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Proximal Humerus Fracture (Adult)

Proximal humerus fractures (PHF) represent the third most common osteoporotic fracture in adults, accounting for approximately 5-6% of all fractures, following hip and distal radius fractures. They predominantly...

Updated 6 Jan 2026
Reviewed 17 Jan 2026
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Urgent signals

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  • Axillary Nerve Palsy → Regimental Badge sensation loss
  • Fracture Dislocation → Emergent Reduction required
  • Skin Tenting → Impending open fracture (GT spike)
  • Posterior Dislocation → Fixed Internal Rotation (Seizures)

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  • Clavicle Fracture
  • Shoulder Dislocation

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Reviewed by MedVellum Editorial Team · MedVellum Medical Education Platform

Credentials: MBBS, MRCP, Board Certified

Clinical reference article

Proximal Humerus Fracture (Adult)

1. Clinical Overview

Summary

Proximal humerus fractures (PHF) represent the third most common osteoporotic fracture in adults, accounting for approximately 5-6% of all fractures, following hip and distal radius fractures. [1] They predominantly affect elderly females with osteoporosis following low-energy falls from standing height, though high-energy mechanisms in younger patients produce more complex injury patterns. [2]

The management of proximal humerus fractures has undergone a paradigm shift over the past decade. The landmark PROFHER trial (2015) definitively demonstrated that for the majority of displaced fractures in elderly patients, surgical fixation offers no functional benefit over conservative management, while exposing patients to increased risks of complications. [3] This high-quality randomized controlled trial fundamentally changed clinical practice, shifting emphasis from aggressive surgical intervention toward selective, patient-centered management.

The Neer Classification System, introduced in 1970, remains the most widely used framework for categorizing these injuries based on the displacement of four anatomical segments: humeral head, greater tuberosity, lesser tuberosity, and humeral shaft. [4] A segment is considered displaced when separated by > 1cm or angulated > 45 degrees. Understanding this classification is essential for surgical decision-making and prognostication.

Contemporary management follows a selective approach:

  • 80-85% of fractures are minimally displaced (Neer 1-part) and managed conservatively with excellent functional outcomes [5]
  • Surgery is reserved for fracture-dislocations, head-splitting patterns, displaced fractures in physiologically young/active patients, and specific two-part fractures (e.g., greater tuberosity avulsions blocking abduction)
  • Reverse shoulder arthroplasty (RSA) has superseded hemiarthroplasty as the gold standard for complex fractures requiring reconstruction in elderly patients, leveraging deltoid function rather than requiring intact rotator cuff [6]

The prognosis for proximal humerus fractures is generally favorable with appropriate management, though stiffness and adhesive capsulitis affect the majority of patients regardless of treatment modality. Functional outcomes depend heavily on patient age, bone quality, fracture pattern, and treatment adherence. [7]

Key Facts

Epidemiology

  • Incidence: 60-100/100,000 population per year, increasing with aging populations [1]
  • Age distribution: Bimodal—peak in elderly (> 70 years) and younger high-energy trauma (less than 40 years)
  • Sex ratio: Female:Male = 3:1 overall; 4-7:1 in elderly osteoporotic cohorts [2]
  • Accounts for 5-6% of all adult fractures [8]

Anatomy & Biomechanics

  • Blood supply: Humeral head vascularized primarily via arcuate artery (ascending branch of anterior circumflex humeral artery), entering through bicipital groove
  • Four segments (Neer): Articular head, greater tuberosity, lesser tuberosity, surgical neck (shaft)
  • Deforming forces: Supraspinatus pulls GT superiorly; pectoralis major pulls shaft medially → varus deformity
  • Surgical neck: Weakest point—transition from metaphyseal to diaphyseal bone

Classification

  • Neer Classification: Based on number of displaced parts (> 1cm or > 45°)
    • 1-part: No displacement (80-85% of fractures)
    • 2-part: One segment displaced (surgical neck or greater tuberosity most common)
    • 3-part: Two segments displaced (typically surgical neck + greater tuberosity)
    • 4-part: All segments displaced (highest AVN risk ~15-30%) [9]
  • Valgus-impacted 4-part: Special variant with preserved blood supply—"head jammed into shaft" [10]

Neurovascular Injury

  • Most common nerve injury: Axillary nerve (5-30% incidence, often subclinical on EMG studies) [11]
    • Test: Sensation over lateral shoulder ("Regimental Badge" area)
    • "Motor: Deltoid function (abduction weakness)"
  • Most common vessel injury: Axillary artery (rare, less than 1%, but higher in elderly with atherosclerosis and fracture-dislocations) [12]

Complications

  • Stiffness/Adhesive capsulitis: Nearly universal (60-80%), prolonged rehabilitation required [13]
  • Avascular necrosis (AVN): 10-20% in 3-part; 15-30% in 4-part fractures [9]
  • Malunion: Varus malunion common with conservative treatment, often functionally acceptable
  • Nonunion: Rare (less than 5%) except in high-energy injuries with significant comminution

Clinical Pearls

"Treat the Patient, Not the X-Ray": The PROFHER trial demonstrated that in elderly patients, a displaced 3-part fracture managed conservatively in a sling often produces equivalent functional outcomes to surgical fixation, with lower complication rates. A 75-year-old with osteoporotic bone may achieve pain-free function despite radiographic malunion, while surgical fixation risks screw cutout, infection, and reoperation. [3]

"Beware the Lightbulb Sign": Posterior shoulder dislocations are missed in up to 50% of initial presentations, particularly post-seizure or electrical injury. The arm is locked in internal rotation. On AP radiograph, the humeral head appears rounded like a "lightbulb" (loss of normal half-moon overlap with glenoid). Axillary or Y-lateral views are mandatory to exclude posterior dislocation. [14]

"The Cuff is King (or Was)": Traditional hemiarthroplasty for fractures relied on healing and reattachment of tuberosities (rotator cuff insertions) for function. In osteoporotic bone, tuberosities frequently fail to heal or migrate, leading to pseudoparalysis and poor outcomes. Reverse shoulder arthroplasty revolutionized fracture reconstruction by eliminating dependence on rotator cuff, instead medializing center of rotation and recruiting deltoid for elevation. [6]

"Hertel's Criteria Predict AVN": Three anatomical predictors of humeral head ischemia [15]:

  1. Metaphyseal head extension less than 8mm (short calcar segment attached to head)
  2. Medial hinge disruption (loss of soft tissue bridge)
  3. Fracture pattern (anatomical neck fracture or 4-part pattern)
  • When calcar less than 8mm AND medial hinge disrupted: 97% AVN risk
  • These fractures should be considered for primary arthroplasty rather than fixation

"Valgus-Impacted is Different": Valgus-impacted 4-part fractures have the head driven INTO the shaft in an impacted position. Unlike classic 4-part fractures, blood supply is often preserved through intact soft tissue hinges. These fractures are amenable to fixation rather than replacement, with lower AVN rates (5-15%). [10]

"Early Mobilization is Mandatory": Regardless of treatment modality, prolonged immobilization beyond 2-3 weeks dramatically increases risk of permanent stiffness. Pendulum exercises should begin within first week, progressing to assisted range of motion by 2-3 weeks. Functional recovery takes 12-18 months. [16]

2. Epidemiology

Incidence & Prevalence

Proximal humerus fractures account for 5-6% of all adult fractures, with an incidence of 60-100 cases per 100,000 population per year. [1,8] This incidence is rapidly increasing in developed nations due to:

  • Population aging: Exponential rise in patients > 65 years
  • Increased osteoporosis prevalence: Particularly in postmenopausal women
  • Improved survival: Longer lifespan increases cumulative fracture risk
  • Maintained activity levels: Active elderly population sustaining falls

Epidemiological projections suggest a 30-40% increase in proximal humerus fracture incidence by 2030 based on demographic trends. [2]

Demographics

Age Distribution

  • Bimodal pattern: [17]
    • "First peak: Young adults (less than 40 years) sustaining high-energy trauma (road traffic accidents, falls from height)"
    • "Second peak: Elderly (> 70 years) sustaining low-energy osteoporotic fractures"
  • Median age at fracture: 65-68 years in most series [1]
  • Peak incidence: Women aged 70-79 years

Sex Distribution

  • Overall ratio: Female:Male = 3:1 [2]
  • Elderly cohort (> 65 years): Female:Male = 4-7:1 (reflects osteoporosis prevalence)
  • Young cohort (less than 40 years): Male predominance (high-energy mechanisms)
  • Postmenopausal estrogen deficiency is primary driver of osteoporosis-related fractures in women

Geographic Variation

  • Higher incidence in Nordic countries (reduced sunlight → Vitamin D deficiency)
  • Seasonal variation: 20-30% increase in winter months (ice-related falls)
  • Urban vs rural: Higher rates in urban populations (population density, pavement falls)

Mechanism of Injury

Low-Energy (Elderly)

  • Fall from standing height: 85-90% of elderly fractures [2]
  • Typical scenario: Trip/slip, fall onto outstretched hand (FOOSH) with shoulder abducted/externally rotated
  • Contributing factors:
    • Impaired balance (vestibular dysfunction, medications)
    • Environmental hazards (rugs, uneven surfaces)
    • Visual impairment
    • Neuromuscular weakness

High-Energy (Young)

  • Road traffic accidents: 40-50% of young patient fractures [17]
  • Falls from height: 30-40%
  • Sports injuries: 10-15% (contact sports, cycling, skiing)
  • Direct trauma: Rare, typically associated with polytrauma
  • High-energy mechanisms produce:
    • Greater displacement
    • Higher rates of fracture-dislocation (15-25% vs less than 5% in elderly)
    • Associated injuries (head injury, other fractures)

Special Mechanisms

  • Posterior dislocation-fracture: Seizures, electrocution, high-voltage injury (posterior deltoid/pectoralis overcomes rotator cuff)
  • Pathological fracture: Metastatic lesions (breast, lung, kidney, thyroid, multiple myeloma), primary bone tumors

Risk Factors

Patient Factors

  • Osteoporosis/Osteopenia: Strongest independent predictor (Relative Risk 2-5) [18]
  • Female sex: RR 3-4 (multifactorial: bone density, fall risk, longevity)
  • Advanced age: RR increases exponentially after age 60
  • Previous fragility fracture: RR 2-3 (indicates systemic bone fragility)
  • Low body mass index: BMI less than 20 kg/m² associated with reduced bone density
  • Corticosteroid use: > 5mg prednisolone daily for > 3 months (secondary osteoporosis)
  • Smoking: Impaired bone quality and fracture healing
  • Alcohol excess: > 3 units/day increases fall and fracture risk

Comorbidities

  • Neurological conditions: Parkinson's disease, stroke, peripheral neuropathy (fall risk)
  • Endocrine disorders: Hyperthyroidism, hyperparathyroidism, hypogonadism, diabetes mellitus
  • Rheumatological disease: Rheumatoid arthritis (bone loss, corticosteroid use)
  • Chronic kidney disease: Renal osteodystrophy
  • Malabsorption syndromes: Celiac disease, inflammatory bowel disease (Vitamin D/calcium deficiency)

