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OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Proximal humeral fracture

Musculoskeletal medicine and orthopaedics · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Fracture-dislocation can threaten the limb

Open injury, skin pressure, absent pulse, progressive plexus deficit or a locked fracture-dislocation needs urgent specialist treatment rather than routine sling care.

Action: Perform ABCDE after high energy, inspect skin, document axillary and distal nerve and vascular function, give analgesia and support, obtain orthogonal shoulder imaging and urgently involve shoulder trauma and vascular teams when tissue or perfusion is threatened.

Overview

Recognise proximal humeral fracture and its axillary-nerve, vascular and dislocation associations, distinguish stable patterns from reconstructive emergencies, and preserve function through safe analgesia and rehabilitation.

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.

Practice

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Musculoskeletal medicine and orthopaedicsOriginal SBA

Stable proximal humeral fracture

An older adult has a closed minimally displaced surgical-neck fracture, congruent joint and normal neurovascular findings. What is the best initial management direction?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG38 fractures non-complex assessment and management
  • AO Surgery Reference proximal humerus fractures
  • BOAST peripheral nerve injury
  • BOAST – Outpatient and on-call services for people with fractures or musculoskeletal injury

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom
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.

Aetiology

01

Fragility fall

A standing-height fall onto the arm commonly fractures osteoporotic proximal humerus in an older adult and may expose wider falls risk.

02

High-energy trauma

Collision or fall from height can cause comminution, tuberosity displacement, head-split fracture or dislocation with neurovascular injury.

03

Pathological bone

Preceding pain, known malignancy or an aggressive radiographic lesion suggests metastasis or another pathological cause after minimal force.

Pathophysiology

  1. 1
    Segment displacement

    Rotator-cuff tendons displace greater and lesser tuberosities while pectoralis major and deltoid influence the shaft, altering cuff mechanics.

  2. 2
    Head perfusion risk

    Anatomical-neck disruption, medial-hinge loss and severe displacement can interrupt humeral-head blood supply and cause avascular necrosis.

  3. 3
    Axillary-nerve proximity

    The nerve winds around the surgical neck and can be stretched by displacement, producing deltoid weakness and lateral-arm sensory change.

  4. 4
    Immobilisation stiffness

    Pain and prolonged sling use cause capsular restriction and muscle loss, often producing more disability than a well-aligned healed fracture.

Clinical features and red flags

Stable fragility fracture

Pain, swelling and upper-arm bruising after a fall occur without gross deformity or neurovascular deficit.

Fracture-dislocationRed flag

Marked deformity, locked motion and abnormal head position on orthogonal imaging requires urgent specialist reduction planning.

Axillary deficitRed flag

Weak deltoid contraction or altered lateral-arm sensation may follow surgical-neck displacement.

Arterial injuryRed flag

Coolness, pulse asymmetry, delayed refill or expanding axillary haematoma needs immediate vascular escalation.

Pathological pattern

Minimal trauma, preceding pain or destructive bone change suggests a lesion requiring oncological planning before fixation.

Red flags requiring action

  • A cool hand, pulse change, expanding axillary swelling or multi-nerve deficit suggests axillary artery or brachial-plexus injury.
  • An open wound, fixed skin tenting, head-split pattern or fracture-dislocation requires urgent orthopaedic management.
  • Persistent severe pain or inability to regain movement after an apparently minor fracture may indicate displacement, cuff injury, stiffness or pathological bone.

Investigations

  1. 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.
  2. 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.
  3. 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.
  4. 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.

Differential diagnosis

01

Shoulder dislocation

Loss of contour and fixed position may coexist with fracture; orthogonal views define the joint before any reduction attempt.

02

Rotator-cuff tear

Weak active elevation with preserved passive motion after a fall can represent cuff failure without significant fracture.

03

Clavicle fracture

Superior tenderness and a palpable clavicular step localises the injury outside the proximal humerus and directs dedicated clavicle imaging.

04

Cervical radiculopathy

Neck pain and dermatomal sensory or reflex change may mimic shoulder weakness but does not explain focal bony bruising.

Management

01Initial assessmentDefine joint and limb safetyFirst stepA patient has shoulder pain and bruising after trauma.+
  1. 1Use ABCDE for high energy and inspect wounds, skin and associated shoulder-girdle injury.
  2. 2Provide analgesia and support and record axillary, distal nerve and vascular findings.
  3. 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.+
  1. 1Use a sling for comfort and give a safe oral analgesic plan.
  2. 2Begin hand and elbow movement immediately and pendular then assisted shoulder motion as directed.

Complications

01

Stiffness

Prolonged protection, pain and capsular scarring restrict active and passive elevation and rotation, making timely stability-guided exercise particularly important.

02

Avascular necrosis

Loss of head perfusion causes delayed collapse, pain and arthritis, particularly after anatomical-neck or severe fracture-dislocation.

03

Malunion

Tuberosity or neck healing in poor position impairs cuff leverage, produces impingement and limits overhead function.

04

Nerve or vascular injury

Axillary or plexus dysfunction and arterial damage can cause persistent weakness, sensation loss or limb ischaemia.

Monitoring and follow-up

  • 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.

Special situations

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.

Common pitfalls

  1. 01

    Forcing the arm into an axillary radiograph despite severe pain and suspected fracture-dislocation.

  2. 02

    Calling the limb neurovascularly intact without deltoid motor testing.

  3. 03

    Keeping every older adult in a sling for weeks without progressive motion instructions.

  4. 04

    Choosing surgery from fragment count alone without considering bone, function and goals.

  5. 05

    Missing osteoporosis and falls prevention after a low-trauma upper-arm fracture.

3
Review 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.+
  1. 1Use CT selectively and assess bone quality, head viability, cuff, independence and anaesthetic risk.
  2. 2Choose fixation, arthroplasty or non-operative care through shared specialist decision-making.
  3. 3Document postoperative movement, loading, wound, nerve and rehabilitation instructions precisely.
Key medicines and prescribing safety1 treatment · regimens, roles and cautions+
Provides baseline pain relief supporting sleep, examination and early movement.

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.