Humerus proximal fractureMANAGEMENT

SHOULDER & CLAVICLE · 12 SECTIONS

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453 items

☷ Legend

01Approach to the Critical Patient/attcp40

Immediate priorities

›Proximal humerus fracture initial stabilization

›Airway risk with sedation needs

›NPO status uncertainty

›Aspiration risk factors

›Hemorrhage and shock screen

›High-energy mechanism trigger

›Anticoagulant use trigger

›Limb threat screen

›Cool hand

›Absent radial pulse

›Rapidly progressive neurologic deficit

›Skin threat screen

›Tenting

›Blanching

›Impending open fracture features

Neurovascular and compartment risk

›Distal perfusion and neurologic baseline

›Radial pulse

›Doppler signal if nonpalpable

›Capillary refill

›Side-to-side comparison

›Axillary nerve function

›Lateral deltoid sensation

›Deltoid activation

›Brachial plexus screen

›Median nerve motor and sensation

›Ulnar nerve motor and sensation

›Radial nerve motor and sensation

›Compartments

›Escalate if pain out of proportion with tense swelling

›Escalate if increasing analgesic requirement with worsening exam

Escalation triggers

›Immediate orthopedics escalation

›Fracture-dislocation

›Head-splitting fracture pattern concern

›Open fracture

›Persistent neurovascular deficit after immobilization

›Threatened skin despite immobilization

›Transfer triggers

›Vascular injury concern requiring CTA and vascular capability

›Polytrauma with competing priorities

›Surgical capability mismatch for complex proximal humerus reconstruction

02History/hx34

Injury context

›Mechanism and energy

›Low-energy fall onto outstretched hand

›Fragility fracture context

›Direct lateral shoulder impact

›Greater tuberosity involvement risk

›High-energy MVC or fall from height

›Head-splitting and fracture-dislocation risk

›Seizure or electrocution

›Posterior dislocation association

›Timing and course

›Time since injury

›Progressive swelling trajectory

›Prior manipulation or reduction attempt

›Function and baseline

›Hand dominance

›Baseline shoulder function

›Athletic overhead demands

›Associated symptoms

›Numbness over lateral shoulder

›Axillary nerve concern

›Hand numbness or weakness

›Brachial plexus concern

›Neck pain

›Cervical spine injury co-risk

›Bleeding and bone health

›Anticoagulants

›Antiplatelets

›Osteoporosis diagnosis

›Chronic glucocorticoids

›Prior shoulder surgery or hardware

›Open injury risk

›Wound near shoulder

›Contamination

›Delay to presentation

03Physical Exam/exam42

Shoulder and upper limb exam

›Inspection and skin

›Deformity

›Ecchymosis and swelling

›Tenting or blanching

›Abrasion or laceration near fracture site

›Palpation and landmarks

›Proximal humerus tenderness

›AC joint tenderness

›Clavicle tenderness

›Scapular spine tenderness

›Motion and function

›Active shoulder motion limitation

›Elbow range of motion

›Wrist and hand range of motion

›Neurovascular

›Axillary nerve

›Lateral deltoid sensation

›Deltoid contraction

›Radial nerve

›Wrist extension

›Dorsal first web space sensation

›Median nerve

›Thumb opposition

›Index fingertip sensation

›Ulnar nerve

›Finger abduction

›Small fingertip sensation

›Vascular

›Radial pulse

›Ulnar pulse

›Capillary refill

›Joint above and below

›Cervical spine screen if mechanism warrants

›Elbow tenderness and stability

›Wrist tenderness

PITFALLS

›Common misses

›Posterior shoulder dislocation with subtle deformity

›Limited external rotation clue

›Axillary nerve neuropraxia documentation omission

›Pre and post immobilization neuro exam requirement

›Concomitant rotator cuff tear in older patients

›Persistent weakness after pain control trigger

04Differential Diagnosis/ddx27

Shoulder region mimics and co-injuries

›Fracture patterns and related conditions

›Glenohumeral dislocation without fracture

›Posterior dislocation

›Anterior dislocation

›Scapular fracture

›High-energy association

›Clavicle fracture

›AC joint injury

›Rotator cuff tear

›Brachial plexus injury

›Axillary artery injury

›Alternate diagnoses

›Cervical radiculopathy or cord injury

›Septic arthritis

›Pathologic fracture

›Malignancy concern

Coding targets

›ICD-10 proximal humerus fracture

›S42.20 unspecified fracture of upper end of humerus

