction

of

(md

Y.

mbia-Pre.s-byterian

paper
describes
a classification
lesions
for analysis
of results

Material

anti1

N.

York

judgnwtit
Failure
in the

identify
these
has led to confusion

consideration

YORK,

of Physicians

respond
displaced

and
lesions.

trett.ment

EvAruATIoN*

Coli

Hospital,

Vew

Fractures

NEW

College

Orthopaulic

1970

in

part

at the

N.Y.,
January
Fort
Wa.hington

fracture
Annual
21, 1969.
Avenue,

because

Meeting
New

both

levels

American

of The
\ork,

tuberosity,
be termed

N.

Y.

and the shaft.

Fracture
either
an aiiatmnical-neck
are

Academy

implicated.
of Ott

This
hopaedic

leads

of
to

Stirgeons,

10032.
1077

107S

C.

iticonsist
of

encies

each

level

classification
lesion

the
fract

iii

of

based

to

be

(lassificat

grouped
ion

literature,
tire

as

wit hi

by

the

upon

II

to

level

by

variations

different
of

in

the

observers

fracture

the

ieported

incidence

Iurt.hermore,

6,19,23

permits

a tion-displaced

displacement.

a serious

according

NEll,

as is shown

interpreted

merely

5.

the

mechanism

of

lie

injury

5,22

also

fails

to

portray

Suprospinotus
and external

rotators

TMANATOMIC

NECK

/
ROTATOR

SURGICAL

-Biceps

Fi;.

I )rawiiig

NECK

tendon

IIii

__/

INTERVAL

___
1

i11til tat log

I lie rot alor
inlet-va!,
a ligaineittotis
area
between
the
tendons
of
ati(l stibscaptilaris,
and the fout lisajor
fi-agnietils
of pi-oxima!
humeial
fi-actut-es:
lesser
I tLl)erosil
v, (3) gi-eatetI tibei-osil
v, and
(4) shaft.
1 et tact iou of both t tibeuosit
iotatoi
interval
itid involves hotli the tligi(al-ile(k
and auialoniital-uteck
levels.

the
(1)

aio!
2-13: Auitei-opostei-ioui-oeuitgeiiogranis
of a liialtttlile(l
ft-act
tue
de)i(tiulg
lie t euiiis (ibdu(-t ion ,fraet ore at ud (UI(IUCliOfl
frw-tu
r(.
Fig. 2-A: Vsitli the hornet-its
iuitei-uial1- totaled
the head
appeal-s
to
be iii valgus position,
a(1(ltu(t
loll
fract tue.
lig. 2-13: \\ith I he same
lutumertus
ext eruia!lv
iotat ed Ihe head
appeal-s
to he iii varus
( )sit ion,
abduct loll fract the.
The
apex
of the
angle
is, as in this case,
usually
diu-e(ted
autteriorlv
aiud
not iii the scapular
c()uoulalI)!:uule.

the

sliI)lasI)illat

head,
((ats

tl

(2)
t lie

Figs.

fa!!a(v

2-A

of

ies

iitu:

JoIRNAL

01

BONE

ANt)

JOINT

SURGERY

the
tlie
or

D1S1LACED

PROXIMAL

HtMERA

DISPLACED

DLSPLACEMENT

c)Y_)___

1079

L FRACTURES

FRACTURES

PART

PART__

PART

ANATOMICAL
NECK

nI
SURGICAL

NECK

_____

qc

GREATER
TUBEROSITY

LESSER

TUBEROSITY

c\

7/

.-

c____

ARTICULAR
SURFACE

i:
FRACTURE-

DISLOCATION
ANTERIOR
POSTERIOR

k??
The

FIG.

of the four
najor
segment-i
shown
in Fig. 1 i5 (oulsi(leued.
Group
I iuichudes
a!! proximal
fractures,
regardless
of the number
of lines
of cleavage,
iii
which no segment is displaced
more than 1.0 centimeter
or angulated
more
thaui 4i deguees.
(uouup
II, the anatomical-neck
fracture,
is a displacement
of the
head
segnieuil,
with
or withotut
haiiluuue
tuberosity
componeuuts.
Group
III, the surgical-neck
fracture,
is a displacement
of the
shaft
segment
with
the rotator
cuff intact.
(rotip
IV, the greater
tuberosity
displacemeuut,
o(cuius as It
two-part
and,
with
au uuuimpacted
surgical-uueck
fracture,
as a three-part
lesion.
(3roup
V the
lesser
tuberosity,
occurs
as a two-part
and,
with
an unimpacted
surgical-neck
fracture,
as a threepart
lesion.
Groups
IV and
V blend
as the
four-part
fracture
in which
both
tuherosities
aue displaced
Group
VI, the fracture-dislocation,
implies
damage
outside
the joint
space,
anteu-iou-ly
and
auiatoniica!

posteriorly,

artictular

and

segment.

surface

distribution

fractures,

and

the head-splittiuig

the

type

of lesion.
apex
but.

produce

roentgen

the

jut whj(h
fracture.

