Abstract
Background
Fractures of the proximal humerus are prevalent among the elderly, often posing challenges in anatomical reconstruction and internal fixation. Precise anatomical knowledge tailored to specific populations is essential for optimal surgical outcomes. This study aims to quantitatively evaluate the anatomical characteristics of the proximal humerus in the Vietnamese population through multiplanar computed tomography (CT) and cadaveric measurements, and to determine the consistency between the two modalities.
Methods
A prospective descriptive study was conducted on 75 CT scans and 30 shoulder specimens from 15 fresh cadavers. Parameters measured included the neck-shaft angle, diameters of the humeral head (superior-inferior and anterior-posterior), width of the greater tuberosity, deltoid tuberosity index, and distances from the greater tuberosity to anatomical landmarks such as the lesser tuberosity, bicipital groove, and pectoralis major insertion.
Results
The average neck-shaft angle was 132.36° ± 2.44°, with most values within 130°–140°. The deltoid tuberosity index averaged 1.76 ± 0.20, exceeding thresholds reported in previous studies. No statistically significant differences were found between CT and cadaveric measurements across most parameters (p > 0.05). The anatomical measurements were found to be smaller than those reported in Western populations but comparable to other Asian populations.
Conclusion
The study confirms that CT imaging provides reliable and accurate morphometric data comparable to cadaveric dissection. Key anatomical landmarks such as the pectoralis major insertion, lesser tuberosity, and bicipital groove can serve as consistent intraoperative references for implant positioning in Vietnamese patients.
Keywords: Proximal humerus anatomy, Neck-shaft angle, Deltoid tuberosity index, Computed tomography, Cadaveric morphometry
1. Introduction
Fractures of the proximal humerus are among the most common types of fractures in the elderly, accounting for approximately 4–8 % of all fractures and nearly 50 % of shoulder-related fractures.1,2 These injuries predominantly affect women over the age of 60, with a reported female-to-male ratio of 3:1, particularly in complex three- or four-part fractures classified according to the Neer system.1,2 Complex proximal humeral fractures are often associated with complications such as avascular necrosis of the humeral head, displacement of fracture fragments, and difficulty in achieving both anatomical reduction and functional restoration of the shoulder joint.
A comprehensive understanding of the proximal humerus anatomy is essential for tailoring treatment strategies to individual cases. Anatomically, the proximal humerus comprises the humeral head (approximately one-third of a sphere), anatomical neck, surgical neck, greater and lesser tuberosities, the intertubercular (bicipital) groove, and the metaphyseal region.3 The humeral head articulates with the glenoid cavity of the scapula to form the glenohumeral joint, which facilitates a wide range of shoulder movements.
Globally, numerous studies have investigated the morphological characteristics of the proximal humerus. Notably, Iannotti et al. (1992) examined 140 dry bone specimens to define normal anatomical parameters,4 while Hertel et al. (2002) introduced a three-dimensional spatial coordinate system using computed tomography (CT) to measure geometrical aspects of the humeral head and tuberosities, thereby supporting prosthesis design optimization.5 More recently, Matsumura and colleagues (2016) employed magnetic resonance imaging to analyze the humeral head morphology in a Japanese population.6
In Vietnam, however, detailed morphometric studies of the proximal humerus specific to the Vietnamese population remain limited. A recent study by Nguyen Duc Vuong (2020) described certain radiographic characteristics of the proximal humerus using X-ray and CT imaging.7 Multiplanar CT reconstructions have proven to be a reliable modality for detailed evaluation of complex anatomical structures, with the added advantage of not being affected by patient positioning, as is often the case with conventional radiography.8 Combining CT-derived data with direct cadaveric measurements provides a comprehensive and accurate dataset regarding the size, angles, and spatial relationships of the proximal humerus.
