{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,2,10]],"date-time":"2026-02-10T20:13:53Z","timestamp":1770754433492,"version":"3.50.0"},"reference-count":54,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2024,7,19]],"date-time":"2024-07-19T00:00:00Z","timestamp":1721347200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Bioeng. Biotechnol."],"abstract":"<jats:p><jats:bold>Background:<\/jats:bold> The morphology of proximal humeral fractures (PHFs) is complex, and the fixation and selection of implants need to be guided by the fracture type and classification, which requires an accurate understanding of the fracture line. This study had three purposes. 1) Define and analyze the fracture lines and morphological features of all types PHFs by three-dimensional (3D) mapping technology. 2) Determine the osteotomy position of the biomechanical model of the PHFs according to the fracture heat map. 3) Based on the analysis of the pathological morphology and distribution of a large number of consecutive cases of PHFs, propose a novel classification of PHFs.<\/jats:p><jats:p><jats:bold>Methods:<\/jats:bold> We retrospectively collected 220 cases of PHFs and generated a 3D fracture map and heat map based on computed tomography (CT) imaging. Through analysis of the fracture morphology of the 220 PHFs, a novel classification was proposed. The primary criterion for staging was the continuity between the humeral head and the greater tuberosity and lesser tuberosity, and the secondary criterion was the relationship between the humeral head segment and the humeral shaft.<\/jats:p><jats:p><jats:bold>Results:<\/jats:bold> The fracture line was primarily found around the metaphyseal zone of region of the surgical neck, with the most extensive distribution being below the larger tuberosity and on the posterior medial side of the epiphysis. We suggest that the osteotomy gap should be immediately (approximately 5\u201310\u00a0mm) below the lower edge of the articular surface. The most common type of fracture was type I3 (33 cases, 15.0%), followed by type IV3 fracture (23 cases, 10.4%), and type III2 fracture (22 cases, 10.0%). Interobserver and intraobserver reliability analysis for the fracture classification revealed a k value (95% confidence interval) of 0.639 (0.57\u20130.71) and 0.841, <jats:italic>P<\/jats:italic> &amp;lt; 0.01, respectively.<\/jats:p><jats:p><jats:bold>Conclusion:<\/jats:bold> In this study, the fracture line and morphological characteristics of PHFs were clarified in detail by 3D mapping technique. In addition, a new classification method was proposed by analysis of the morphological characteristics of 220 PHFs, A two-part fracture model for PHFs is also proposed.<\/jats:p>","DOI":"10.3389\/fbioe.2024.1366089","type":"journal-article","created":{"date-parts":[[2024,7,19]],"date-time":"2024-07-19T04:25:21Z","timestamp":1721363121000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["Morphology and novel classification of proximal humeral fractures"],"prefix":"10.3389","volume":"12","author":[{"given":"Jichao","family":"Liu","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ziyan","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jie","family":"Ding","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jian","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Qian","family":"Sheng","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Chengdong","family":"Piao","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2024,7,19]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"422","DOI":"10.1302\/2046-3758.76.Bjr-2017-0356.R1","article-title":"Biomechanical evaluation of a new gliding screw concept for the fixation of proximal humeral fractures","volume":"7","author":"Acklin","year":"2018","journal-title":"Bone and Jt. Res."},{"key":"B2","doi-asserted-by":"publisher","first-page":"1653","DOI":"10.1016\/j.jse.2017.03.006","article-title":"Spatial mapping of humeral head bone density","volume":"26","author":"Alidousti","year":"2017","journal-title":"J. Shoulder Elb. Surg."