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Shoulder

Proximal Humerus Fracture

A proximal humerus fracture is a break in the upper portion of the arm bone (humerus), near the shoulder. These injuries are common, especially in older adults with osteoporosis, but they can also occur in younger individuals following significant trauma.

Most proximal humerus fractures are nondisplaced or minimally displaced, and can be treated without surgery. However, in more severe or displaced cases—especially involving multiple fracture fragments or disrupted joint surfaces—surgical intervention may be necessary to restore shoulder function.

With proper management, most people recover baseline use of their arm and shoulder.

The humerus is the long bone of the upper arm. The proximal humerus is the upper part of the bone that forms the ball of the shoulder joint.

Key anatomical landmarks include:

  • Humeral head – the ball that fits into the shoulder socket (glenoid)
  • Greater tuberosity – attachment site for rotator cuff muscles
  • Lesser tuberosity – attachment for the subscapularis muscle
  • Surgical neck – narrow region just below the head
  • Anatomical neck – area directly beneath the articular surface or cartilage

Four parts are commonly referred to in fracture classification:

  1. Humeral head
  2. Greater tuberosity
  3. Lesser tuberosity
  4. Shaft (diaphysis)

The shoulder relies on proper alignment of these structures for mobility and strength.

These fractures typically occur from direct trauma or falls, especially:

  • Fall onto an outstretched hand (FOOSH) – common in the elderly
  • Direct blow to the shoulder – e.g., from a fall, sports injury, or car accident
  • High-energy trauma – such as motor vehicle accidents or falls from a height (often in younger people)

Risk factors include:

  • Osteoporosis or low bone density
  • Age over 65
  • Poor balance or prior history of falls

Common signs and symptoms of a proximal humerus fracture include:

  • Severe shoulder pain after trauma
  • Swelling and bruising
  • Limited ability to move the shoulder or arm
  • A visible deformity or unusual shoulder shape (in displaced fractures)
  • Tenderness over the upper arm or shoulder
  • Numbness or tingling in the arm if nerves are involved (especially the axillary nerve)

Physical Examination

  • Assessment of shoulder alignment, tenderness, swelling, bruising
  • Evaluation of neurovascular status (blood flow and nerve function)

Imaging Studies

  • X-rays: The first-line tool to identify and classify the fracture
    • Standard views: AP, lateral, and axillary
  • CT scan: May be used to assess complex or multi-part fractures, or for surgical planning

The most commonly used classification is the Neer classification, which divides fractures based on the number of displaced parts (greater than 1 cm or angulated more than 45°):

  • One-part: No major displacement – most common and typically treated nonoperatively
  • Two-part: One fragment is displaced (e.g., greater tuberosity or surgical neck)
  • Three-part: Displacement of two fragments
  • Four-part: Displacement of all three tuberosities and the head – often unstable

Approximately 85% of proximal humerus fractures are nondisplaced or minimally displaced and can be managed without surgery.

Indications for Nonoperative Treatment:

  • One-part or stable two-part fractures
  • Low-demand elderly patients
  • Patients with medical conditions that increase surgical risk
  • Patients with intact joint alignment and minimal angulation

Nonoperative Approach:

  1. Immobilization
    • Sling or shoulder immobilizer for 1–2 weeks
    • Stabilizes the arm and reduces pain
  2. Pain Management
    • Ice and NSAIDs
  3. Physical Therapy
    • Begins early (within 1–2 weeks) to prevent stiffness
    • Passive range of motion → active motion → strengthening over 6–12 weeks
    • Continued home exercises for several months

Expected Recovery:

  • Bone healing in 6–8 weeks; can be longer in older patients with comorbidities
  • Return to near-full function in 3–6 months
  • Minor loss of range of motion is common but usually well-tolerated

Surgery is required in displaced, unstable, or complex fractures, particularly in younger or more active patients.

Indications for Surgery:

  • Two-, three-, or four-part fractures with displacement
  • Fracture dislocations
  • Open fractures (skin broken)
  • Significant angulation or separation of fracture fragments
  • Poor healing potential or high functional demands
  • Loss of blood supply to the humeral head (risk of avascular necrosis)

Surgical Options:

  1. Open Reduction and Internal Fixation (ORIF)
    • Bone fragments are realigned and fixed with plates, screws, or rods
    • Often used in younger patients with good bone quality
  2. Intramedullary Nailing
    • A rod is placed down the shaft of the humerus
    • Minimally invasive option for some fracture patterns
  3. Hemiarthroplasty
    • The head of the humerus is replaced with a prosthesis
    • Used when the humeral head is badly damaged or cannot be reconstructed
  4. Reverse Total Shoulder Arthroplasty
    • The entire shoulder joint is replaced, with the ball and and socket reversed
    • Preferred for complex fractures in elderly patients with rotator cuff damage

Risks of Surgery:

  • Infection
  • Stiffness or loss of motion
  • Hardware failure
  • Nonunion or malunion
  • Nerve injury (especially axillary nerve)
  • Blood vessel injury
  • Avascular necrosis (loss of blood supply to bone)

Nonoperative Treatment Outcomes:

  • Most nondisplaced fractures heal with good pain relief and function
  • Minor loss of shoulder range of motion is possible, especially in older adults
  • Risk of shoulder stiffness or frozen shoulder without early motion

Surgical Outcomes:

  • Younger patients often regain excellent shoulder function after fixation
  • Reverse shoulder arthroplasty has good results for elderly patients with severe fractures
  • Rehabilitation is longer, but surgery may prevent long-term dysfunction in selected patients
  • Long-term outcomes depend on:
    • Age
    • Fracture pattern
    • Type of treatment
    • Compliance with therapy

Recovery varies by treatment type but often includes:

  • 6–8 weeks for bone healing
  • 3–6 months for regaining full function
  • Physical therapy is essential regardless of treatment type
  • Full recovery may take up to 12 months

  • Severe pain or deformity of the shoulder after a fall
  • Inability to move the shoulder or arm
  • Numbness, tingling, or weakness in the arm
  • Swelling, bruising, or warmth suggesting infection after surgery

Proximal humerus fractures are common shoulder injuries, particularly in older adults. Most can be managed effectively without surgery if the bone fragments remain aligned. Surgical treatment may be necessary in more severe fractures to restore joint stability and shoulder function. With proper treatment and physical therapy, most people recover shoulder function and can return to daily activities.

At a Glance

Dr. Hasani Swindell

  • Fellowship-Trained Sports Medicine Specialist
  • Board-Certified Orthopedic Surgeon
  • Summa Cum Laude Graduate from the University of Pittsburgh
  • Medical Degree from Columbia University
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