Proximal humerus fractures account for approximately 6% of all adult fractures and are the third most common fracture in the elderly. Approximately 85% are minimally displaced (< 1 cm displacement, < 45° angulation) and can be managed nonoperatively. [1-2] Incidence increases with age, with most occurring from a fall from standing height in osteoporotic patients. [1][3]
1. History
- Mechanism of injury: Fall on outstretched hand (FOOSH), direct blow to lateral shoulder, high-energy trauma (MVA, sports) in younger patients
- Timing: When did the injury occur? Any delay in presentation?
- Arm position at time of injury: Abducted, extended, or direct impact
- Pain characterization: Location (anterior/lateral shoulder), severity, radiation to deltoid/arm
- Functional status: Ability to move arm, hand grip, sensation in fingers
- Pre-injury functional level: Dominant hand, occupation, activity level, independence with ADLs
- Important negatives: Syncope or mechanical fall? Seizure? Pathologic fracture concern (cancer history, night pain)?
2. Alarm Features
- Neurovascular compromise: Absent or diminished distal pulses, expanding hematoma, cool/pale hand → concern for axillary artery injury (rare but devastating; associated with displaced fractures in elderly patients) [4-5]
- Axillary nerve injury: Loss of sensation over lateral deltoid ("regimental badge area"), inability to abduct shoulder
- Brachial plexus injury: Weakness or numbness in multiple nerve distributions [4]
- Open fracture: Skin breach with exposed bone
- Fracture-dislocation: Severe deformity, locked shoulder, associated with higher risk of avascular necrosis (AVN) of the humeral head [6-7]
- Compartment syndrome of the upper arm (rare)
- Pathologic fracture: Minimal trauma, known malignancy, lytic lesion on imaging
3. Medications
- Acute pain management:
- Acetaminophen and NSAIDs as first-line analgesics [1]
- Opioids for breakthrough pain (short course)
- Nerve blocks: interscalene or supraclavicular brachial plexus block for acute pain control in the ED
- Medications contributing to falls: Antihypertensives, sedatives, benzodiazepines, anticholinergics — review and optimize
- Osteoporosis treatment: Consider initiating or optimizing calcium, vitamin D, and bisphosphonates after fracture healing (not acutely)
- Anticoagulants: Note if on anticoagulation — increases hematoma risk and complicates surgical planning
- Avoid: Corticosteroid injections into the fracture site; NSAIDs are sometimes debated regarding fracture healing, though short-term use is generally acceptable
4. Diet
- Calcium and Vitamin D: Ensure adequate intake (1,200 mg calcium, 800–1,000 IU vitamin D daily) for bone health, especially in elderly patients
- Protein: Adequate protein intake supports fracture healing
- Hydration: Maintain hydration, particularly in elderly patients at risk for dehydration post-injury
- Alcohol: Excessive alcohol use is a risk factor for falls and impaired bone healing
5. Review of Systems
- Neurologic: Numbness/tingling in hand or fingers, weakness in wrist extension or grip (axillary nerve, radial nerve, brachial plexus)
- Vascular: Cold or discolored hand, swelling of the arm
- Musculoskeletal: Neck pain (cervical spine injury), ipsilateral wrist/elbow pain (associated injuries from fall), chest wall pain (rib fractures)
- Constitutional: Dizziness, syncope, or seizure preceding the fall
- Oncologic: Unintentional weight loss, fatigue, bone pain elsewhere (pathologic fracture)
6. Collateral History and Family History
- Collateral: Witnessed fall? Mechanism details from bystanders or EMS. Baseline functional status and cognitive function in elderly patients. Living situation (alone vs. with support)
- Family history: Osteoporosis, fragility fractures, metabolic bone disease
- Social context: Ability to perform ADLs with one arm immobilized, home safety assessment, fall risk factors, substance use
7. Risk Factors
- Osteoporosis — the dominant risk factor in elderly patients [1][3]
- Age > 65 years, female sex (71–94% female in major trials) [8-9]
- Fall risk: Polypharmacy, visual impairment, gait instability, cognitive impairment, environmental hazards
- Low BMD / prior fragility fracture
- Alcohol use, smoking — impair bone density and healing
- High-energy mechanism in younger patients (sports, MVA)
