Proximal Humerus Fracture
What is a proximal humerus fracture?
A proximal humerus fracture is a break in the upper part of the arm bone close to the shoulder joint. It commonly occurs after a fall onto the shoulder or outstretched hand, but can also follow higher-energy trauma. The fracture may involve the surgical neck, the greater or lesser tuberosity, the humeral head, or several parts of the bone at once.
These injuries vary widely. Some fractures are minimally displaced and remain well aligned. Others are displaced, unstable, comminuted, associated with shoulder dislocation, or involve the joint surface. The best treatment depends on the fracture pattern, bone quality, age, activity level, rotator cuff function, medical health and the patient’s goals.
Common symptoms
Patients usually describe sudden shoulder pain after an injury, difficulty lifting or moving the arm, swelling, bruising and tenderness around the shoulder and upper arm. Bruising may track down the arm over the first few days.
Numbness, tingling, weakness in the hand or arm, severe deformity, open wounds, or symptoms after a high-energy injury require urgent assessment. The nerves and blood vessels around the shoulder are checked carefully, particularly when the fracture is displaced or associated with dislocation.
Diagnosis and imaging
Diagnosis starts with a focused history, examination of the shoulder and arm, and assessment of nerve and vascular function. X-rays are the first-line investigation and usually show the fracture pattern and alignment.
CT scanning is often useful when the fracture is complex, displaced, involves the joint surface, or when surgery is being considered. CT helps assess the number and position of fragments, tuberosity displacement, head-splitting injury, fracture-dislocation, bone loss and whether the humeral head remains reconstructable.
Non-operative treatment
Many proximal humerus fractures can be treated without surgery, particularly when the fragments are not severely displaced, the head remains aligned with the socket, and the fracture is stable. Non-operative treatment usually involves sling support, pain control, early hand, wrist and elbow movement, and staged shoulder rehabilitation.
Follow-up imaging is used to confirm that the fracture position remains acceptable as healing begins. Rehabilitation is progressed carefully, balancing fracture healing with the need to avoid prolonged stiffness. Non-operative treatment can be very appropriate in selected patients, including many older patients and patients where the risks of surgery outweigh the likely benefit.
Surgical treatment: Fixation versus reverse shoulder replacement
Surgery may be considered when the fracture is significantly displaced, unstable, involves the joint surface, is associated with dislocation, threatens shoulder function, or is unlikely to heal in a satisfactory position without intervention.
Fixation, or open reduction and internal fixation (ORIF), aims to realign the bone fragments and hold them with a plate, screws, sutures or other fixation. ORIF may be suitable when the humeral head is reconstructable, the tuberosities can be restored, bone quality is adequate, and preserving the native shoulder joint is realistic.
Reverse total shoulder replacement may be considered for complex fractures where reliable fixation is unlikely, particularly in older patients, poor bone quality, head-splitting fractures, severe comminution, fracture-dislocations, or patterns where the tuberosities and rotator cuff may not provide dependable shoulder mechanics. In a reverse shoulder replacement, the shoulder mechanics are changed so the deltoid can help lift the arm when the fracture pattern or cuff function makes reconstruction less predictable.
The decision is individual. A/Prof Ernstbrunner considers the fracture pattern, imaging, bone quality, rotator cuff status, medical risk, functional demands, independence, hand dominance and the patient’s goals before recommending non-operative care, ORIF or reverse shoulder replacement.
Recovery and follow-up
Recovery depends on the fracture pattern and treatment method. Sling use is common early, whether the fracture is treated surgically or without surgery. Movement and strengthening are progressed in stages according to healing, stability and pain.
After non-operative treatment, recovery focuses on fracture healing, gradual restoration of movement and prevention of stiffness. After ORIF, rehabilitation protects the fixation while the bone heals. After reverse shoulder replacement for fracture, rehabilitation protects the tuberosities and soft tissues while gradually restoring functional use.
It is common for recovery to take months. Some stiffness, weakness or discomfort can persist during the healing phase, particularly after complex fractures. Follow-up appointments and imaging are used to monitor healing, guide rehabilitation and identify complications early.
Proximal Humerus Fracture FAQs
Do all proximal humerus fractures need surgery?
No. Many proximal humerus fractures heal well without surgery, especially when the fragments remain acceptably aligned and the shoulder joint is stable. Surgery is considered when the fracture pattern, displacement, instability or patient factors make non-operative treatment less likely to restore useful shoulder function.
What is the difference between non-operative treatment and ORIF?
Non-operative treatment allows the fracture to heal with sling support and staged rehabilitation. ORIF is surgery to realign the bone fragments and hold them with fixation, usually a plate and screws with suture support where needed. ORIF is considered when the native shoulder can be reconstructed reliably.
When is reverse shoulder replacement used for a fracture?
Reverse shoulder replacement may be considered when the fracture is too complex for reliable fixation, when bone quality is poor, when the humeral head is not reconstructable, or when the rotator cuff and tuberosities are unlikely to support predictable shoulder mechanics after fixation.
Why might an older patient be offered reverse shoulder replacement instead of plates and screws?
In older patients with poor bone quality or severe comminution, plates and screws may not hold the fragments reliably. Reverse shoulder replacement can sometimes provide a more predictable path to pain relief and functional elevation when reconstruction of the broken bone is unlikely to succeed.
Will I need a CT scan?
A CT scan is often helpful for displaced, complex or joint-involving proximal humerus fractures. It gives more detail than plain x-rays and helps determine whether the fracture is suitable for non-operative treatment, ORIF or shoulder replacement.
How long does recovery take after a proximal humerus fracture?
Recovery is usually measured in months. The timeline depends on the fracture pattern, treatment type, bone healing, stiffness, pain, rehabilitation progress and the patient’s goals. Heavy lifting, overhead activity and return to sport or manual work require staged clearance.
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