Proximal Humerus Fracture
Classification systems
- AO/OTA grouping for the proximal humeral segment
- Descriptive: valgus-impacted, varus, head-split, fracture-dislocation
Mechanism
A low-energy fall onto the outstretched hand or directly onto the shoulder in an osteoporotic patient is the classic route; high-energy trauma or a seizure or electric shock producing violent muscle contraction accounts for the young and the fracture-dislocation patterns.
Age considerations
- Paediatric
- The proximal humeral physis contributes most of the humeral length growth and lies in a plane that remodels exceptionally well, so generous angulation is accepted and the great majority are treated in a sling.
- Young adult
- Implies higher energy, so look for a head-split, a fracture-dislocation and articular involvement. Head preservation with anatomical reduction and fixation is the aim, accepting the risk of head osteonecrosis.
- Elderly
- Most are treated non-operatively with good functional results. When surgery is chosen, poor metaphyseal bone quality drives implant selection, and reverse arthroplasty is considered where the tuberosities cannot be reconstructed or the cuff is deficient.
Management options
Sling and graded rehabilitationshowhide
Indication
Minimally displaced and impacted patterns, and most fractures in older lower-demand patients regardless of moderate displacement.
Implant design notes
No implant. Collar-and-cuff or broad-arm sling; the weight of the arm itself helps maintain alignment in valgus-impacted patterns.
Approach
Non-operative, with a structured physiotherapy progression.
Steps overview
- Assess axillary nerve sensation over the deltoid and deltoid contraction where pain allows
- Obtain a true anteroposterior and an axillary or scapular-Y view to exclude dislocation
- Sling for comfort, generally two to three weeks
- Begin pendulum and passive forward elevation within the first fortnight
- Progress to active-assisted then active motion, with strengthening deferred until union
- Re-radiograph at three and six weeks to confirm no progressive displacement
Notes
Prolonged immobilisation is the enemy — stiffness causes more long-term disability than modest malunion. Set expectations about a slow twelve-month recovery curve.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Locking plate fixationshowhide
Indication
Displaced two-, three- or four-part fractures in physiologically younger patients with a reconstructable head and reasonable bone stock.
Implant design notes
Fixed-angle locking plate with divergent subchondral screws creating an angularly stable construct in soft metaphyseal bone, plus suture holes to repair and tension the tuberosities to the plate. Medial calcar support with a screw beneath the head is the single most important mechanical detail against varus collapse.
Approach
Deltopectoral approach for wide exposure, or a deltoid-splitting lateral approach for greater tuberosity access with care for the axillary nerve running transversely.
Steps overview
- Beach-chair position with the arm free and fluoroscopy from the head end
- Deltopectoral interval: retract the cephalic vein, expose the fracture, preserve soft tissue to the tuberosities
- Place traction sutures in the rotator cuff attachments of both tuberosities
- Reduce the head out of varus, disimpact if needed, and provisionally hold with wires
- Position the plate lateral to the bicipital groove and below the tuberosity tip to avoid impingement
- Insert divergent subchondral locking screws including calcar support, avoiding joint penetration
- Tie the tuberosity sutures through the plate to complete the construct
- Check a full fluoroscopic rotation series for screw penetration, then close and start early passive motion
Notes
Varus collapse with secondary intra-articular screw penetration is the classic failure; check the head on multiple rotational views intraoperatively. Plate placed too proximally causes impingement.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Reverse shoulder arthroplastyshowhide
Indication
Unreconstructable head-split or four-part fractures in older patients, especially with a deficient or degenerate rotator cuff, or as salvage after failed fixation.
Implant design notes
Medialised centre of rotation with a glenoid baseplate and glenosphere, so the deltoid can elevate the arm without a functioning cuff. Tuberosity repair around the stem still improves rotation and should be attempted.
Approach
Deltopectoral or superolateral approach, protecting the axillary nerve and preserving deltoid function.
Steps overview
- Beach-chair position; deltopectoral exposure with tuberosity traction sutures
- Remove the head fragments and prepare the glenoid, reaming to the subchondral plate
- Fix the baseplate with a central and peripheral screws, then seat the glenosphere
- Prepare the humerus, set stem height and version, and trial for stability and tension
- Insert the definitive stem and reduce; repair the tuberosities around the implant
- Verify stability through rotation and close over a drain if required
Notes
Reliable pain relief and forward elevation, less predictable rotation. Deltoid function and axillary nerve integrity must be confirmed before offering this.
Resident summary compiled from standard orthopaedic trauma teaching; verify against your departmental protocol.
Viva pearls
- Always document axillary nerve function before and after treatment — it is the nerve examiners ask about and the one most often injured.
- Medial calcar support is the mechanical answer to varus collapse in locking plate fixation.
- Neer's classification depends on displacement of the four parts, and its interobserver reliability is modest — say so, and add that treatment is driven by patient factors and head viability.
- A valgus-impacted four-part fracture with an intact medial periosteal hinge has a better blood supply and a better prognosis than the varus equivalent.
- Stiffness, not malunion, is the commonest source of long-term disability — mention early motion in every answer.
Sources for further reading
- Rockwood and Green's Fractures in Adults — proximal humerus
- Standard operative orthopaedics textbook — shoulder fractures and arthroplasty
- Apley and Solomon's System of Orthopaedics and Trauma — the shoulder
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Resident-authored study summary in original wording, not reproduced from copyrighted source text.