The

because
the
other
plane,
fracture,

Each
hutneral

classification.

terms

port

abduction

of angulation
rarely
in the

depending

is important
jolts of the

the

It. also is confusing

to find that. opinions
fracture-dislocation.
The glenohumeral-joint
humeral

heads

and

detached,

the

articular

out

glenoid

VOL.

of the
52-A.

NO.

6,

when

cavity.

SEPTEMBER

there
surface
This
1970

is muscle
of the
has

of the
differ
capsule

atony

humerus

led to such

are

fracture

misleading

anteriorly,
occasionally
in some
planes.
Anterior
angulation
can

abduction

of rotation

ciuciulat iou of the head.

The
are (lie impt-essiouu ft-acttile

adduction

is directed
or scapular

of either

position

and

fracture

usually
coronal

appearance
on the

iii estimating
the
head
are dislocated,

fracture
humerus

terms

the

addtict.ion

2-A

and

2-B).

as to what
constitutes
is large enough
to contaiii

1,6,9,10,20

or when
can

or

(Figs.

easily

one

of the

be subluxated

as fracture-subluxation

two

tuberosit.ies
or
7,21,

is

rotated
rotary

1080

C.

S.

II

NEER,

4-A

HO.

Fio.

4-B

Figs.
4-A,
4-13,
Ito!
4-C:
Atutetopostetioi
ittelltgeuioglanss
of head-segneiit
displacernei#{236}t
at
(he atuatontical
neck,
(itoup
I I. This
lesiouu caut go
t Ii I ecogi
iized
and
lead
I o disabilit
v fi-onl
riialtiilli)ii
01 tvtisctilii
uieci-osis.
Fig,
4-A:
Ou-igiuual
l-oentgenogl-anl
na(le
with
t he
htinlel-us
intei-nall1-01 ated,
i-esult ing
in
failttue to uecognize

the

Fig. 4-13: Same

ft-act
111109 \sit Ii t he hutneius
BIg I he (Iispla(en)eult.
Fig.
4-C:
Similai
avasttila

Fuu.

(lisiLo-ation

sl)ecifY

the

nuscle

attachnients

attent

tVl)e

inl/)a.(-ted

of

fi-actui-e-dislocatioii

by

(lisj)laceflleIlt
in
)roclucing
displacenieuit

in

ternis

these

a sI)ecific

lesion.

hills

Feceive(l

Indeed,

fail

the

to

iole of
little

suipiisingly

1011.

The

classification

mechuauiisuii
mote

of

of the

analogous

four

the

in

isot

Siuice

treatment

and

of the

all

accurate

identification

well

the

surface.

fragments,
as
The classification
were

euicouultele(.l

that

displacement

Group

I,

This
lines,

its

more

than

fractures
usually

if in imuin
group

which
These
held

seems

one

the

(Fig.

or

they

be

fractures

effect

of

muscle

status
and
continuity
formed
to i(lentifv
the

was

the

pose

that

1)isplacecl

both

circulatory

illustrated

on

of
fractures

logical

lines.

depict

nor

of

types

3).

Displacement

all fractures,

includes

no segment

45 (legrees.
14

it
to

as the

fracture

displacement
displaced

fiacture

of

its O1(ler

actually

of the
of

minimally

prognosis,

tiuniber

ott free

auticulai

level

absence

0)1

attachuileuits

require

ous the

p1eseisce

segments.

regardless

Classification

based,

is

on

major

together,

more

Four-Segment

adopted

but

injury

problems

grouped

are

ited,

lesion,
complicated
yea u-s a ftei inj uuy,

FIovever,

22

lo)tatOlV

The

of

t -o

i- necuosis,

nunuths
shov-

fout

tot

4-C

1(11(1

20

lesion.

tue visttahzed
extei-nallv

lesions
togethei

regardless

is (lisplaced

This

group
present
by

soft

of the

tliaus

more

constitutes
over
similar
problems
tissue

or are

1.0

or

usumber

centimeter

of fracture

or is angulated

85 per ccitt of proximal

in management.
The

impacted,
THE

level

JOURNAL

permitting
01

BONE

early
AND

JOINT

humeral
fragments

functional
SURGERY

DISPLACED

exercises;

head

however,
1111(1 shaft

II,

Group

Pure
roentgenogram

to (lisability

This
neck

S/taft

is

Although

Figs.
segment
Fig.
abduct

i-A. .-B,
and
displacement
.5-A:
Angulated
ion.

neck

can
of the

escape
humerus

lesiots

upper

end

may

be

before

required

the

without

separation

isolice
unless
is obtained

or avascular

necrosis

of one

a good

(Fig.

4-A)

4-B

(ligs.

tubeiosity

anteroposterior
and

and

lea(l

may

4-C).