Understanding the anatomical features of the proximal humerus in the Vietnamese population is vital for clinical diagnosis, fracture assessment, and the selection of appropriate osteosynthesis techniques and fixation devices. These morphometric parameters also serve as a valuable reference for designing implants such as locking plates, intramedullary nails, or prosthetic components tailored to the Vietnamese anatomical context.
The aim of this study is to investigate the anatomical characteristics of the proximal humerus using CT imaging at the Hospital for Traumatology and Orthopedics and cadaveric dissection at the University of Medicine and Pharmacy in Ho Chi Minh City.
2. Materials and methods
2.1. Study population
This study was conducted on a total of 75 computed tomography (CT) scan samples from 69 patients at the Hospital for Traumatology and Orthopedics in Ho Chi Minh City between March 2018 and December 2019. Additionally, 30 shoulder specimens were obtained from 15 fresh cadavers at the University of Medicine and Pharmacy, Ho Chi Minh City, during the period from January to March 2020.
2.2. Inclusion criteria
CT imaging: Patients who underwent non-contrast-enhanced CT scans of the unaffected shoulder with a slice thickness of 0.625 mm. The scan images were required to fully encompass the proximal humerus, from the humeral head to the deltoid tuberosity.
Cadaveric samples: Fresh cadaveric specimens provided by the Department of Anatomy, University of Medicine and Pharmacy, Ho Chi Minh City.
2.3. Exclusion criteria
Both CT and cadaveric samples were excluded if any of the following conditions were present: degenerative changes, bone cysts, tumors, congenital anomalies, or prior surgical interventions involving the proximal humerus on the examined side. Patients or legal guardians who did not consent to participate, or CT images of insufficient quality, were also excluded.
2.4. Study design
This was a prospective, descriptive case series study.
2.5. Procedures
2.5.1. CT imaging analysis
For each eligible patient, demographic data including age, sex, and side of the scanned shoulder were recorded. CT image datasets were processed using Radiant DICOM Viewer software (version 2022.1.1). Using the 3D Multiplanar Reconstruction (MPR) mode, the axial, coronal, and sagittal planes were reconstructed based on identifiable anatomical landmarks of the humeral head (see Fig. 1).
Fig. 1.
Measurement of anatomical parameters of the proximal humerus using computed tomography (CT).
Number 1, 2, and 3 demonstrate the identification of the principal anatomical planes (axial, coronal, and sagittal).
Figure A: Measurement of the neck-shaft angle.
Figure B: Measurement of the anterior-posterior diameter of the humeral head.
Figure C: Measurement of the distance from the superior border of the greater tuberosity to the apex of the humeral head.
Subsequently, the following morphometric parameters of the proximal humerus were measured on appropriate reconstructed slices (Fig. 2):
Fig. 2.
Anatomical assessment of the proximal humerus on cadaveric specimens.
Figure A: Identification of key anatomical landmarks.
Figure B: Measurement of the superior-inferior diameter of the humeral head.
Figure C: Measurement of the distance from the superior border of the pectoralis major tendon to the apex of the greater tuberosity.
Figure D: Measurement of the width of the greater tuberosity.
Figure E: Measurement of the distance from the highest point of the lesser tuberosity to the apex of the greater tuberosity.
Figure F: Measurement of the distance from the superior margin of the bicipital groove to the apex of the greater tuberosity.
Neck-shaft angle.
Distance from the apex of the greater tuberosity to the humeral head.
Distance from the apex of the greater tuberosity to the highest point of the lesser tuberosity.
Distance from the apex of the greater tuberosity to the superior margin of the bicipital groove.
Superior-inferior and anterior-posterior diameters of the humeral head.
Width of the greater tuberosity.
Deltoid tuberosity index (DTI).
Measurements were recorded on images corresponding to the most accurate anatomical planes for each parameter.
2.5.2. Cadaveric dissection and measurements
In each cadaveric specimen, a deltopectoral skin incision was performed to expose the proximal humerus. Key anatomical landmarks—including the acromion, greater tuberosity, lesser tuberosity, and the superior border of the pectoralis major muscle—were identified and marked.
