Fracture of Surgical Neck of Humerus
This is one of the most common fractures in elderly osteoporotic women. It is called the "Surgical Neck" because it is narrower and more prone to fracture than the "Anatomical Neck" (which is just below the head).
[Image of Proximal Humerus Fracture Types]1. Anatomy & Nerves
- Location: Junction of the shaft and the proximal end (below tuberosities).
- Nerve at Risk: Axillary Nerve (wraps around the surgical neck).
- Vessels: Posterior Circumflex Humeral artery.
2. Neer Classification (4-Part System)
Based on the 4 segments: Head, Shaft, Greater Tuberosity, Lesser Tuberosity. A segment is "displaced" if:
- Separation > 1 cm OR
- Angulation > 45 degrees.
3. Clinical Features
- Large bruise on the upper arm and chest wall (Hennequin's Sign) appears after 24-48 hours.
- Pain and swelling.
4. Management
- One-Part (Non-displaced): 80% of cases. Treated with Collar & Cuff Sling for 3-4 weeks.
- Two/Three/Four-Part: Often requires surgery (ORIF with Plate/Screws or Nailing).
- Elderly with severe comminution: Hemiarthroplasty or Reverse Shoulder Arthroplasty.
5. Physiotherapy
- Week 1-3: Pendulum (Codman’s) exercises. Hand/Elbow ROM.
- Week 4-6: Active assisted ROM (Pulleys, Stick exercises).
- Week 6+: Strengthening. Warning: Stiffness is the main enemy!
25 Practice MCQs
Q1. The nerve most at risk in Surgical Neck fractures is:
Answer: B). It runs in close proximity to the surgical neck.
Q2. Neer classification defines a segment as displaced if separation is more than:
Answer: A). Or angulation > 45 degrees.
Q3. Hennequin's sign refers to:
Answer: A). Due to gravity, blood tracks down to the elbow and chest.
Q4. The most common demographic for this fracture is:
Answer: B). Often from a low-energy fall.
Q5. Codman's exercises are also known as:
Answer: B). Uses gravity to gently mobilize the joint.
Q6. Which artery accompanies the Axillary nerve?
Answer: B). It winds around the surgical neck.
Q7. Anatomical Neck fractures are dangerous because:
Answer: A). It disrupts blood supply to the head. Surgical neck fractures have lower AVN risk.
Q8. The majority (80%) of proximal humerus fractures are:
Answer: A). Treated conservatively.
Q9. Which is NOT one of the 4 parts in Neer's classification?
Answer: D). The Lesser Tuberosity is the 4th part.
Q10. Reverse Shoulder Arthroplasty is preferred in elderly if:
Answer: B). Reverse polarity allows the Deltoid to lift the arm without the cuff.
Q11. Main complication of conservative management is:
Answer: B). Early mobilization is critical.
Q12. Abduction is initiated by:
Answer: A). First 15-30 degrees.
Q13. The pectoralis major pulls the shaft fragment:
Answer: A). Creates displacement.
Q14. A "Two-part Surgical Neck Fracture" implies:
Answer: A). The most common displaced pattern.
Q15. When checking Axillary nerve function, test sensation over:
Answer: B). Specific dermatome for Axillary nerve.
Q16. Internal fixation is usually achieved with:
Answer: A). Proximal Humeral Internal Locking System (PHILOS) is gold standard.
Q17. Sleeping posture recommended in acute phase:
Answer: A). Reduces pain and swelling.
Q18. Valgus impacted fractures usually have a prognosis that is:
Answer: A). The medial hinge is intact, preserving blood supply.
Q19. In 3-part fractures involving the Greater Tuberosity, which motion is lost?
Answer: A). Because the rotator cuff (Supraspinatus/Infraspinatus) is detached.
Q20. "Head-splitting" fractures have a very high risk of:
Answer: B). Articular surface is destroyed.
Q21. Pendulum exercises should be done:
Answer: A). This is passive mobilization. Active swinging defeats the purpose.
Q22. Union typically occurs by:
Answer: B). Though rehab continues for months.
Q23. Complex Regional Pain Syndrome (CRPS) is:
Answer: A). Also known as RSD; requires aggressive pain management.
Q24. Can a "Hanging Cast" be used?
Answer: A). In neck fractures, the weight of a cast can distract the fragments too much (non-union).
Q25. The "Ice Cream Cone" appearance usually refers to:
Answer: B). The epiphysis (ice cream) slips off the metaphysis (cone).
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