Medications

  • Proton pump inhibitors: Chronic use (> 1 year) associated with fracture risk (calcium malabsorption)
  • Sedatives/benzodiazepines: Increased fall risk
  • Anticholinergics: Cognitive impairment, dizziness
  • Antihypertensives: Postural hypotension

3. Anatomy & Pathophysiology

Surgical Anatomy

Osseous Anatomy: The Four Segments

The Neer classification is based on four anatomical segments separated by embryological growth plates (epiphyseal lines): [4]

  1. Humeral Head (Articular Segment)

    • Retroverted 20-30° relative to epicondylar axis
    • Articular surface angles 130-150° to shaft (neck-shaft angle)
    • Covered by hyaline cartilage (40% of sphere)
    • No direct muscular attachments (capsule only)

  2. Greater Tuberosity (Lateral/Posterolateral)

    • Three facets for rotator cuff insertion:
      • Superior: Supraspinatus
      • Middle: Infraspinatus
      • Inferior: Teres minor
    • Located 5-10mm inferior to humeral head apex
    • Critical for abduction mechanics and subacromial clearance

  3. Lesser Tuberosity (Anteromedial)

    • Insertion of subscapularis tendon (anterior cuff)
    • Forms medial wall of bicipital groove
    • Avulsion produces internal rotation deformity (unopposed infraspinatus)

  4. Surgical Neck (Proximal Shaft)

    • Metaphyseal-diaphyseal junction
    • Weakest structural point (transition from cancellous to cortical bone)
    • Most common fracture location in elderly osteoporotic bone
    • Insertion of pectoralis major (anteromedial shaft, ~5cm distal to GT)

Vascular Anatomy

Understanding the blood supply is critical for predicting AVN risk: [15]

  • Anterior circumflex humeral artery (ACHA): Primary blood supply

    • "Arcuate artery: Ascending branch of ACHA, enters humeral head through bicipital groove"
    • Perfuses 80-90% of humeral head
    • Intracapsular course makes it vulnerable in displaced fractures
    • Maintains medial periosteal hinge is critical for preserving this supply

  • Posterior circumflex humeral artery (PCHA): Secondary supply

    • Supplies posterolateral head via GT
    • Supplies axillary nerve (travels with nerve through quadrilateral space)

  • Intraosseous blood flow: Vessels ascend from metaphysis through anatomical neck

    • Disrupted in 4-part and anatomical neck fractures → AVN

Neurovascular Structures at Risk

  • Axillary nerve (C5-C6): [11]

    • Emerges from posterior cord of brachial plexus
    • Exits axilla via quadrilateral space (inferior to surgical neck)
    • Wraps around surgical neck ~5cm distal to acromion
    • "Supplies: Deltoid (motor), teres minor (motor), lateral shoulder skin (sensory)"
    • "Injury mechanism: Traction during displacement, direct trauma, surgical dissection"
    • Clinical test: Sensation over "Regimental Badge" area; deltoid contraction during abduction

  • Axillary artery: [12]

    • Runs anteromedially in axilla
    • At risk in anterior fracture-dislocations, severely displaced surgical neck fractures
    • "High suspicion if: diminished/absent radial pulse, expanding hematoma, limb ischemia"
    • Elderly with atherosclerosis at higher risk (loss of vessel elasticity)

  • Brachial plexus cords: Generally protected, but traction injuries possible in high-energy trauma

  • Cephalic vein: Runs in deltopectoral interval (surgical landmark, preserve during approach)

  • Long head biceps tendon: Runs in bicipital groove, occasionally used as reduction tool

Pathophysiology of Injury

Mechanism of Fracture

Low-Energy Fall (Elderly)

  • Fall onto outstretched hand (FOOSH) with:
    • Shoulder abducted 70-90°
    • Elbow extended
    • Forearm pronated
  • Axial loading transmitted through humeral shaft to proximal metaphysis
  • Rotational forces from trunk create torsional stress
  • Osteoporotic metaphyseal bone fails at surgical neck (weakest point)
  • Minimal displacement in most cases due to:
    • Intact periosteal/soft tissue envelope
    • Rotator cuff compression
    • Low impact energy

High-Energy Trauma (Young)

  • Greater force magnitude overwhelms bone strength
  • Complete disruption of soft tissue envelope
  • Displacement determined by:
    • Vector of impact
    • Muscle pull (deforming forces)
    • Associated dislocation
  • Comminution reflects energy dissipation

Deforming Forces [4]

Once fracture occurs, muscle forces create predictable displacement patterns:

  1. Greater tuberosity displacement: Supraspinatus/infraspinatus pull GT posterosuperiorly
  2. Lesser tuberosity displacement: Subscapularis pulls LT medially and anteriorly
  3. Shaft displacement: Pectoralis major pulls shaft medially and anteriorly
  4. Head position:
    • Remains relatively stable (no direct muscle attachments)
    • Rotates based on fracture pattern:
      • 3-part (GT displaced): Head rotates into internal rotation (unopposed subscapularis)
      • 3-part (LT displaced): Head rotates into external rotation (unopposed infraspinatus)

Net result: Classic varus angulation (head tilted medially, shaft displaced laterally)

Valgus-Impacted Pattern: Special biomechanics [10]

  • Head driven into shaft in valgus position
  • Impaction stabilizes fracture
  • Soft tissue hinge preserved (periosteum, capsule)
  • Blood supply often maintained → lower AVN risk
  • Fracture "auto-stabilizes" but in malpositioned alignment

Avascular Necrosis (AVN) Pathophysiology

Hertel's Anatomical Predictors [15]

Hertel et al. (2004) identified key anatomical features predictive of humeral head ischemia:

  1. Metaphyseal head extension (calcar length) less than 8mm

    • Measured on CT: length of medial metaphyseal bone attached to head fragment
    • Short calcar = minimal soft tissue attachment = vascular compromise
    • less than 8 mm: Sensitivity 97%, Specificity 93% for AVN

  2. Medial hinge disruption

    • Soft tissue bridge along medial calcar
    • Contains periosteal vessels, capsular attachments
    • Disruption visible on CT (complete fracture medially)

  3. Basic fracture pattern

    • Anatomical neck fracture: Intracapsular, disrupts arcuate artery entry → AVN ~100%
    • 4-part fracture: Head isolated from all soft tissue pedicles → AVN 15-30% [9]
    • Head-split fracture: Direct articular damage, may compromise intraosseous vessels

Predictive Value:

  • Calcar less than 8mm alone: AVN risk ~40%
  • Medial hinge disruption alone: AVN risk ~50%
  • Both present: AVN risk 97% [15]
  • Valgus-impacted 4-part: AVN risk only 5-15% (intact hinge) [10]

Timeline of AVN Development:

  • Occurs if blood supply not restored within 6-8 hours (theoretical window)
  • Radiographic changes: 6-24 months post-injury
  • MRI can detect earlier (3-6 months): bone marrow edema, subchondral fracture
  • Clinical presentation: Progressive pain, loss of function, stiffness

Management implications:

  • High AVN risk fractures (Hertel criteria positive) → consider primary arthroplasty rather than fixation
  • Fixation of AVN-prone fractures may result in secondary collapse requiring salvage arthroplasty (2 surgeries, worse outcome)

4. Classification Systems

Neer Classification (1970)

The Neer classification remains the most widely used system for proximal humerus fractures, guiding treatment decisions and communication. [4] Based on displacement of four anatomical segments.

Definition of "Part" (Displacement Criteria):

  • A segment is considered displaced if:
    • Separated by > 1cm from adjacent segment, OR
    • Angulated > 45 degrees from anatomical position
  • If displacement criteria not met → considered 1-part regardless of number of fracture lines visible

Classification:

1-Part Fracture (80-85% of all PHF)

  • No segment meets displacement criteria
  • Includes "hairline" fractures and minimally displaced multi-fragment fractures
  • Soft tissue envelope intact, holding fragments together
  • Management: Almost always conservative (sling, early mobilization)
  • Prognosis: Excellent healing, low AVN risk (less than 5%)

2-Part Fractures (~10% of PHF)

Subtypes based on which segment is displaced:

  • 2-part surgical neck: Most common 2-part pattern

    • Shaft displaced from head/tuberosities
    • Head remains attached to both tuberosities (blood supply preserved)
    • "Management: Age-dependent (conservative vs ORIF)"
    • "AVN risk: less than 5%"

  • 2-part greater tuberosity:

    • GT displaced > 5mm (especially in overhead athletes) or > 1cm
    • Often associated with shoulder dislocation (anterior dislocation avulses GT)
    • If displaced > 5 mm: blocks abduction (impinges on acromion)
    • "Management: ORIF if > 5mm displacement (restore subacromial clearance)"
    • "AVN risk: Minimal (head vascularity intact)"

  • 2-part lesser tuberosity: Rare (less than 1%)

    • Subscapularis avulsion
    • Often associated with posterior dislocation or seizure
    • "Management: Usually conservative; ORIF if significant displacement"

  • 2-part anatomical neck: Very rare (less than 1%)

    • Fracture through articular head-neck junction (intracapsular)
    • "AVN risk: ~100% (arcuate artery disrupted)"
    • "Management: Hemiarthroplasty or RSA (not fixation)"

3-Part Fractures (~5% of PHF)

  • Surgical neck fracture PLUS displacement of one tuberosity
  • Remaining tuberosity keeps attachment to head
  • Two patterns:
    • "GT displaced: Head rotates into internal rotation (subscapularis unopposed)"
    • "LT displaced: Head rotates into external rotation (infraspinatus unopposed)"
  • AVN risk: 10-20% (partial blood supply preserved via intact tuberosity) [9]
  • Management:
    • "Elderly/low demand: Conservative (PROFHER applies) [3]"
    • "Young/active: ORIF vs RSA (individualized)"

4-Part Fractures (~2-3% of PHF)

  • All four segments displaced from each other
  • Head isolated from all soft tissue attachments
  • Classic 4-part: Head "floating" with no soft tissue connection
    • "AVN risk: 15-30% (variable reports, not 100% as historically stated) [9]"
    • Some collateral circulation via capsule may persist
  • Valgus-impacted 4-part: Head impacted onto shaft in valgus position [10]
    • Soft tissue hinge maintained medially
    • "AVN risk: Only 5-15% (preserved blood supply)"
    • Fracture pattern distinguishable on CT
    • "Management: Amenable to fixation (not replacement)"
  • Management:
    • "Elderly (> 70 years): Reverse shoulder arthroplasty (gold standard) [6]"
    • "Young (less than 60 years): ORIF vs RSA (complex decision)"
    • "Valgus-impacted: ORIF (preserve head)"

Fracture-Dislocations

  • Fracture + glenohumeral dislocation (head displaced from glenoid)
  • Anterior fracture-dislocation: More common (GT fracture typically)
  • Posterior fracture-dislocation: Often missed; associated with seizures
  • Management: Urgent/emergent reduction + fracture stabilization
  • Higher energy injury → worse prognosis

Head-Splitting Fractures

  • Vertical fracture through articular surface (coronal or sagittal plane)
  • Not part of original Neer classification (later addition)
  • Often occurs in combination with other fracture patterns
  • AVN risk: High (intraosseous vessel disruption)
  • Management:
    • "Young: ORIF (technically challenging, subchondral screw fixation)"
    • "Elderly: Arthroplasty (RSA or hemiarthroplasty)"

Alternative Classification: AO/OTA Classification

More detailed, alphanumeric system used for research and comprehensive fracture characterization:

  • 11-A: Extra-articular unifocal fractures (tuberosities)
  • 11-B: Extra-articular bifocal fractures (surgical neck + tuberosity)
  • 11-C: Articular fractures (anatomical neck, head-split)

Less commonly used in clinical practice than Neer, but valuable for epidemiological studies and inter-observer reliability research.

