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Proximal Humerus Fracture

Fracture of the proximal portion of the humerus, the third most common osteoporotic fracture (after hip and distal radius), accounting for 4-5 percent of all fractures with annual incidence 60-105 per 100,000; classified by Neer (1970) into one-, two-, three-, and four-part fractures; treatment ranges from conservative for non-displaced (85 percent) to surgical fixation, hemiarthroplasty, or reverse total shoulder arthroplasty.

Written by: Saygı Hospital Health Guide Editorial Board
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This content has been compiled by the Saygı Hospital Health Guide Editorial Board and is periodically reviewed by a specialist physician.

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What is Proximal Humerus Fracture?

Proximal humerus fracture is the breakage of the proximal portion of the humerus, comprising the head, anatomic neck, greater and lesser tuberosities, and surgical neck. It is the third most common osteoporotic fragility fracture after hip and distal radius fractures, accounting for 4-5 percent of all skeletal fractures and 26 percent of humeral fractures. Annual incidence varies by age — 60-105 per 100,000 overall, but 300 per 100,000 in women > 80 years, with bimodal distribution: younger patients (high-energy mechanisms — motor vehicle accidents, sports, falls from height) and elderly (predominant — low-energy falls in osteoporotic patients, particularly postmenopausal women).

Anatomy and biomechanics: Proximal humerus consists of head (articular surface, retroverted 30-40°, neck-shaft angle 130-150°), anatomic neck (junction of articular cartilage with bone), greater tuberosity (insertion of supraspinatus, infraspinatus, teres minor — superior, posterior, lateral), lesser tuberosity (insertion of subscapularis — anterior medial), surgical neck (metaphyseal-diaphyseal transition where most fractures occur), and bicipital groove (between tuberosities, contains long head of biceps tendon). Blood supply primarily from anterolateral branch of anterior circumflex humeral artery (ascending into intertubercular groove and supplying head — anastomotic arc of Laing) and arcuate artery; disruption with displacement of head fragment can lead to avascular necrosis (AVN) particularly in 4-part fractures (20-40 percent AVN risk).

Classification — Neer 1970 (still gold standard despite limitations): based on number of displaced fragments using 1 cm displacement and 45° angulation as cutoff. 1) One-part — single fragment regardless of fracture lines (most common, 85 percent — non-displaced); 2) Two-part — single displaced fragment (e.g., displaced surgical neck, displaced greater tuberosity); 3) Three-part — two displaced fragments with one tuberosity displaced (e.g., surgical neck + greater tuberosity); 4) Four-part — all four major fragments displaced (head, lesser tuberosity, greater tuberosity, shaft); 5) Fracture-dislocation; 6) Head-splitting fracture. AO/OTA classification — type 11 (proximal humerus): A (extra-articular unifocal), B (extra-articular bifocal), C (intra-articular). Hertel classification — uses 12 fragment patterns (binary description) more reliably predicts AVN risk.

Symptoms

Severe shoulder pain immediately after injury
Inability to move shoulder due to pain
Visible deformity (swelling, asymmetry compared to opposite side)
Bruising and swelling around shoulder, sometimes extending to chest, axilla, and arm
Tenderness over fracture site on palpation
Crepitus on movement
Loss of normal shoulder contour (squared appearance suggests dislocation)
Inability to abduct or rotate shoulder
Numbness or tingling in arm or hand (axillary nerve injury — most common nerve injury in proximal humerus fractures, 5-30 percent)
Decreased or absent radial pulse (vascular injury — rare but emergent, axillary artery)
Visible bone with open wound (open fracture, rare in proximal humerus)

Risk Factors

Osteoporosis (postmenopausal women > 65, elderly with vitamin D deficiency, prior fragility fracture)
Low-energy fall (most common in elderly — falling from standing height, slipping)
High-energy trauma in young patients (motor vehicle accident, motorcycle, sports — football, hockey, snowboarding, skiing, mountain biking, falls from height)
Athletic activities (football, baseball pitchers, swimmers, weightlifters)
Workplace trauma (industrial, construction)
Pathologic fracture (metastatic disease — breast, lung, prostate, kidney, multiple myeloma, primary bone tumor)
Female sex (3:1 ratio in elderly due to osteoporosis)
Age > 65 (osteoporotic fragility fracture risk)
Smoking (impairs bone healing)
Long-term corticosteroid use
Chronic alcohol abuse (poor balance, osteopenia)
Vision impairment (fall risk)
Cognitive impairment (fall risk)
Polypharmacy with sedatives or antihypertensives (fall risk)

When to See a Doctor?

