- Mechanism
- Fall onto outstretched arm
- high-energy in younger
- Most common in
- Adults over 60
- Treatment
- Sling + early rehabilitation (most)
- Surgery
- ORIF or reverse arthroplasty (selected)
- Classification
- Neer (one- to four-part)
What a proximal humerus fracture is.
The proximal humerus is the top of the upper-arm bone — the part that forms the "ball" of the ball-and-socket shoulder joint. A proximal humerus fracture is a break in this region. In older adults the typical mechanism is a fall from standing height onto the outstretched arm; in younger adults it usually requires significantly higher-energy trauma (a fall from height, a motorcycle crash, a sporting collision).
The fracture is classified by the number of major bone fragments (the Neer classification): one-part (minimally displaced), two-part, three-part, or four-part. The number of parts and the degree of displacement guide treatment.
How the diagnosis is made.
The diagnosis is made on plain radiographs (true AP, axillary, outlet views). For complex or displaced fractures, a CT scan with 3D reconstruction is essential for surgical planning. Examination identifies the location of pain, any deformity, and crucially the function of the axillary nerve (sensation over the deltoid and deltoid function once pain is controlled).
Treatment.
Non-operative
The majority of proximal humerus fractures are managed without surgery. The principles are:
- Sling immobilisation for 2–3 weeks for pain control.
- Early supervised pendulum exercises and passive range of motion.
- Active-assisted range from 3–4 weeks.
- Active range from 6 weeks.
- Strengthening from 12 weeks once union is confirmed.
Final outcome from non-operative treatment is usually reached at 9–12 months. Most patients regain functional motion and pain-free use of the arm. Some loss of overhead reach and external rotation is common.
Surgical
Surgery is considered for displaced, comminuted, or unstable fractures, particularly in younger active patients. Options include:
- Open reduction and internal fixation (ORIF) — with a locking plate. Suited to two-, three- and selected four-part fractures with good bone stock.
- Hemiarthroplasty — less commonly used now; reserved for younger patients with non-reconstructable fractures and an intact cuff.
- Reverse total shoulder arthroplasty — the preferred option in older patients with complex four-part fractures, particularly when bone quality is poor and the cuff may not heal reliably around an ORIF.
Dr Coory's approach is to review the full set of imaging (often CT in addition to plain films), assess the patient's functional demands and bone quality, and recommend the simplest treatment that will reliably restore function.
Frequently asked questions.
Do most proximal humerus fractures need surgery?
No. The majority are managed non-operatively with sling, early rehabilitation and time. Surgery is reserved for displaced, comminuted or unstable fractures, particularly in younger active patients.
How long does it take to heal?
Bone healing is usually complete by 8–12 weeks. Functional recovery continues for 6–12 months — rehabilitation is the operation that lasts.
Will I regain full motion?
Most patients regain functional motion and pain-free use. Some loss of overhead reach and external rotation is common, particularly in older patients with more complex fractures. Diligent rehabilitation is the strongest protective factor.
Is a reverse shoulder replacement ever used for a fracture?
Yes. Reverse total shoulder arthroplasty is the preferred surgical option for many complex four-part fractures in older patients, where ORIF has a high rate of failure due to poor bone quality.
Can the nerve to my deltoid be damaged?
The axillary nerve is anatomically close to the fracture and can be stretched at the time of injury or during surgery. Sensation over the deltoid and function of the deltoid muscle are checked at every visit. Most injuries are transient and recover.
References.
- Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–697.
- Handoll HH, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;11:CD000434.
- Neer CS 2nd. Displaced proximal humeral fractures. Part I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077–1089.