Understanding and Managing Surgical Neck, Anatomical Neck / Greater Tuberosity Fractures

What is a surgical Neck of Humerus Fracture vs Anatomical Neck of Humerus vs Greater Tuberosity Fracture? What are the causes and characteristics of these fractures?

Surgical neck of humerus, anatomical neck of humerus and greater tuberosity fractures all refer to fractures in different parts of the humerus – upper arm bone. 

Surgical Neck of Humerus Fracture

Location and Description:

  • The surgical neck of the humerus describes the bone located just below the tubercles (greater and lesser tuberosities) of the humeral head.
  • It is a common site for fractures, particularly in older adults, often due to falls on an outstretched hand.

Characteristics:

  • Displacement: Fractures here can be displaced or non-displaced.
  • Vascular Considerations: Less likely to disrupt blood supply to the humeral head compared to anatomical neck fractures.

Causes:

  • Falls: Commonly caused by falls in the elderly.
  • Direct Trauma: Can also result from direct blows to the upper arm.

Anatomical Neck of Humerus Fracture

Location and Description:

  • The anatomical neck of the humerus describes the bone located just below the articular surface of the humeral head, above the tubercles.
  • Fractures here are less common but more serious due to the risk of compromising blood supply to the humeral head.

Characteristics:

  • Complexity: Often involve the joint surface and can result in avascular necrosis of the head of the humerus.
  • Severity: Usually more severe and challenging to treat than surgical neck fractures.

Causes:

  • High-Energy Trauma: Often result from high-energy trauma, for example car accidents or falls from significant heights.

Greater Tuberosity Fracture

Location and Description:

  • The greater tuberosity is a bony prominence on the lateral aspect of the humerus, where the rotator cuff muscles attach.
  • Fractures of the greater tuberosity can occur in isolation or in addition to a more complex fracture pattern.

Characteristics:

  • Displacement: Can be minimally displaced or significantly displaced, affecting shoulder function.
  • Rotator Cuff Involvement: Often associated with injuries to the rotator cuff tendons.

Causes:

  • Falls: Commonly result from falls, particularly onto the shoulder.
  • Direct Trauma: Can also occur from direct impacts to the shoulder.
Humerus Fracture
Accident involving a fall potentially leading to a fracture

Risk Factors and potential complications of Surgical Neck Humerus, Anatomical Neck of humerus and Greater Tuberosity Fractures

The risk factors and complications vary depending on the type of fracture:

1. Surgical Neck of Humerus Fracture

Risk Factors:

  • Age: Elderly individuals, especially those with osteoporosis.
  • Falls: Increased risk due to balance issues or environmental hazards.
  • Low Bone Density: Osteoporosis or other conditions that weaken bones.
  • High-Energy Trauma: Car accidents, sports injuries, or falls from a height.

Potential Complications:

  • Non-Union or Delayed Union: The fracture may heal slowly or not at all.
  • Malunion: Healing in an incorrect position, potentially affecting arm function.
  • Nerve Injury: Risk of injury to the axillary nerve, leading to weakness or numbness in the shoulder.
  • Vascular Injury: Less common, but possible disruption of blood supply.
  • Shoulder Stiffness: Reduced range of motion due to prolonged immobilisation.
  • Rotator Cuff Tears: Associated injuries to the rotator cuff muscles or tendons

2. Anatomical Neck of Humerus Fracture

Risk Factors:

  • High-Energy Trauma: Car accidents, falls from a height, or severe sports injuries.
  • Younger Adults: Often due to high-energy impacts.
  • Low Bone Density: Osteoporosis or other conditions that weaken bones.
  • Sports: Contact sports like rugby or wrestling or activities with a high risk of falls.

Potential Complications:

  • Avascular Necrosis: Due to disruption of blood supply to the humeral head, leading to bone death.
  • Non-Union or Delayed Union: Challenges in healing due to the complex nature of the fracture.
  • Malunion: Healing in an incorrect position, potentially affecting joint mechanics and function.
  • Nerve Injury: Risk of injury to the axillary nerve or other nearby nerves.
  • Arthritis: Post-traumatic arthritis due to joint involvement.
  • Shoulder Stiffness: Reduced range of motion due to prolonged immobilisation or joint damage.