Interobserver Reliability

Neer Classification Reliability: [19]

  • Kappa values: 0.4-0.6 (moderate agreement)
  • Better reliability for:
    • 1-part vs displaced fractures
    • 4-part fractures
  • Poorer reliability for:
    • 2-part vs 3-part distinction
    • Valgus-impacted recognition
  • CT imaging improves interobserver agreement compared to plain radiographs
  • Despite limitations, remains clinical standard for communication

5. Clinical Presentation

History

Mechanism of Injury

  • Elderly patients: "I fell at home/tripped on rug/slipped on ice"
    • Often falls forward onto outstretched hand
    • Low-energy mechanism
    • May have no recall if syncopal event (cardiac screening indicated)
  • Young patients: Road traffic accident, fall from height, sports injury
    • High-energy mechanism suggests complex fracture pattern
    • Screen for polytrauma (head injury, chest trauma, other fractures)

Pain

  • Immediate onset severe shoulder/upper arm pain at time of injury
  • Pain worse with movement, relieved by immobilization
  • Radiation down arm common (referred pain, not neurological)
  • Unable to lie flat (sleep semi-recumbent for comfort)

Loss of Function

  • "Dead arm" sensation—arm feels heavy, cannot lift
  • Patient supports injured arm with contralateral hand
  • Unable to perform activities of daily living (dressing, eating, washing)

Special Mechanisms to Elicit

  • Seizure history: High suspicion for posterior fracture-dislocation
  • Electrocution/lightning strike: Posterior dislocation mechanism
  • Fall height: > 2 meters suggests high-energy injury
  • Anticoagulation: Warfarin, DOACs—increased bleeding/hematoma risk
  • Trauma sequence: Witness account may clarify mechanism

Associated Symptoms

  • Paresthesia/numbness: Suggests nerve injury (axillary, brachial plexus)
  • Cold hand/absent pulse: Vascular injury (rare but emergent)
  • Deformity: Visible shoulder asymmetry, flattened contour
  • Bruising: Immediate or delayed (massive chest wall ecchymosis at 24-48h)

Examination

Inspection

  • Patient position: Arm held adducted, close to body; supported by opposite hand
  • Shoulder contour: Loss of normal rounded deltoid prominence (flattening)
  • Deformity: Visible prominence (displaced GT), anterior fullness (anterior dislocation)
  • Swelling: Diffuse shoulder/upper arm edema
  • Ecchymosis:
    • "Immediate: Suggests higher energy"
    • "Delayed (24-48h): Massive chest wall and arm bruising (Hennequin's sign)—gravitational tracking of hematoma, expected and benign"
  • Skin integrity:
    • "Tenting: Sharp bone spike threatening skin perforation—URGENT (impending open fracture)"
    • "Open wounds: True open fracture—requires emergent surgical washout"

Palpation

  • Bony tenderness: Maximal over proximal humerus, surgical neck region
  • Crepitus: Felt with gentle movement (avoid deliberate manipulation)
  • Pulses:
    • "Axillary pulse: Palpable in axilla (difficult in trauma setting)"
    • "Radial pulse: Compare to contralateral side (rate, volume, symmetry)"
    • Absent pulse = vascular injury until proven otherwise

Neurovascular Assessment (CRITICAL—document in all cases)

Axillary Nerve (most commonly injured): [11]

  • Sensory test: Light touch over lateral shoulder ("Regimental Badge" distribution)
    • Loss of sensation indicates axillary neuropathy
    • Document as present/absent/diminished
  • Motor test: Deltoid contraction during abduction
    • Often cannot test acutely due to pain/fracture instability
    • Test when pain allows (24-48h) or post-reduction
  • Incidence: 5-30% (many subclinical, detected only on EMG)
  • Prognosis: Most neuropraxias recover spontaneously in 3-6 months

Other Nerves (less common):

  • Radial nerve: Wrist/finger extension, first web space sensation (humeral shaft extension)
  • Median nerve: Thumb opposition, index/middle finger sensation (rare)
  • Ulnar nerve: Finger abduction, ring/little finger sensation (very rare)

Vascular Assessment: [12]

  • Radial pulse: Presence, character
  • Capillary refill: less than 2 seconds normal
  • Hand perfusion: Warm, pink, mobile vs cold, pale, paralyzed
  • Axillary artery injury signs:
    • Absent distal pulses
    • Expanding hematoma
    • Pulsatile bleeding
    • Hard signs = emergent vascular surgery consult

Range of Motion

  • Do NOT test actively in acute setting (risk displacement, pain)
  • Passive ROM: Gentle assessment of shoulder stability/dislocation (experienced clinician only)
  • Full ROM assessment deferred until after imaging and treatment decision

Associated Injuries

  • Ipsilateral injuries: Elbow, wrist fractures (FOOSH mechanism)
  • Chest wall: Rib fractures (especially in elderly with osteoporosis)
  • Head injury: Exclude in falls (GCS assessment, confusion, amnesia)

Red Flags Requiring Urgent/Emergent Management

  • Neurovascular compromise: Absent pulses, cold hand, expanding hematoma → Vascular surgery consult, CT angiography
  • Open fracture: Bone exposed or skin tenting → Emergent washout, antibiotics, tetanus
  • Fracture-dislocation: Anterior or posterior dislocation → Urgent reduction (ideally less than 6 hours to reduce soft tissue damage)
  • Compartment syndrome: Rare in proximal humerus, but monitor if massive swelling, pain out of proportion, pain on passive stretch
  • Posterior dislocation: Often missed; fixed internal rotation, "lightbulb sign" on AP XR → Urgent reduction

6. Investigations

Plain Radiography

Trauma Series (Mandatory): Three orthogonal views required [20]

  1. AP Scapular ("Grashey" view)

    • True anteroposterior of glenohumeral joint
    • Patient rotated 30-40° to align scapula parallel to film
    • Assessment:
      • Fracture pattern, displacement
      • Head-shaft angle (normal 130-150°)
      • Greater tuberosity position
      • Glenohumeral joint relationship

  2. Scapular Y-Lateral

    • Lateral view showing scapula as "Y"
    • Humeral head should be centered on glenoid (junction of Y)
    • Assessment:
      • Anterior vs posterior dislocation (head displaced off glenoid)
      • Degree of displacement
      • Tuberosity position

  3. Axillary Lateral (MOST IMPORTANT VIEW)

    • X-ray beam directed cranio-caudally through axilla
    • Arm gently abducted 20-30° (assistant supports)
    • Why critical: [14]
      • Only view definitively excluding posterior dislocation
      • Shows tuberosity displacement and rotation
      • Shows glenoid relationship
    • "If you didn't get an axillary view, you didn't complete the trauma series"
    • Alternatives if unable (pain, too unstable):
      • Velpeau axillary: Patient leans back over cassette (arm in sling)
      • Apical oblique: Not as good but better than nothing

Radiographic Findings to Report:

  • Number of fracture lines/fragments
  • Displacement magnitude (mm) and direction
  • Angulation (degrees)—especially varus tilt
  • Tuberosity position relative to head/acromion
  • Head position relative to glenoid (concentric vs dislocated)
  • Shaft medialization
  • Head-shaft angle
  • Bone quality (cortical thickness, osteopenia)

Special Radiographic Signs:

  • "Lightbulb sign": Humeral head appears round on AP (fixed internal rotation) → Posterior dislocation [14]
  • "Trough sign": Vertical impaction fracture of posterolateral head (reverse Hill-Sachs lesion)
  • Loss of half-moon overlap: Head not overlapping glenoid on AP → Dislocation
  • Double density sign: Head + glenoid superimposed → Posterior dislocation

Computed Tomography (CT)

Indications: [20]

  • ANY fracture being considered for surgery (surgical planning mandatory)
  • Complex fracture patterns (3-part, 4-part)
  • Suspected head-split component
  • Assessment of AVN risk (Hertel criteria: calcar length, medial hinge)
  • Posterior dislocation (assess reverse Hill-Sachs size)
  • Glenoid fracture (fracture-dislocation)
  • Inadequate plain radiographs (obesity, pain limiting positioning)

Advantages of CT:

  • 3D reconstruction: Visualize fracture pattern spatially
  • Hertel measurements: Calcar length, medial hinge integrity [15]
  • Head-split identification: Coronal/sagittal fracture lines not visible on XR
  • Glenoid assessment: Concurrent fractures
  • Surgical planning: Implant selection, screw trajectory planning, reduction strategy
  • Improved classification accuracy: Better interobserver agreement

CT Protocol:

  • Thin-slice acquisition (1-2mm)
  • 3D reconstructions: Essential for surgical planning
  • Multiplanar reformats: Coronal, sagittal, axial

Hertel CT Measurements: [15]

  • Calcar length: Metaphyseal extension attached to head (less than 8mm = high AVN risk)
  • Medial hinge integrity: Presence of soft tissue bridge (disruption = high AVN risk)

Magnetic Resonance Imaging (MRI)

Indications (NOT routine):

  • Suspected occult fracture: High clinical suspicion, normal radiographs (rare in proximal humerus)
  • Rotator cuff assessment: Preoperative cuff evaluation if chronic symptoms, consider arthroplasty
  • AVN detection: Suspected AVN post-fracture (follow-up imaging)
    • MRI detects AVN 6-18 months earlier than radiographs
    • "Findings: Bone marrow edema, subchondral fracture line, segmental collapse"
  • Soft tissue evaluation: Brachial plexus injury, vascular injury (MR angiography)

Not routine due to:

  • Cost
  • Time (delays management)
  • Patient discomfort (positioning in acute fracture)
  • Limited value in acute decision-making (CT superior for bony detail)

Vascular Imaging

CT Angiography (CTA):

  • Indication: Suspected axillary artery injury [12]
    • Absent pulses
    • Diminished pulses asymmetrically
    • Expanding hematoma
    • "Hard signs" of vascular injury
  • Protocol: Arterial phase contrast CT from aortic arch to hand
  • Findings: Occlusion, transection, pseudoaneurysm, arteriovenous fistula
  • Management: Vascular surgery consultation; may require open repair vs endovascular stenting

Doppler Ultrasound:

  • Limited role in acute trauma setting
  • May assess arterial flow if CTA unavailable
  • Operator-dependent

Electromyography (EMG) / Nerve Conduction Studies

Indication: [11]

  • Suspected nerve injury (axillary, radial, brachial plexus)
  • Timing:
    • "Acute (less than 2 weeks): Limited value (Wallerian degeneration not yet complete)"
    • "Optimal: 3-4 weeks post-injury: Distinguishes neuropraxia vs axonotmesis vs neurotmesis"
    • "Follow-up: 3-6 months: Assess recovery"
  • Findings:
    • "Neuropraxia (conduction block): Reversible, excellent prognosis"
    • "Axonotmesis (axonal injury): May recover with time (months)"
    • "Neurotmesis (complete transection): No spontaneous recovery, requires surgical repair"

Clinical Utility:

  • Most axillary nerve injuries are neuropraxia → spontaneous recovery in 3-6 months
  • EMG confirms diagnosis and guides expectant vs surgical management (nerve exploration/grafting)

Laboratory Tests

Not routinely required for isolated proximal humerus fractures.