›S42.21 surgical neck fracture of humerus

›S42.24 greater tuberosity fracture of humerus

›S42.29 other fracture of upper end of humerus

›SNOMED CT concepts

›Proximal humerus fracture

›Greater tuberosity fracture

›Surgical neck fracture of humerus

›Humeral head fracture

›Shoulder fracture-dislocation

05Laboratory Tests/lt19

When labs matter

›Targeted labs only

›Planned procedural sedation

›Glucose if diabetes risk

›Pregnancy test if applicable

›Planned operative pathway

›CBC for anemia or bleeding concern

›Electrolytes and creatinine for perioperative planning

›Coagulation studies if anticoagulants or liver disease

›Open fracture

›CBC for baseline

›Lactate if systemic illness concern

›Major trauma context

›Type and screen

›Venous blood gas if shock concern

›Interpretation pearls

›Normal labs do not exclude vascular injury

›Exam-driven escalation priority

›INR target for regional anesthesia decisions per local protocol

›Anesthesia involvement trigger

06Diagnostic Tests/dt70

Scoring Systems

›Neer classification

›Neer parts definition

›Part displacement threshold

›Greater than 1 cm separation

›Greater than 45 degrees angulation

›One-part fracture

›No segment meeting displacement threshold

›Two-part fracture

›One displaced segment

›Three-part fracture

›Two displaced segments with head still articulating

›Four-part fracture

›Three displaced segments with head segment involved

›Clinical implications

›One-part typical nonoperative pathway

›Multi-part higher avascular necrosis risk

›AO OTA proximal humerus classification

›Extra-articular unifocal

›Extra-articular bifocal

›Articular

›Surgical planning communication tool

Radiographs

›Required views

›Shoulder series

›AP in scapular plane

›Scapular Y

›Axillary view

›Velpeau axillary view option if abduction limited

›Include joint above and below when shaft extension suspected

›Humerus AP and lateral

›Elbow views if pain or swelling

›Key interpretation targets

›Fracture location

›Surgical neck

›Anatomic neck

›Greater tuberosity

›Lesser tuberosity

›Displacement and angulation

›Neer displacement thresholds

›Dislocation

›Glenohumeral alignment

›Greater tuberosity displacement

›Less than 5 mm typical nonoperative

›Greater than 5 mm operative consideration due to impingement risk

›Varus angulation and medial calcar comminution

›Instability and malunion risk

›Post-reduction imaging

›Mandatory after any manipulation

›Neurovascular exam documentation paired with post films

MRI

›Indications

›Occult fracture with high suspicion and negative radiographs

›Rotator cuff tear suspicion affecting management

›Persistent pain and weakness after initial immobilization period

›Contraindications and limitations

›Non MRI compatible implants

›Acute pain limiting positioning

›Diagnostic performance considerations

›High sensitivity for marrow edema and occult fracture patterns

›Soft tissue injury delineation

›Indications

›Complex fracture morphology for surgical planning

›Head-splitting pattern concern

›Fracture-dislocation characterization

›Intra-articular extension uncertainty

›Protocol considerations

›Thin-slice shoulder CT with 3D reconstructions when surgical planning needed

›Vascular imaging pathway

›CTA upper extremity if hard signs of vascular injury

›Expanding hematoma

›Absent pulses with ischemic signs

›Bruit or thrill

07Disposition/dispo24

Site of care and follow-up

›Discharge criteria

›Hemodynamically stable

›Pain controlled with oral regimen

›Neurovascularly intact after immobilization

›No threatened skin

›Reliable follow-up within timeframe

›Admission criteria

›Uncontrolled pain despite ED optimization

›Neurovascular compromise

›Open fracture

›Fracture-dislocation

›Unsafe discharge supports

›Polytrauma

›Orthopedics follow-up timing

›Minimally displaced fracture

›3 to 7 days

›Displaced fracture or greater tuberosity involvement

›24 to 72 hours

›Post reduction fracture-dislocation

›Next day or within 48 hours

›Activity restrictions

›Sling immobilization

›No lifting with affected arm

›Elbow wrist hand range of motion encouraged

08Treatment/t90

Immediate life-saving interventions

›Limb threat actions

›If pulseless or ischemic hand, immediate reduction attempt if dislocated and rapid ortho and vascular escalation

