FRACTURE OF THE NECK OF THE HUMERUS WITH
DISLOCATION OF THE HEAD FRAGMENT*
CHARLES S. NEER, M.D., THOMAS
AND HARRISON L.
New York, New Ebr-k
T
HIS paper presents a series of fracture-
disIocations of the shouIder treated by the
Fracture Service of the New York
Orthopaedic-CoIumbia-Presbyterian Medical
Center between the years rQzg and 1952. The
Iiterature upon this subject is rather smaIl
FIG. I. Fractures of the upper humerus occur through
Iines of epiphyseal union. Four fragments resuIt: (I)
head, (2) greater tuberosity, (3) lesser tuberosity,
(4) shaft.
and it is disappointing to find that authors var;
in opinion as to what a “fracture-dislocation
of this joint reaIIy is. This, of course, leads to
confusion regarding resuIts of treatment. For
example, one articIel has been wideIy quoted
in support of cIosed manipuIative reduction.
The author is said to have been successfu1 with
this method in six of seven fracture-disIocations.
When one actuaIIy studies these cases, it is
apparent that three of them were straight
forward “surgical neck” fractures and three
* From the Department of Orthopaedic Surgery, College of Physicians and Surgeons, CoIumbia University,
Fracture Service, Presbyterian-New York Orthopaedic Hospitats, New York, N. Y.
252
H. BROWN, JR., M.D.
MCLAUGHLIN, M.D.
other cases, in which dislocation was shown to
be present, the fracture was impacted with
Iittle displacement. It is, therefore, appropriate
to correlate terminology and pathoIogy before
going on to the details of treatment and resuIts.
TERMINOLOGY
Codman” suggested that fractures of the
neck of the humerus occurred through ap-
proximately the lines of epiphyseal union.
(Fig. I.) Four major fragments resuIt: (I) The
anatomic head, (2) the greater tuberosity, (3)
the lesser tuberosity and (4) the shaft. Figures
3 and 4 illustrate the vahdity of his conclusion.
It is, therefore, confusing to attempt, as some
writers have done, to distinguish “surgical
neck fracture-disIocations” from “anatomic
neck fracture-disiocat~ons.” The term “ humeral
neck fracture” is perhaps more accurateIy
descriptive. The four-fragment pattern varies
or& in the degree of displacement of the
individual fragments.
It seems proper to emphasize a second point
made by Codman. 2 The mechanism of injury,
nameIy, Iocking of the humerus against the
acromion in the “pivota position,” is precisely
the same for both fractures of the humera neck
and subcoracoid disIocations of the gIeno-
humera joint. Younger subjects usuaIIy dis-
locate rather than fracture, whereas, in older
individuaIs the bone generally gives way. The
Iatter is presumably due to the reIative weak-
ness of bone in the aged. It is probable that
many of these fractures are associated with
significant soft part damage and are in a sense
fracture-disIocations spontaneousIy reduced.
(Group I, Fig. 2.) It is not possibte to estimate
and the
American Journal of Surgery
 Neer et al.-Fracture of Neck of Humerus 253

the number of lesions of this sort but it must ment rests upon the brachial plexus (Fig. 5),
be quite Iarge. (TabIe I.) making surgica1 approach difficult unless
As the title suggests, this paper concerns it- executed from above downward.7
self only with twenty patients in whom the Clinical. The average age was, interestingly,
head fragment remained extruded for roentgen midway between young and oId, being fifty-six
proof of dislocation. Group I (Fig. 2) illustrates years. One might expect double lesions to
TABLE I

K
INCIDENCE-FRACTURE-DISLOCATION, 1929-1951

1 No. I Percent
I

I;r. neck humerus.. 92’

LMocation .I 855 I :;:; “N IwpRcrEo

Anterior.
Posterior
759
25 i ~
Fr. tuberosity. 71 I
Fr. neck with dislocation. 20 I I
Anterior 1’:
Posterior 3 ~
1
1,796 1 IO0
I IWliCrm

