Proximal Humerus Fracture

History: acute pain after a fall (FOOSH or direct impact onto the shoulder), inability to use the arm, and progressive bruising tracking down the arm and into the chest wall (Hennequin sign) over hours to days.

Examination:

• •Tender, swollen shoulder; arm held supported at the side
• •Reduced active and passive range of motion
• •Axillary nerve assessment: regimental badge sensation AND deltoid contraction. Test deltoid by palpating for isometric contraction (patient pushes elbow outward against your hand without moving the shoulder), NOT by resisted abduction which can complete an unstable fracture
• •Skin tenting, open wounds, distal pulses, brachial plexus screen
• •Associated injuries (head, cervical spine, chest, ipsilateral elbow and wrist)

Red flags requiring urgent specialist assessment per NICE NG38: open wound, skin tenting, vascular injury, fracture-dislocation, head-splitting fracture, and suspected pathological fracture. Axillary nerve injury occurs in around 5-6% of PHFs and must be documented at presentation; failure to recognise it before manipulation is a medicolegal hazard. Differentials include isolated anterior dislocation (squared-off contour, empty glenoid, no fracture line), clavicle and ACJ injuries, acute traumatic cuff tear, and pathological fracture on a low-energy mechanism.

The shoulder trauma series is the diagnostic baseline:

• •AP shoulder (true AP / Grashey view in the plane of the scapula)
• •Scapular Y / lateral scapular view
• •Axillary view, or the modified axillary (Velpeau) view if positioning is too painful. The axillary view is the most commonly missed view and catches occult posterior dislocation

The Neer classification drives further imaging and management. A fragment counts as displaced if it is greater than 1 cm displaced or greater than 45 degrees angulated. Fractures are then categorised as 1-part (minimally displaced), 2-part, 3-part, 4-part, plus fracture-dislocation and head-splitting variants. Modern surgical practice uses a lower threshold of greater than 5 mm displacement for the greater tuberosity (3-5 mm in overhead athletes), particularly for posterosuperior displacement which causes subacromial impingement and rotator cuff dysfunction.

CT is indicated for 3- and 4-part fractures, comminuted patterns, head-splitting injuries, articular surface assessment, or when plain films are inadequate. CT is generally needed before complex surgical planning.

MRI is rarely required acutely; it has a role in suspected pathological or occult fracture, or in pre-operative cuff assessment in younger patients with persistent weakness after pain settles.

NICE NG38 supports non-surgical management for uncomplicated displaced low-energy PHFs in adults, with surgery considered specifically for open wound, skin tenting, vascular injury, fracture-dislocation, or split humeral head.

Conservative management (around 80% of cases):

• •Polysling or collar-and-cuff for 2-3 weeks
• •Pendular exercises from week 1; progressive passive then active-assisted ROM weeks 2-6; strengthening from 6-8 weeks
• •Repeat radiograph at 1-2 weeks (displacement check) and 4-6 weeks (union)
• •Stiffness is the dominant complication and is prevented by early mobilisation

Analgesia per NG38: paracetamol; paracetamol plus codeine; IV paracetamol with titrated IV morphine for severe pain. NSAIDs are not offered to frail or older adults with fractures; consider them in non-frail younger adults at the lowest effective dose for the shortest period.

Surgical options:

• •Greater tuberosity displaced over 5 mm (3-5 mm in overhead athletes), particularly posterosuperior: ORIF (suture, plate, or arthroscopic fixation)
• •Surgical neck fracture displaced or angulated beyond Neer thresholds in a younger or high-demand patient: locking plate ORIF or intramedullary nail
• •3-part reconstructable fracture in a younger or high-demand patient: locking plate ORIF
• •4-part, head-splitting, or anatomical neck with high AVN risk in older patients: reverse total shoulder arthroplasty (rTSA) is now often preferred over hemiarthroplasty because it does not depend on tuberosity healing or rotator cuff integrity for function

VTE prophylaxis (NICE NG89): not routinely needed for upper limb surgery under local or regional anaesthesia; consider if GA exceeds 90 minutes or postoperative mobilisation will be difficult. Frailty, analgesia, falls assessment, and FLS referral run in parallel to fracture-specific decisions.

Stiffness is the dominant complication of conservative management, so early supervised mobilisation is essential. Timelines vary between UK units; the schedule below is illustrative.

Phase 1 (weeks 0-3): protection and pain control - polysling, pendular exercises from week 1, elbow, wrist, and hand mobilisation immediately, analgesia per NG38.

Phase 2 (weeks 2-6): progressive mobilisation - out of sling for exercises from around week 2-3, passive then active-assisted ROM, with repeat radiograph at 4-6 weeks before strengthening.

Phase 3 (weeks 6-12): progressive rotator cuff and scapular strengthening, functional reach and overhead activity, aggressive treatment of residual stiffness.

Phase 4 (3-6 months): sport-specific reconditioning. Overhead sport typically 4-6 months; contact sport 6 months and after specialist clearance.

Post-ORIF rehabilitation is surgeon-led with protected ROM initially, full mobilisation usually permitted around 6 weeks once the construct is stable. Post-rTSA: ADLs by around 3 months with lifelong contact-sport restriction and weight-lifting cap typically under 5-10 kg.

Bone health and falls prevention run in parallel: FLS referral, calcium, vitamin D, bone-protection therapy, and physiotherapy-led balance and strength work to reduce future fracture risk.

• •PROFHER (JAMA 2015) - UK pragmatic multicentre RCT: no clinically important advantage of surgery over conservative management for displaced PHFs involving the surgical neck in adults; underpins UK conservative-first practice. Does not apply to open, vascular, dislocated, head-splitting, or other clear surgical indications.
• •Hettrich et al JBJS 2010 - Demonstrated PCHA provides around 64% of humeral head supply, overturning the traditional ACHA-dominant teaching; informs AVN risk assessment and arthroplasty decision-making.
• •NICE NG38 - Non-complex fracture management: defines surgical-consideration triggers (open, tenting, vascular, dislocation, head-splitting) and the analgesia ladder; NSAIDs are not offered to frail or older adults with fractures.
• •NICE CG146 / NOGG / NICE TA464 - Underpin Fracture Liaison Service referral and bone-protection therapy after any fragility fracture over 50.
• •PROFHER-2 (ongoing) - UK trial comparing rTSA vs hemiarthroplasty for complex PHFs in older adults; expected to refine arthroplasty choice in non-reconstructable fractures.

• •Neer displacement rule: greater than 1 cm OR greater than 45 degrees angulation; greater tuberosity surgical threshold drops to greater than 5 mm (3-5 mm in overhead athletes)
• •Around 80% of PHFs are minimally displaced and managed conservatively; PROFHER underpins conservative-first practice for displaced surgical-neck fractures
• •NICE NG38 surgical consideration triggers: open wound, skin tenting, vascular injury, fracture-dislocation, split humeral head
• •Test the deltoid by palpating an isometric contraction, NOT by resisted abduction acutely - resisted abduction can complete an unstable fracture
• •rTSA is now often preferred over hemiarthroplasty for older adults with non-reconstructable 4-part, head-splitting, or high-AVN fractures
• •Any low-energy PHF in an adult over 50 mandates FLS referral per NICE CG146, NOGG, and TA464