3. Greater Tuberosity Fracture

Risk Factors:

  • Falls: Especially onto the shoulder, common in both young and elderly populations.
  • Sports: Activities involving heavy lifting, throwing, or direct impact.
  • Direct Trauma: Blunt force impacts to the shoulder.
  • Osteoporosis: Increased susceptibility in older adults.

Potential Complications:

  • Rotator Cuff Injury: Tears or damage to the rotator cuff muscles and tendons, affecting shoulder function.
  • Non-Union or Delayed Union: Particularly if the fracture is significantly displaced.
  • Malunion: Healing in an incorrect position, potentially affecting shoulder mechanics.
  • Shoulder Impingement: Due to improper healing or bone spurs.
  • Shoulder Stiffness: Reduced range of motion, particularly if immobilisation is prolonged.
  • Arthritis: Post-traumatic arthritis due to joint involvement.

Summary

Surgical Neck of Humerus Fracture:

  • Risk Factors: Elderly age, falls, low bone density, high-energy trauma.
  • Complications: Non-union, malunion, nerve injury, shoulder stiffness, rotator cuff tears.

Anatomical Neck of Humerus Fracture:

  • Risk Factors: High-energy trauma, younger adults, low bone density, sports.
  • Complications: Avascular necrosis, non-union, malunion, nerve injury, arthritis, shoulder stiffness.

Greater Tuberosity Fracture:

  • Risk Factors: Falls, sports, direct trauma, osteoporosis.
  • Complications: Rotator cuff injury, non-union, malunion, shoulder impingement, shoulder stiffness, arthritis.

Proper management and treatment by an orthopaedic specialist are crucial to address these risk factors and minimise potential complications. Access Ortho is an urgent injuries fracture clinic that can provide the care you need for fractures and sprains.

Diagnosing  Humerus Surgical Neck, Anatomical neck and Greater Tuberosity Fractures  

Common Steps in Diagnosis of humerus neck and tuberosity fractures are:

  • Clinical Evaluation:
    • History: Understanding the mechanism of injury (e.g., fall, direct trauma, high-energy impact).
    • Symptoms: Assessing pain, swelling, bruising, deformity, and functional impairment.
    • Physical Examination: Checking for tenderness, crepitus, range of motion, and neurovascular status (e.g., sensation and blood flow).
  • Imaging Studies:
    • X-rays: Primary imaging modality to visualise fracture patterns and displacement.
    • CT Scans: Used for complex fractures to provide detailed bone structure and assess the extent of the injury.
    • MRI: Occasionally used to evaluate soft tissue involvement, such as rotator cuff injuries or to rule out associated injuries.

Accurate diagnosis by an orthopaedic team through clinical evaluation and appropriate imaging is crucial for effectively treating and managing humerus fractures. Access Ortho offers orthopaedic care for fractures. 

Treatment Options for Humerus Neck and Tuberosity Fractures 

1. Surgical Neck of Humerus Fracture

Non-Surgical Treatment:

  • Immobilisation: Use of a sling or shoulder immobiliser for 2-6 weeks to allow bone healing.
  • Pain Management: Over-the-counter pain medications (e.g., acetaminophen or NSAIDs).
  • Physical Therapy: Gradual introduction of exercises to restore movement and strength once the bone has partially healed.

Surgical Treatment:

  • Indications: Significant displacement, multi-part fractures, or failure to heal with non-surgical methods.
  • Procedures:
    • Closed Reduction and Percutaneous Pinning (CRPP): Aligning the bone fragments and fixing them with pins through small skin incisions.
    • Open Reduction and Internal Fixation (ORIF): Realigning the bone fragments and securing them with plates and screws.
    • Intramedullary Nailing: Inserting a rod into the central canal of the humerus to stabilise the fracture.

2. Anatomical Neck of Humerus Fracture

Non-Surgical Treatment:

  • Rarely Used: Due to the high risk of complications like avascular necrosis and complex fracture patterns.

