01OverviewDefinition, clinical context and the essential points that orientate the chapter.
The proximal humerus includes the articular head, tuberosities and anatomical and surgical necks. Classification helps communication but does not replace patient factors. Establish handedness, baseline independence, cuff symptoms, cognition and treatment goals. A minimally displaced fracture in a frail adult may recover better with functional non-operative care than complex reconstruction, while a young patient with head-split injury needs urgent specialist planning.
Support the arm and control pain while avoiding repeated movement. Radiographs must show joint congruence; CT is selective for complex three-dimensional anatomy. Non-operative care needs an explicit movement schedule rather than indefinite sling use. Operative options include fixation, nail or arthroplasty based on fragments, bone, blood supply, cuff, age and function. Follow active and passive motion, nerve recovery, alignment and pain, and assess bone health after fragility injury.
A practical anatomical description is more useful than memorising fragment numbers alone. Identify whether the surgical neck, anatomical neck, greater tuberosity or lesser tuberosity is involved, and whether the head is split, impacted, dislocated or deprived of medial support. Tuberosity position matters because the rotator cuff inserts there; malunion can block elevation and external rotation. Greater displacement and anatomical-neck disruption raise concern for humeral-head perfusion, but a treatment decision still integrates bone quality, pre-injury function and the likelihood that fixation will remain stable.
Stable treatment begins with comfort and controlled movement. Support the elbow and forearm rather than allowing the wrist to carry the limb's weight. Encourage finger, wrist and elbow movement from the outset and check the axilla and sling edge for pressure. Pendular exercises progress to assisted elevation according to pain and fracture stability; resisted loading waits for healing. At early review, reassess active and passive motion, deltoid contraction and cuff function. A radiograph is repeated when loss of alignment would change management, not merely because a calendar interval elapsed.
Surgical indications include immediate tissue threats and selected reconstructive patterns. Open fracture, arterial compromise, irreducible dislocation and threatened skin require urgent treatment. Fixation may suit reconstructible displaced fractures in a patient likely to benefit; arthroplasty may better address non-reconstructible head-split or fracture-dislocation in selected older adults. Reverse shoulder arthroplasty depends on deltoid and nerve function and carries dislocation, infection and periprosthetic risks. Document the chosen implant, tuberosity strategy, weight bearing and rehabilitation limits so therapy does not guess.
Frailty modifies both anaesthesia and recovery. Delirium, poor balance, walking-frame dependence and contralateral weakness can make a sling more hazardous than the fracture. Coordinate geriatric review, nutrition, analgesic adverse-effect prevention and home support. A fragility fracture triggers osteoporosis and falls pathways. In a younger patient with an unexpected low-energy break, preceding pain or a destructive lesion, pause routine fixation and obtain tumour-aware imaging and referral so biopsy tracks and definitive reconstruction are planned safely.
Early follow-up should identify the patient who is diverging from the expected course. Increasing swelling, new sensory loss, skin pressure or vascular change is urgent. Loss of previously improving active elevation may indicate tuberosity displacement, cuff injury or axillary neuropathy. Persistent severe pain, crepitus or failure of radiographic progression requires assessment for nonunion, collapse or infection. Compare active with passive motion: both restricted suggests stiffness, whereas disproportionate active weakness suggests cuff, deltoid or nerve dysfunction and directs ultrasound, MRI or electrodiagnostic assessment.
The rehabilitation plan should state phases rather than a vague instruction to move. The earliest phase controls pain and maintains distal joints; the next adds pendular and supported range; later phases restore active elevation and resistance after stability is demonstrated. Sudden loading, pushing up from a chair and lifting away from the body can stress the healing construct. Therapists and carers need the same written restrictions. Driving and manual work resume only when pain, motion, strength, cognition and medicine effects permit safe control.
Key points
- Most proximal humeral fractures in older adults follow a fragility fall and can be treated without surgery when closed, aligned and neurovascularly safe.
- Inspect bruising, swelling, wounds and skin pressure and examine clavicle, scapula, elbow and wrist for associated injury.
- Test deltoid contraction and lateral-arm sensation plus distal radial, median and ulnar functions and pulses before and after support or manipulation.
- Obtain true AP and orthogonal scapular-Y or axillary imaging without forcing painful abduction; CT supports complex articular and fracture-dislocation planning.
- Describe surgical or anatomical neck, greater or lesser tuberosity, displacement, comminution, head split and joint congruence.
- Use a sling for comfort, regular analgesia and early pendular then assisted motion in stable patterns to limit stiffness.
- Urgent surgery is considered for open injury, vascular compromise, irreducible fracture-dislocation, head split or threatened skin; other operative decisions are individualised.
- After low-trauma fracture, address falls, osteoporosis, nutrition and ability to manage a sling through current fracture-liaison and outpatient pathways.
02AetiologyUnderlying causes, associations and risk factors, with why each one matters.
Fragility fall
A standing-height fall onto the arm commonly fractures osteoporotic proximal humerus in an older adult and may expose wider falls risk.
High-energy trauma
Collision or fall from height can cause comminution, tuberosity displacement, head-split fracture or dislocation with neurovascular injury.
Pathological bone
Preceding pain, known malignancy or an aggressive radiographic lesion suggests metastasis or another pathological cause after minimal force.
03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.
- 1Segment displacement
Rotator-cuff tendons displace greater and lesser tuberosities while pectoralis major and deltoid influence the shaft, altering cuff mechanics.
- 2Head perfusion risk
Anatomical-neck disruption, medial-hinge loss and severe displacement can interrupt humeral-head blood supply and cause avascular necrosis.
- 3Axillary-nerve proximity
The nerve winds around the surgical neck and can be stretched by displacement, producing deltoid weakness and lateral-arm sensory change.