Displacement
just

occurs

displaced

degrees.

immobilization

anatomical

This

of malunion

fracture

and

of

lost

FRACTURES

Displacement

at the

rare.
of the

because

III,

period

HUMERAL

one.

as

rt icular-Sepnen

(luite

Gi-oup

a brief
rotate

displacement

or both

PROXIMAL

more
fissure

distal
than

fractures

to
1.0
may

the

at

tuberosities

centimeter
be

or

is

the

level

jroximally,

present

of

angulated

the

more
the

suigicttl
thIns

45

rotator-cuff

-----

the

VOL.

Fig.
5-B:
Non-contact
head
held
in uieutu-al
Fig. 5-C: Commiuiuted
52-A,

NO.

6,

SEPTEMBER

.5-C: Anteroposterior
seeui in Group-Ill
fracture,
same

fracture
rotatiout
fu-actuu-e,
1970

u-oentgenograms
fractuu-es.
maluuiioii
as iii

illust
Figs.

i-at hug

2-A

with
the shaft
displaced
medially
by the intact
rotator
cuff.
twisted by placing
the arm
a(-ross

and

by
the

the

thu-ee I vpes

2-B,

showiuug

the
chest

major
1

shaft-

maximum

l)ectoualis
iii

of

sling.

and

10S2

C. S. NEER,

6-A

FIG.
Fig.

6-A

Group-V

II

through

FIG.

Original

6-E:

anteroposterior

6-A:

Gioup-I\

The greater
tuberosity
undisplaced
surgical-neck
Fig.
6-B:
Group-TV
thi-ee-part.
fracture.
The
greater-tuberosity
an unimpacted
suu-gi(al-ne(k
fi-acture
which
permits
the head
scaptularis
so that.
the articular
surface
faces postei-ioi-ly.
nornsal

are

slightly

category
The

and

abduction
non-union.

rotated

neutral

rotation

placed

by

head

ulnar-pin

5-A).
stability

the

IV,
The

retracted,

causes

The

centimeters,

ternally

rotator

are

often

is

rotation.

across

by

The

pectoralis

5-C).

applied

and

Greater-Tuberosity
greater

than

and

in

which

the

major.

of

interval
the

or

centimeter

a longitudinal

(Fig.
tear

articula.r
minimally

segment
displaced

three-part

pattern,

one

from

of

of

more
(Figs.

and

affords

traction

in

w-orse

can

rotation

is

fracture
by

displacement

fracture

1), but,

of

in

when

in addition

lesser

the

rotator

only

the

posterior

remains
fracture

it.s facets

the

tear

occurs

only
are

elevation

shaft

This

immobilization

twist

This

is

and

a position

relax

the

arm

in

tissue

may

lead

to

extends
the

and head
fragments

be adequately

distally
arm

is

are

in-

held

may

aligned

the

un-

to

placing

when

t.o relax

displaced

is often

be
by

in
dis-

over-

pectoralis.

Displacement

tuberosity

1.0

head

stub-

position.

is made

in neutral

the

angulatioti

abduction

chest.,
because
the tuberosities
intact
rotator
cuff. Intermediate

(Fig.

t.raction

by

fractures

Residual

of

the

the

with

associated

iotated

sleeve
is usually
intact
posteriorly
reduction
is accomplished
by

undergoes

iemains

patients.

limitation

head

the

Epiphyseal

is impacted.

fracture

permanent

periosteal
w-hen
closed

displacement
be iuiternally

to

shaft.

in adult

butt

component.

in neutral

overriding

seen

is displaced

or in a tight
sling. Instability
and interposition
of soft
Associated
neurovascular
damage
is not. uncommon.
comminuted
surgical-neck
fracture,
in which
fragmentation

The

nomonic

types

head

an

closed
reduction
(Fig.
5-B)
is helpful.
The
displacement

several

more

the

by

of the arm forward

beyond
the pivotal
separated
surgical-neck
fracture
is one
tind anteriorly,
pulled
by the pectoralis

after
pectoralis

Group

hold

tilted

suigical-neck

degrees

elevation
The
medially
the

Three

18

2-A, 2-B,
considerable

and

unless

anqulated

45

stable

two-part
fuacture.
or without
an

intact

abducted

than

for

with

positiouu,

attachments

this

atid

UlOttI)-I\

fractures.

Fig.

in

6-B

illusttating

roeuitgenoguarrus

to

for

tendon

tuberosity.
cuff.

tear

part

of the

interval.