Surgical Treatment:

  • Indications: Most anatomical neck fractures require surgical intervention due to the complexity and risk of avascular necrosis.
  • Procedures:
    • ORIF: Aligning the bone fragments and securing them with plates and screws.
    • Hemiarthroplasty: Replacing the fractured part of the humerus with a prosthesis if the humeral head is severely damaged.
    • Total Shoulder Arthroplasty: Replacing both the humeral head and the glenoid (shoulder socket) in cases of extensive joint damage.

3. Greater Tuberosity Fracture

Non-Surgical Treatment:

  • Indications: Minimally displaced fractures (<5 mm) or fractures without significant rotator cuff involvement.
  • Immobilisation: Use of a sling for 2-4 weeks to allow the bone to heal.
  • Pain Management: Over-the-counter pain medications.
  • Physical Therapy: Early passive motion exercises to prevent stiffness, followed by strengthening exercises.

Surgical Treatment:

  • Indications: Displaced fractures (>5 mm), fractures affecting shoulder mechanics, or associated rotator cuff injuries.
  • Procedures:
    • ORIF: Securing the bone fragments with screws or suture anchors to restore the normal anatomy of the shoulder.
    • Arthroscopic Surgery: Minimally invasive surgery to repair the fracture and any associated rotator cuff injuries.

Seeking prompt medical advice from orthopaedic specialists is essential to improving outcomes and minimising recovery times. Access Ortho can offer rapid appointments for acute injuries.

Humerus Fracture
Arm sling for immobilisation of Humerus Fracture

Outlook and Prognosis for Humerus Surgical and Anatomical Neck Fractures and Greater Tuberosity Fractures

1. Surgical Neck of Humerus Fracture

Outlook:

  • Generally Good: Many surgical neck fractures heal well with proper treatment, especially if they are non-displaced.
  • Function Recovery: Most patients regain a good range of motion and strength after rehabilitation.

Prognosis:

  • Healing Time: Typically, it takes 6-12 weeks, depending on the fracture and patient factors like age and overall health.
  • Complications: Possible complications include non-union, malunion, nerve injury, and shoulder stiffness.
  • Rehabilitation: Early physical therapy is crucial for preventing stiffness and restoring function.

2. Anatomical Neck of Humerus Fracture

Outlook:

  • Guarded to Poor: Anatomical neck fractures have a high risk of complications, for example, avascular necrosis (AVN) of the humeral head.
  • Function Recovery: Recovery of function can be challenging due to the  severity of these fractures.

Prognosis:

  • Healing Time: Healing can take longer, often extending beyond 12 weeks, especially if surgery is required.
  • Complications: High risk of AVN, non-union, malunion, joint stiffness, and post-traumatic arthritis.
  • Rehabilitation: Intensive and prolonged rehabilitation is often necessary to achieve the best possible outcome.

3. Greater Tuberosity Fracture

Outlook:

  • Generally Good: The prognosis for greater tuberosity fractures is typically favourable, especially if there is minimal displacement.
  • Function Recovery: Most patients can expect to regain good shoulder function with appropriate treatment and rehabilitation.

Prognosis:

  • Healing Time: Typically 6-8 weeks for bone healing, but full functional recovery may take longer.
  • Complications: Possible complications include shoulder impingement, rotator cuff injury, non-union, and stiffness.
  • Rehabilitation: Early and consistent physical therapy is essential to restore range of motion and strength.
Humerus Fracture Rehabilitation
Physiotherapy following arm injury

When to Seek Emergency Medical Attention for a Suspected Humeral Neck or Greater Tuberosity Fracture 

It can be difficult to know when to seek emergency medical attention. If you experience the following, you should seek medical advice: 

If you experience the following symptoms, you should seek medical attention urgently at your nearest hospital emergency department. 