- Seizure disorders — posterior fracture-dislocations classically associated
8. Differential Diagnosis
- Shoulder dislocation (anterior or posterior) — may coexist with fracture
- Acromioclavicular joint separation
- Clavicle fracture (proximal, midshaft, or distal)
- Rotator cuff tear — acute traumatic tear can mimic or accompany fracture
- Scapula fracture — high-energy mechanism
- Humeral shaft fracture — more distal pain and deformity
- Pathologic fracture through metastatic lesion (breast, lung, renal, thyroid, myeloma)
- Cervical radiculopathy — referred shoulder pain without bony tenderness
9. Past Medical History
- Osteoporosis / osteopenia: DEXA results, prior treatment
- Prior shoulder injuries or surgeries
- Malignancy: Metastatic bone disease
- Seizure disorder: Posterior fracture-dislocations
- Chronic steroid use: Bone quality
- Diabetes, peripheral vascular disease: Healing and vascular status
- Anticoagulation therapy: Surgical planning
10. Physical Exam
- Inspection: Swelling, ecchymosis (often extends to chest wall and arm within 24–48 hours), deformity, skin integrity (open fracture)
- Palpation: Point tenderness over proximal humerus, crepitus
- Range of motion: Typically severely limited by pain; do not force — assess gently
- Neurovascular exam (critical):
- Axillary nerve: Sensation over lateral deltoid, deltoid contraction
- Radial/median/ulnar nerve: Wrist extension, finger flexion/abduction, sensation in hand
- Vascular: Radial and ulnar pulses, capillary refill, hand temperature and color
- Comparison with contralateral side
- Examine ipsilateral elbow and wrist for concomitant injuries [1]
11. Lab Studies
- Routine labs are generally not required for isolated proximal humerus fractures
- Consider in elderly/comorbid patients:
- CBC, BMP (renal function, electrolytes — especially if syncope preceded fall)
- Coagulation studies if on anticoagulants or pre-surgical planning
- Type and screen if significant hematoma or surgical candidate
- Osteoporosis workup (outpatient): Vitamin D level, calcium, PTH, DEXA scan
- If pathologic fracture suspected: CBC, CMP, ESR, SPEP/UPEP, PSA, alkaline phosphatase
12. Imaging
- First-line: Shoulder radiograph series — AP (internal and external rotation), scapular Y view, and axillary lateral view (minimum 3 views) [10]
- CT shoulder without contrast: Indicated for complex or displaced fractures to better characterize fracture pattern, number of fragments, and displacement — the optimal modality for delineating proximal humeral fracture patterns per ACR Appropriateness Criteria. 3D reconstructions further enhance classification accuracy [10-12]
- CT angiography: If vascular injury suspected (absent pulses, expanding hematoma) [5][13]
- MRI: Not typically needed acutely; may be useful later if concomitant rotator cuff tear is suspected
- When imaging is unnecessary: Imaging is always indicated when proximal humerus fracture is clinically suspected
13. Special Tests
- Neer Classification (most widely used): [1][8]
- Based on displacement of 4 segments: articular surface (head), greater tuberosity, lesser tuberosity, shaft
- A segment is a "part" only if displaced > 1 cm or angulated > 45°
- 1-part (minimally displaced): ~85% of all proximal humerus fractures
- 2-part, 3-part, 4-part: Increasing complexity and surgical consideration
- Note: Interobserver reliability is poor [14-15]
- AO/OTA Classification: Focuses on vascularity — Type A (intact supply), B (possible compromise), C (likely compromise) [8]
- Point-of-care ultrasound (POCUS): Can identify fracture and effusion at bedside but not a substitute for radiographs
- Bedside nerve exam: Document axillary nerve function before and after any manipulation
14. ECG
- Not routinely indicated for isolated proximal humerus fracture
- Obtain if: Syncope preceded the fall, elderly patient with cardiac history, pre-operative evaluation, or chest pain
- Consider: Arrhythmia as cause of syncopal fall leading to fracture
15. Assessment