},{"key":"B3","doi-asserted-by":"publisher","first-page":"2222","DOI":"10.2106\/JBJS.H.00881","article-title":"Mapping of scapular fractures with three-dimensional computed tomography","volume":"91","author":"Armitage","year":"2009","journal-title":"J. Bone Jt. Surg. Am."},{"key":"B4","doi-asserted-by":"publisher","first-page":"294","DOI":"10.5435\/00124635-200805000-00008","article-title":"Fixed-angle locked plating of two-three-and four-part proximal humerus fractures","volume":"16","author":"Badman","year":"2008","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"B5","doi-asserted-by":"publisher","first-page":"6140","DOI":"10.3390\/jcm11206140","article-title":"Management of proximal humerus fractures in adults-A scoping review","volume":"11","author":"Baker","year":"2022","journal-title":"J. Clin. Med."},{"key":"B6","doi-asserted-by":"publisher","first-page":"18","DOI":"10.1002\/jor.20957","article-title":"Age- and sex-related changes of humeral head microarchitecture: histomorphometric analysis of 60 human specimens","volume":"28","author":"Barvencik","year":"2010","journal-title":"J. Orthop. Res."},{"key":"B7","doi-asserted-by":"publisher","first-page":"17","DOI":"10.1097\/00003086-200206000-00004","article-title":"Classification and diagnosis of intracapsular fractures of the proximal femur","volume":"399","author":"Caviglia","year":"2002","journal-title":"Clin. Orthop. Relat. Res."},{"key":"B8","doi-asserted-by":"publisher","first-page":"1960","DOI":"10.2106\/jbjs.18.00477","article-title":"Computer-assisted virtual surgical technology versus three-dimensional printing technology in preoperative planning for displaced three and four-Part Fractures of the proximal end of the humerus","volume":"100","author":"Chen","year":"2018","journal-title":"J. Bone Jt. Surg. Am."},{"key":"B9","doi-asserted-by":"publisher","first-page":"2625","DOI":"10.1002\/jor.24429","article-title":"Secondary perforation risk in plate osteosynthesis of unstable proximal humerus fractures: a biomechanical investigation of the effect of screw length","volume":"37","author":"Ciric","year":"2019","journal-title":"J. Orthop. Res."},{"key":"B10","doi-asserted-by":"publisher","first-page":"12","DOI":"10.1186\/s13037-019-0195-3","article-title":"Inter-observer reliability of alternative diagnostic methods for proximal humerus fractures: a comparison between attending surgeons and orthopedic residents in training","volume":"13","author":"Cocco","year":"2019","journal-title":"Patient Saf. Surg."},{"key":"B11","doi-asserted-by":"publisher","first-page":"438","DOI":"10.1186\/s13018-022-03327-7","article-title":"Three-dimensional fracture mapping and analysis of coronal fractures in AO\/OTA types 33-B3 and C3","volume":"17","author":"Ding","year":"2022","journal-title":"J. Orthop. Surg. Res."},{"key":"B12","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1002\/jor.23603","article-title":"Comparison of 2 versus 3 dimensional fracture mapping strategies for 3 dimensional computerized tomography reconstructions of scapula neck and body fractures","volume":"36","author":"Dugarte","year":"2018","journal-title":"J. Orthop. Res."},{"key":"B13","doi-asserted-by":"publisher","first-page":"11","DOI":"10.1186\/s10195-024-00754-6","article-title":"Three-dimensional printed models can reduce costs and surgical time for complex proximal humeral fractures: preoperative planning, patient satisfaction, and improved resident skills","volume":"25","author":"Fidanza","year":"2024","journal-title":"J. Orthop. Traumatol."},{"key":"B14","doi-asserted-by":"publisher","first-page":"3245","DOI":"10.3390\/app12073245","article-title":"3D printing applications in orthopaedic surgery: clinical experience and opportunities","volume":"12","author":"Fidanza","year":"","journal-title":"Appl. Sci."},{"key":"B15","doi-asserted-by":"publisher","first-page":"1298","DOI":"10.1016\/j.jos.2021.08.008","article-title":"Proximal humeral fractures treated with a low-profile plate with enhanced fixation properties","volume":"27","author":"Fidanza","year":"","journal-title":"J. Orthop. Sci."