  • Severe Pain:
    • Intense, unmanageable pain that does not improve with rest or over-the-counter pain medications. 
  • Visible Deformity:
    • Obvious deformity or misalignment of the shoulder or upper arm, indicating a possible displaced fracture. 
  • Inability to Move the Arm:
    • Complete inability to move the arm or shoulder, which may suggest a severe fracture or associated injuries. 
  • Numbness or Tingling:
    • Numbness, tingling, or sensation loss in the arm, hand, or fingers, indicating potential nerve injury. 
  • Circulatory Issues:
    • Signs of compromised blood flow, such as pale, cold, or bluish skin or absent pulses in the arm.
  • Open Fracture:
    • The presence of bone protruding through the skin increases the risk of infection. This requires immediate surgical intervention.
  • Severe Swelling and Bruising:
    • Rapidly increasing swelling and bruising, which may indicate severe injury or bleeding.
  • Associated Injuries:
    • Suspected fractures accompanied by other serious injuries, such as head trauma, chest injuries, or multiple fractures.

If you experience the following symptoms, you can attend a fracture clinic such as Access Ortho or, out of hours, your nearest emergency department. 

  • Moderate Pain:
    • Persistent pain that limits the use of the arm or shoulder but is manageable with over-the-counter medications.
  • Mild to Moderate Swelling:
    • Swelling and bruising that develop over a few hours but are not rapidly increasing.
  • Reduced Range of Motion:
    • Difficulty moving the arm or shoulder, but some movement is still possible.
  • Previous Shoulder or Arm Injuries:
    • History of previous fractures or shoulder problems that may complicate the current injury.

Frequently Asked Questions

Why do they call fractures around the tuberosity of the humerus neck fractures?

Fractures around the tuberosity of the humerus are often referred to as neck fractures because they occur in the proximal (upper) part of the humerus, near the anatomical neck and surgical neck of the bone. The anatomical neck is an area just below the humeral head, while the surgical neck is slightly lower, near the attachment site for the rotator cuff muscles. Fractures in this region can affect the humeral head’s stability and the shoulder joint’s function, hence being grouped as neck fractures. The greater and lesser tuberosities are bony prominences near the anatomical neck, where rotator cuff tendons attach, and fractures in this area can impact shoulder mechanics and rotator cuff function.

What’s the difference between a surgical neck and an anatomical neck fracture of the humerus?

The differences between surgical neck and anatomical neck fractures of the humerus are: 

Surgical Neck Fracture:

  • Location: Below the humeral head and anatomical neck, in the upper portion of the shaft.
  • Mechanism of Injury: Often results from falls, especially in older adults, or from direct trauma.
  • Characteristics: Typically less complicated than anatomical neck fractures, but can still cause significant pain and functional impairment.
  • Treatment: May involve non-surgical methods like immobilisation or surgical methods like internal fixation if displaced.

Anatomical Neck Fracture:

  • Location: Just below the humeral head, at the junction between the head and the shaft of the humerus.
  • Mechanism of Injury: Often occur from high-energy trauma, for example, car accidents or significant falls.
  • Characteristics: More complex and serious due to the risk of disruption to the blood supply to the humeral head, potentially leading to avascular necrosis (AVN).
  • Treatment: Often requires surgical intervention, such as internal fixation or even shoulder replacement, depending on the severity.
How long does a surgical and anatomical neck fracture of the humerus take to heal?

Healing time for surgical neck and anatomical neck fractures of the humerus varies between injuries and severity of the fracture. 

Surgical Neck Fracture:

  • Healing Time: It typically takes 6-12 weeks for the bone to heal, but full functional recovery may take longer.
  • Factors Affecting Healing: Age, overall health, fracture severity, and adherence to rehabilitation protocols.
  • Rehabilitation: Early physiotherapy is important to regain range of motion and strength, with a gradual return to normal activities.

Anatomical Neck Fracture:

  • Healing Time: Healing can take longer, often extending beyond 12 weeks due to the complexity and potential complications.
  • Factors Affecting Healing: High risk of avascular necrosis, severity of the fracture, patient’s age, health, and the extent of surgical intervention required.
  • Rehabilitation: Intensive and prolonged rehabilitation is often necessary, with close monitoring for complications such as AVN. Complete functional recovery may take several months, and some patients may not regain complete pre-injury function.