If you experience any of the following symptoms, seek medical attention promptly:

  • Severe shoulder pain after fall or trauma with inability to move arm
  • Visible shoulder deformity, swelling, or extensive bruising
  • Inability to lift arm or use shoulder after injury
  • Numbness, tingling, or weakness in arm or hand after injury
  • Cold or pale arm with weak/absent pulse (vascular emergency)
  • Worsening shoulder swelling or persistent severe pain after recent injury
  • Suspected dislocation with inability to move shoulder (urgent reduction needed)
  • Open wound over shoulder with bone visible (CALL EMERGENCY 112)
  • Elderly patient with new shoulder pain after fall (high suspicion for fracture)
  • Cancer patient with new shoulder pain (consider pathologic fracture)

Treatment Methods

01
Initial assessment: detailed history (mechanism, timing, dominant arm, prior shoulder problems, comorbidities, fall risk factors), physical examination (visible deformity, swelling, ecchymosis, palpation tenderness, range of motion limitation, neurovascular examination — axillary nerve sensation lateral deltoid 'regimental badge' area, radial nerve, brachial pulse, capillary refill); immediate sling immobilization for comfort, ice application, oral analgesia (acetaminophen, NSAIDs, opioids); evaluation by orthopedic surgeon as soon as possible
02
Imaging: 1) AP and Y-scapular (lateral) X-rays of shoulder — visualize fracture pattern, displacement, angulation, dislocation; transthoracic axillary view if Y-view inadequate to assess head position; 2) CT scan with 3D reconstruction — for surgical planning, complex patterns, intra-articular involvement, head-splitting fractures, occult fractures; 3) MRI — soft tissue evaluation (rotator cuff, labrum, biceps), occult fractures, AVN assessment; 4) Bone scan — stress fractures, occult fractures, pathologic fractures
03
Conservative management (85 percent of proximal humerus fractures): indications — non-displaced or minimally displaced (Neer 1-part, displacement < 1 cm, angulation < 45°), elderly with low functional demands, patients unable to undergo surgery; technique — sling immobilization 1-3 weeks (immobilize until comfortable, generally < 2 weeks for 1-part to prevent stiffness), early gentle pendulum exercises (Codman exercises) within 7-10 days, progressive passive range of motion at 3-4 weeks, active assisted at 6 weeks, active and resistive at 6-8 weeks; expected union 6-8 weeks; weekly follow-up X-rays first 2-3 weeks to confirm maintenance of alignment, then at 6 weeks; complications include shoulder stiffness (30-50 percent — minimize with early rehabilitation)
04
Surgical management indications: displaced 2-, 3-, or 4-part fractures, fracture-dislocations, head-splitting fractures, irreducible greater tuberosity displacement > 5 mm (rotator cuff disruption), open fractures, polytrauma, vascular injury, irreducible posterior dislocation; timing — generally within 2 weeks of injury for optimal soft tissue handling, can be delayed in polytrauma until stable; older patients with comorbidities may benefit from less invasive options
05
Surgical techniques: 1) ORIF with locking plate — for 2-, 3-, and selected 4-part fractures with viable head; deltopectoral approach (medial deltoid splitting alternative for greater tuberosity), reduction with provisional K-wires, locking plate (PHILOS Synthes, Periloc Smith&Nephew, Acumed Polarus, AO LCP) with multiple fixed-angle locking screws into head fragment, calcar screws (medial buttress essential for stability and prevention of varus collapse); cement augmentation (PMMA + tobramycin) in osteoporotic bone increases fixation strength; 2) Intramedullary nailing — for surgical neck fractures with intact tuberosities (2-part), proximal humerus nails (PHN, Synthes Multiloc, Trigen, T2) inserted antegrade through articular surface, secondary bend allows fixation through head; advantages include minimal soft tissue dissection, biomechanically strong; complications include rotator cuff injury at insertion, shoulder pain; 3) Hemiarthroplasty (replacement of humeral head with prosthesis) — historically for 4-part fractures and head-splitting fractures with non-viable head, especially