Using a calibrated vernier caliper, the following anatomical parameters were measured directly:
The width of the greater tuberosity.
The distance from the apex of the greater tuberosity to the highest point of the lesser tuberosity.
The distance from the apex of the greater tuberosity to the superior margin of the bicipital groove.
The superior-inferior and anterior-posterior diameters of the humeral head.
The height of the pectoralis major tendon insertion on the humeral shaft.
The distance from the superior border of the pectoralis major tendon to the apex of the greater tuberosity.
These measurements were conducted in a standardized manner to ensure accuracy and reproducibility.
2.5.3. Ethical considerations
This study was approved by the Institutional Review Board of the University of Medicine and Pharmacy at Ho Chi Minh City (Approval No. 485/HĐĐĐ-ĐHYD, dated August 26, 2020). All participants were fully informed about the study objectives and procedures and provided written informed consent prior to participation. They retained the right to withdraw from the study at any time without any consequences. All personal information and patient data were kept strictly confidential and used solely for research purposes.
3. Results
Between March 2018 and December 2019, a total of 75 proximal humerus CT scans from 69 patients (25 males and 44 females) were analyzed at the Hospital for Traumatology and Orthopedics in Ho Chi Minh City. Among them, 63 patients underwent CT imaging of one shoulder, while 6 patients had scans of both shoulders. The mean age of the study population was 58.99 ± 6.73 years, ranging from 50 to 78 years. The male-to-female ratio was approximately 1:1.59. The distribution of left and right shoulders was nearly equal, accounting for 52 % and 48 %, respectively.
The anatomical measurements of the proximal humerus obtained from CT scans are presented in Table 1.
Table 1.
Morphometric parameters of the proximal humerus measured on CT scans (n = 75).
| Parameter | Mean ± SD | Range (Min – Max) |
|---|---|---|
| Neck-shaft angle (°) | 132.36 ± 2.44 | 125.4–137.6 |
| Superior-inferior diameter of the humeral head (mm) | 41.30 ± 2.78 | 36.78–41.22 |
| Anterior-posterior diameter of the humeral head (mm) | 39.21 ± 2.98 | 36.65–41.02 |
| Width of the greater tuberosity (mm) | 31.22 ± 2.04 | 29.16–33.24 |
| Distance from the highest point of the lesser tuberosity to the GT apex (mm) | 12.31 ± 2.09 | 10.25–14.41 |
| Distance from the superior bicipital groove to the GT apex (mm) | 6.87 ± 1.83 | 5.94–8.72 |
| Distance between the greater tuberosity and humeral head apex (mm) | 5.67 ± 0.67 | 4.51–7.14 |
| Optimal maximum calcar screw length (mm) | 59.25 ± 2.67 | 55.78–62.35 |
| Deltoid tuberosity index (DTI) | 1.76 ± 0.20 | 1.40–2.39 |
GT = greater tuberosity.
Additionally, 30 proximal humerus specimens (15 left and 15 right shoulders) were collected from 15 fresh cadavers for cadaveric evaluation. The morphometric data derived from cadaveric specimens are summarized in Table 2.
Table 2.
Morphometric parameters of the proximal humerus measured on cadaveric specimens (n = 30).
