Neer's paper: Proximal Humerus Fractures - Gavin Jennings 29/5/2003

Displaced proximal humeral fractures. I. Classification and evaluation.

JBJS A 1970 Sep; 52(6): 1077-89     Neer CS 2nd

Neer considered existing classification systems to be inadequate in identifying injuries which required operative intervention

Looked at anatomy of fractures (300) selected “at random” from the displaced fractures treated by MUA or surgery at New York Orthopaedic Hospital from 1953-1967. Mean age 55yrs

Classification based on presence or absence of displacement of one or more of four major segments (identified by Codman) ie head, tuberosities, shaft.

Considered displaced only if displaced by more than one cm or > 45 degrees.

Grouped as follows:

1.       Minimal displacement

85% of fractures. Head and shaft rotate as one. Conservative management.

2.   Articular segment displacement

ie Anatomical neck NB. AVN risk

3.   Shaft displacement

ie Surgical neck. Cuff grossly intact Head neutral rotation. Three types in adult: Angulated, Separated, Comminuted

4.   Greater Tuberosity Displacement

Indicates longitudinal cuff tear ( usually at interval). In three part, neck fracture allows head to rotate to face posteriorly due to subscap pull. Prevents closed reduction, but blood supply good.

5.   Lesser Tuberosity Displacement

In three part, neck fracture allows supraspinatus to ER and abduct articular surface. Prevents closed reduction, but blood supply good.

6. Fracture Dislocation

Includes displaced fractures of articular surface. Impression fracture usually occurs with post dislocation. If small reduces easily. If more than 20% tends to redisplace unless subscap transplanted. If more than 50% use prosthesis.

Roentgenographic Appraisal

Suggests AP and lateral scapular views

Criteria for Evaluation

Provides scoring system based on pain, function, ROM ( ? Validation) 100 points.

Summarises saying one and two part treat by closed means ( with exception of greater tuberosity and displaced neck fractures). Three part difficult to reduce by closed means (but does it matter). Four part- blood supply destroyed. This is where controversy lies- see Part II !

Displaced proximal humeral fractures. II Treatment of three and four part displacement

JBJS A 1970 Sep; 52(6): 1090-1103    Neer CS 2 ^nd

117 consecutive patients with 3or 4 part or fracture dislocations with mean follow up of 4.8 years treated as follows:

·          Closed reduction (anaesthesia) in 77, position accepted in 31

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