Abstract
Objective
In complicated Neer three‐ and four‐part proximal humerus fracture (PHF), greater tuberosity (GT) fragments are often comminuted, and the currently widely used locking plate may not fix GT fragments effectively. A further understanding of morphological characteristics of the GT fragments may help explore new fixation devices. This study aimed to determine the fracture line morphology of the GT fragment of Neer three‐ or four‐part PHF and analyze the location relationship between the locking plate and the GT fragment.
Methods
Seventy‐one three‐dimensional computed tomography scans of Neer three‐ and four‐part PHF were retrospectively reviewed between January 2014 and June 2019. Fracture fragments were reconstructed and virtually reduced in the Mimics software, and fracture lines of GT fragments were depicted on a humerus template in the 3‐matic software and then were superimposed altogether. The common sites of the GT fracture were identified, and the location relationship between the locking plate and GT fragments was analyzed in a computer‐simulated scenario.
Results
The fracture line morphology of GT fragments was similar between Neer three‐ and four‐part PHF. The overall morphology of GT fragments was in a fan shape, which could be summarized as anterior, superior, posterior, and middle lines. Of these, we identified 51 split and 29 avulsion type GT fragments based on the Mutch classification, and they could occur simultaneously in a PHF. The overall morphology of split type fragments was in a fan shape, and avulsion type fragments showed a quite distinguishable distribution pattern. A GT fragment could be classified as anterior‐split, posterior‐split, complete‐split, anterior ‐avulsion, and posterior‐avulsion type based on its morphology and location. The median percentage of fragment area covered by the plate was 32.3% in all of the fragments, and it was 69.4%, 23.0%, 37.2%, 21.8%, 0.0% in anterior‐split, posterior‐split, complete‐split, anterior‐avulsion, and posterior‐avulsion type GT fragments. We defined the posterior‐split, anterior‐avulsion, and posterior‐avulsion type GT fragments as the risky GT fragments, and they occurred in 43 (60.6%) Neer three‐ and four‐part PHFs.
Conclusion
The fracture line morphology of GT fragments of Neer three‐ and four‐part PHF was in a fan shape. GT fragments could be classified based on their location and morphology. The extent of GT fragment coverage provided by the locking plate differed in various fragment types, and we identified the anterior‐avulsion, posterior‐avulsion, and posterior‐split type fragments as the risky GT fragments with a high incidence rate in Neer three‐ and four‐part PHFs.
Keywords: Fracture, Greater tuberosity, Internal fracture fixation, Morphology, Proximal humerus
The image showed that the fracture fragments of proximal humerus were reconstructed and virtually reduced in the Mimics software. Reduced fracture models were then imported into the 3‐matic software, and moved, rotated, or horizontally flipped to best match the 3‐D template of proximal humerus. Smooth curves were depicted freehand on the template to represent fracture lines of GT fragments of each case and saved individually. Fracture lines in the same classification category were imported into the 3‐matic software to overlap one another on the template, resulting in a superimposed compilation of fracture lines.
Introduction
In upper limb fractures, the incidence of proximal humerus fracture (PHF) is second only to distal radius fracture, affecting more women than men. 1 , 2 Greater tuberosity (GT) fractures account for approximately 20% of PHF. 3 Most of the isolated GT fractures with minimal displacement can be treated non‐surgically, 4 and those with surgical indications could be managed with various techniques based on morphology. 5 , 6 , 7 In complicated Neer three‐ and four‐part PHF, GT fragments are often comminuted, and the currently widely used locking plate may not fix GT fragments effectively, which are prone to displace during early rehabilitation, leading to malunion and fixation failure. 8 , 9 Therefore, exploring new fixation devices has received much attention in recent years, which is tightly associated with a further understanding of morphological characteristics of the GT fragments of Neer three‐ and four‐part PHF.