In

in a normal
relationship
of the surgical
neck may
to the

retraction

of the
THE

JOURNAL

the

is

usually

BONE

at

the

t.uberosity

two-part

tuberosity,

pathog-

occurs

greater

with the
be present

OF

is retracted

separation

The

posterior

this

attachment
The

pattern,

shaft.,
(Fig.

is
the

although
a
6-A). In the

displacement
AND

JOINT

at
SURGERY

DISPLACED

Fig. 6-C: GrOttl)-\

normal
position,
with
Fig.
surgical-neck

auid

6-li:

Group-V
fracture

external

rotators

PROXIMAL

HUM

preseuits

at

and

the

defect

nseuge

in

iii the

the surgical
uieck
is also
rotated
by the subscapularis.
articular

segment.

displacement.
a good
VOL.

52-A,

The

source
NO.

rotator

which

posteriorly

supply
1970

but the head I-emaiuls

component.
displacemeust.
and
uuuimpacted
and abducted
by the supraspiuiatu.s

is displaced

its

n-tj

fuacture. Both

tubetosities

are

displaced

auid

the

head

interval.

This

attached

SEPTEMBER

four-part

present

to face

of blood
6,

the

10S3

FRACTURES

two-part
fracture. The
lesser
tuberositv
or without.
an undisplaced
surgical-uieck
three-part
fracture.
The
lesser-tuberosity
permit
the head
to be externally
rot.ated
as the articular
surface
faces
anteriorly.

riG.

Groups

ERAL

muscles
to the

allows

the

exaggerates
(Figs.
act
head

articular

the
6-B

and

rotator-cuff
7). This

to prevent
closed
remains
because

segment

defect
is a much

reduction.
soft parts

to

be internall
and causes
the
more

serious

Nevertheless,
are attached

to

lOS-I

0.

5.

NEER,

It

FIG.7

ing the
rotatorsdisplacemeuuts
of I he I wo types
of
I hree-part
fu:tct tires,
( 110111)5
I V auI(l u .1 : I )etaclnneuut
(f the gtealeu
t tih.eu-osit-,
( iotip
I V, stit h au iuuustah)le stuigi(alu eck fillet lute, allt)Vs
I lie head
I o be
itut eu-na1lrot at ed,
exagget-al
i lug I he n ii at ut--cull
defect
,
B:
I )et lI(hin(uul
( )f I he
lesseu I uih)et( isil :- (_ u-)ttl) , III ud shaft
alh.av
t he head
I ( ) I e ext eu-nall
ii 1 at ed
111(1 ab)dtt(te(l.

1)tasvings

(lie

((tilt

artictilar

i-list

segnient

liii

OJXui Ie(lltctiOul,

be

niuchi

(111(11 that

better

(iig.

6-1)).

Group

Fhie

austeri(.)rly.
of

L(.s.ser- Tuberosity
t\VO-j)alt

titl(lisl)lace(I

the

Neither

(hisj)lItCeulieflt

as

occurs

ext ernal

an

of blood
of the

sup.)ly

luad

in which

during

is l)tesetVe(l

12

humeral

ftacture

isolated

surgical

iseck

fibers

austerior

(lefect

hovever,

source

survival

four-part

the

thst

of

5h)1(lt(ls

p1ominence.

for

tl

vould

apear

to

is (letache(l

head

I)isplaeement

lesion

fracture

t uberosit-

if this

thst j)rogno)sis

appears

avulsion

(lig.

at. the
to

be

or

iii

rotator

iliterval

of clinical

iflij)OItaulce.

with

association

Displacenient

fi(1)

of

1111(1 produces
Its the

the
displacement
at the surgical
tieck
:tllows
the
ly rot ate(l Itui(l abducted
by t lie supras)inat
us and

tIst

an

lesser

a boise
three-part.

atticulai

segment

tO) be

1OtlLtO)ls.

This
exaggeuates
the
IOtatOI-cliff
(lefect
Itii(l interferes
with
closed
reTlw ;urticular
surface
is niade
to face anteriorly
(ligs.
6-I) and 7). At open
aiticular
cartilage
is foutid
presenting
at the gaping
tear
in thit rotator

ductiots.
reduction,

cuff,
tious.

which

situatio)n

It.

However,

the

head

suggests

that

segment

retains

the

head
abundant

is dislocated,
soft-part

a false fracture-dislocaattachments
posteriorly

and adeouate
blood
supply.
Open
reduction
can be readily
accomplished
rotating
the
head
and
approximating
the
tuberosities
and
cuff.
In the
fracture,
both
tuberosities
are retracted
and,
as in all four-part
lesions,
supply

to

placed

laterally

displaced
ion

is

is classified

between
and

head

has

the
out

descriptive.

of

This

11usd injury
formation.
superior;

fracture

as a severely

occurs

been

retracted
contact

However,

I 1, Fia.ct u re- D is-beat

Group

or

humeral

laterally

ilisloeal

lesion

the

displaced

severed.

