Predictive value of valgus head-shaft angle in identifying Neer 4-part proximal humerus fractures. A radiographic and CT-scan analysis of 120 cases

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Luigi Murena
Chiara Ratti
Guido Maritan
Nicholas Rasio
Maria Grandesso
Giulia Barbati
Marcello Cusitore
Gianluca Canton


Proximal humerus fractures, 4-part fracture, predictive value, Valgus displacement, Humeral head-shaft angle


Background and aim of the work: Understanding the fracture morphology and its relation to the expected
outcome and risk of complications is fundamental for proximal humerus fractures (PHFs) management.
Most Neer 3- and 4-part fractures may deserve surgical treatment. Unfortunately, plain x-rays may not be able
to differentiate between a 3- or 4-part fractures unless an axillary or analogue projection is carried out. Aim of
the present study is to evaluate whether a high valgus head-shaft angle degree is predictive of a Neer 4-part
rather than a 3-part fracture. Methods: The study included 120 3-(75 cases) and 4-(45 cases) part PHFs (valgus
displaced in 98 cases), M:F ratio = 1:2.6, mean age 65.7 years, classified on CT scan images. The humeral head
shaft angle was calculated on AP x-rays and statistically correlated with 3 and 4-part fractures to identify values
predictive of 4-part fracture. Results: Valgus head/shaft angle was significantly higher in 4-part fractures, especially in the valgus displaced group (p < 0.001). A cutoff value of 168.5° was identified as predictive of a 4-part fracture with a sensibility of 74% and specificity of 78%. Increasing by 1 degree the humeral head-shaft angle, the chance to have a 4-part fracture increases of 3% in the whole population and of 11% in the valgus sub-group.
Conclusion: The severity of PHF can be predicted analysing valgus head shaft angle on AP x-rays with a sensibility of 74% and specificity of 78% in identifying a 4-part fracture with a cutoff value of 168.5°.


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