FIG. 2. Classification of humeral neck fracture-dis-

lesions which have been described as “frac- locations.
ture-subIuxation,“3 “abduction fracture-dis-
location, “4“comminutedfracture-dislocation,”” occur in this age group. The history invariabIy
“fracture with dislocation of the shaft”6 and was that of a very heavy faI1 and the patient
by various other terms. It is not intended to was often obese. The left shoulder was involved
discuss Group I further, this has been deaIt in thirteen of seventeen injuries. In contrast
with elsewhere,7-8 but rather to concentrate to many textbook statements, nerve and
upon seventeen anterior and three posterior vascuIar injury was unusua1 with transient
Group II lesions. brachial pIexus symptoms occurring in onIy
two patients and in no instance was operation
ANTERIOR (SUBCORACOID) forced by major-vesse1 injury.‘” (Table II.)
FRACTURE-DISLOCATIONS
TABLE II
Pathology. The fracture remained impacted CIJNICAL--SFVEiXTEEN ANTEKIOR
Ave. age.. ,56 yr.
in onIy two of seventeen subcoracoid dispIace-
Patient. (often obese)
ments. In fifteen patients the head fragment Mechanism. I lard fall (details vague)
had been extruded through the capsuIe and Down stairs.. 4
remained in the “upside down” position as the From train.. 2
arm returned to the side. These lesions present On ice.
Other”faI1” ._.....,_.. :::.:.I ‘1’: 3
a remarkably constant picture, as ihustrated
Hit by car. 2
in Figures 3 and 4. The head is detached, Neurovascular damage. ‘unu.w:rl)
extracapsular, and often rotated as much as Nerve.. 2
I 80 degrees. The greater tuberosity is retracted ?lI:t jor vessel 0
by the external rotators, the Iesser tuberosity
POSTERIOR (SUBSPINOCS)
remains attached to the subscapuIaris and the
FRACTURE-DISLOCATION
shaft is puIIed upward by the Iong muscles
crossing the shoulder joint. The separation of Patbology. The anterior portion of the
the tuberosities uproots the long tendon of the articuIar surface of the humerus is often gouged
biceps. The head fragment is essentiaIIy devoid out by impingement against the posterior
of soft-part attachments and, so Largomarsinog gIenoid in subspinous dislocations.11 However,
has suggested, is even more susceptibIe to the entire anatomic head was separated from
avascular necrosis than the femora1 head in that the humerus and remained posterior in three of
it lacks a ligamenturn teres. The head frag- twenty-five posterior disIocations. (Fig. 6.) In
March, 1033
254 Neer et aI.-Fracture of Neck of Humerus

3A 3B

4A 4B

FIG. 3. A, anteroposterior view and B, lateral view of n typica unimpacted

anterior fracture-dislocation; note the four fragments.
FIG. 4. Two other unimpacted anterior fracture-dislocations. Note constant
pattern and resemblance to Figure 3.

twcCI of the:se patients the lesser tuberosity had, below shoulder level. (Table III.) AH three
in additic m, been avuIsed by the taut sub- patients were muscular young males
sea.pularis . The head fragment retained few
TREATMENT
if any sosft-part attachments. Figure 7 illus-
tra tes the value of obtaining latera or axiIIary Table IV lists the possibIe methocrls of treat-
rot:ntgen views as well as the usuat anterior- ment and indicates the experience with each.
TABLE IV
TABLE III
TREATMENT-TWENTY FRACTURE-DISL .OCATIl 3NS
CLINICAL-THREE POSTERIOR
I. Do nothing.. o
Ave.age....................................36yr.
2. Closed reduction. 6
Mechanism. .Arm below shoulder Ievcl
I 3. Open reduction.. 3
Electrician (shock).
4. Removal head. 16
EpiIeptic (attack). I
SimpIe removal-8
“Fell on ice”. I
With reconstruction-8
Neurovascular damage. none
5, Fusion.. . I
6. RepIacement prosthesis, o
posterior when evaluating posterior gIeno-
humeral dispIacements. CIosed reduction was performed upon six
Clinical. The mechanism of these injuries is occasions and was successfu1 in onIy the two
made obscure by the fact that two of the instances in which the fracture was impacted.
patients were rendered unconscious. One can The head fragment was subsequentIy removed
assume internal rotation leverage with the arm in the four failures. Open reduction was ac-
American Journal of Surgery
 Neer et al.-Fracture of Neck of Humerus 255

compIished in three unimpacted fractures, the inadequate and injudicious in four unimpacted
head and tuberosities being attached to the lesions. Open reduction resulted in failure
shaft by means of suture wire on the bicepital consistantly in three unimpacted Iesions.
tendon. In one patient, the head fragment Figure 8 Zustrates the preoperative, six-week
slipped out of position two days after open postoperative and sixteen-year follow-up result
reduction and was removed two weeks later. of an open reduction indicating severe avascular

Fit. 6. Axillary view of an unimpacted posterior

fracture-dislocation. Head fragment remains
posterior and lesser tuberosity is often avulsed
(not shown).

necrosis. Two other open reductions developed

early complication, already described, requir-
FIG. 5. Unimpacted anterior fracture-dislocation. ing excision of the head.
Note the head fragment extracapsuIar resting upon Resection of the bead removed the fulcrum
the brachial plexus. The retraction of the tuberosities necessary for glenohumeral abduction and
exposes biceps tendon.
rotation. During the early months following
A second required removal of the head for TABLE v
control of infection. Primary arthrodesis was FOLLOW-VP-TWENTY FRACTURE-DISl.OCAI‘IONS
attempted in one of the earlier cases, however, 4 mo.-2 yr 7
,this procedure did not invite repetition. 2-4yr 1
4-6yr I
Ostectomy for removal of the humeral head
6-8 yr. 4
was performed upon sixteen patients and in 8-loyr 3
eight of these an additional reconstructive IO--I2 yr.. I