},{"key":"B16","doi-asserted-by":"publisher","first-page":"1069","DOI":"10.1007\/s00402-019-03175-x","article-title":"The influence of screw length on predicted cut-out failures for proximal humeral fracture fixations predicted by finite element simulations","volume":"139","author":"Fletcher","year":"2019","journal-title":"Archives Orthop. Trauma Surg."},{"key":"B17","doi-asserted-by":"publisher","first-page":"372","DOI":"10.1016\/j.jbspin.2004.04.002","article-title":"Osteoporotic fractures of the proximal humerus, pelvis, and ankle: epidemiology and diagnosis","volume":"72","author":"Guggenbuhl","year":"2005","journal-title":"Jt. Bone Spine"},{"key":"B18","doi-asserted-by":"publisher","first-page":"1787","DOI":"10.21037\/atm-21-6168","article-title":"Three-dimensional computed tomography mapping of 136 tongue-type calcaneal fractures from a single centre","volume":"9","author":"Guo","year":"","journal-title":"Ann. Transl. Med."},{"key":"B19","doi-asserted-by":"publisher","first-page":"e932748","DOI":"10.12659\/MSM.932748","article-title":"Evaluation of sanders type 2 joint depression calcaneal fractures in 197 patients from a single center using three-dimensional mapping","volume":"27","author":"Guo","year":"","journal-title":"Med. Sci. Monit."},{"key":"B20","doi-asserted-by":"publisher","first-page":"e300","DOI":"10.1016\/j.jse.2017.05.014","article-title":"Fracture line morphology of complex proximal humeral fractures","volume":"26","author":"Hasan","year":"2017","journal-title":"J. Shoulder Elb. Surg."},{"key":"B21","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1097\/01.blo.0000092968.12414.a8","article-title":"Where should implants be anchored in the humeral head?","volume":"415","author":"Hepp","year":"2003","journal-title":"Clin. Orthop. Relat. Res."},{"key":"B22","doi-asserted-by":"publisher","first-page":"427","DOI":"10.1016\/j.jse.2004.01.034","article-title":"Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus","volume":"13","author":"Hertel","year":"2004","journal-title":"J. Shoulder Elb. Surg."},{"key":"B23","doi-asserted-by":"publisher","first-page":"218","DOI":"10.1186\/s12891-019-2599-8","article-title":"Treatment of the surgical neck fracture of the humerus with a novel external fixator in the elderly with osteoporosis: biomechanical analysis","volume":"20","author":"Huang","year":"2019","journal-title":"BMC Musculoskelet. Disord."},{"key":"B24","doi-asserted-by":"publisher","first-page":"47","DOI":"10.1186\/s12938-018-0479-3","article-title":"Biomechanical analysis of plate systems for proximal humerus fractures: a systematic literature review","volume":"17","author":"Jabran","year":"2018","journal-title":"Biomed. Eng. OnLine"},{"key":"B25","doi-asserted-by":"publisher","first-page":"601","DOI":"10.1007\/s10439-018-02160-6","article-title":"Parametric design optimisation of proximal humerus plates based on finite element method","volume":"47","author":"Jabran","year":"2019","journal-title":"Ann. Biomed. Eng."},{"key":"B26","doi-asserted-by":"publisher","first-page":"1959","DOI":"10.1111\/os.13523","article-title":"Fracture line morphology of greater tuberosity fragments of neer three\u2010 and four\u2010Part Proximal humerus fractures","volume":"15","author":"Ju","year":"2022","journal-title":"Orthop. Surg."},{"key":"B27","doi-asserted-by":"publisher","first-page":"276","DOI":"10.1097\/Bot.0000000000000252","article-title":"Factors that influence reduction loss in proximal humerus fracture surgery","volume":"29","author":"Jung","year":"2015","journal-title":"J. Orthop. Trauma"},{"key":"B28","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/j.jot.2015.09.006","article-title":"Computational anatomy of the proximal humerus: an ex vivo high-resolution peripheral quantitative computed tomography study","volume":"4","author":"Kamer","year":"2016","journal-title":"J. Orthop. Transl."