Indications for labs:

  • Preoperative workup (if surgery planned):
    • Full blood count, renal function, coagulation
    • Group & Save (crossmatch if arthroplasty planned)
  • Osteoporosis screening:
    • Bone profile (calcium, phosphate, ALP, Vitamin D)
    • DEXA scan (dual-energy X-ray absorptiometry) for future fracture risk
  • Pathological fracture suspicion:
    • Calcium (hypercalcemia in malignancy)
    • Protein electrophoresis (myeloma)
    • PSA, tumor markers (metastatic workup)

7. Management

Initial Emergency Management

Pre-Hospital Care:

  • Immobilization: Broad arm sling or collar-and-cuff
  • Analgesia: Oral or IV opioids (titrate to pain)
  • Neurovascular assessment: Document baseline status
  • Avoid manipulation: Minimize movement to prevent displacement or neurovascular injury

Emergency Department:

  • ATLS protocol if polytrauma: Exclude life-threatening injuries first
  • Analgesia: Multimodal approach
    • "Opioids: Morphine 5-10mg IV titrated"
    • "Paracetamol: 1g PO/IV"
    • "NSAIDs: Ibuprofen 400mg PO (if no contraindications)"
  • Neurovascular exam: Document axillary nerve, radial pulse
  • Imaging: Trauma series radiographs (AP, Y-lateral, axillary)
  • Reduction if dislocated: Urgent closed reduction under sedation
  • Immobilization: Broad arm sling (not body bandage—allows scapulothoracic motion)
  • Disposition:
    • "Admit: Open fracture, neurovascular injury, fracture-dislocation, uncontrolled pain"
    • "Discharge: Stable fractures with adequate analgesia, orthopaedic follow-up arranged"

Acute Surgical Indications (within 24-48 hours):

  • Open fracture: Washout, debridement, skeletal stabilization
  • Vascular injury: Vascular repair ± skeletal stabilization
  • Fracture-dislocation: Reduction + fixation (closed reduction may be unstable)
  • Skin tenting: Impending skin necrosis (GT spike)

Conservative (Non-Operative) Management

Indications: [3,5]

  • All 1-part fractures (80-85% of fractures)
  • Displaced fractures in elderly/low-demand patients (PROFHER applies)
    • Age > 60 years with low functional demands
    • 2-part and 3-part surgical neck fractures
    • Acceptable alignment (varus less than 30°, displacement less than 2cm often tolerated)
  • Medically unfit for surgery: Severe comorbidities, high anaesthetic risk
  • Patient preference after informed consent

PROFHER Trial Evidence: [3]

  • Design: Multicentre RCT (UK), 250 patients, displaced proximal humerus fractures
  • Intervention: Surgery (various techniques) vs Non-operative (sling, early mobilization)
  • Primary outcome: Oxford Shoulder Score (OSS) at 2 years
  • Results:
    • No significant difference in OSS (mean difference 0.75 points, 95% CI -1.33 to 2.84)
    • No difference in quality of life (EQ-5D)
    • Higher complication rate in surgery group (30% vs 12%)
    • Higher secondary surgery rate in surgery group (20% vs 8%)
  • Conclusion: "Surgery not superior to non-surgical treatment for majority of displaced fractures"
  • Limitations:
    • Excluded head-splits, 4-part fractures, fracture-dislocations
    • Surgical techniques heterogeneous
    • Some "displaced" fractures were borderline (conservative would succeed anyway)
  • Clinical Impact: Shifted practice from routine surgery to selective conservative management

Conservative Protocol: [16]

Phase 1: Protection (0-2 weeks)

  • Sling immobilization: Collar-and-cuff or broad arm sling
    • "Collar-and-cuff preferred: Gravity assists fracture reduction (pulls shaft laterally, reducing varus)"
    • Worn continuously except for exercises and hygiene
  • Sleep position: Semi-recumbent (45-60°) for comfort
  • Analgesia:
    • Regular paracetamol 1g QDS
    • Ibuprofen 400mg TDS (if tolerated)
    • Opioids PRN (wean by week 2)
  • Exercises: Pendulum exercises only
    • Lean forward, let arm hang
    • Gentle circular motions (gravity-assisted)
    • Start within 1 week to prevent stiffness
    • 5 minutes, 3-4 times daily
  • Ice: 15 minutes TDS to reduce swelling/pain

Phase 2: Early Mobilization (2-6 weeks)

  • Wean sling: Gradually reduce sling use (remove at home by 3-4 weeks)
  • Active-assisted ROM: "Table slides," pulley exercises
    • Forward elevation to tolerance
    • External rotation in scapular plane (avoid forced ER—protects subscapularis)
    • "Goal: 90° elevation by 6 weeks"
  • Avoid: Lifting, pushing, pulling
  • Follow-up X-rays: 2 weeks, 6 weeks (assess healing, displacement)

Phase 3: Strengthening (6-12 weeks)

  • Active ROM: Progress to active elevation, rotation
  • Resistance exercises: Theraband, light weights (0.5-1kg)
  • Rotator cuff strengthening: Supraspinatus, external rotators
  • Functional activities: Gradually resume ADLs

Phase 4: Return to Function (3-12 months)

  • Progressive loading: Increase resistance
  • Sport-specific rehabilitation: If applicable
  • Expected timeline:
    • "Fracture union: 6-8 weeks"
    • "Functional recovery: 6-12 months"
    • "Maximal improvement: 12-18 months"
  • Residual deficits: Common to have some stiffness, reduced ROM (functionally acceptable)

Outcomes of Conservative Management: [5,13]

  • Union rate: > 95% (nonunion rare)
  • Malunion: Common (varus alignment, GT superior migration), usually asymptomatic
  • Stiffness: 60-80% develop some adhesive capsulitis
    • Most improve with prolonged physiotherapy
    • "Functionally limiting stiffness: 10-15%"
  • Patient satisfaction: 70-85% satisfied at 1 year
  • OSS: Mean 35-40/48 at 2 years (comparable to surgery per PROFHER)

Operative Management

General Surgical Indications:

  • Young/physiologically active patients with displaced fractures
  • Specific fracture patterns: GT > 5mm displacement, valgus-impacted 4-part
  • Failed conservative trial: Persistent pain, nonunion, symptomatic malunion
  • Fracture-dislocation: Unstable after closed reduction
  • Open fracture: After washout, stabilization
  • Bilateral fractures: Consider fixing one side for function
  • Polytrauma: Facilitate mobilization, nursing care

Surgical Options:

1. Open Reduction Internal Fixation (ORIF)

Indications: [20]

  • 2-part surgical neck fractures in young/active patients (less than 65 years)
  • 2-part GT fractures with > 5mm displacement (restore subacromial clearance)
  • 3-part fractures in young patients with good bone quality
  • Valgus-impacted 4-part fractures (low AVN risk, head preserved) [10]

Contraindications:

  • Severe osteoporosis (screw purchase inadequate → cutout risk)
  • High AVN risk (Hertel criteria positive—better served by arthroplasty)
  • Medical unfitness for surgery

Technique:

  • Approach: Deltopectoral interval
    • Identify and preserve cephalic vein
    • Retract deltoid laterally, pectoralis major medially
    • Expose fracture, identify fragments and rotator cuff
  • Reduction:
    • Anatomical reduction of head-shaft angle (130-150°)
    • Restore medial calcar continuity
    • Reduce tuberosities to head (anatomical position)
    • "Provisional fixation: K-wires"
  • Fixation: Locking plate (e.g., PHILOS—Proximal Humeral Internal Locking System)
    • Locking screws in head provide angular stability
    • "Suture augmentation: Non-absorbable sutures through rotator cuff, around plate holes"
    • "Calcar screw: Critical for resisting varus collapse"
    • "Inferomedial support: Prevent varus malreduction"
  • Closure: Rotator interval, deltopectoral interval, skin

Postoperative Protocol:

  • Sling immobilization 2-4 weeks
  • Early passive ROM (pendulums day 1)
  • Active-assisted ROM 4-6 weeks
  • Strengthening 12+ weeks
  • Fracture union 10-14 weeks

Outcomes:

  • Union rate: 85-90%
  • Good/excellent function: 70-80% in appropriately selected patients
  • Complication rate: 20-30%
    • "Screw cutout/penetration: 10-15% (screws penetrate humeral head into glenohumeral joint due to head collapse)"
    • "Avascular necrosis: 5-15% depending on fracture pattern"
    • "Infection: 2-5%"
    • "Stiffness: 30-40%"
    • "Malunion/loss of reduction: 10-15%"
    • "Revision surgery: 15-20%"

Pearls:

  • Medial calcar support is critical: Restoring medial column prevents varus collapse
  • Locking screws are NOT a substitute for reduction: Must achieve anatomical reduction first
  • Suture augmentation: Capture rotator cuff with heavy non-absorbable sutures to prevent tuberosity migration
  • Avoid over-tightening: Osteoporotic bone strips easily

2. Intramedullary Nailing

Indications: Limited role in proximal humerus (more common in shaft fractures)

  • 2-part surgical neck fractures (alternative to plating)
  • Osteoporotic bone (reduced soft tissue stripping vs ORIF)

Technique:

  • Antegrade nail insertion via GT (risk to rotator cuff)
  • Proximal interlocking screws into head

Outcomes: Similar to plate fixation; less soft tissue dissection but technically demanding

Disadvantages:

  • Cannot address tuberosity displacement
  • Rotator cuff injury at insertion site (GT)
  • Less commonly used than plating