The

art icular

tuberosit.ies
(Fig.
wit Ii the glenoid,
the
pat homechanics
fracture

rather

external

by

(Ic-

four-part
the blood

is usually

segment

dis-

G-E).
When
the
head
is
the term
lateral
fractureseem
clearer
when
this
than

a fracture-dislocation.

ion

with

outside
the joitit,
The displacement
but
no instance

a true

dislocat

ion

which

implying
a greater
of the humeral
head may
of superior
displacement,
in turts

THE

JOURNAL

implies

damage

higamentous

threat

of pericapsular

be anteroinferior,
w-ith

associated
OF

BONE

AXD

bone

posterior,
a fracture
JOINT

SURGERY

of

1)ISPLACED

Figs.

S-A

dislocat

PROXIMAL

HUMERAL

loss

FRACTURES

I hu-( nigh

S-I ): Ot-igiutal
autt eu-oposteu-iouroeuut geuuogu-anss
illttst tat it ig a
egnseuut
dist u-ibtition is impoutauut
ill est imat
hug t lie -itctulat
utiustual two-pai-t
suu-gical-tueck lesioui with both tul)et-osities ii ((lilt

jot is,

\I.

)it

Fig.
head,
Fig.

S-A:

Auu

S-Is:

ivu-o-pau-I

Fig,

S-(:

tubeu-

gt-eatet--t

displaceruietut

sity

It (OlilBiOti

etiot

it
t

ftact

of

ii

utiLity

tti(-

he head.
wit hit he

it ij t tiV.

--,

provide

Fig.

Thu-ee-pau-t
Fouuu-pau-t

S-I):

the

proximal

and

t hiee-part

the

humeral

tissue

lsead

remains

in

posterior

the

head

commonly

w-ith

Displaced

VOL.

NO.

SELTF:MBER

of the
of
1970

I a-hinieiut

0)1 the

the

articular

with
the

humeral

S-I)).

luu

uenuaiti

1(1

segment.

its anteriou

remains

to provid(
In

Neurovascular

supply

10

wit Ii soft-

tuberosities,

head

t hue t vo-part

lie blOo(l

-(),

one

tuberosity

(lig.

at

st udv.

this

auud

fracture-dislocations.

four-part
pait

s ft -p:uu-t

iii

S-B,

5-A,

to

greater

is detached

anterior
while

6,

the

its

euicouuitereol

continuity

three-part

fractures

because,
52-A,

in

auud

because

attached

while

fracture-dislocations

head

was

adequate

remains

is (let ached.

(ligs.

usually

is

always

locations

humerus,

the

of

I iuheu-osii

the head,
the head

fracture-dislocations

attachments,

tions

to
itt which

lesioui

end

tuberosity
the

lesset-

The

lesiouu.

c uuusiderahle h)l()od siupplv

The

lesset

thiee-part
circulation

four-part

to

fuacture-dis-

symptoms

occur

more

displacements.
articular
the

articular

surface

are

cartilage

classified
has

with
been

Iuacture-olisloca-

crushie(l

by

impact

1086

C. S. NEER,

FIG.
Figs.
9-A atid
roentgeuuogram.s
cassette.
Fig.
9-A:
The
pendicular
to
the
Fig.
9-B:
The
plane.

agaiisst

the

extruded
dislocation
When

and

end

stays

impression

within

defect

covered
plantation

the

extrude

and

defect

joint

prosthesis

head-splitting

fracture

of cart.ilage
into

Recognition
other

to

many

of
the

fractures,

bot.h

supplemented

and t.he arm

is perpendicular
plane.

With

position
of

w-hen

in

other

and

t.o the

with

9-A

the

of the upper
the greater

per-

plane.
scapular

the

of cartilage

recognized

are

be

earls-,

than

13

20

per

articular
into the
cent

a central

of

the

fragment
is
defect. in the
cartilage-

despite
transto render
this

impact

posteriorly.

closed

cent

of the

readily
recurs
used at times

of the

of

The

which

articular

may
surface

be

of

two

with

the

four

It

made

the

careful

and

end of the humerus

and lesser t.uberosities

case
to

upper

the

cats be
is used

patient

to

two

other,

roentgen-

of the

axillary

is.
most

obtain

t.o each

end

is parallel

positioning,

of

axillary

with

of the

second

segments

the

angles

projections
view

in

is helpful

at right

rotational,

initial

major

As

confusing.