| Parameter | Mean ± SD | Range (Min – Max) |
|---|---|---|
| Width of the greater tuberosity (mm) | 32.07 ± 3.72 | 29.92–40.19 |
| Superior-inferior diameter of the humeral head (mm) | 40.34 ± 4.51 | 32.62–50.34 |
| Anterior-posterior diameter of the humeral head (mm) | 39.60 ± 3.18 | 33.13–45.28 |
| Distance from the highest point of the lesser tuberosity to GT apex (mm) | 13.10 ± 2.13 | 10.95–15.21 |
| Distance from the superior bicipital groove to GT apex (mm) | 7.14 ± 1.62 | 5.85–8.62 |
| Distance from the superior border of the pectoralis major to GT apex (mm) | 59.45 ± 7.99 | 39.47–73.77 |
| Height of the pectoralis major tendon insertion (mm) | 59.76 ± 8.11 | 44.31–74.51 |
4. Discussion
The mean neck-shaft angle in our study was 132.36° ± 2.44°, which is generally lower than values reported in previous studies using different methodologies. For instance, Goldberg et al. (2020) reported a mean angle of 137° ± 6° based on dry bone specimens,9 McPherson et al. (1997) observed a mean of 141° ± 8.6° from radiographic images,10 and Hertel et al. (2002) reported 137° ± 3.62° using CT analysis.5 Direct measurement on cadaveric specimens is known to be less precise compared to computed tomography (CT), and several studies have indicated that upper limb positioning during radiographic acquisition may influence the measurement of the neck-shaft angle, with values obtained from X-rays often tending to be higher than those measured using CT.
In our study, the use of multiplanar reconstruction (MPR) with CT helped mitigate errors related to humeral positioning, providing more accurate and consistent measurements. When comparing our results with those of other studies utilizing CT-based methods, we observed statistically significant differences (p < 0.05). However, our findings are closely aligned with those reported by Jeong et al. (2009), who found a mean neck-shaft angle of 133.42° ± 6.16°, and Sahu et al. (2020), who reported 133.8° ± 6.4°,11,12 likely due to the similar imaging and measurement techniques.
In our sample, 82.67 % of proximal humeri had a neck-shaft angle within the commonly cited range of 130°–140°, a range frequently observed in anatomical studies of the proximal humerus. Other authors have similarly reported that approximately 80 % of the population falls within this range. Nevertheless, approximately 20 % of individuals exhibit neck-shaft angles outside this range—either below 130° or above 140°—indicating that although this angle has a typical range, it remains subject to individual and ethnic variability.
Regarding the distance from the apex of the greater tuberosity to the humeral head, our findings yielded a smaller average value compared to those reported by Loebenberg et al. (6.7 mm), Takase et al. (6.7 ± 2 mm), and Yoo et al. (7.50 ± 0.99 mm).13, 14, 15 This discrepancy may be attributed to racial and anatomical differences, particularly the smaller body habitus of the Vietnamese population compared to Western cohorts. Nevertheless, all aforementioned studies reported values within a general range of 5–10 mm, consistent with our results. Based on these findings, it is advisable that, during internal fixation of proximal humeral fractures, the distance from the apex of the greater tuberosity to the superior edge of the plate be maintained within 5–8 mm for optimal alignment.
Spross et al. (2015) introduced the deltoid tuberosity index (DTI) as a simple radiographic tool that correlates with local bone mineral density in the proximal humerus, proposing a critical threshold of 1.4 below which the risk of intraoperative fracture and screw cutout increases.16 Wickman et al. (2022) later supported a similar threshold value of 1.44.17 In our study, the mean DTI was 1.76 ± 0.20, notably higher than the thresholds reported in these earlier studies. This variation may be explained by differences in the patient population; most participants in our study were between 50 and 60 years of age. While age-related bone quality decline may have begun, it was likely not as pronounced as in older populations studied previously. Despite some variability among studies, DTI remains a simple, reliable index that can serve as a preoperative predictor of bone strength and potential fixation-related complications.
Several anatomical parameters were assessed in both CT scans and cadaveric specimens, and these are summarized in Table 3.
Table 3.
