The classification of complex fractures of the proximal humerus has long been an area of dispute reflecting an inability to agree on the anatomy of these injuries based on conventional X-rays alone. We demonstrated here that 3-dimensional CT reconstructions, when viewed in a systematic fashion, can yield superior understanding and an enhanced concurrence among observers as to the nature of these fractures. This has lead to a modification of the Neer classification diagram of proximal humeral fractures to reflect their true 3-dimensional anatomy. A 3-dimensional understanding is crucial in and of itself during any process of surgical reconstruction, but a 3-dimensional classification is additionally useful insofar as it informs other aspects of clinical decision making. For example, in a particular category of injury what if any surgery is indicated? In this regard one must first know the natural history of the specific fracture type without the benefit of operative intervention. Towards an answer to this basic question we have categorized non-operated proximal humeral fracture patients according to the new 3-dimensional classification and have followed their clinical progress. We present here the Natural History in unoperated patients with the types of Complex injuries who historically have been the ones commonly recommended to surgery.
Motion is considerably compromised but pain is minimal and functional status is acceptable to most patients. Contrary to common belief avascular necrosis is rare even in severely displaced injuries. Additional new observations concerning Valgus/Varus, Head Split, and rotational injuries will also be presented. Future studies based on this 3-dimensional classification system need to be done to compare these natural history results with various types of surgical interventions.