Fracture mapping was firstly proposed by Armitage et al. 10 in 2009, which used computer software to reconstruct three‐dimensional fracture models and superimposed all fracture lines from multiple cases on a standard model. The heat map or frequency diagram was used to analyze the distribution pattern of fracture lines and its relationship with bone landmarks and surrounded soft tissue attachments. So far, research on fracture map has mainly focused on the Pilon fractures, ankle fractures, Hoffa fractures, tibial plateau fractures, distal radius fractures, and so on, 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 and has had a wide application in fracture diagnosis and treatment, including surgical exposure, reduction techniques, and implant design to match the fracture morphology.
Concerning the problems we faced in the treatment of complex PHF, it would be of great value to depict the fracture line morphology of GT fragments of Neer three‐ and four‐part PHF. Although a previous study reported by Hasan et al. 15 had displayed fracture line morphology of PHF, it included nearly 50% of less comminuted Neer two‐part fractures, which could not accurately reveal distribution pattern of fracture lines in complicated Neer three‐ and four‐part PHF. This study aimed to identify the fracture line morphology of GT fragments of Neer three‐ and four‐part PHF and investigate the location relationship between the locking plate and GT fragments.
Materials and Methods
Patient Demographic Characteristics
This study was reviewed and approved by the Peking University People′s Hospital Ethics Committee (2020PHB072‐01). In this study, the database was retrospectively retrieved to identify all PHF in our level I trauma center between January 2014 and June 2019.
Inclusion criteria: (i) Neer three‐ or four‐part PHF; (ii) aged above 18 years old; (iii) underwent shoulder CT scan preoperatively.
Exclusion criteria: (i) Neer three‐part PHF featuring a lesser tuberosity fracture morphology; (ii) pathological fractures; (iii) CT scan slice more than 3 mm.
The cohort was composed of 39 Neer three‐part and 32 Neer four‐part fractures with 59 (83.1%) females and a mean age of 69 years. There were 32 left and 39 right shoulders concomitant with six anterior and four posterior dislocations.
Three‐Dimensional CT
Raw data were obtained from the Department of Radiology of Peking University People's Hospital. Multi‐plane reconstructions were calculated by using the Mimics software (Version 20, Materialize) in the Department of Orthopaedics and Trauma.
Proximal Humerus Templates and Fracture Models
The method of fracture mapping described by Xie et al. 19 was used in the study. Briefly, shoulder CT data from a healthy volunteer was used to reconstruct a template of proximal humerus. Then CT data from all patients were imported into the Mimics software (Version 20, Materialize) and analyzed in three planes individually. Fracture fragments of proximal humerus were reconstructed and virtually reduced in the Mimics software (Figure 1). Reduced fracture models were then imported into the 3‐matic software (Version 20, Materialize, Leuven, Belgium), and moved, rotated, or horizontally flipped to best match the 3‐D template of proximal humerus (Figure 2). Smooth curves were depicted freehand on the template to represent fracture lines of GT fragments of each case and saved individually. Fracture lines in the same classification category were imported into the 3‐matic software (Version 20, Materialize, Leuven, Belgium) to overlap one another on the template, resulting in a superimposed compilation of fracture lines. Then, the white lines were depicted freehand to represent the area with intensive fracture lines distribution in Adobe Photoshop software (Version 2020, Adobe, the U.S.). The outline of widely used PHILOS plate was drawn to scale on the template to simulate the fracture fixation during operation. The percentage of fragment area covered by the plate was analyzed in Adobe Photoshop software (Version 2020, Adobe, the U.S.) (Figure 3).
FIGURE 1.
Reconstruction of a 3‐D humerus model. (A) original fracture model; (B) virtually reduced fracture model
FIGURE 2.
Align the reduced fracture model with the template of proximal humerus.
FIGURE 3.
Depicting the GT fracture lines and measuring the percentage of fragment area covered by the locking plate
Outcomes
The main outcome was to describe the fracture line morphology of GT fragments in Neer three‐ and four‐part PHF and analyze the coverage of the locking plate for GT fragments.