- 4Immobilisation stiffness
Pain and prolonged sling use cause capsular restriction and muscle loss, often producing more disability than a well-aligned healed fracture.
04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.
Pain, swelling and upper-arm bruising after a fall occur without gross deformity or neurovascular deficit.
Marked deformity, locked motion and abnormal head position on orthogonal imaging requires urgent specialist reduction planning.
Weak deltoid contraction or altered lateral-arm sensation may follow surgical-neck displacement.
Coolness, pulse asymmetry, delayed refill or expanding axillary haematoma needs immediate vascular escalation.
Minimal trauma, preceding pain or destructive bone change suggests a lesion requiring oncological planning before fixation.
05InvestigationsWhat to request, why it matters and how to interpret it.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
True AP and orthogonal shoulder radiographsFirst step - Why
- Define fragments, displacement, tuberosities and glenohumeral congruence.
- Interpretation and limitations
- Do not force axillary positioning; a scapular-Y or modified view can demonstrate joint position safely.
- 02
CT of complex proximal humerus - Why
- Map head split, tuberosity comminution and fracture-dislocation anatomy for surgery.
- Interpretation and limitations
- Use when it changes operative planning, not for every stable two-part fracture.
- 03
Serial neurovascular examination - Why
- Detect axillary, plexus or arterial change before and after support or intervention.
- Interpretation and limitations
- Document deltoid motor, lateral-arm sensation, distal nerves, pulses and refill specifically.
- 04
Bone-health and falls assessment - Why
- Identify osteoporosis and modifiable falls risk after low-trauma fracture.
- Interpretation and limitations
- Referral must lead to named risk assessment and treatment rather than a generic suggestion.
06Differential diagnosisRealistic alternatives and the features that help distinguish them.
Shoulder dislocation
Loss of contour and fixed position may coexist with fracture; orthogonal views define the joint before any reduction attempt.
Rotator-cuff tear
Weak active elevation with preserved passive motion after a fall can represent cuff failure without significant fracture.
Clavicle fracture
Superior tenderness and a palpable clavicular step localises the injury outside the proximal humerus and directs dedicated clavicle imaging.
Cervical radiculopathy
Neck pain and dermatomal sensory or reflex change may mimic shoulder weakness but does not explain focal bony bruising.
07ManagementImmediate care, first-line treatment, alternatives and escalation.
01Initial assessmentDefine joint and limb safetyFirst stepA patient has shoulder pain and bruising after trauma.+
- 1Use ABCDE for high energy and inspect wounds, skin and associated shoulder-girdle injury.
- 2Provide analgesia and support and record axillary, distal nerve and vascular findings.
- 3EscalationObtain orthogonal radiographs and urgently escalate fracture-dislocation, tissue or perfusion threat.
02Stable fractureProtect and prevent stiffnessThe closed fracture is acceptably aligned with a congruent joint and intact limb.+
- 1Use a sling for comfort and give a safe oral analgesic plan.
- 2Begin hand and elbow movement immediately and pendular then assisted shoulder motion as directed.
- 3Review pain, alignment and active function and shorten immobilisation when stability permits.
03Complex decisionMatch reconstruction to patient and patternThere is displacement, comminution, head split, dislocation or high functional demand.+
- 1Use CT selectively and assess bone quality, head viability, cuff, independence and anaesthetic risk.
- 2Choose fixation, arthroplasty or non-operative care through shared specialist decision-making.
- 3Document postoperative movement, loading, wound, nerve and rehabilitation instructions precisely.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Paracetamol for adult fracture pain
Give 500 mg to 1 g orally when required up to four times daily, at least 4 hours apart and no more than 4 g in 24 hours.Use a lower ceiling for low body weight or hepatic risk and count combination products.
08ComplicationsImportant consequences, why they occur and why they matter clinically.
Stiffness
Prolonged protection, pain and capsular scarring restrict active and passive elevation and rotation, making timely stability-guided exercise particularly important.
Avascular necrosis
Loss of head perfusion causes delayed collapse, pain and arthritis, particularly after anatomical-neck or severe fracture-dislocation.
Malunion
Tuberosity or neck healing in poor position impairs cuff leverage, produces impingement and limits overhead function.
Nerve or vascular injury
Axillary or plexus dysfunction and arterial damage can cause persistent weakness, sensation loss or limb ischaemia.
09Monitoring and follow-upTreatment response, safety checks and longer-term review.
- Recheck skin, sling pressure and distal neurovascular findings after swelling changes.
- Compare active and passive elevation and rotation as pain settles.
- Review radiographic alignment when displacement risk or symptoms justify it.
- Investigate persistent weakness for cuff or axillary-nerve injury and persistent pain for nonunion or avascular necrosis.
- Confirm falls and bone-health referrals have an accepting service and treatment owner.
10Special situationsVariants, exceptions and circumstances that change the usual approach.
Bruising travels distally
Proximal fracture ecchymosis can spread toward the elbow and chest and does not by itself indicate a second fracture.
Motor completes axillary testing
Lateral-arm sensation may remain normal despite deltoid denervation, so contraction must be documented.
Sling is not definitive therapy
It provides comfort while biology heals; a movement schedule determines whether avoidable stiffness develops.
Patient factors outweigh fragments alone
Bone quality, cognition, cuff, independence and goals change the value and risk of complex reconstruction.
11Common pitfallsFrequent interpretation and management errors.
- 01
Forcing the arm into an axillary radiograph despite severe pain and suspected fracture-dislocation.
- 02
Calling the limb neurovascularly intact without deltoid motor testing.
- 03
Keeping every older adult in a sling for weeks without progressive motion instructions.
- 04
Choosing surgery from fragment count alone without considering bone, function and goals.
- 05
Missing osteoporosis and falls prevention after a low-trauma upper-arm fracture.