Proximal humerus fractures are classified using the Neer system to guide management. The vast majority (~85%) are minimally displaced 1-part fractures amenable to nonoperative treatment with sling immobilization and rehabilitation. [1][16] High-certainty evidence from the PROFHER trial and Cochrane review demonstrates no clinically important difference in patient-reported outcomes between surgical and nonsurgical treatment for displaced fractures in older adults at 1- and 2-year follow-up. [8-9] Complications of concern include AVN (especially in 3- and 4-part fractures and fracture-dislocations), axillary nerve injury, malunion, and shoulder stiffness. [4][6][8] Full recovery from even minimally displaced fractures averages approximately 8 months. [17]
16. Treatment Plan
Initial stabilization (ED)
- Sling immobilization (coaptation splint or sling-and-swathe)
- Ice, elevation
- Analgesics: acetaminophen + NSAIDs ± opioids for breakthrough pain [1]
- Regional anesthesia (interscalene block) for severe pain
Nonoperative management (85% of cases): [1][16][18]
- Sling for 2–6 weeks (typically 3 weeks, then begin gentle pendulum exercises) [1][9]
- Staged rehabilitation protocol:
- Weeks 0–3: Sling immobilization, pendulum exercises, elbow/wrist/hand ROM
- Weeks 3–6: Active-assisted shoulder ROM
- After 6 weeks: Active ROM and progressive strengthening
- Full recovery: average 6–8 months [17]
Surgical indications: [1][18-19]
- Displaced or unstable fractures (> 1 cm displacement or > 45° angulation)
- Fracture-dislocations
- Open fractures
- Neurovascular compromise
- Head-split fractures
- Young, active patients with significantly displaced fractures
Surgical options: [16][19-20]
- ORIF with locking plate: Preferred for displaced 2- and 3-part fractures in younger patients
- Intramedullary nailing: Alternative fixation
- Hemiarthroplasty: For complex 4-part fractures (declining use)
- Reverse shoulder arthroplasty (RSA): Increasingly favored for complex 3- and 4-part fractures in elderly patients; superior functional outcomes compared to hemiarthroplasty [13][20]
Key evidence: The PROFHER trial (JAMA 2015) and NITEP trial found no benefit of surgery over nonoperative treatment for displaced fractures in patients ≥ 60 years, with higher complication and reoperation rates in surgical groups. [9][21]
17. Disposition
Discharge criteria (majority of patients)
- Minimally displaced (1-part) fracture
- Adequate pain control with oral medications
- Neurovascularly intact
- Able to manage ADLs with sling (or has home support)
- Reliable follow-up arranged
Admission criteria
- Neurovascular compromise requiring urgent intervention
- Open fracture
- Fracture-dislocation requiring urgent reduction/surgery
- Polytrauma
- Inability to manage at home (elderly, lives alone, inadequate pain control)
- Suspected pathologic fracture requiring workup
Orthopedic consultation triggers
- All displaced or unstable fractures (Neer 2-, 3-, 4-part)
- Fracture-dislocations
- Open fractures
- Neurovascular injury
- Young, active patients with displaced fractures
- Failed closed reduction
18. Follow-Up / Return Precautions
Follow-up timing
- Orthopedic follow-up within 7–10 days for all proximal humerus fractures
- Repeat radiographs at 1–2 weeks to assess for interval displacement
- Serial follow-up at 2, 6, and 12 weeks to monitor healing and guide rehabilitation progression
Return precautions — instruct patients to return immediately for:
- Increasing numbness, tingling, or weakness in the hand or fingers
- Cold, pale, or blue discoloration of the hand
- Worsening pain despite medications
- Fever, redness, or drainage at the injury site
- Inability to move fingers
Patient counseling
- Expect significant bruising extending to the chest wall and arm over 48–72 hours — this is normal
- Sleep upright or semi-reclined for comfort
- Keep elbow, wrist, and hand moving to prevent stiffness
- Do not lift anything with the affected arm
- Recovery is gradual; full function may take 6–8 months even for minimally displaced fractures [17]
- Osteoporosis evaluation should be pursued as an outpatient if not previously done [3]
References
1. Acute Shoulder Injuries in Adults. — Simon LM, Nguyen V, Ezinwa NM. American Family Physician. 2023.
2. Acute Proximal Humeral Fractures in Adults. — Lowry V, Bureau NJ, Desmeules F, Roy JS, Rouleau DM. Journal of Hand Therapy : Official Journal of the American Society of Hand Therapists. 2017.
3. Proximal Humerus Fractures in the Elderly Work Up, Classifications and Fracture Biomechanics. — Kalacun D, Komadina R, Brilej D. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2025.