Statistical Analysis
SPSS 25.0 software (IBM, the U.S.) was used for statistical processing. Patients and fracture characteristics were demonstrated as the mean and standard deviation or proportion. The percentage of fragment area covered by the plate was shown as median and quartiles. The Mann‐Whitney and Kruskal‐Wallis H tests were used to test whether the differences in percentage of fragment coverage between groups were significant or not. A p of <0.05 was considered as significant. Characteristics of the distribution pattern of fracture lines were descriptive.
Results
Characteristics of Patients
The characteristics of these patients were summarized in Table 1. Female patients were dominant in the cohort. A total of 10 (14.1%) patients were concomitant with shoulder dislocation.
TABLE 1.
Characteristics of PHF patients included in the study
| Neer three part (n = 39) | Neer four part (n = 32) | Neer three and four part (n = 71) | |
|---|---|---|---|
| Age, years, mean ± SD | 69.0 ± 15.0 | 69.1 ± 10.1 | 69.0 ± 13.0 |
| Gender, n (%) | |||
| Male | 5 (12.8%) | 7 (21.9%) | 12 (16.9%) |
| Female | 34 (87.2%) | 25 (78.1%) | 59 (83.1%) |
| Location, n (%) | |||
| Left | 13 (33.3%) | 19 (59.4%) | 32 (45.1%) |
| Right | 26 (66.7%) | 13 (40.6%) | 39 (54.9%) |
| Dislocation, n (%) | |||
| Anterior | 2 (5.1%) | 4 (12.5%) | 6 (8.5%) |
| Posterior | 2 (5.1%) | 2 (6.3%) | 4 (5.6%) |
| None | 35 (89.8%) | 26 (81.3%) | 61 (85.9%) |
Analysis of Fracture Line Morphology by the Neer Proximal Humerus Classification
The fracture line morphology of GT fragments was similar between Neer three‐ and four‐part PHF (Figures S1 and S2). Superimposing their fracture lines altogether, the overall morphology of GT fragments of both Neer three‐ and four‐part PHF was shown in Figure 4. It was in a fan shape, all of the fracture lines were summarized as anterior, superior, posterior, and middle lines. The majority of anterior lines were oblique and distributed at 2–15 mm behind the bicipital groove. Eleven fracture lines passed through the bicipital groove and involved the lateral edge of the lesser tuberosity, with some even extending across the articular surface. According to previous study of RC footprint, 20 most of anterior lines started from the superior RC footprint and ran backwards and downwards. The superior lines were arc‐shaped and located where the upper edge of GT met the rim of the articular surface. Some of superior lines were scattered and passed through the articular surface. The posterior lines were obliquely and intensively distributed at the posterior edge of GT. The posterior lines traveled forwards and downwards and merged with the anterior lines forming a “V” shape. The middle lines originated from the central area of the superior RC footprint and ran along vertically, merging with the apex of the “V”, which split the whole fragment into anterior and posterior parts. The number of fracture lines that passed through the bicipital groove was five (12.8%) in Neer three‐part vs six (16.8%) in Neer four‐part PHF.
FIGURE 4.
Fracture line morphology of GT fragments of Neer three‐ and four‐part proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
Analysis of Fracture Line Morphology by the Mutch Classification
The Mutch classification divided isolated GT fragments into split, avulsion, and compression types. 21 The morphology of all GT fragments was analyzed in the Mimics software to explore the Mutch classification's application in Neer three‐ or four‐part PHF. We found that not all of them could be classified into these three types. Some fractures were head‐split type, and some were split with extension to the humeral shaft. Finally, we identified typical 51 split and 29 avulsion type fragments and zero compression type. The superimposed fracture lines of split and avulsion type fragments were shown in Figures S3 and S4, respectively.
The overall morphology of split type fragments was quite similar to that of all GT fragments. We used the middle lines originated from the superior RC footprint as the boundary. The typical morphology of split type GT fragments can be classified as anterior‐, posterior‐ and complete‐split types according to its location, shown in Figure 5. Among 51 split‐type fragments, there were six (11.8%) anterior‐split, 27 (52.9%) posterior‐split, and 18 (35.3%) complete‐split type fragments.