},{"key":"B29","doi-asserted-by":"publisher","first-page":"1852","DOI":"10.1016\/j.jse.2018.03.020","article-title":"Which additional augmented fixation procedure decreases surgical failure after proximal humeral fracture with medial comminution: fibular allograft or inferomedial screws?","volume":"27","author":"Kim","year":"2018","journal-title":"J. Shoulder Elb. Surg."},{"key":"B30","doi-asserted-by":"publisher","first-page":"e103297","DOI":"10.1371\/journal.pone.0103297","article-title":"The mechanical benefit of medial support screws in locking plating of proximal humerus fractures","volume":"9","author":"Lammi","year":"2014","journal-title":"PLoS ONE"},{"key":"B31","doi-asserted-by":"publisher","first-page":"4","DOI":"10.1186\/s10195-020-0543-1","article-title":"Reliability and reproducibility of the new AO\/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems","volume":"21","author":"Marongiu","year":"2020","journal-title":"J. Orthop. Traumatol."},{"key":"B32","doi-asserted-by":"publisher","first-page":"829","DOI":"10.2106\/JBJS.20.00665","article-title":"Current controversies in the treatment of geriatric proximal humeral fractures","volume":"103","author":"Mease","year":"2021","journal-title":"J. Bone Jt. Surg. Am."},{"key":"B33","doi-asserted-by":"publisher","first-page":"370","DOI":"10.3390\/medicina59020370","article-title":"Statistical morphology and fragment mapping of complex proximal humeral fractures","volume":"59","author":"Mys","year":"2023","journal-title":"Medicina"},{"key":"B34","doi-asserted-by":"publisher","first-page":"1077","DOI":"10.2106\/00004623-197052060-00001","article-title":"Displaced proximal humeral fractures: PART I. Classification and evaluation","volume":"52","author":"Neer","year":"1970","journal-title":"J. Bone Jt. Surg. Am."},{"key":"B35","doi-asserted-by":"publisher","first-page":"280","DOI":"10.1111\/ans.13451","article-title":"Interobserver agreement of Neer and AO classifications for proximal humeral fractures","volume":"86","author":"Papakonstantinou","year":"2016","journal-title":"ANZ J. Surg."},{"key":"B36","doi-asserted-by":"publisher","first-page":"2042","DOI":"10.1111\/os.13645","article-title":"Morphological analysis of fractures of the proximal humerus by the fracture mapping technique","volume":"15","author":"Ren","year":"2023","journal-title":"Orthop. Surg."},{"key":"B37","doi-asserted-by":"publisher","first-page":"455","DOI":"10.1016\/j.jse.2015.08.006","article-title":"Classification of proximal humeral fractures based on a pathomorphologic analysis","volume":"25","author":"Resch","year":"2016","journal-title":"J. Shoulder Elb. Surg."},{"key":"B38","doi-asserted-by":"publisher","first-page":"234","DOI":"10.1016\/s1058-2746(09)80041-4","article-title":"Distribution of bone mineral density and bone strength of the proximal humerus","volume":"3","author":"Saitoh","year":"1994","journal-title":"J. Shoulder Elb. Surg."},{"key":"B39","doi-asserted-by":"publisher","first-page":"1968","DOI":"10.1016\/j.jse.2015.06.028","article-title":"Screw augmentation reduces motion at the bone-implant interface: a biomechanical study of locking plate fixation of proximal humeral fractures","volume":"24","author":"Schliemann","year":"2015","journal-title":"J. Shoulder Elb. Surg."},{"key":"B40","doi-asserted-by":"publisher","first-page":"495","DOI":"10.1016\/j.jse.2009.11.003","article-title":"Biomechanical comparison of a proximal humeral locking plate using two methods of head fixation","volume":"19","author":"Schumer","year":"2010","journal-title":"J. Shoulder Elb. Surg."},{"key":"B41","doi-asserted-by":"publisher","first-page":"e374","DOI":"10.5435\/JAAOS-D-18-00360","article-title":"Intramedullary fixation for proximal humeral fractures","volume":"28","author":"Sears","year":"2020","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"B42","doi-asserted-by":"publisher","first-page":"285","DOI":"10.1186\/s13018-019-1345-0","article-title":"Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis","volume":"14","author":"Shi","year":"2019","journal-title":"J. Orthop. Surg. Res."