4. Axillary Artery Injury Associated With Proximal Humeral Fractures: Review of Long-Term Vascular, Orthopedic, and Neurologic Outcomes. — Ng AJ, Arora V, Tang HH, et al. Annals of Vascular Surgery. 2016.
5. Axillary Artery Injury as a Complication of Proximal Humeral Fractures. Two Case Reports and a Review of the Literature. — Zuckerman JD, Flugstad DL, Teitz CC, King HA. Clinical Orthopaedics and Related Research. 1984.
6. Avascular Necrosis and Posttraumatic Arthritis After Proximal Humerus Fracture Internal Fixation: Evaluation and Management. — Cancio-Bello AM, Barlow JD. Current Reviews in Musculoskeletal Medicine. 2023.
7. Fracture Dislocations of the Proximal Humerus Treated With Open Reduction and Internal Fixation: A Systematic Review. — Miltenberg B, Masood R, Katsiaunis A, et al. Journal of Shoulder and Elbow Surgery. 2022.
8. Interventions for Treating Proximal Humeral Fractures in Adults. — Handoll HH, Elliott J, Thillemann TM, Aluko P, Brorson S. The Cochrane Database of Systematic Reviews. 2022.
9. Surgical vs Nonsurgical Treatment of Adults With Displaced Fractures of the Proximal Humerus: The PROFHER Randomized Clinical Trial. — Rangan A, Handoll H, Brealey S, et al. The Journal of the American Medical Association. 2015.
10. ACR Appropriateness Criteria® Acute Shoulder Pain: 2024 Update. — Laur O, Ha AS, Bartolotta RJ, et al. Journal of the American College of Radiology : JACR. 2025.
11. CT of Acute Shoulder Girdle Fractures in Adults: Biomechanics, Classification, and Management. — Dreizin D, Champ K, Dattwyler MP, Garzan AD, Edmond T. Radiographics : A Review Publication of the Radiological Society of North America, Inc. 2026.
12. Advanced CT Visualization Improves the Accuracy of Orthopaedic Trauma Surgeons and Residents in Classifying Proximal Humeral Fractures: A Feasibility Study. — Dauwe J, Mys K, Putzeys G, et al. European Journal of Trauma and Emergency Surgery : Official Publication of the European Trauma Society. 2022.
13. Team Approach: Reverse Shoulder Arthroplasty in the Setting of a 4-Part Proximal Humerus Fracture With Vascular Compromise. — Droz LG, Meyer AM, Brown MJ, et al. JBJS Reviews. 2025.
14. The Impact of Three-Dimensional CT Imaging on Intraobserver and Interobserver Reliability of Proximal Humeral Fracture Classifications and Treatment Recommendations. — Berkes MB, Dines JS, Little MT, et al. The Journal of Bone and Joint Surgery. American Volume. 2014.
15. Intraobserver and Interobserver Reliability of Recategorized Neer Classification in Differentiating 2-Part Surgical Neck Fractures From Multi-Fragmented Proximal Humeral Fractures in 116 Patients. — Sumrein BO, Mattila VM, Lepola V, Laitinen MK, Launonen AP. Journal of Shoulder and Elbow Surgery. 2018.
16. Treatment of Proximal Humeral Fractures: A Critical Analysis Review. — Jawa A, Burnikel D. JBJS Reviews. 2016.
17. Minimally Displaced Fractures of the Greater Tuberosity: Outcome of Non-Operative Treatment. — Rath E, Alkrinawi N, Levy O, et al. Journal of Shoulder and Elbow Surgery. 2013.
18. Conservative Treatment of Proximal Humerus Fractures: When, How, and What to Expect. — Martinez-Catalan N. Current Reviews in Musculoskeletal Medicine. 2023.
19. Management of Acute Proximal Humeral Fractures. — Kancherla VK, Singh A, Anakwenze OA. The Journal of the American Academy of Orthopaedic Surgeons. 2017.
20. Management of Proximal Humeral Fractures in Adults: A Systematic Review and Meta-Analysis. — Lapner P, Sheth U, Nam D, et al. Journal of Orthopaedic Trauma. 2023.
21. Surgery With Locking Plate or Hemiarthroplasty Versus Nonoperative Treatment of 3-4-Part Proximal Humerus Fractures in Older Patients (NITEP): An Open-Label Randomized Trial. — Launonen AP, Sumrein BO, Reito A, et al. PLoS Medicine. 2023.