Proximal Humerus Fractures: A Review of Anatomy, Classification, Management Strategies, and Complications

Proximal humerus fractures are prevalent in older adults, particularly women, primarily due to osteoporosis and increased fall risk. These fractures often result from low-energy falls in elderly patients, while in younger individuals, they are more likely to occur with high-energy trauma, which may involve additional injuries to soft tissue and neurovascular structures. Proper anatomical understanding, including key structures and blood supply, is crucial for effective management and to prevent complications. Several classification systems assist in guiding treatment for proximal humerus fractures, including Codman's, Neer's, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) system, and the Codman-Hertel system, which helps predict ischemia risk. Evaluation of proximal humerus fractures begins with Advanced Trauma Life Support (ATLS) protocols, emphasizing a thorough shoulder assessment, particularly focusing on skin integrity in elderly patients. Neurological and vascular examinations are essential due to the common occurrence of nerve injuries, especially involving the axillary nerve. Imaging typically includes multiple standard views, with advanced imaging reserved for complex cases and for assessing associated soft tissue injuries. Treatment options range from conservative management for stable fractures to surgical intervention for more complex cases. Surgical choices include techniques like fixation, nailing, and various arthroplasty options, with some procedures potentially offering advantages for older adults with bone quality or soft tissue challenges. Rehabilitation is a vital component of recovery, with emphasis on early mobility and gradual strengthening to restore function, especially in older patients. Complications following open reduction and internal fixation (ORIF) for proximal humerus fractures can include issues such as non-union, malunion, osteonecrosis, infection, joint stiffness, and fixation failure. In cases where non-union or fixation failure occurs, revision surgery or arthroplasty may be necessary. Joint stiffness may require further intervention if physical therapy is insufficient, while symptomatic osteonecrosis might also need surgical management. Malunion is generally better tolerated in older patients but may require correction in younger individuals. Other surgical options, such as hemiarthroplasty (HA) and reverse shoulder arthroplasty (RSA), share similar risks, including infection, fractures, complications at the tuberosity, stiffness, and instability. RSA may be favored when there are tuberosity or rotator cuff issues. Closed reduction with percutaneous pinning carries a high risk of pin migration and malunion, which can result in deformities, pain, and dysfunction. Proper anatomical knowledge is essential to avoid neurovascular injury and to manage common issues such as pin-site infections effectively.