Proximal Humerus Fracture Classifications

  1. Proximal Humerus Fracture: AO Classification

  2. Proximal Humerus Fracture: Habermeyer Classification

  3. Proximal Humerus Fracture: Neer’s Classification

  4. Sequelae of surgery of proximal humerus fractures: Boileau classification

  5. Predictors of humeral head ischaemia: Hertel

  6. Hertel’s Binary or Lego description system for proximal Humerus fractures

Proximal Humerus Fracture: AO Classification

Müller M, In: Manual of internal fixation, 118-125, 1988

A: Extra-articular unifocal fracture

A1 Extra-articular unifocal tuberosity fracture

  1. Gr Tuberosity, not displaced
  2. Gr Tuberosity, displaced
  3. associated with GH dislocation

A2 Extra-articular unifocal impacted metaphyseal fracture

  1. no frontal displacement
  2. varus malalignment
  3. valgus malalignment

A3 Extra-articular unifocal non-impacted metaphyseal fracture

  1. simple, angulated  
  2. simple, translated
  3. multifragmentary

B: Extra-articular bifocal fracture

B1 Extra-articular bifocal fracture with metaphyseal impaction

  1. Lateral and Gr tuberosity
  2. Medial and lesser tuberosity
  3. Posterior and Gr tuberosity

B2 Extra-articular bifocal fracture without metaphyseal impaction

  1. without rotational displacement
  2. with rotational displacement
  3. multifrag metaphyseal with one of the tuberosities involve

B3 Extra-articular bifocal fracture with GH dislocation

  1. Vertical cervical line, Gr Tuberosity intact, Ant-med dislocation
  2. Vertical cervical line, Gr Tuberosity fracture, Ant-med dislocation
  3. Lesser tuberosity fracture, posterior dislocation

C: Articular Fracture

C1 Slightly displaced

  1. cephalotubercular, valgus alignment
  2. cephalotubercular, varus alignment
  3. anatomical neck

C2 Impacted and significantly displaced

  1. cephalotubercular, valgus alignment
  2. cephalotubercular, varus alignment
  3. Transcephalic and tubercular, varus alignment

C3 Dislocated

  1. anatomical neck
  2. anatomical neck and tuberosities
  3. cephalotubercular fragments

Proximal Humerus Fracture: Habermeyer Classification

Type 0: One part, non-dislocated

Type A: Two part fractures  

A1: Gr tuberosity avulsion

A2: Lesser tuberosity avulsion

Type B: Surgical neck

B1: 2 part fracture

B2: 3 part, surg neck and one tuberosity

B3: 4 part, surg neck and both tuberosity

Type C: Anatomical neck fracture, high risk of head AVN

C1: 2 part fracture

C2: 3 part, anat neck and one tuberosity

C3: 4 part, anat neck and both tuberosity

Type X: Anterior or posterior fracture dislocation

Proximal Humerus Fracture: Neer’s Classification

Neer II,CS, JBJS (A), 52: 1077-1089, 1970

Minimally displaced one part fractures

No segment displaced > 1cm or angulated > 45 deg

Two part fracture of anatomical neck, articular segment displaced

High risk of AVN

Two part fracture of the surgical neck with shaft displacement:

  • Impacted- >45 deg angulation, apex anterior
  • Unimpacted- shaft dispalced antero-med, head neutral
  • Comminuted- fragmented upper shaft

Two part greater tuberosity displacement

Two part lesser tuberosity displacement

Three part displacements: one tuberosity remains attached to the head

Greater tuberosity displacement

Lesser tuberosity displacement

Four part fractures, fracture dislocation and head splitting fractures:

articular segment displaced out of contact with glenoid, no soft tissue attachment, no tuberosity contact

Sequelae of surgery of proximal humerus fractures: Boileau classification

Boileau et al, JSES,10: 299-308, 2001

Type 1: Humeral head collapse or necrosis, minimal tuberosity malunion

Type 2: locked dislocations of fracture dislocations

Type 3: surgical neck non-union

Type 4: severe tuberosity malunion

Predictors of humeral head ischemia : Hertel

R. Hertel, A. Hempfing, M. Stiehler, M. Leunig. JSES, Volume 13, 2004, Pages 427-433

Good predictors of ischemia:

  • Length of metaphyseal head extension (accuracy 0.84 for calcar segments <8 mm)
  • Integrity of the medial hinge (accuracy 0.79 for disrupted hinge)
  • Basic fracture pattern (accuracy 0.7 for fractures comprising the anatomic neck)

Poor predictors of ischemia

  • Angular displacement of the head (accuracy 0.62 for angulations over 45 deg)
  • Extent of displacement of the tuberosities (displacement over 10 mm: accuracy 0.61)
  • Gleno-humeral dislocation (accuracy 0.49)
  • Head-split components (accuracy 0.49)

By combination of the above criteria : anatomic neck, short calcar, disrupted hinge, positive predictive values of up to 97% obtained in Hertel’s study.

Hertel’s Binary or Lego description system for proximal Humerus fractures

R. Hertel, A. Hempfing, M. Stiehler, M. Leunig. JSES, Volume 13, 2004, Pages 427-433

Five basic fracture planes:

  1. between the greater tuberosity and the head
  2. between the greater tuberosity and the shaft
  3. between the lesser tuberosity and the head
  4. between the lesser tuberosity and the shaft
  5. between the lesser tuberosity and the greater tuberosity

12 basic fracture patterns:

6 possible fractures dividing the humerus into two fragments,

5 possible fractures dividing the humerus into three fragments,

Single fracture pattern dividing the humerus into four fragments