One

and

Lesion

classification.

humerus

9-B).

plane
and

is

from

t.ransthoracic,

and

scapular

information,

is made
in

fragments

50 per

relationships

of the

to make

(Figs.

is made

the main
tendon

and

humerus

to t.he sagittal

more

may

system
can

end

the

the

encount.ered
with a posterior
w-itli an anterior
dislocation.

than

Appraisal

this

necessary

sling

15usd lateral
agaitist

pieces.

projections

upper

possible
a

this

roentgenograms
distance
between
of tuberosity

the

application

of the

ograms.
It. is usually

the

dislocation

anteriorly

disconnected

oblique

roentgenograms

of

lesion

results

Roentgenographic

essential

humerus

more

and

subscapularis.

is- fragmented

end

involves

is unstable

of

medial

the

involves

the

fragments

euid

space,

impression

TIse

of
stable.

upper

30 degrees

tends
to occur
unless
of the subscapularis

t.lse articular

surface,

the

joint

small

the

surface,
redislocation
as by transplantation
Whets

the

is

When

9-B

show

impression
fracture
is commonly
occurs
to a significant.
extent.

is effective.

articular
stabilized,

lesion

FIG.

the technique
for obtaitsiuug
anteroposterior
of t.he humerus.
The patient.
is erect
and
leatsing

to

anteroposterior
roeustgenogram
of
scapular
plane
by placing
the tube
lateral
roeuitgenogram
of the upper

glenoid

the

head.

9-A

9-B:
I)rawitsgs
of the upper

from it. The

but rarely

reduction

II

the
or

erect

humerus

scapular
rotational

made
as required.
The
to indicate
the severity

displacement.
THE

JOURNAL

OF

BONE

AND

JOIXT

SURGERY

DISPLACED

PROXIMAL

HUMERAL

TABLE
CRITERIA

1.

Pain
(35
a. Noise.

Extension

occasional,

30
on

ordinary
25

tolerable,

2.

a.

(30

io
140

ioo
80

1
0

10
8
6

less
External
position
60

4
2

rotation
(from
anatomical
with
elbow
bent)
5

4
2

30

3
1

Zero

less

Internal
position

of head

Mouth
Belt buckle
Opposite
axilla

2
2
2

Brassiere

hook

Stability
Lifting
Throwing
Pounding

Range

in Motion

Flexion

(25

(sagittal

rotation
(from
anatomical
with
elbow
bent)

90 (T6)
70 (T12)
50
30

(L5)

5
4
3

(gluteal)

2
2
2

less
Anatomy
(10 units) (rotation,
joint incongruity,
retracted

2
2

failure
avascular

metal,
myositis,
necrosis)

0
angulation,

tuberosities,

non-union,

None

units)

plane)

180
170
130

10

Mild

Moderate

Marked

zero

to 2

100

2
1

so
less
*

l)lat)e)

Pushing
hold
overhead

3.

(coronal

Poor
Trace
Reaching
Top

C.

1
0

units)

Strength
Normal
Good
Fair

b.

15
less
Abduction

15

disabled

Function

30

iso

nsakes
aspirin

concessions,
uses
e. Marked,
serious
limitations
Totally

45

no compromise

activity

d. Moderate,

f.

OF RESULTS

35

ius activity
Mild,
no effect

c.

FOR EVALUATION

units)
ignores

b. Slight,

1057

FRACTURES

Excellent,

above

89

units;

satisfactory,

Total
80

units;

point.s

100

unsatisfactory,

70

units;

failure,

units

below

70

units

Evaluation
Assessment

definition
tion
w-it.h

of

of the

of functional
each

the

for

treatment

under

The
been

have

accept.ed

of

lesion

recovery.

and

author

be generally

results

the

specific

of Results

criteria
difficult

future

but

most

is graded

results

this

a failure.

joints,

is

117

in

method

accorded

patients

and

are

judging

Functional

range,

a greater
with three-part

unit

reported

in the

also

for good, fair,

to compare.

more

on

an

accurate

interpreta-

and poor results

have
varied
An objective
system
that can
results

clinic

the
in

for

strength
fractures

is needed

several

most.
any

important

value
than
and four-part

succeeding

only

on an objective

of long-term

The numerical
rating
method
employed
in our
in Table
I. This system
is based
on 100 units.
Pain,
tion
to the patient.,
is assigned
35 units.
The result
pain

not

depends

discussion

years

important
with

considera-

patient.

in the

is. show-n
significant

shoulder

and
Isave

than

anatomy

been

rated

in
The

by

article.

Discussion
Existing

oversimplified
VOL.

52.A,

classifications

and
NO.

of

inadequate.

6, SEPTEMBER

1970

fractures

It

of

is essential

the

proximal
part
of the
to the understanding

humerus
of the

are
more

loss

C.

complex

sluRtlder

separated

froni

of treatmeist

the

fails

obtain

exercises.