},{"key":"B43","doi-asserted-by":"publisher","first-page":"1689","DOI":"10.2106\/JBJS.H.00133","article-title":"Surgical treatment of three and four-part proximal humeral fractures","volume":"91","author":"Solberg","year":"2009","journal-title":"J. Bone Jt. Surg. Am."},{"key":"B44","doi-asserted-by":"publisher","first-page":"e1","DOI":"10.1016\/j.jse.2012.09.018","article-title":"A comprehensive classification of proximal humeral fractures: HGLS system","volume":"22","author":"Sukthankar","year":"2013","journal-title":"J. Shoulder Elb. Surg."},{"key":"B45","doi-asserted-by":"publisher","first-page":"1785","DOI":"10.1007\/s00264-020-04544-7","article-title":"The plate fixation strategy of complex proximal humeral fractures","volume":"44","author":"Sun","year":"2020","journal-title":"Int. Orthop."},{"key":"B46","doi-asserted-by":"publisher","first-page":"1921","DOI":"10.1016\/j.injury.2015.05.049","article-title":"Displaced proximal humeral fractures: when is surgery necessary?","volume":"46","author":"Tamimi","year":"2015","journal-title":"Injury"},{"key":"B47","doi-asserted-by":"publisher","first-page":"1914","DOI":"10.1016\/j.injury.2015.05.017","article-title":"Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock","volume":"46","author":"Tauber","year":"2015","journal-title":"Injury"},{"key":"B48","doi-asserted-by":"publisher","first-page":"531","DOI":"10.1007\/s00223-002-0013-9","article-title":"Three-dimensional distribution of bone density in the proximal humerus","volume":"73","author":"Tingart","year":"2003","journal-title":"Calcif. Tissue Int."},{"key":"B49","doi-asserted-by":"publisher","first-page":"29","DOI":"10.1186\/s13018-020-02094-7","article-title":"A novel surgical approach and technique and short-term clinical efficacy for the treatment of proximal humerus fractures with the combined use of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation","volume":"16","author":"Wang","year":"2021","journal-title":"J. Orthop. Surg. Res."},{"key":"B50","doi-asserted-by":"publisher","first-page":"194","DOI":"10.1016\/j.bone.2018.02.010","article-title":"Regional variations of cortical bone in the humeral head region: a preliminary study","volume":"110","author":"Wang","year":"2018","journal-title":"Bone"},{"key":"B51","doi-asserted-by":"publisher","first-page":"596","DOI":"10.1016\/j.jse.2007.01.006","article-title":"Age- and gender-related distribution of bone tissue of osteoporotic humeral head using computed tomography","volume":"16","author":"Yamada","year":"2007","journal-title":"J. Shoulder Elb. Surg."},{"key":"B52","doi-asserted-by":"publisher","first-page":"2373","DOI":"10.1007\/s00264-022-05499-7","article-title":"Classification and morphology of hyperextension tibial plateau fracture","volume":"46","author":"Yao","year":"2022","journal-title":"Int. Orthop."},{"key":"B53","doi-asserted-by":"publisher","first-page":"571","DOI":"10.1016\/j.jse.2021.08.036","article-title":"Identification of recurring scapular fracture patterns using 3-dimensional computerized fracture mapping","volume":"31","author":"Yimam","year":"2022","journal-title":"J. Shoulder Elb. Surg."},{"key":"B54","doi-asserted-by":"publisher","first-page":"1191","DOI":"10.1016\/j.injury.2016.02.028","article-title":"Biomechanical effect of the configuration of screw hole style on locking plate fixation in proximal humerus fracture with a simulated gap: a finite element analysis","volume":"47","author":"Zhang","year":"2016","journal-title":"Injury"}],"container-title":["Frontiers in Bioengineering and Biotechnology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fbioe.2024.1366089\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,7,19]],"date-time":"2024-07-19T04:25:23Z","timestamp":1721363123000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fbioe.2024.1366089\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,7,19]]},"references-count":54,"alternative-id":["10.3389\/fbioe.2024.1366089"],"URL":"https:\/\/doi.org\/10.3389\/fbioe.2024.1366089","relation":{},"ISSN":["2296-4185"],"issn-type":[{"value":"2296-4185","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,7,19]]},"article-number":"1366089"}}