in younger patients; modern preference reduced due to inferior outcomes compared to reverse TSA; specialized fracture-specific stems (Aequalis, Univers Apex, Bigliani-Flatow) with fenestrations for greater tuberosity reattachment with sutures; 4) Reverse total shoulder arthroplasty (RTSA) — increasingly preferred for elderly with 3-4 part fractures, especially with rotator cuff insufficiency; advantages include not relying on tuberosity healing, predictable functional outcomes, immediate active motion; specialized fracture-specific designs (Trabecular Metal Reverse, RSP, Aequalis Reversed Fracture); 5) Percutaneous pinning (Resch technique) — for selected valgus impacted 3-4 part fractures with intact medial calcar in young patients; minimally invasive, allows partial preservation of fragment vascularity
06
Postoperative rehabilitation: 1) Phase 1 (0-2 weeks) — sling for 4-6 weeks (longer for fracture stability), gentle pendulum exercises immediately, ice, elevation, pain control with multimodal analgesia (acetaminophen, NSAIDs, gabapentin, regional anesthesia interscalene block intraoperatively), ambulation with sling; 2) Phase 2 (2-6 weeks) — passive range of motion in supine position (avoiding active rotation that stresses tuberosities), continued sling between exercises, progressive ROM as tolerated; 3) Phase 3 (6-12 weeks) — active assisted ROM, gradual elimination of sling, progress to active ROM, gentle isometric strengthening; 4) Phase 4 (3-6 months) — resistive strengthening (theraband, light weights), proprioception, return to activities; 5) Phase 5 (6+ months) — sport-specific rehabilitation, return to overhead activities and sports gradually; full recovery 6-12 months for ORIF, 6-9 months for arthroplasty
07
Special situations and considerations: 1) Pathologic fractures — radiation oncology and orthopedic oncology consultation, biopsy if primary tumor unknown, prophylactic stabilization for impending pathologic fracture, palliative resection or stabilization for established fracture; 2) Polytrauma — damage control orthopedics with provisional stabilization, definitive treatment delayed until stable; 3) Open fractures — emergency antibiotics, irrigation, debridement, internal or external fixation; 4) Vascular injury — vascular surgery consultation, repair of axillary artery; 5) Brachial plexus injury — observation initially (60-80 percent recover spontaneously over 3-6 months), surgical exploration if no recovery at 3-4 months
08
Long-term complications and management: 1) Avascular necrosis (AVN) of humeral head (3-part 8 percent, 4-part 20-40 percent, posterior fracture-dislocation 30-40 percent) — observation if asymptomatic, eventual hemiarthroplasty or reverse TSA if symptomatic; 2) Nonunion (1-10 percent — surgical neck most common) — bone grafting and revision fixation, eventual arthroplasty; 3) Malunion (10-20 percent — particularly greater tuberosity displacement) — corrective osteotomy if symptomatic; 4) Shoulder stiffness (30-50 percent — most common complication) — physical therapy, manipulation under anesthesia, arthroscopic capsular release if refractory; 5) Hardware-related problems (15-30 percent — screw cutout into joint particularly in osteoporotic bone) — hardware revision or arthroplasty; 6) Rotator cuff dysfunction (greater tuberosity malunion or fracture nonunion) — physical therapy, eventual arthroplasty; 7) Heterotopic ossification (10-30 percent — usually asymptomatic, surgical excision rare); 8) Post-traumatic arthritis (especially head-splitting and 4-part fractures, 30-50 percent at 10+ years); 9) Axillary nerve dysfunction (5-30 percent — usually neuropraxia, recovery in 3-6 months; permanent in 1-3 percent); 10) Functional limitations (up to 30 percent of elderly never regain full function despite optimal treatment, considerations for occupation and ADL needs)

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Health Disclaimer: The information on this page is prepared for general informational purposes only. It does not replace medical diagnosis and treatment. Please consult your physician for your complaints. Saygı Hospital does not accept responsibility for actions taken based on the information on this page.