Proximal Humerus Fracture

The shoulder is one of the most complex joints in your body and allows your arm to rotate and move in many different directions. The shoulder joint is described as a “ball and socket” joint, however, the socket is very shallow and is similar to a golf ball resting on a tee. The shoulder is made up of three bones: the humerus (upper arm bone), the clavicle (collarbone), and the scapula (shoulder blade). The humerus bone has a proximal (top) and distal (bottom) portion. The proximal humerus is an important attachment site for the rotator cuff muscles.

Proximal humerus fractures can occur due to acute traumatic events, such as a fall. These injuries occur more commonly in elderly patients, but can occur in young patients after a high energy injury, such as a motor vehicle accident.

The most common symptom of a proximal humerus fracture is pain, particularly with any movement of the arm. Patients may also notice a significant amount of bruising that travels down the arm towards the elbow. This is normal and is due to gravity acting on the bruise from the fracture. Swelling of the upper arm and elbow can also occur.

Proximal humerus fractures are diagnosed using physical examination and imaging studies to confirm the diagnosis. The physical examination is used to identify areas of pain and to evaluate the nerves and vessels of the arm. X-rays show the fracture pattern and if the shoulder joint is dislocated. CT (computed tomography) may be needed to closely look at the fracture pieces to help plan surgery, if needed.

Treatment

The treatment of proximal humerus fractures depends on the severity of the injury and number of fracture pieces. The majority of patients do well with non-surgical treatment. Patients who receive non-surgical treatment will have weekly visits with X-rays to monitor the location of the fracture pieces and make sure the fracture is healing correctly. Patients will be placed in a sling to protect the injured arm, with the amount of time in the sling depending on the severity of the injury. After X-rays show sufficient healing, physical therapy will be started to work on strengthening the shoulder and regaining function.

Surgery is used in patients with specific injury patterns that will not do well without surgery or in patients with persistent symptoms where the fracture has healed incorrectly (malunion) or has not healed (nonunion). There are two options for surgery based on the type of fracture.

Open reduction and internal fixation (ORIF): This option is used in young patients and in patients who have a fracture with distinct pieces. This procedure is performed through an incision through the front of the shoulder. A metal plate and screws is used to hold the fracture pieces together in proper alignment. The plate and screws can stay in forever, but in 20% of patients, the plate and screws cause pain or discomfort and can be removed a minimum of several months after the surgery

Reverse shoulder replacement: This option is reserved as a surgery for patients with a severe fracture with many pieces that is unlikely to heal without surgery. The broken pieces are removed and the top of the humerus bone and the glenoid bone are replaced with metal and plastic.