These

ments,

w-iths
arise

s-ith

massive

closed

it

treatnsent

reduction

with

is acceptable?

luique

atid
In

the

nected

articular

What.

are
or

0l)et

its the

the

relative

But

shoulder

elderly
the

objectively.
deterrent

litts

beets

patients

who

exception

fifty-five

do

ietther
years

atid

not

tlse

to

the

prob-

fiactures

vessels

good

of the

results,

to

anatomical

head

better
head

rarely

occurs.

the

results

of

imperfectiots
cats

how

is destroyed.
survive

compared

its

the

tech-

if s-e are

treatment.

thee

most

had

productive

tusd

the

fractures
occur

this

series

orderly

make

defitsed

injuries

Occasionally
in my

its their

to

clearly

ctts

be developed

of complicated
that.

results.

of other

fractures

may

be

patients

discots-

those

head-splittirsg

techniques

of treatment.,

optimum
were

with

consideration

in the

the

it disitstegrate?

is ret.aitsed?

and

misconception
The

Cats

or -ill

20

fragment.
Other

uisder

rule.

restore

\Vhat

fractures

method

lesion

require

distortion.

by

to compare
degree
of

and

replacemeist.

majority

real

in tise

anatomical

future

articular

impression

the

The

tt.nd

to

replacement

the

prevalent

than

fractures

means.

resorptiots
the

union

to progress

the

displace-

unstable

improved?

which

the

of

functional

tw-o-part

accompanied

difficult

yields

bone

of the

that

closed

are

with

of prostisetic

regardless

it is esseistial

Most.

marked

reduction.

be
into

ill

of

in

reduction

crushitig
its large
treated
by prosthetic

coussidered
One further

the

merits

regardless

of certain

by

most.

circulation

erster

procedures

future.

)rogress,

result

segment.

closed

Articular
be logically

the

of sources

by early

displacements

problem

necrosis

of fixatiots

fractures

group.

displacement

open

If open

method

four-part

of

un-

surface.

important

tlsose

to

relatively

a. number

treated
and

controlled

yet

seem

reports

are

displacement,

large

four-part

appear

nieatss,

would

confused

from

minimum

as one

t he

may

gatisered

tuberosity

rotatory

it

closed

group,

w-ith

and

present

causitsg

be

add

fractures

be satisfactorily

greater

articular

ures

to

t.ogetlser
and
of a method

questions.

ade(uately

in the

segmetst.
by

tliis

be

is likely

displaced

data

of three-plsrt

fract

relationships
In

cats

case

tendotss

articular

account

since

therapeutic

of the

defects

of the

iisto

be separated

can

type be grouped
Atsy proponetst

lesions.

Vet,

agreed
that fractures
of fracture
lines, can

neck,

Three-part

Some

serious

comparable
to

exception

in the

this

that

lesions

the

tlio surgical

lems

take

II

of a similar

or less

literature.

answ-ers

It is generally
the level or usumber

t.lse

to

perplexing
to

fractures

serious

it. is desirable

order

of

that

more

who

already

commots,
its

injuries

the

NEER,

S.

is true,

an

of

its very

average

but.

as

age

of

years.

Summary

Ots

the

displaced
new

basis

inadequate

on

the

to

shsaft.

describe
or

surface

includitsg

the

the

made

scale

for

clear

definition

evaluating

to
t.lse

of

progress

encountered.

the

in the

and

lateral

and

parallel

results
lesiots,

greater
was
with

of treatment
of

Behaiidlutsg
1929.

von

of

the

the

of

the

scapular

more

for

based

t.uberosity,
this

and
system,

etid

of

A numerical

because,

in

results

are

shoulder

to

segments:

proximal

plane.

rating

complex

was

apply

300

found

major

lesser
to

in

Isumerus,

were

four

necessary

is described
criteria

of the

classification

the

tuberosity,

roeistgenograms

objective

treatment

new-

each

found

lesions

etsd

classifications

The
of

head,

anatomical

proximal

Existing

displacement

examination

vertical

and

of tlse

injuries.

lesion
of

lsumeral

roentgen

atiteroposterior

humerus

of these

a.bsetsce

of

Careful

appearatsce

fracture-dislocatiotss

made

was

presence

articular

roetstgenographic

and

classification

be

future

of

fractures

tlse

rat.ing

addition

to)

esseistial

for

injuries.

References
1.

B#{246}nii.io,

f. Chir.,

Die
23S-245,

Louu.:xz:

219:

Verrenkuuigsbr#{252}schen

THE

JOURNAL

der

OF

Schulter.

BONE

l)euttsche

ANI)

JOINT

Zeitschr.

SURGERY

DISPLACED

PROXIMAL

IIUMERAL

1089

FRACTURES

2. B#{212}HLEII, LoloENz:
The
Treatnietst
of Fractutt#{128}s. Ed. . New York,
Griuuie auid Strattout,
1956.
3. CODMAN,
E. A. : The Shoulder.
1tuptuue of the Sttpraspiuuatus
Tendouu
auud Other
Lesiouus
iui or
about
the Subacromial
Bursa.
Boston,
Privately
Priusted,
1934.
4. COMMITTEE
ON RESULT
EVALUATiON,
THE
AMERIcAN
ACADEMY
oF
OIOTHoP;sEntc
SUuwt:0NS
Personal

5.

consnuuuiicat

l)FHNu:,

ERNST:

Etiology
6.

7.

of the

EIN;sIossoN,
tip of 302

ion.

Fractures

Traunsa.