FIGURE 5.
The typical morphology of split type GT fragments. (A) anterior split type. (B) posterior split type. (C) complete split type
It is noteworthy that the morphology of avulsion type fragments was distinguishable from that of split type fragments. The fracture lines were mainly distributed around the RC footprints. We defined the area near the superior RC footprint as anterior zone and the area around the footprints of infraspinatus and teres minor as posterior zone. The typical avulsion type GT fragments can be classified as anterior‐ and posterior‐avulsion types based on its location, shown in Figure 6. There were 14 (48.3%) anterior‐avulsion and 15 (51.7%) posterior‐avulsion type fragments.
FIGURE 6.
The typical morphology of avulsion type GT fragments. (A) anterior avulsion type. (B) posterior avulsion type
Analysis of Fracture Line Morphology of the Varus/Valgus Displaced PHF
Neck‐shaft angle was measured as described by Iannotti and Pearl by calculating the angle subtended by the centerline of the shaft and a perpendicular line to the base of the anatomic neck. 22 Neck‐shaft angles with <130° were considered varus, whereas >140° were considered valgus and 130–140° were considered neutral. In this group of patients, we identified 48 varus and 23 valgus displaced PHF. The superimposed fracture lines of varus and valgus displaced PHF were shown in Figures S5 and S6, respectively. GT fracture lines in both varus and valgus displaced PHF could be summarized as anterior, posterior, middle, and superior lines with similar distribution.
Coverage of the Locking Plate for GT Fragments
The locking plate completely covered only two cases (2.8%) of GT fragments in 71 Neer three‐ and four‐part PHF. The median percentage of coverage provided by the plate was 32.3% in all of fragments, and it was shown in Table 2 categorized by the Neer proximal humerus classification. The median percentage of coverage was 3.3% in the avulsion type vs 36.5% in the split type fragments, with a significant difference (p < 0.01). We further investigated the coverage in different fragments categorized by their morphology and location, shown in Table 2. Compared with anterior‐split and complete‐split type fragments, the locking plate provided much less coverage to posterior‐split, anterior‐avulsion, and posterior‐avulsion type fragments.
TABLE 2.
Percentage of fragment coverage provided by the locking plate
| Percentage of fragment coverage provided by the locking plate (%) | p | |
|---|---|---|
| Neer classification, median (quartiles) | 0.36 | |
| Neer three part (n = 39) | 30.3 [12.7, 48.4] | |
| Neer four part (n = 32) | 33.9 [26.9, 40.1] | |
| Neer three and four part (n = 71) | 32.3 [21.3, 41.0] | |
| Mutch classification, median (quartiles) | <0.01 | |
| Anterior avulsion (n = 8) | 21.8 [0.8, 43.5] | |
| Posterior avulsion (n = 11) | 0.0 [0.0, 9.2] | |
| Anterior split (n = 5) | 69.4 [51.6, 88.3] | |
| Posterior split (n = 15) | 23.0 [15.8, 35.9] | |
| Complete split (n = 23) | 37.2 [30.7, 56.2] | |
Given the little coverage of the locking plate provided for the posterior‐split, anterior‐avulsion, and posterior‐avulsion type fragments, we'd like to define them as risky GT fragments. Among 80 split and avulsion type GT fragments, the incidence rate of risky fragments was 70%. The risky GT fragments occurred in 43 (60.6%) Neer three‐ and four‐part PHFs.
Discussion
Previous studies have depicted the fracture line morphology of PHF and its association with RC footprints. 15 Our study mainly focused on the morphology of GT fragments of complicated PHF and analyzed the location relationship between the locking plate and GT fragments. The fracture line pattern of GT fragments of Neer three‐ and four‐part PHF was in a fan shape, associated with the RC footprints, and the fragments could be classified as anterior‐split, posterior‐split, complete‐split, anterior‐avulsion, and posterior‐avulsion types based on its location and morphology. The PHILOS locking plate which aims to fix the humeral head and the shaft could not cover the GT fragment with great efficacy, and preoperative evaluation of its type might help design surgical plans.