›Immobilization after reduction with repeat vascular exam

›If open fracture, antibiotics and tetanus pathway before prolonged imaging when feasible

›Constriction relief

›Ring removal

›Tight clothing and jewelry removal

›Pain control and antiemesis

›Multimodal approach

›Avoid oversedation in elderly

Immobilization and Splinting

›Upper extremity immobilization selection

›Sling and swathe

›Standard for proximal humerus fractures

›Coaptation splint

›If extension into humeral shaft with instability

›Posterior long arm

›If concomitant elbow injury suspected

›Immobilization principles

›Comfort position

›Slight elbow flexion

›Arm supported to reduce traction pain

›Swelling phase

›Avoid circumferential casting

›Reassessment

›Neurovascular exam after immobilization

›Skin checks for pressure points

Reduction

›Indications for urgent reduction

›Fracture-dislocation

›Neurovascular compromise

›Threatened skin

›Analgesia and anesthesia options

›Non-opioid analgesia

›Acetaminophen PO 1000 mg q6h

›Maximum 4000 mg per day

›Ibuprofen PO 400 mg q6h

›Maximum 2400 mg per day

›Opioid analgesia

›Hydromorphone IV 0.2 mg to 0.5 mg q5 to 10 min PRN

›Titrate to pain and respiratory status

›Fentanyl IV 25 mcg to 50 mcg q5 min PRN

›Titrate to effect

›Regional anesthesia

›Interscalene block when expertise available

›Phrenic nerve palsy risk

›Procedural sedation

›Ketamine IV 0.5 mg per kg to 1 mg per kg

›Repeat 0.25 mg per kg to 0.5 mg per kg q5 to 10 min PRN

›Airway readiness and continuous monitoring

›Propofol IV 0.5 mg per kg to 1 mg per kg

›Repeat 0.25 mg per kg to 0.5 mg per kg q1 to 3 min PRN

›Hypotension risk in elderly

›Technique principles

›Gentle traction and countertraction

›Deformity exaggeration when fragments locked

›Reverse mechanism for dislocation pattern when clear

›Avoid repeated forceful attempts

›Post reduction requirements

›Immediate neurovascular recheck

›Post reduction radiographs

›Immobilization in stable position

›Failed reduction pathway

›Persistent neurovascular deficit triggers immediate escalation

›Irreducible dislocation triggers urgent orthopedics

›Worsening pain with tense swelling triggers compartment concern escalation

Open fracture medications and timing

›Antibiotics

›Cefazolin IV 2 g q8h

›First dose within 60 minutes of presentation when open suspected

›If severe beta-lactam allergy, clindamycin IV 900 mg q8h

›MRSA risk consideration per local protocol

›If heavy contamination or farm injury, add gentamicin IV 5 mg per kg daily

›Renal function dosing adjustment

›Tetanus prophylaxis

›Unknown or incomplete immunization

›Tdap or Td

›Tetanus immune globulin 250 units IM

›Up to date immunization with dirty wound and last booster over 5 years

›Tdap or Td booster

›Wound care

›Sterile saline moistened dressing

›Avoid deep probing in ED

›Orthopedics urgent washout pathway

DVT prophylaxis when relevant

›Typical isolated upper extremity fracture

›Routine pharmacologic prophylaxis not standard

›Elevated risk scenarios

›Prolonged immobilization with major comorbidity

›Polytrauma

›Operative admission

›Prior VTE

›Alignment with local protocol

›Medicine or surgery service decision ownership

09Special Populations/sp34

Pregnancy

›Maternal and fetal considerations

›Left lateral positioning if symptomatic hypotension

›Analgesia selection

›Acetaminophen preferred first-line

›NSAID avoidance in later pregnancy per obstetric guidance

›Imaging considerations

›Radiographs acceptable with shielding when appropriate

›CT risk-benefit when vascular injury concern

›Obstetric involvement triggers

›Abdominal trauma

›Vaginal bleeding

›Contractions

Geriatric

›Fragility fracture pathway

›Low-energy fall mechanism common

›Osteoporosis evaluation referral

›Higher delirium risk with opioids

›Treatment trends and evidence

›More than 80 percent minimally displaced and treated nonsurgically

›AAOS educational summary

›Operative vs nonoperative outcomes uncertainty in displaced fractures

›PROFHER trial no difference at 2 years for selected displaced fractures