F.:
Cases.

of

the

Surg.

Uppeu-

Cliii.

Euud

North

Fuactutes
of the Upper
Euud
Ada
Orthop.
Scauidiuiavica,

T. J : Fuaoture-Sttbhuxatiouis
Aug. 1948.

FAIJII(ANK,

454-460,

the

of

Iliumerits.

America,

of the Humerus.
Stupplemeuutum

of the

A Cla.-isificatioti

25 : 28-47,

Base(l

I)iscussiouu
Based
on
32 : 131-142,
1958.

Shotulder.

the

on

1945.

J.

Bouie

and

Joint

the

Follow-

Suug.,

30-B

Joxu:s,
LAURENCE:
The Shotuldet Joitit-Obsetvatiouis
on
the
Atuatonsy
auid
Physiology.
With au Atialysis
of a ilecotistructive
Opeuatiouu
Followiuig
Extensive
Injury.
Sturg.,
(istuec..,
ausd Obstet.,
75 : 443-444,
1942.
9. Joxi:s,
RoJtt:RT:
Certain
Iuijturies Comniouuly
Associated
with
l)isplacemeuut
of the head
of the
Ilumeuus.
British
Med. J., 1 : 1385-1386,
1906.
10. KNtGHv,
B. A., auud M.syxu:, J. A.: Commiuututed
Fractuues
auud Fu-actut-e-l)islocatiouu
Iuuvolvitig
the Aiticutlar
Surface
of
the Humetal
head.
J. Boute and Joint Surg , 39-A:
1343-1355,
l)ec.
8.

1957.
1 1.

Kocarit,
Leipsig,

12.

L.SING,
1105-1116,
O(t. 1956.
\1cLsUoHLuN,
11. L.: Posterior
584-590,
July
1952.
\1o1tuI3u11,
L. A., and PATTF:IISON,

13.
14.

T.: Beitrage
zur Ketuuituiiss
Carl $ollmauu,
1896.
P. G.: The Arterial
Supply

J. Botie
15.
16.
17.
18.
19.
20.

21.

22.
23.

VOL.

NF:u:uo,
humerus

atid
C.

S.,

with

Joiuit
II;

Sttrg.,
Baowx,

1)islocatioui

einiger
of the

1)islocatiouu

puaktisch
Adiult
of

Ilumertts.

the

Shoulder.

B. L., Juo. : Fractiures

49-A : 1018, Jttly 1967.
T.

H.,

of the

C.

JR.;

head

and

of the

Ft-actuu-euuformen.

Am.

Basel

J. Botue

and

Joiuut

Siurg.,

J.

auud

Joiuut.

Surg

Bouue

Pu-oximal

11. L.:

McLAUGHLtN,

Fragmeuut.

wichtiger

Fractutue

Euud
of

of

the

the

auid
38-A:

34-A:

Ilumeutts.

Neck

J. Suuug., 85 : 252-255,
1953.
Head.
J. Bouue atud Joiuit Sut-g,

of

the

S., II: Aiticulat

Heplacemeuut
of the Ilumeral
37-A:
Apr.
1955.
C. S., II: Prosthetic
Replacement
of the Humeral
head.
Iuudicatioius
auud Operative
Techuiique.
Surg. Cliii. North
America,
43:
1581-1597,
1963.
NEER,
C. S., II, atid Hoawtvz,
B. S.: Fractures
of
the Proximal
hltunseral
Epiphyseal
Plate.
Clin.
Oithop.,
41: 24-31,
1965.
BoilF:RTs,
S. M.: Fractures
of the Upper
Euud of the Humeuus.
Ati End-Result
Study
which
Shows
the Advantages
of Early Motioui. J. Am. Med.
Assuu., 98: 367-373,
1932.
SILFVF:RsKIhLD,
NILs:
Ots the treatment
of Fracture-1)islocatiotis
of the Shoutlder-Joiuut.
With
Special
Reference
to the Capability
of the llead-Fragmeuit,
1)iscouuuuected
from
Capsiule
and
Periostettm
to Euiter
iuito Bony Uusiouu. Acta Chir. Scandinavica,
64: 227-293,
1928.
THosiPsox,
F. R., atal WINANT,
E. M.: Utiusual
Fractuure-Subltuxatiouus
of the Shoulder
Joiuut.
J. Bone arid Joint Surg.,
32-A: 575-582,
July 1950.
WATSON-JONES,
IL: Fractures
ausd Joiuut Iuujuries.
Ed. 4, Vol.
2, pp. 473-476.
Baltimore,
The
Williams
and Wilkitus Co., 1955.
WENTWORTH,
E. T.: Fractures
Iuivolviuug
the Shoulder
Joint.
New
Yot-k
Slate
J. Med.,
40:
1282-1288,
1940.
NI:ER,

215-228,
NEEtI:

52-A,

NO.

6,

SEPTEMBER

1970