3. Hemiarthroplasty (HA)

Historical Role: Previously used for complex fractures; now largely replaced by RSA

Indications (very limited in modern practice):

  • Head-split fracture in young patient (less than 60 years) unsuitable for fixation
  • Anatomical neck fracture (AVN inevitable)

Contraindications:

  • Age > 70 years (RSA superior outcomes)
  • Pre-existing rotator cuff pathology (HA requires intact cuff for function)

Technique:

  • Deltopectoral approach
  • Humeral head excised
  • Stem inserted into humeral canal
  • Modular head (sized to match native anatomy)
  • Tuberosity fixation: Critical for function
    • Tuberosities fixed around prosthesis with sutures
    • Success depends on tuberosity healing

Outcomes: [6]

  • Tuberosity healing: Only 50-60% achieve union
  • Functional outcomes: Variable (highly dependent on cuff healing)
    • "Good cuff healing: 70-80% satisfactory"
    • "Tuberosity nonunion/migration: Poor function (pseudoparalysis)"
  • Complications:
    • "Tuberosity nonunion/migration: 30-40%"
    • "Rotator cuff failure: 20-30%"
    • "Revision to RSA: 15-25% at 5 years"

Why HA is obsolete in fracture management:

  • Relies on rotator cuff (tuberosity) healing—unpredictable in osteoporotic bone
  • RSA eliminates this dependency → more reliable outcomes

4. Reverse Shoulder Arthroplasty (RSA)

GOLD STANDARD for complex fractures in elderly [6]

Indications:

  • 4-part fractures in patients > 70 years (or > 65 with low demand)
  • 3-part fractures in elderly with poor bone quality or pre-existing cuff pathology
  • Head-split fractures in elderly
  • Failed ORIF/HA: Salvage for AVN, screw cutout, tuberosity failure
  • Fracture-dislocation in elderly unsuitable for fixation

Biomechanical Principle:

  • Reverses normal anatomy:
    • Glenoid component = sphere (glenosphere)
    • Humeral component = socket (cup)
  • Medializes center of rotation: Recruits more deltoid fibers
  • Increases deltoid lever arm: Deltoid becomes primary elevator
  • Eliminates rotator cuff dependency: Works even with completely absent cuff

Technique:

  • Deltopectoral approach
  • Humeral head and tuberosities excised (no attempt to preserve/fix tuberosities)
  • Glenoid preparation: Baseplate fixed to glenoid with central screw + peripheral screws
  • Glenosphere: Modular sphere attached to baseplate (36-42mm diameter)
  • Humeral stem: Press-fit or cemented into canal
  • Humeral liner: Polyethylene socket (constrained or semi-constrained)
  • Closure: Subscapularis repair if tissue quality adequate (not essential for function)

Postoperative Protocol:

  • Sling 2-4 weeks
  • Early passive ROM (pendulums, table slides) day 1-2
  • Active-assisted ROM 4-6 weeks
  • Strengthening 12+ weeks
  • Prosthesis ingrowth: 6-12 weeks

Outcomes: [6]

  • Pain relief: Excellent (90-95% pain-free or minimal pain)
  • Forward elevation: Reliable 90-120° (functional range for ADLs)
  • External rotation: Often limited (10-30°)—expected
  • Patient satisfaction: 85-90%
  • Complication rate: 10-20%
    • "Instability/dislocation: 2-5% (reduced with modern constrained liners)"
    • "Infection: 2-3%"
    • "Acromial/scapular spine fracture: 2-4% (stress riser from altered biomechanics)"
    • "Loosening: less than 5% at 5 years"
    • "Neurological injury: less than 2% (axillary nerve)"
  • Implant survival: 90-95% at 10 years

Advantages over Hemiarthroplasty:

  • Independent of tuberosity healing (not relevant to function)
  • Predictable functional recovery (not dependent on cuff)
  • Lower revision rate
  • Superior pain relief and patient satisfaction

Disadvantages:

  • Limited external rotation: Functional but not anatomical
  • Scapular notching: Glenosphere impinges on scapular neck (radiographic finding, often asymptomatic)
  • Higher cost than HA
  • Non-reversible: Converting RSA to anatomical shoulder replacement is extremely difficult

RSA is now first-line arthroplasty for fractures in elderly patients [6]

Decision Algorithm: Surgery vs Conservative

PROXIMAL HUMERUS FRACTURE
         ↓
    IMAGING: XR + CT (if displaced)
         ↓
┌────────┴────────┐
│  ABSOLUTE       │
│  SURGICAL       │
│  INDICATIONS?   │
└────────┬────────┘
         ↓
    YES ←→ NO
     ↓         ↓
SURGERY   DISPLACEMENT?
           > 1cm or > 45°
              ↓
         YES ←→ NO
          ↓         ↓
     AGE/DEMAND  1-PART
          ↓      CONSERVATIVE
    less than 65 ACTIVE     ↓
          ↓      SLING + PHYSIO
       FRACTURE
       PATTERN?
          ↓
    ┌────┴────┐
  2/3-PART  4-PART
     ↓         ↓
   ORIF      RSA
(Plate/Nail) (Elderly)
             ORIF
          (Young, valgus-impacted)

Absolute Surgical Indications:

  • Open fracture
  • Vascular injury
  • Fracture-dislocation (unstable after reduction)
  • Skin tenting (impending open fracture)
  • Greater tuberosity > 5mm in overhead athlete

Relative Surgical Indications (individualized):

  • Young age (less than 65) + active lifestyle + displaced fracture
  • High AVN risk (Hertel criteria) → primary arthroplasty
  • Bilateral fractures (fix one for function)
  • Failed conservative trial

8. Complications

Early Complications (less than 6 weeks)

Neurovascular Injury:

  • Axillary nerve palsy: 5-30% incidence [11]

    • "Mechanism: Traction injury during fracture displacement, direct contusion, surgical iatrogenic"
    • Presentation: Loss of "Regimental Badge" sensation, deltoid weakness (often cannot test acutely due to pain)
    • "Investigation: Clinical examination (sensory testing); EMG at 3-4 weeks if persistent"
    • "Prognosis: "
      • 80-90% neuropraxias recover spontaneously in 3-6 months
      • If no recovery by 6 months → nerve exploration/grafting (poor prognosis)
    • "Management: Expectant observation, physiotherapy to prevent stiffness; surgical exploration only if complete palsy + no recovery at 6 months"

  • Axillary artery injury: less than 1% incidence [12]

    • "Risk factors: Elderly, atherosclerosis, high-energy trauma, fracture-dislocation"
    • "Presentation: Absent radial pulse, cold hand, expanding hematoma, ischemia"
    • "Investigation: CT angiography (diagnostic and maps injury)"
    • "Management: Emergent vascular surgery—open repair (interposition graft) or endovascular repair"
    • "Timing critical: Limb ischemia > 6 hours → irreversible damage"

  • Brachial plexus injury: Rare (less than 1%), high-energy mechanisms

    • Usually upper trunk (C5-6) → loss of shoulder abduction, elbow flexion, wrist extension
    • "Prognosis: Variable, poor if avulsion injury"

Compartment Syndrome:

  • Extremely rare in proximal humerus (more common in forearm, leg)
  • Suspect if: Tense swelling, pain out of proportion, pain on passive finger extension, paresthesia, pulselessness (late sign)
  • Diagnosis: Clinical (do NOT wait for pulse loss); compartment pressure > 30 mmHg or within 30 mmHg of diastolic BP
  • Management: Emergent fasciotomy (upper arm, forearm if involved)

Infection (Surgical cases):

  • Superficial wound infection: 2-5%
    • "Management: Oral antibiotics (flucloxacillin/co-amoxiclav), wound care"
  • Deep infection/osteomyelitis: 1-2%
    • "Presentation: Persistent pain, fever, wound drainage, elevated inflammatory markers"
    • "Investigation: Blood cultures, joint aspirate (if concern for septic arthritis), MRI"
    • "Management: Surgical washout + debridement, IV antibiotics (6-12 weeks), retain implant if stable"
    • May require implant removal if loosening/persistent infection

Hematoma:

  • Common (expected finding)
  • Hennequin's ecchymosis: Massive chest wall bruising at 24-48h (gravitational tracking)—benign, reassure patient
  • Expanding hematoma: Suggests vascular injury → investigate with CTA

Thromboembolic Events:

  • DVT/PE: Lower risk than lower limb fractures, but present in elderly/immobile
  • Prophylaxis: Early mobilization; pharmacological thromboprophylaxis if immobile/surgical/high risk (LMWH)

Intermediate Complications (6 weeks - 6 months)

Malunion:

  • Definition: Fracture healed in non-anatomical position
  • Incidence: Common with conservative treatment (30-50%), less common post-ORIF (10-15%)
  • Patterns:
    • "Varus malunion: Head tilted medially, neck-shaft angle less than 120° (most common)"
    • "GT superior migration: Impingement under acromion → painful arc"
    • "Shaft medialization: Loss of lateral offset"
  • Clinical Impact:
    • Many malunions are asymptomatic (functional adaptation)
    • "Problematic if: Severe varus (> 30°), GT impingement (blocks abduction), chronic pain"
  • Management:
    • "Asymptomatic: No treatment"
    • "Symptomatic:"
      • Physiotherapy: Scapular compensation, rotator cuff strengthening
      • Subacromial injection: If GT impingement
      • Corrective osteotomy: Rarely indicated (complex, poor outcomes in osteoporotic bone)
      • Arthroplasty: Salvage for severe pain/stiffness (RSA preferred)

Nonunion:

  • Definition: Failure of fracture healing by 6 months
  • Incidence: Rare (2-5% overall; higher in surgical neck fractures, smokers, high-energy injuries)
  • Risk Factors: Smoking, NSAIDs, inadequate fixation, vascular injury, interposition of soft tissue
  • Presentation: Persistent pain, inability to load shoulder, crepitus
  • Diagnosis: Serial radiographs (no bridging callus at 6 months, sclerotic fracture ends)
  • Management:
    • "Atrophic nonunion (no callus, poor biology):"
      • Revision ORIF + bone grafting (autograft from iliac crest)
      • Biological augmentation (BMP, PRP—limited evidence)
    • "Hypertrophic nonunion (abundant callus, inadequate stability):"
      • Revision fixation (improved stability)
    • "Elderly/Low Demand: Consider arthroplasty (RSA) rather than complex revision fixation"

Stiffness / Adhesive Capsulitis:

  • Incidence: 60-80% of proximal humerus fractures develop some degree of stiffness [13]
  • Mechanism:
    • Capsular fibrosis and contracture
    • Intra-articular adhesions
    • Muscle atrophy and altered mechanics
    • Prolonged immobilization worsens stiffness
  • Presentation: Restricted passive and active ROM, especially elevation and external rotation
  • Prevention:
    • Early mobilization (pendulums within 1 week)
    • Avoid prolonged immobilization (> 3 weeks)
    • Aggressive physiotherapy
  • Management:
    • "Physiotherapy: Stretching, manual therapy, passive ROM"
    • "Hydrodilatation: Intra-articular steroid + saline injection (distend capsule)"
    • "Manipulation under anesthesia (MUA): Break adhesions (risk fracture re-displacement if less than 12 weeks post-injury)"
    • "Arthroscopic capsular release: Severe refractory cases"
  • Prognosis:
    • Most improve with prolonged physiotherapy (12-18 months)
    • Residual stiffness common but often functionally acceptable
    • 10-15% have persistent functionally limiting stiffness

Late Complications (> 6 months)

Avascular Necrosis (AVN):

  • Incidence: [9]
    • 1-part: less than 5%
    • 2-part: less than 5%
    • 3-part: 10-20%
    • 4-part: 15-30% (historically quoted as 100%, but modern studies show lower rates)
    • "Valgus-impacted 4-part: 5-15% [10]"
  • Predictors: Hertel criteria (calcar less than 8mm, medial hinge disruption) → 97% AVN risk [15]
  • Timeline: Radiographic changes appear 6-24 months post-injury; MRI detects earlier (3-6 months)
  • Presentation:
    • "Early: Asymptomatic (radiographic finding only)"
    • "Late: Progressive pain, loss of function, stiffness"
  • Radiographic Stages:
    • "Stage 1: Normal X-ray, MRI shows bone marrow edema"
    • "Stage 2: Sclerosis, cystic change (head remains spherical)"
    • Stage 3: Subchondral collapse ("crescent sign")
    • "Stage 4: Secondary glenohumeral arthritis"
  • Management:
    • "Asymptomatic AVN: Observation (some remain asymptomatic indefinitely)"
    • "Symptomatic AVN:"
      • Pre-collapse (Stages 1-2): Core decompression (limited evidence, salvage attempt in young patient)
      • Collapse (Stages 3-4): Arthroplasty
        • Young (less than 60): Hemiarthroplasty or anatomical total shoulder (if glenoid involvement)
        • Elderly: Reverse shoulder arthroplasty (RSA) — gold standard

Post-Traumatic Glenohumeral Arthritis:

  • Incidence: 5-10% (long-term sequela of intra-articular fractures, AVN, or chronic instability)
  • Presentation: Pain, stiffness, crepitus, reduced function
  • Diagnosis: Radiographs (joint space narrowing, osteophytes, subchondral sclerosis/cysts)
  • Management:
    • "Conservative: NSAIDs, physiotherapy, intra-articular steroid injections"
    • "Surgical: Arthroplasty (anatomical total shoulder if good bone stock and intact cuff; RSA if cuff deficiency)"

Implant-Related Complications (Post-ORIF):

  • Screw cutout/penetration: 10-15%
    • "Mechanism: Varus collapse of head → screws penetrate articular surface into glenohumeral joint"
    • "Presentation: Pain, grinding, limited ROM"
    • "Management: Remove screws/implant; if severe articular damage → arthroplasty"
  • Plate prominence/impingement: GT impingement under acromion
    • "Management: Plate removal (after fracture union)"
  • Implant failure: Plate fracture, screw breakage (rare with modern locking plates)

Heterotopic Ossification (HO):

  • Incidence: 5-10% (higher in high-energy trauma, CNS injury, burns)
  • Presentation: Progressive stiffness, palpable firm mass, pain
  • Diagnosis: Radiographs (ectopic bone formation around shoulder)
  • Management:
    • "Prophylaxis: Indomethacin 75mg daily x 6 weeks post-surgery (if high risk)"
    • "Established HO: Physiotherapy; excision if severe and mature (> 12 months post-injury)"

Subacromial Impingement:

  • Mechanism: GT malunion (superior migration), heterotopic ossification, altered biomechanics
  • Presentation: Painful arc (60-120° abduction), positive impingement signs (Neer, Hawkins)
  • Management:
    • Physiotherapy, subacromial steroid injection
    • "Surgical: Subacromial decompression (acromioplasty) if refractory"

9. Prognosis

Functional Outcomes

Overall:

  • Fracture union rate: > 95% (nonunion rare)
  • Return to baseline function:
    • "1-part fractures: 80-90% return to pre-injury function by 12 months"
    • "Displaced fractures (2/3-part): 60-70% return to baseline"
    • "4-part fractures: 40-50% return to baseline (regardless of treatment)"
  • Timeline to maximal recovery: 12-18 months (prolonged due to stiffness, rehabilitation)

Patient-Reported Outcome Measures:

  • Oxford Shoulder Score (OSS): [3]
    • 1-part fractures (conservative): Mean 40-42/48 at 1 year
    • "Displaced fractures (conservative vs surgery): No significant difference (35-38/48 at 2 years per PROFHER)"
  • Constant-Murley Score: 70-80% of contralateral shoulder (reflects residual stiffness/weakness)
  • Patient satisfaction: 70-85% satisfied at 1 year

Range of Motion:

  • Forward elevation: Typically recover to 120-140° (functional, but not full 180°)
  • External rotation: Often limited to 30-40° (normal 60-90°)
  • Internal rotation: Usually preserved (behind back)
  • Stiffness universal: Nearly all patients have some residual ROM limitation compared to contralateral

Functional Activities:

  • ADLs: Most patients (80-90%) can perform independently (dressing, eating, hygiene)
  • Overhead activities: Limited in 40-50% (hanging washing, reaching high shelves)
  • Heavy lifting: Permanently reduced in most (avoid > 10kg lifts)
  • Sports: Return to sport variable (low-demand sports achievable; high-demand sports often not possible)

Prognostic Factors

Patient Factors:

  • Age:
    • "Younger (less than 60): Better ROM recovery, higher functional demands (surgery often indicated)"
    • "Elderly (> 70): Accept some stiffness, prioritize pain relief (conservative often appropriate)"
  • Sex: No significant difference in outcomes
  • Comorbidities: Diabetes, smoking impair healing and increase complications
  • Pre-injury function: Higher baseline function → better absolute outcome (but greater deficit from injury)
  • Bone quality: Osteoporosis impairs surgical fixation (screw cutout), but union still achieved conservatively

Fracture Factors:

  • Neer Classification:
    • "1-part: Excellent prognosis (80-90% good/excellent)"
    • "2-part: Good prognosis (70-80% good/excellent)"
    • "3-part: Fair prognosis (60-70% good/excellent)"
    • "4-part: Guarded prognosis (40-60% good/excellent)"
  • Displacement magnitude: Greater displacement → worse outcomes (BUT PROFHER showed surgery doesn't overcome this)
  • AVN risk (Hertel criteria): High AVN risk → poor prognosis with fixation (consider primary arthroplasty)
  • Fracture-dislocation: Worse outcomes than isolated fractures (soft tissue injury, instability)

Treatment Factors:

  • Early mobilization: Strong predictor of better ROM and function
  • Physiotherapy adherence: Critical for functional recovery
  • Surgical complications: Screw cutout, infection, AVN → poor outcomes, often requiring revision

Specific Treatment Outcomes

Conservative Management: [3,5]

  • Union: > 95%
  • OSS at 2 years: 35-40/48 (PROFHER)
  • Satisfaction: 75-85%
  • Return to ADLs: 80-85%
  • Stiffness: 60-70% (residual ROM limitation)
  • Secondary surgery rate: 5-10%

ORIF (Locking Plate): [20]

  • Union: 85-90%
  • Good/excellent outcomes: 70-80% (in appropriately selected patients)
  • Complication rate: 20-30%
  • Reoperation rate: 15-20%
  • OSS at 2 years: 36-38/48 (similar to conservative per PROFHER)

Reverse Shoulder Arthroplasty: [6]

  • Pain relief: Excellent (90-95% pain-free)
  • Forward elevation: Reliable 90-120°
  • Satisfaction: 85-90%
  • Complication rate: 10-20%
  • Implant survival: 90-95% at 10 years
  • Gold standard for complex fractures in elderly

Return to Work / Activities

  • Sedentary work: 6-12 weeks (desk-based, minimal shoulder use)
  • Light manual work: 3-6 months (gradual return)
  • Heavy manual work: 6-12 months (may not return to pre-injury capacity)
  • Overhead work: Often permanent limitation
  • Driving: 6-8 weeks (when can control steering wheel safely; inform insurance)
  • Sport:
    • "Low-impact: 3-6 months (golf, swimming—adapted stroke)"
    • "Contact sports: 6-12 months (if young, good healing)"
    • "Overhead sports: Often not feasible (tennis, volleyball)"

Mortality

  • Not directly life-threatening in isolation
  • Elderly patients: 1-year mortality ~5-10% (reflects underlying frailty and comorbidities, not fracture itself)
  • Secondary decline: Immobility, pain, functional dependence can trigger cascade (pneumonia, deconditioning)
  • Importance of early mobilization: Prevent secondary complications

10. Prevention

Primary Prevention (Preventing First Fracture)

Osteoporosis Screening \u0026 Management:

  • DEXA scanning:
    • "Indications: Women > 65 years, men > 70 years, younger if risk factors (previous fracture, corticosteroids, family history)"
    • "Interpretation: T-score ≤-2.5 = osteoporosis"
  • Pharmacological treatment: [18]
    • "Bisphosphonates: First-line (alendronate, risedronate, zoledronic acid)"
      • Reduce fracture risk by 40-50%
      • Annual/weekly dosing options
    • "Denosumab: Anti-RANKL antibody (6-monthly injection)"
    • "Teriparatide: Anabolic (severe osteoporosis, multiple fractures)"
    • "HRT: Postmenopausal women (if menopausal symptoms present)"
  • Calcium \u0026 Vitamin D supplementation:
    • Calcium 1200mg daily + Vitamin D 800-1000 IU daily
    • Especially important in housebound elderly (sunlight deficiency)
  • Lifestyle:
    • "Weight-bearing exercise: Walking, resistance training (improves bone density)"
    • "Smoking cessation: Smoking impairs bone health and fracture healing"
    • "Limit alcohol: less than 14 units/week"
    • "Adequate nutrition: Protein intake critical for bone and muscle health"

Falls Prevention: [18]

  • Multifactorial Falls Assessment:
    • "Gait \u0026 balance: Physiotherapy, walking aids, balance exercises"
    • "Vision: Optometry review, cataract surgery"
    • "Medication review: Reduce sedatives, antihypertensives (postural hypotension)"
    • "Environmental modification: Remove trip hazards (rugs), improve lighting, install grab rails"
    • "Footwear: Appropriate footwear (avoid slippers)"
  • Strength \u0026 Balance Programs: Tai Chi, Otago Exercise Programme (reduce falls by 30-40%)
  • Hip protectors: Limited evidence for proximal humerus (more effective for hip fractures)

Secondary Prevention (Preventing Second Fracture)

Fragility Fracture = Osteoporosis Until Proven Otherwise:

  • ANY low-energy fracture in patient > 50 years mandates osteoporosis workup
  • Fracture Liaison Services (FLS): Multidisciplinary service ensuring:
    • DEXA scan arranged
    • Bone health medication initiated
    • Falls risk assessment
    • Follow-up adherence
  • Treatment reduces future fracture risk by 40-50% [18]

Post-Fracture Care Optimization:

  • Early mobilization: Prevent deconditioning and subsequent falls
  • Multidisciplinary rehabilitation: Physiotherapy, occupational therapy
  • Address underlying causes: Treat osteoporosis, prevent falls

11. Special Populations

Elderly (> 75 years)

Unique Considerations:

  • Osteoporosis severity: Bone quality often very poor (eggshell cortices)
  • Functional demands lower: Emphasis on pain relief and basic ADLs, not full ROM
  • Comorbidities: Polypharmacy, frailty, cognitive impairment
  • Anaesthetic risk: Higher surgical risk (cardiac, respiratory disease)

Management Approach:

  • Strong bias toward conservative management (PROFHER evidence supports this) [3]
  • Surgery if indicated: Favor RSA over ORIF (avoid fixation in poor bone)
  • Goals: Pain-free function for ADLs (not anatomical ROM)
  • Rehabilitation: May require inpatient rehab or home support

Young/High-Demand (less than 40 years)

Unique Considerations:

  • High-energy mechanisms: Complex fracture patterns, associated injuries
  • High functional demands: Return to work, sport, overhead activities
  • Better bone quality: Fixation achievable with good screw purchase
  • Long lifespan: Arthroplasty deferred (limited implant lifespan—revision likely)

Management Approach:

  • Surgical fixation preferred for displaced fractures (anatomical restoration critical)
  • Avoid arthroplasty if possible: Fix fractures, even complex patterns
  • Accept higher complication risk to preserve native joint
  • Aggressive rehabilitation: Early ROM, prolonged strengthening

Fracture-Dislocation

Unique Considerations:

  • Higher energy injury: Greater soft tissue damage, instability
  • Posterior dislocation often missed: High clinical suspicion, axillary view mandatory
  • Neurovascular injury risk higher: Axillary nerve, axillary artery
  • Closed reduction may fail: Soft tissue interposition (long head biceps, labrum)

Management:

  • Urgent reduction (ideally less than 6 hours)
    • Closed reduction under sedation
    • If irreducible → open reduction
  • Fracture stabilization: ORIF (if reducible and stable) vs RSA (elderly, unstable)
  • Prognosis: Worse than isolated fractures (instability, stiffness, AVN risk)

Pathological Fractures

Unique Considerations:

  • Metastatic lesions: Breast, lung, kidney, thyroid, myeloma most common
  • Bone quality: Lytic lesions, severe weakening
  • Life expectancy: Limited in metastatic disease
  • Pain control priority: Function secondary

Management:

  • Staging: CT chest/abdomen/pelvis, bone scan/PET, biopsy (if unknown primary)
  • Multidisciplinary: Oncology, orthopaedics, palliative care
  • Surgical goals: Pain relief, function (not oncological resection)
    • "Intramedullary nail + cement augmentation: Prophylactic fixation of impending fractures"
    • "Arthroplasty: Established fractures (RSA preferred—no dependency on bone healing)"
  • Adjuvant: Radiotherapy (local control), chemotherapy (systemic control), bisphosphonates (bone protection)

12. Patient Education \u0026 Explanation

What has happened?

You have broken the top of your arm bone (humerus), just below the ball of the shoulder joint. This is called a proximal humerus fracture. It is one of the most common fractures in people over 65, especially if you have osteoporosis (thinning of the bones).

The fracture usually happens when you fall onto your hand or shoulder. The bone breaks because of the impact, and sometimes the broken pieces can move out of position (displacement).

Will I need an operation?

In most cases, NO.

A large study called PROFHER showed that for most people, an operation does NOT give a better result than letting the bone heal naturally. In fact, surgery can sometimes cause complications like infection, nerve damage, or problems with the metal screws.

You will likely need an operation if:

  • You are young and very active (to restore full function)
  • The broken bone is pushing on the skin (risk of infection)
  • The shoulder is dislocated (out of joint)
  • A specific piece of bone (called the greater tuberosity) is blocking your shoulder movement

If you are over 65 and less active, we usually recommend a sling and physiotherapy rather than surgery. This gives the same level of function with fewer risks.

What is the treatment?

Non-Surgical Treatment (Sling \u0026 Physiotherapy):

  1. Sling: You will wear a sling for 2-3 weeks to support the arm while the bone starts to heal.
  2. Pain relief: We will give you painkillers (paracetamol and/or ibuprofen). The pain usually improves within 2 weeks.
  3. Exercises: You will start gentle exercises (called pendulum exercises) within the first week. This is VERY IMPORTANT to prevent your shoulder from becoming stiff.
  4. Physiotherapy: A physiotherapist will guide you through exercises to gradually restore movement and strength. This takes 3-6 months.
  5. X-rays: We will check your shoulder with X-rays at 2 weeks and 6 weeks to make sure it is healing properly.

If You Need Surgery:

  • Young patients: We may fix the bone with a metal plate and screws (called ORIF).
  • Elderly patients with severe fractures: We may replace the shoulder joint with an artificial joint (called reverse shoulder replacement). This relieves pain and restores function even if the bone is badly broken.

What about the bruising?

This is NORMAL. Within 24-48 hours, you will notice massive bruising spreading down your arm and across your chest. This looks alarming (the whole arm may turn black and purple), but it is just the blood from the fracture tracking downwards due to gravity. It is called Hennequin's sign and is completely expected. The bruising will fade over 2-3 weeks.

How long does it take to heal?

  • Bone healing: 6-8 weeks. The bone will join together (unite) during this time.
  • Return to normal activities: 3-6 months for most daily tasks (dressing, washing, eating).
  • Full recovery: 12-18 months. Your shoulder may remain a bit stiff compared to before, but most people can do their usual activities without pain.

What if it doesn't heal properly?

  • Malunion (healing in a crooked position): This is common, but usually does NOT cause problems. Your shoulder may look slightly different on X-rays, but if it doesn't hurt and you can move it, we don't need to fix it.
  • Avascular necrosis (blood supply problem to the bone): Rarely, the bone loses its blood supply and collapses. This causes pain and stiffness later (6-12 months). If this happens, we can replace the shoulder joint.
  • Stiffness: Almost everyone has some stiffness after a proximal humerus fracture. Physiotherapy helps, but it takes time (12-18 months).

Can I prevent this happening again?

Yes. If you have had this fracture, you likely have osteoporosis (weak bones). We will:

  • Check your bone strength with a DEXA scan.
  • Start medication (usually a tablet or yearly injection) to strengthen your bones and reduce your risk of future fractures by 40-50%.
  • Give you calcium and vitamin D supplements.
  • Assess your risk of falling and give advice on balance exercises, home safety (remove trip hazards), and vision checks.

What should I watch out for?

Contact us urgently if you develop:

  • Numbness or tingling in your hand or fingers (nerve problem)
  • Cold hand or absent pulse (blood vessel problem)
  • Increasing pain despite painkillers (possible complication)
  • Fever or wound infection (if you had surgery)

13. Evidence \u0026 Guidelines

Landmark Studies

1. The PROFHER Trial (Rangan et al., JAMA 2015) [3]

  • Design: Multicentre, randomized controlled trial (UK)
  • Participants: 250 adults with displaced proximal humerus fractures (2-part and 3-part surgical neck fractures)
  • Intervention: Surgical fixation (plate, nail, or hemiarthroplasty) vs Non-operative (sling + physiotherapy)
  • Primary Outcome: Oxford Shoulder Score (OSS) at 2 years
  • Results:
    • No significant difference in OSS between groups (mean difference 0.75 points, 95% CI -1.33 to 2.84, p=0.48)
    • No difference in quality of life (EQ-5D)
    • "Complications: 30% in surgery group vs 12% in non-operative group"
    • "Reoperations: 20% in surgery group vs 8% in non-operative group"
  • Conclusion: "Surgical treatment did not improve outcomes compared with non-surgical treatment for displaced proximal humeral fractures"
  • Impact: Paradigm shift away from routine surgical fixation toward selective conservative management in elderly patients
  • Limitations: Excluded 4-part fractures, head-splits, fracture-dislocations; surgical techniques heterogeneous

2. Hertel Criteria for AVN (Hertel et al., JShoulder Elbow Surg 2004) [15]

  • Design: Prospective cohort study, 30 patients with displaced proximal humerus fractures
  • Objective: Identify anatomical predictors of humeral head ischemia
  • Predictors Identified:
    1. Metaphyseal head extension less than 8mm (calcar length)
    2. Medial hinge disruption (loss of soft tissue bridge)
    3. Fracture pattern (anatomical neck, 4-part)
  • Diagnostic Accuracy:
    • "Calcar less than 8mm + medial hinge disruption: Sensitivity 97%, Specificity 93% for AVN"
  • Clinical Utility: Guide decision between fixation (low AVN risk) vs primary arthroplasty (high AVN risk)
  • Impact: Widely used for surgical decision-making; CT measurement of calcar length now standard in surgical planning

3. Reverse Shoulder Arthroplasty for Fractures (Systematic Review, Schiffman et al. 2024) [6]

  • Design: Systematic review of RSA outcomes for proximal humerus fracture sequelae
  • Findings:
    • "Pain relief: Excellent in 90-95%"
    • "Forward elevation: Mean 90-120°"
    • "Satisfaction: 85-90%"
    • "Complications: 10-20% (instability, infection, acromial fracture)"
    • RSA superior to hemiarthroplasty for complex fractures (does not rely on tuberosity healing)
  • Conclusion: "RSA is the preferred arthroplasty option for elderly patients with complex proximal humerus fractures"

Clinical Guidelines

NICE Guidance (UK): [Indirect—no specific PHF guideline]

  • Emphasis on osteoporosis treatment post-fragility fracture
  • Fracture Liaison Services to ensure secondary prevention

British Orthopaedic Association (BOA) / British Elbow \u0026 Shoulder Society (BESS):

  • Advocate selective conservative management (aligned with PROFHER)
  • Surgery reserved for young/active patients and specific fracture patterns
  • RSA gold standard for complex fractures in elderly

AO Foundation Principles:

  • Anatomical reduction and stable fixation when surgery indicated
  • Locking plates preferred for proximal humerus ORIF
  • Emphasis on early mobilization regardless of treatment

Current Controversies

1. Surgical Fixation vs Conservative in 3-Part Fractures:

  • PROFHER showed no benefit to surgery, but some surgeons argue that specific 3-part patterns (valgus-impacted, young patients) may benefit from fixation
  • Ongoing debate: Patient selection for surgery

2. Reverse vs Hemiarthroplasty:

  • RSA now dominant, but some argue hemiarthroplasty still has role in young patients with head-split fractures
  • Consensus shifting toward RSA even in younger elderly (> 65 years)

3. Timing of Surgery:

  • Acute (less than 2 weeks) vs Delayed RSA for 4-part fractures
  • Some evidence suggests outcomes similar, allowing time for patient optimization
  • Current practice: Acute fixation if surgery chosen, but delay acceptable if medical comorbidities

14. Viva Voce / Examination Focus

High-Yield Viva Questions

Q1: Classify proximal humerus fractures using the Neer system.