Characteristics of GT Fracture Lines in Neer Three‐ and Four‐Part PHF
Neer proximal humerus classification is based on the presence or absence of displacement of each of the four segments: articular surface of the humeral head, greater tuberosity, lesser tuberosity, humeral shaft over 1cm, or angulation more than 45°. 23 We inferred that distribution patterns of GT fracture lines were distinguishable between Neer three‐ and four‐part PHF given that four‐part fractures were secondary to a higher energy mechanism. However, it was found that the distribution pattern was quite similar between them. GT fracture lines of both Neer three‐ and four‐part PHF could be summarized as anterior, superior, posterior, and middle lines with the similar distribution. Besides, the fracture morphology was similar between the dislocated and non‐dislocated group.
Fracture lines usually concentrated in the intervals between RC footprints; however, a group of fracture lines that originated from the central area of superior RC footprint were not in accordance with the pattern. Mochizuki et al. 20 discovered the infraspinatus footprint occupied a substantial amount of area of the GT, contributing a lot to shoulder joint stability. Besides, the rotator cable also played an important role. Previous studies found the posterior insertion area of the rotator cable was located in the region between the middle and inferior facets of the GT. 24 Given the anatomical characteristics of soft tissue attachments, there were several possible explanations for this group of middle fracture lines. One was that they were related to posterior insertion sites of the rotator cable, and other was that the infraspinatus tendon consisted of anterior and posterior bundles or at least had two anatomically separated insertion sites, and the fracture lines ran along their intervals.
Despite many similarities with Hasan's research in fracture line morphology, 15 the overall incidence of the bicipital groove fracture was remarkably different. Due to high bone density and protection from surrounded soft tissues, the bicipital groove was rarely broken. In Hasan's study, no fracture lines passed through the bicipital groove, while five (12.8%) cases in Neer three‐part and six (16.8%) in Neer four‐part PHF ran through it in our study. The overall incidence was 15.5%. Notably, Hasan et al. included approximately half of two‐part fractures in the analysis, which could partially explain the lower incidence of the bicipital groove fractures. Our study revealed that the higher energy the patient suffered, the more chances the bicipital groove was broken with.
New GT Fragment Classification Based on the Morphology and Location
Mutch et al. 21 have divided isolated GT fractures into three types: split, avulsion, and compression. Although the morphological system was employed in isolated GT fractures, we would like to know whether it could be utilized to classify GT fragments of complex Neer three‐ and four‐part PHF. When analyzing GT fragments in the Mimics software, we found that not all of them could be classified into the three types. For instance, the head‐splitting type fractures showed a distinctive fracture line pattern. Finally, of all GT fragments, we identified 51 split type and 29 avulsion type fragments. Fracture lines of split type fragments could also be summarized as the four groups of lines with the similar distribution. However, the distribution of avulsion type fragments showed a distinguishable pattern from that of split type fragments. The fracture lines of avulsion type fragments were mainly distributed around the RC footprint, which was in good accordance with the injury mechanism proposed in the Mutch classification system that avulsion type fractures were mainly caused by forceful contraction of RC muscles. Considering the morphology and location of a GT fragment based on the Mutch classification, we would like to divide it into five types: anterior‐split, posterior‐split, complete‐split, anterior‐avulsion, and posterior‐avulsion types.
Coverage of the Locking Plate for GT Fragments
In our study, the locking plate could completely cover only two (2.8%) cases of GT fragments of both Neer three‐ and four‐part PHF in a computer‐simulated scenario, which was consistent with surgical observations that most of the GT fragments could not be covered by the plate with great satisfaction. The locking plate wasn't specially designed for GT fractures, and the tension‐reducing RC sutures were usually employed to stabilize GT fragments in Neer three‐ and four‐part PHF fixation surgery. However, Arvesen et al. 25 found that tension‐relieving RC sutures did not increase stability to the repair of GT fragments in a biomechanical test, which suggested the plate fixation accounted for most of the fragment stability.