Comparison of selected proximal humerus anatomical parameters measured on CT images and cadaveric specimens.
| Parameter | CT Imaging (n = 75) | Cadaveric Specimens (n = 30) | p-value |
|---|---|---|---|
| Superior-inferior diameter of the humeral head (mm) | 41.30 ± 2.78 | 40.34 ± 4.51 | 0.1887 |
| Anterior-posterior diameter of the humeral head (mm) | 39.20 ± 2.98 | 39.60 ± 3.18 | 0.5435 |
| Width of the greater tuberosity (mm) | 31.20 ± 2.04 | 32.07 ± 3.72 | 0.1279 |
| Distance from the highest point of the lesser tuberosity to GT apex (mm) | 12.30 ± 2.09 | 13.10 ± 2.13 | 0.0810 |
| Distance from the superior bicipital groove to GT apex (mm) | 6.87 ± 1.83 | 7.14 ± 1.62 | 0.4825 |
Data are presented as mean ± standard deviation. Statistical significance was assessed using the paired t-test. A p-value <0.05 was considered statistically significant.
In our study, the differences between CT and cadaveric measurements for both the anterior-posterior and superior-inferior diameters of the humeral head were not statistically significant (p = 0.5435 and p = 0.1887, respectively). Similarly, the width of the greater tuberosity measured via CT (31.20 ± 2.04 mm) and cadaveric dissection (32.07 ± 3.72 mm) showed no significant difference (p = 0.1279). These findings support the conclusion that computed tomography is a reliable modality for assessing proximal humeral anatomy, with measurements closely approximating those obtained through direct anatomical dissection.
The values for humeral head diameter (both superior-inferior and anterior-posterior) in our study were generally lower than those reported in studies conducted on Western populations, but were comparable to data from Asian populations using similar methodologies. This disparity may be explained by racial and anthropometric differences, particularly height and body size, as studies from the United States and Europe often reflect populations with greater average stature than that of the Vietnamese cohort.
Recent CT-based studies have reported humeral head dimensions in other Asian populations. Sahu et al. (2020) documented mean superior-inferior and anterior-posterior diameters of 42.3 ± 3.0 mm and 40.1 ± 2.8 mm, respectively, in an Indian population,12 while Suroto et al. (2022) reported 41.3 ± 3.5 mm and 39.3 ± 2.4 mm in an Indonesian population.18 Although these values are slightly higher than those in our Vietnamese cohort, the differences were not statistically significant when comparing superior-inferior diameters (p = 0.059 and p = 0.98) and anterior-posterior diameters (p = 0.093 and p = 0.8146), suggesting that the body habitus of these populations may be sufficiently similar.
Regarding the width of the greater tuberosity, Quinlan et al. (2021) reported a mean value of 35 ± 4 mm in an American population using MRI,19 whereas Zhiyao Li et al. (2023) measured 31.39 ± 2.74 mm on CT scans in a Chinese population.20 The American data were significantly higher than ours (p < 0.001), while the Chinese data were not significantly different (p = 0.6388), further emphasizing the influence of ethnic and regional variation.
Understanding the dimensions of the humeral head and greater tuberosity in the Vietnamese population is crucial for surgeons in selecting appropriate implant sizes, determining screw trajectories, and optimizing plate positioning tailored to local anatomical norms.
Similarly, no statistically significant differences were observed between CT and cadaveric measurements for the distance from the apex of the greater tuberosity to the highest point of the lesser tuberosity (p = 0.081) or to the superior border of the bicipital groove (p = 0.4825). To our knowledge, no prior studies have reported these specific measurements. In clinical settings, particularly in cases of comminuted fractures of the greater tuberosity, accurately identifying the tuberosity apex can be challenging. Therefore, alternative, consistent anatomical landmarks—such as the highest point of the lesser tuberosity and the bicipital groove—may serve as more reliable intraoperative references.
