[Fractures of the proximal humerus]

The Neer four-part classification for displaced proximal humeral fractures is the most useful classification so far devised for consistent diagnosis and treatment. Nevertheless, there are several points in the Neer classification that need changing. Group II fractures, i.e., displaced fractures of the anatomical neck have a severe prognosis, excluding a mild graduation as in group II. Displaced four-segment fractures can be classified in group IV as well as in group V, which means the classification less than sharp. Without disregarding Neer's criteria, we use our own simplified classification: group A: extra-articular non-displaced two- to four-segment fractures; group B: extra-articular displaced two- to four-segment fractures; group C: intra-articular impacted or dislocated two- to four-segment fractures. The prognosis following fracture treatment is heavily influenced by the outcome of avascular necrosis of the head. Additionally, surgical treatment offers the change of further devascularization. Rigid plate fixation leads to a high incidence of avascular necrosis. In the case of displaced fractures, we prefer open reduction and internal fixation by means of tension-band wiring. Screws have a limited use in the presence of decreased pullout strength in osteoporotic bone. A Neer II prosthesis is indicated as a primary procedure for impacted fractures of the humeral head, displaced or dislocated four-part fractures and dislocated three-part fractures in elderly patients. In other patients primary open reduction with internal fixation is preferred. Relief of impaction of the humeral head should be avoided. In case of a late osteonecrosis in younger patients hemiarthroplasty is indicated as a secondary procedure.