The Risky GT Fragment
Our research showed the locking plate provided much less coverage to the avulsion type compared with the split type fragment. The currently widely used locking plate with a width of 20 mm in the upper part was usually located at 8–10 mm below the apex of the GT and 2–4 mm behind the bicipital groove. An anterior avulsion type fragment and posterior fragment were usually out of coverage of the locking plate. Our results demonstrated that the locking plate could not cover the posterior‐split, anterior‐avulsion, and posterior‐avulsion type fragments with good efficacy. Given the importance of fragment coverage, we thus would like to call the posterior‐split, anterior‐avulsion, and posterior‐avulsion type fragment “the risky GT fragment,” which was prone to migrate after the locking plate fixation. Accordingly, additional fixation techniques are needed to stabilize these risky GT fragments.
Notably, the risky fragments occurred in 43 (60.6%) Neer three‐ and four‐part PHFs with a high incidence rate. Besides, the split and avulsion type GT fragments could occur at the same time. Approximately 40% of anterior‐avulsion type fragments occurred with a posterior‐avulsion fragment, and 40% combined with a posterior‐split fragment. Moreover, up to 80% of anterior‐split fragments combined with a posterior‐split type fragment, which suggested these two types of fragments often happened in the meantime.
Limitations
This study has several limitations. Firstly, the size and the morphology of proximal humerus differed in every patient. Although the reduced fracture models were moved, rotated, or horizontally flipped to best match the 3‐D template of proximal humerus, we hardly matched every proximal humerus with the template flawlessly. Besides, we drew fracture lines freehand in the 3‐matic software. Therefore, there was some bias when we depicted fracture lines in the template.
Conclusion
The fracture line morphology of GT fragments of Neer three‐ and four‐part PHF was in a fan shape. GT fragments could be classified based on its location and morphology. The extent of GT fragment coverage provided by the locking plate differed in various fragment types, and preoperative evaluation of fragment type might help design surgical plans.
Author's Contribution
Data collection and acquisition, computer processing: Jiabao Ju, Mingtai Ma, Yichong Zhang, Zhentao Ding; Study design and interpretation of the data: Zhongguo Fu and Jianhai Chen. All authors discussed the results and contributed to the final manuscript.
Conflict of Interest
The authors declared that there was no conflict of interest.
Funding Information
This work was financially supported by the Peking University People's Hospital Scientific Research Development Funds (RDL2021‐08: PTU2021‐06).
Supporting information
FIGURE S1. Fracture line morphology of GT fragments of Neer three‐part proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S2. Fracture line morphology of GT fragments of Neer four‐part proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S3. Fracture line morphology of split type GT fragments. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S4. Fracture line morphology of avulsion type GT fragments. (A) anterior view. (B) lateral view. (C) posterior view. (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S5. Fracture line morphology of GT fragments of varus displaced proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S6. Fracture line morphology of GT fragments of valgus displaced proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
Acknowledgement
We gratefully acknowledged Zixiao Zhang and Sizheng Zhan for data processing.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
FIGURE S1. Fracture line morphology of GT fragments of Neer three‐part proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S2. Fracture line morphology of GT fragments of Neer four‐part proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S3. Fracture line morphology of split type GT fragments. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S4. Fracture line morphology of avulsion type GT fragments. (A) anterior view. (B) lateral view. (C) posterior view. (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S5. Fracture line morphology of GT fragments of varus displaced proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology
FIGURE S6. Fracture line morphology of GT fragments of valgus displaced proximal humerus fractures. (A) anterior view; (B) lateral view; (C) posterior view; (D) superior view. The white lines showed primary distribution pattern of fracture line morphology