From cadaveric dissection, we found that the mean distance from the superior border of the pectoralis major tendon to the apex of the greater tuberosity was 59.45 ± 7.99 mm, and the mean height of the pectoralis major tendon insertion was 59.76 ± 8.11 mm. Murachovsky et al. (2006) and Torrens et al. (2008) both reported an average tendon height of 56 mm and proposed using the pectoralis major as a reference point for humeral height restoration in hemiarthroplasty procedures.21,22 Ponce et al. (2013) conducted a meta-analysis incorporating height, weight, and gender and found that the pectoralis major tendon height increased by 1.7 mm for every 10 mm in patient height above 1.7 m. The mean distance from the tendon to the greater tuberosity was 59 mm in males and 57 mm in females.23 Kulkamthorn et al. (2022) conducted a cadaveric study in a Thai population and reported similar values: an average tendon height of 60.73 ± 7.89 mm and a mean distance from the tendon's upper border to the greater tuberosity of 61.32 ± 7.53 mm.24 Given the similar body habitus between Thai and Vietnamese individuals, these results are consistent with our findings (p = 0.5348 and p = 0.4432).
Accurate anatomical understanding of the proximal humerus is fundamental for successful fracture fixation and implant design, particularly in populations with unique skeletal characteristics. Le et al. highlighted the considerable variability in proximal humeral geometry, suggesting the need for individualized assessment to avoid implant malalignment.25 Building on this, the current study provides population-specific data for Vietnamese individuals, contributing to the growing body of literature emphasizing the importance of ethnicity-based morphometric research. Nguyen et al. underscored the evolution of hand and upper extremity surgery in Vietnam and the need for training and design adaptations suitable for regional practices and anatomy.26
Race- and gender-related anthropometric differences in long bones and joints are critical considerations in the design of orthopedic implants, particularly in anatomically complex regions like the proximal humerus. Standard implant systems, often developed based on Western population data, may not adequately match the morphological characteristics observed in Asian populations, potentially affecting surgical outcomes. Rollo et al. introduced a novel proximal humerus plate (PGR plate) and compared it with the widely used Philos plate, highlighting how plate geometry and fixation strategy significantly influence outcomes in three- and four-part fractures. Their findings demonstrated that implant design tailored to anatomical challenges—especially involving the greater tuberosity—can enhance fixation stability and reduce complications such as varus collapse and screw cut-out. These observations support the need for population-specific morphometric data, like those presented in our study, to inform implant design and improve clinical outcomes across diverse demographic groups.27
In most cases of proximal humerus fracture, the insertion of the pectoralis major tendon on the humeral shaft remains intact. Therefore, this structure may serve as a reliable and consistent anatomical landmark for plate positioning and intraoperative orientation.
5. Conclusion
This study provides a comprehensive morphological analysis of the proximal humerus in Vietnamese individuals aged 50 years and older, using both computed tomography (CT) imaging and cadaveric dissection. The results demonstrate that the majority of neck-shaft angles fall within the commonly referenced range of 130°–140°, though notable variation exists between individuals and across populations.
In cases of proximal humerus fractures—particularly comminuted fractures involving the greater tuberosity—accurate identification of the tuberosity apex can be challenging. Based on our findings, we recommend the use of consistent anatomical landmarks such as the highest point of the lesser tuberosity, the superior margin of the bicipital groove, and the upper border of the pectoralis major tendon as reliable references for plate positioning. The measured distance from the apex of the greater tuberosity to the humeral head, typically within the 5–10 mm range, supports the clinical guideline of positioning PHILOS plates approximately 5–8 mm below the tuberosity apex—an approach that appears suitable for the Vietnamese population.
Our findings also confirm that CT-based measurements are comparable to those obtained from cadaveric specimens, validating CT as a reliable modality for anatomical assessment. The dimensional values observed in the Vietnamese cohort differ from those reported in Western populations but are consistent with findings from other Asian populations, highlighting the importance of population-specific anatomical data.
Understanding these anatomical characteristics can assist orthopedic surgeons in selecting appropriate implant dimensions and orientations, thereby improving surgical accuracy and outcomes. This study contributes valuable reference data to support surgical planning and internal fixation strategies for proximal humerus fractures in the Vietnamese population.
Funding
None.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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