Proximal humeral fracture — Rapid

Synopsis

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.

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.

Key red flags

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.

Fracture-dislocation

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

Axillary deficit

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

Arterial injury

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

Investigation priorities

True AP and orthogonal shoulder radiographsFirst step

Define fragments, displacement, tuberosities and glenohumeral congruence.

Management branches

Initial assessmentDefine joint and limb safety

A patient has shoulder pain and bruising after trauma.

Use ABCDE for high energy and inspect wounds, skin and associated shoulder-girdle injury.
Provide analgesia and support and record axillary, distal nerve and vascular findings.
Obtain orthogonal radiographs and urgently escalate fracture-dislocation, tissue or perfusion threat.

Stable fractureProtect and prevent stiffness

The closed fracture is acceptably aligned with a congruent joint and intact limb.

Use a sling for comfort and give a safe oral analgesic plan.
Begin hand and elbow movement immediately and pendular then assisted shoulder motion as directed.
Review pain, alignment and active function and shorten immobilisation when stability permits.

Key medicines

Paracetamol for adult fracture painGive 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.

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