procedure was executed, e.g., transposition of f2-mr4 yr.. ._. 2

14-16 yr.. 0
the cuff, biceps tendon suspension, excision of
16~18 gr.. I
acromion, or excision of outer end of ctavicle. Average follow-up -6 yrs.
Although repIacement prosthesis is currently
being investigated, this method was not this procedure the shoulder was flail, hut with
employed in this series. progressive fibrosis and ossification gleno-
humeral motion became restricted. Figure 9
RESULTS
demonstrates the preoperative and six years’
Physical evaluation and radiologic examina- result of simple excision of the head. Note the
tion was maintained for an average period of acromial impingement upon fuI1 abduction due
six years after treatment. Table v indicates to the absence of the f&rum. External rotation
the length of follow-up. was usualIy Iess than zero due to posterior dis-
One of the impacted subcoracoid Iesions placement of the greater tuberositv. Fatigue
treated by closed reduction obtained an almost pain was the major compIaint. Five of the
perfect resuIt whiIe the resutt of the second nineteen resections deveIoped soIid bony bridg-
impacted fracture-dislocation was compromised ing from humerus to scaputa. Table VI describes
by the rapid devetopment of avascuIar necrosis various reconstructive procedures performed
of the head fragment. Closed reduction proved with head remova and, contrary to previous

March, ‘933
 Neer et aI.-Fracture of Neck of Humerus

7A 7B
FIG. 7. A, anteroposterior view and B, lateral view of unimpacted posterior
fracture-dislocation. Axillary and lateral roentgenograms arc essential to the
evaIuation of posterior dispIacements.

8A 8B 8C
FIG. 8. A, preoperative; B, six-week Ipostoperative
- and C, sixteen-year follow-up result of an open reduction. Note
late necrosis of the head.

impression, ‘~3-l~ it was concluded that plastic excision of the outer end of the clavicle seemed
procedures upon the muscuIotendinous cuff or to be a worth whiIe adjunct to head removaL
the acromion did not improve the result. Time Iapse from injury to operation13 (seven
There was usuaIIy from 5 to 25 degrees gIeno- patients within twenty-four hours, four patients
humera motion foIlowing head remova regard- within ten days, seven patients from ten days
less of whether or not a pIastic procedure had to six months) did not definiteIy effect the
accompanied the resection. In one patient resuIt nor did postoperative management.
TABLE VI The muscIe power and personality of the
REMOVALHUMERAL HEAD-NINETEEN CASES patient seemed to be the major determining
SimpIe removal.. . 8 factors. In spite of these handicaps, fourteen of
Excision acromion. 5
5
nineteen resection patients were satisfied with
Transpose cuff (tuberosities).
Biceps tendon suspension.. . 2 their result and were carrying out their usual
Excision outer end cIavicIe. . I work without appreciabIe disability.
American Journal of Surgery
 Lj-
Neer et al.-Fracture of Neck of Humerus

9A 9B 9c
FIG. 9. SimpIe excision of the head fragment. A, preoperative; B and (Z, six-year
. result showing maximum abduc-
tion. Note impingement of the humerus upon the acromion due to the absence of the f&rum of the normal head.

Primary arthrodesis was attempted in onIy

one patient proving to be a difficult procedure,
requiring long postoperative immobilization
and resulting in fusion faiIure.14
TabIe v II sums up the results. SimpIe removaI
of the head seemed to be the best procedure to

TABLE VII
SUMMARY RESULTS-TWENTY FRACI-URE-DISLOCATIONS

Failure Work
_-. - ---.

6 Closed reductions. 5
3 Open reductions.. 3
16 Removal head... ,. ,.,.... o 5 mo.
1 Fusion., I yr.
I 1

date for unimpacted Iesions. Nevertheless, the

Iimited motion and fatigue pain folIowing resec-
tion has suggested the possible vaIue of a
replacement prosthesis to serve as a fuIcrum for FIG. IO. A recently devised articular rcplaccmcnt
motion. Figure IO depicts an attempt to currently being investigated.
achieve such an instrument. This was onI>
recentIy devised and has not as yet had ade-
should be reduced by carefully performed open
quate trial.
or closed methods, but with the knowledge
that the head may subsequently undergo
CONCLUSIONS
necrotic change.
I. Twenty fractures of the neck of the 4. The best treatment to date for unim-
humerus with disIocation of the head fragment pacted lesions is simpIe excision of the head
are presented. The pathology and terminology fragment.
are correlated. 3. RepIacement prothesis presents logical
2. Primary arthrodesis is rendered difFicuIt possibilities and may prove of value in dealing
by humera neck fracture. with major injuries of humera head. Its true
3. If the fracture is impacted, the dislocation worth remains to be determined.

March, 193’3
258 Neer et al-Fracture of Neck of Humerus

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American Journal of Surgery