›Disposition considerations

›Admission threshold lower with poor supports

›PT OT needs

›Fall risk mitigation plan

Pediatrics

›Remodeling potential

›Younger children tolerate greater angulation and displacement

›Older adolescents lower remodeling capacity

›Growth plate concerns

›Salter-Harris patterns

›Gentle technique if reduction needed

›Nonaccidental trauma consideration

›Inconsistent history

›Additional injuries

10Background/b36

Epidemiology

›Incidence and demographics

›Incidence 89.3 per 100000 women per year and 28.2 per 100000 men per year in one population study

›Overall incidence about 110 per 100000 population per year in a large database analysis

›Women disproportionately affected among age 65 years and older

›Second most common upper extremity fracture after distal radius

›Mechanism patterns

›Low-energy falls predominant in older adults

›High-energy trauma more common in younger patients

Pathophysiology

›Anatomy and deforming forces

›Rotator cuff pulls tuberosity fragments

›Supraspinatus greater tuberosity superior displacement

›Subscapularis lesser tuberosity medial displacement

›Varus collapse mechanism

›Medial calcar comminution instability

›Complications mechanisms

›Avascular necrosis risk

›Disruption of humeral head blood supply with multi-part patterns

›Stiffness risk

›Prolonged immobilization and pain-limited motion

›Malunion and nonunion risk

›Varus malunion in unstable patterns

Therapeutic Considerations

›Nonoperative rationale

›Minimally displaced fractures have good outcomes with sling and early motion

›Early pendulum and assisted motion reduces stiffness risk

›Operative rationale

›Articular congruity and tuberosity position preserve shoulder mechanics

›Greater tuberosity displacement over 5 mm associated with impingement and loss of abduction and external rotation

›Indications categories

›Absolute surgical indications described in expert guidance

›Dislocated humeral head

›Head-splitting fracture

›Greater tuberosity displaced superiorly or posteriorly

›Significant varus angulation with medial pillar instability

›Evidence framing

›PROFHER randomized trial

›No functional outcome difference at 2 years in selected displaced fractures randomized to operative vs nonoperative

11Patient Discharge Instructions/pdi24

Copy discharge instructions

›Proximal humerus fracture discharge plan

›Sling and swathe

›Wear continuously except hygiene and exercises as instructed

›Elevation

›Hand above heart when resting

›Ice

›15 to 20 minutes every 2 to 3 hours for 48 hours

›Pain control

›Acetaminophen as directed on label

›Ibuprofen as directed on label if safe for you

›Opioid only if prescribed

›Mobility

›Finger wrist elbow motion several times daily

›No lifting or pushing with injured arm

›Return to ED now

›Increasing pain not controlled

›New numbness or weakness

›Cool pale or blue hand

›Increasing tight swelling

›Splint or sling causing skin pressure injury

›Fever or wound drainage

›Follow-up

›Orthopedics appointment within recommended timeframe from discharge paperwork

›Repeat x-ray timing per orthopedics plan

12References/r13

Evidence-based sources

›Source set

›Neer classification displacement thresholds greater than 1 cm separation or 45 degrees angulation

›PMC review of Neer classification

›Epidemiology rates

›Female incidence 89.3 per 100000 per year and male incidence 28.2 per 100000 per year in one study

›Overall incidence about 110 per 100000 per year in a large database analysis

›Nonoperative prevalence

›More than 80 percent minimally displaced and treated nonsurgically in AAOS educational material

›Greater tuberosity operative threshold

›Displacement greater than 5 mm operative consideration and less than 5 mm typical nonoperative in Orthobullets summary

›Operative vs nonoperative outcomes

›PROFHER trial summary in OTA curriculum document

›Internal build specification :contentReference[oaicite:0]{index=0}

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed March 6, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.