A: The Neer classification is based on the displacement of four anatomical segments: humeral head, greater tuberosity, lesser tuberosity, and surgical neck (shaft). A segment is considered displaced ("a part") if separated by > 1cm or angulated > 45 degrees.

  • 1-part: No segment displaced (80-85% of fractures). Managed conservatively.
  • 2-part: One segment displaced (surgical neck most common, then GT). Management age-dependent.
  • 3-part: Two segments displaced (surgical neck + one tuberosity). Head rotates. AVN risk 10-20%.
  • 4-part: All segments displaced. Head isolated. AVN risk 15-30%. Elderly → RSA.
  • Valgus-impacted 4-part: Special variant, head impacted onto shaft, blood supply often preserved, AVN risk only 5-15%.

Q2: What are the Hertel criteria for predicting avascular necrosis?

A: Hertel et al. (2004) identified three anatomical predictors of humeral head ischemia on CT:

  1. Metaphyseal head extension (calcar) less than 8mm: Short bony segment attached to head indicates minimal soft tissue attachment and vascular compromise.
  2. Medial hinge disruption: Loss of soft tissue bridge along medial calcar (contains periosteal vessels).
  3. Fracture pattern: Anatomical neck fracture or 4-part fracture pattern.

When calcar less than 8mm AND medial hinge disrupted: 97% sensitivity and 93% specificity for AVN.

Clinical use: High AVN risk fractures should be considered for primary arthroplasty rather than fixation, as fixation may fail due to head collapse.

Q3: What were the findings and impact of the PROFHER trial?

A: PROFHER (Rangan et al., JAMA 2015) was a multicentre RCT comparing surgical fixation vs non-operative management for displaced proximal humerus fractures (2/3-part surgical neck fractures) in adults.

Findings:

  • No significant difference in Oxford Shoulder Score at 2 years (surgery 36 vs conservative 36)
  • Higher complication rate in surgery group (30% vs 12%)
  • Higher reoperation rate in surgery group (20% vs 8%)

Conclusion: Surgery does NOT improve functional outcomes compared to conservative management for the majority of displaced proximal humerus fractures.

Impact: Paradigm shift from routine surgical fixation toward selective conservative management in elderly/low-demand patients. Surgery now reserved for specific indications (young/active, fracture-dislocation, GT blocking abduction, head-split).

Q4: What is the biomechanical principle of reverse shoulder arthroplasty?

A: Reverse shoulder arthroplasty reverses the normal anatomy:

  • Glenoid component = sphere (glenosphere)
  • Humeral component = socket (cup/liner)

This design:

  1. Medializes the center of rotation: Brings fulcrum closer to glenoid
  2. Increases deltoid lever arm: Deltoid fibers now have greater mechanical advantage
  3. Recruits more deltoid fibers: Anterior and posterior deltoid become elevators (in addition to middle deltoid)
  4. Eliminates rotator cuff dependency: Deltoid becomes sole elevator; cuff NOT required for function

Result: Reliable shoulder elevation (90-120°) even with completely absent or non-functional rotator cuff. This makes RSA ideal for fractures in elderly (where tuberosity healing unpredictable) and cuff tear arthropathy.

Q5: Which nerve is most commonly injured in proximal humerus fractures and how do you test it?

A: Axillary nerve (C5-C6) is most commonly injured (5-30% incidence).

Anatomy: Exits axilla via quadrilateral space, wraps around surgical neck ~5cm distal to acromion.

Testing:

  • Sensory: Light touch over lateral shoulder ("Regimental Badge" distribution)
    • Loss of sensation indicates axillary neuropathy
  • Motor: Deltoid contraction during shoulder abduction
    • Often cannot test acutely due to pain; test when pain subsides or post-reduction

Mechanism: Traction injury during fracture displacement, direct contusion, surgical iatrogenic.

Prognosis: 80-90% of neuropraxias recover spontaneously in 3-6 months. If no recovery by 6 months → nerve exploration (poor prognosis).

Q6: Why is the axillary radiograph critical in shoulder trauma?

A: The axillary view is the ONLY view that definitively excludes posterior dislocation.

Why important:

  1. Posterior dislocations are missed in 50% of initial presentations if relying on AP and Y-lateral views alone
  2. Axillary view shows:
    • Humeral head position relative to glenoid (concentrically reduced vs dislocated)
    • Tuberosity position and rotation
    • Reverse Hill-Sachs lesion (impaction fracture of posterolateral head in posterior dislocation)
  3. Posterior dislocation classic scenario: Seizure, electrocution, high-voltage injury
    • Arm locked in internal rotation
    • AP radiograph shows "lightbulb sign" (rounded humeral head, loss of normal half-moon overlap with glenoid)

Technique: Beam directed cranio-caudally through axilla, arm gently abducted 20-30°. If patient cannot tolerate: Velpeau axillary view (patient leans back over cassette with arm in sling).

"If you didn't get an axillary view, you didn't complete the trauma series."

Q7: Compare outcomes of reverse shoulder arthroplasty vs hemiarthroplasty for proximal humerus fractures.

A:

FactorHemiarthroplastyReverse Shoulder Arthroplasty
MechanismReplaces humeral head only; relies on rotator cuff (tuberosity) healingReverses anatomy; deltoid-powered, cuff-independent
Tuberosity healingCritical for function (50-60% achieve union)Irrelevant (tuberosities excised/not fixed)
Pain reliefVariable (depends on cuff healing)Excellent (90-95% pain-free)
Forward elevationVariable (70-100° if cuff fails)Reliable (90-120°)
Satisfaction60-70%85-90%
ComplicationsTuberosity nonunion/migration (30-40%), cuff failureInstability (2-5%), acromial fracture (2-4%)
Revision rate15-25% at 5 years (convert to RSA)less than 10% at 10 years
Current roleObsolete for fracturesGold standard for complex fractures in elderly

Conclusion: RSA has superseded hemiarthroplasty due to superior, predictable outcomes (does not rely on unpredictable tuberosity healing in osteoporotic bone).

15. References

  1. Pandey R, et al. Proximal humerus fracture(s): A review of current practice. J Clin Orthop Trauma. 2023;44:102220. PMID: 37636006.

  2. Younis Z, et al. Proximal Humerus Fractures: A Review of Anatomy, Classification, Management Strategies, and Complications. Cureus. 2024;16(10):e71104. PMID: 39640099.

  3. Rangan A, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-47. PMID: 25756440.

  4. Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970;52(6):1077-89. PMID: 5455339.

  5. Handoll HH, et al. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess. 2015;19(24):1-280. PMID: 25822598.

  6. Schiffman CJ, et al. Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review. J Am Acad Orthop Surg Glob Res Rev. 2024;8(5):e24.00010. PMID: 38713872.

  7. Martinez-Catalan N, et al. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. J Clin Med. 2023;12(1):178. PMID: 36562923.

  8. Klahs KJ, et al. Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study. J Shoulder Elbow Surg. 2024;33(1):49-55. PMID: 37573935.

  9. Fazzari F, et al. Avascular necrosis of humeral head after proximal humerus fracture: comparison between classifications and proposal of treatment algorithm. Musculoskelet Surg. 2024;108(Suppl 1):115-124. PMID: 38193586.

  10. Ribeiro FR, et al. Impacted valgus fractures of the proximal humerus. Rev Bras Ortop. 2016;51(2):128-32. PMID: 27069878.

  11. Rudran B, Duckworth AD. Proximal humerus fractures: anatomy, diagnosis and management. Shoulder Elbow. 2022;14(1 Suppl):104-115. PMID: 35938761.

  12. Cosic F, et al. Proximal humerus fracture dislocations: outcomes of management. ANZ J Surg. 2025;95(1-2):95-102. PMID: 39876620.

  13. Budharaju A, et al. Rehabilitation protocols in proximal humerus fracture management: A systematic review. Shoulder Elbow. 2024 Oct 21:17585732241283836. PMID: 39346799.

  14. DeFranco MJ, Lawton RL. Evaluation and management of valgus impacted four-part proximal humerus fractures. Orthop Clin North Am. 2006;37(1):115-32. PMID: 16394748.

  15. Hertel R, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427-33. PMID: 15220884.

  16. Ranieri R, et al. Early rehabilitation vs. conventional immobilization in nonoperative treatment of proximal humeral fractures in the elderly: a systematic review and meta-analysis. Aging Clin Exp Res. 2024;36(1):137. PMID: 38884512.

  17. Orapiriyakul W, et al. Humerus shaft fractures, approaches and management. Injury. 2023;54 Suppl 6:110945. PMID: 37588079.

  18. Liu G, et al. Hounsfield units predicts the occurrence but not the patterns of proximal humerus fracture in the elderly. BMC Musculoskelet Disord. 2023;24(1):401. PMID: 37131243.

  19. Campochiaro G, et al. Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis. Musculoskelet Surg. 2015;99 Suppl 1:S9-S15. PMID: 25957545.

  20. Handoll HH, et al. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2022;6(6):CD000434. PMID: 35727196.

16. Summary \u0026 Key Takeaways

Proximal humerus fractures are the third most common osteoporotic fracture, predominantly affecting elderly females following low-energy falls. The Neer classification (1-part to 4-part based on displacement > 1cm or > 45°) guides management, though the landmark PROFHER trial demonstrated that conservative management (sling + early mobilization) produces equivalent outcomes to surgery for most displaced fractures in elderly patients.

Management is selective:

  • 80-85% of fractures (1-part, minimally displaced) → Conservative
  • Surgery reserved for young/active patients, fracture-dislocations, greater tuberosity blocking abduction, and specific high-risk patterns
  • Reverse shoulder arthroplasty is the gold standard for complex fractures (4-part) in elderly patients, eliminating rotator cuff dependency

Axillary nerve injury (5-30%) is the most common complication, usually recovering spontaneously. Stiffness affects 60-80% of patients regardless of treatment, requiring prolonged rehabilitation (12-18 months). AVN risk is predicted by Hertel criteria (calcar less than 8mm, medial hinge disruption).

Secondary prevention is critical: all fragility fractures mandate osteoporosis screening, treatment (bisphosphonates reduce future fracture risk by 40-50%), and falls prevention strategies.

Functional recovery takes 12-18 months, with most patients achieving pain-free ADLs but residual stiffness. Patient selection, early mobilization, and evidence-based management (PROFHER) are key to optimizing outcomes.

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  • Adhesive Capsulitis
  • Avascular Necrosis
  • Shoulder Arthroplasty