Anatomical and Pathological Classification of Proximal Humeral Fractures

Classification of fractures of the proximal humerus is essential and should be taken into consideration when planning a surgical reconstruction. The Neer four-part classification for proximal humeral fractures remains the most useful and valuable classification used. In addition, some different variety of four-part fractures and head splitting fractures, as described by Duparc and Jakob, should be included in this classification. However, all classifications fail to consider three main problems that should be taken into consideration: (a) Poor intra-and interobserver reliability: the imprecise recognition of the fracture patterns is often due to the poor quality of the radiographs taken in emergency; computed tomography should be requested if there is any doubt over the fracture type. (b) Difficulty in assessing the displacement of the fracture: there is a tendency to underestimate or to overestimate the severity of some fractures. (c) Age, relevant to bone quality, is probably the most critical factor that should be taken into consideration and that is ignored in any classification; before deciding a treatment for a proximal humeral fractures surgeons should distinguish between young patients with good bone quality and old patients with poor bone quality and osteoporosis.