Proximal humerus fractures occur most commonly in the elderly and their incidence is increasing.
Non-displaced proximal humerus fractures are commonly managed non-operatively using immobilisation methods (e.g. sling, collar and cuff).
Gentle range-of-motion exercises can begin after seven days in most stable fractures depending upon pain and tolerance.
Physical therapies may be initiated after three weeks, ensuring that no aggressive range-of-motion exercises, whether passive or actively assisted, are done until bony union has occurred.
For unstable fractures, surgical stabilisation may be required to achieve stability and pain relief, however this is not without risks.
Classification
A ‘one-part’ fracture is one in which the fragment is not displaced at all or is displaced 45 degrees. Neer additionally defined two, three and four-part fractures to indicate the number of main segments affected by displacement (see figure 1).
Epidemiology
Most proximal humerus fractures occur in the elderly with approximately 70% occurring in women, presumably due to the greater incidence of osteoporosis. Most of these occur due to a fall from standing. In most cases they are an isolated injury.
- One-part fracture: These non-displaced or minimally displaced fractures account for over 70% of all proximal humerus fractures. They are almost always treated conservatively.
- Two-part fracture: Frequently seen in the setting of anterior shoulder dislocation. These fractures account for approximately 20% of proximal humerus fractures.
- Three-part fracture: These fractures account for approximately 5% of proximal humerus fractures.
- Four-part fracture: These fractures are uncommon. However, this pattern has poor non-operative results. As the articular surface is no longer attached to any parts of the humerus which are attached to soft tissues, it has a high incidence of osteonecrosis.
Presentation
There is usually marked swelling, pain, tenderness and bruising of the proximal portion of the arm, due to bleeding from the bone and soft tissues.
Imaging
Standard imaging studies of proximal humeral fractures consist of true anterior-posterior, outlet and axillary view X-rays. Additional CT imaging is recommended if fracture lines cannot be reliably detected, as seen in complex three and four-part fractures with multiple-fragmented involvement of the head and tuberosities. However, while CT imaging improves the reliability of fracture classification over radiographs alone, there is no evidence that CT imaging improves outcome.
Management options
Most one-part or non-displaced fractures can be treated conservatively. However, fractures of the anatomic neck of the humerus have a high rate of subsequent osteonecrosis. Patients with this type of fracture should be referred to an orthopaedic surgeon even if there is no significant displacement of fragments.
Surgical intervention is generally needed for significantly displaced multi-part fractures and thus all displaced fractures should be referred to an orthopaedic surgeon for evaluation. Further indications for referral include fracture-dislocations and joint instability. Urgent orthopaedic referral is indicated for all nerve and vascular injuries, open fractures and fracture dislocations.
One-part fractures
Management:
- Analgesia
- Immobilise in standard sling or collar and cuff sling. Swathes can be used for pain control but otherwise unnecessary unless shoulder is unstable.
- Functional assessment:
- Mobility
- Personal care
- Minimal trauma fracture in patients >50 years, arrange bone health assessment (i.e. bone density assessment)
- Refer to falls clinic
- Refer for physiotherapy consult
Follow up:
- One-part fractures are almost always treated conservatively, apart from fractures of the anatomic neck of the humerus.
- Orthopaedic outpatient follow up in 3-4 days.
Two, three and four-part fractures
Management:
- Analgesia
- Sling or sling, splint and swathe
- Orthopaedic consult in ED
Follow up:
- Orthopaedic outpatient follow up
Fracture dislocations
Management:
- Analgesia
- Secure in position of most comfort for the patient
- Assess limb neurovascular status
- Orthopaedic consult in ED
Follow up:
- Orthopaedic outpatient follow up
Potential complications
Loss of shoulder mobility is among the more common complications of proximal humerus fractures. The decrease in motion ranges from clinically insignificant to adhesive capsulitis (i.e. frozen shoulder), in which shoulder movement is painful and limited in all orientations. The risk of developing diminished range of motion is more likely to occur in patients who do not perform range of motion exercises during recovery.
Although osteonecrosis of the humeral head is not common (7.9%), it can occur in patients with complex two, three and four-part fractures, especially in fractures involving the anatomic neck or severely displaced fractures. Other complications include non-union and impingement from avulsed fracture fragments.
Patient advice
- Sling required for 2-4 weeks depending on the patient and fracture. For one-part fractures, patient should start gradual mobilisation in the sling (e.g. gentle pendulum exercises) at 1-2 weeks
- Pain from the fracture and restriction of movement is usual for 2-3 weeks and will require regular analgesia, then analgesia as required.
- Refer to physiotherapist for advice and commencement of mobilisation.
Fact sheets
- Clavicle fracture (broken collar bone) patient fact sheet
- Shoulder dislocation patient fact sheet
- Slings patient fact sheet
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/networks/eci/clinical/tools/proximal-humerus-fractures