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Proximal humeral fractures in adults

Proximal humeral fractures in adults
Literature review current through: Jan 2024.
This topic last updated: Dec 06, 2023.

INTRODUCTION — Proximal humeral fractures occur most commonly in older adults, and their incidence is increasing. Fractures of the humerus can occur proximally, in the shaft (diaphysis), or distally. The majority of both proximal and midshaft humeral fractures are nondisplaced and can be treated conservatively (ie, nonsurgically). Complex fracture patterns pose greater challenges for treatment.

Proximal fractures of the humerus will be reviewed here. Other injuries around the proximal humerus and shoulder girdle, and other related issues, are discussed separately:

Nonstress and stress fractures of the shaft of the humerus: (See "Midshaft humerus fractures in adults" and "Stress fractures of the humeral shaft".)

Trauma of shoulder region: (See "Clavicle fractures" and "Acromioclavicular joint injuries ("separated" shoulder)" and "Acromioclavicular joint disorders" and "Shoulder dislocation and reduction".)

Shoulder pain and traumatic injury in older adults: (See "Evaluation of the adult with shoulder complaints" and "Geriatric trauma: Initial evaluation and management".)

CLINICAL ANATOMY — The humerus is the largest bone in the upper extremity. The proximal humerus articulates with the glenoid of the scapula to form the glenohumeral (shoulder) joint (figure 1 and figure 2 and figure 3). The muscles and tendons of the rotator cuff, the acromion, and ligamentous attachments, such as those between the coracoid process of the scapula and the acromion, stabilize the glenohumeral articulation and provide for the shoulder's wide range of motion. The distal humerus articulates with the radius and ulna at the elbow.

According to the Neer classification, the proximal humerus is divided into four sections: the anatomical neck, the surgical neck (figure 4), the greater tuberosity, and the lesser tuberosity (figure 5) [1]. (See 'Neer classification' below.)

The anatomical neck is at the base of the widened articular surface of the humeral head.

The surgical neck is located at the constriction distal to the humeral head and tuberosities (figure 4). The surgical neck is where the articular capsule attaches and several penetrating arteries enter to provide part of the vascular supply to the humeral head.

The greater and lesser tuberosities are the sites of attachment for the tendons of the rotator cuff muscles (figure 6). The greater tuberosity is located lateral to the humeral head on the superior aspect of the humerus. It provides the attachment for three of the rotator cuff muscles: supraspinatus, infraspinatus, and teres minor. The lesser tuberosity is located on the anterior surface of the humerus and provides the attachment for the subscapularis muscle.

The humeral shaft supplies the attachment for a number of powerful muscles (figure 7). The pectoralis major inserts on the proximal shaft (figure 8), while the deltoid muscle attaches to the midshaft. The biceps brachialis (figure 9) and triceps muscle (figure 10) groups attach more distally.

The tendon of the long head of the biceps brachialis muscle passes between the lesser and greater tuberosities as it courses in a shallow groove on the anterior surface of the humerus (figure 11). The long head tendon attaches to the scapula on the superior portion of the glenoid where its fibers merge with those of the fibrocartilaginous superior glenoid labrum.

The proximal humerus receives its blood supply from branches of the axillary artery. Two branches, the anterior and posterior humeral circumflex arteries, originate distal to the anatomic neck and travel proximally to supply the humeral head (figure 12). Thus, fractures occurring at the anatomic neck can disrupt the blood supply and result in osteonecrosis (avascular necrosis) of the humeral head. The humeral shaft is supplied by the axillary and the brachial artery, which branches distally to become the radial and ulnar arteries. This vascular supply can be disrupted by a humeral shaft fracture if there is considerable displacement of fragments.

Proximity of the humerus to the axillary nerve and brachial plexus accounts for the risk of neurologic injury complicating humeral fractures (figure 12 and figure 13 and figure 14). Nerve injuries are more likely if there is a proximal humeral fracture that is significantly displaced or a concomitant humeral dislocation [2]. The axillary and suprascapular nerves are most often affected. Radial nerve injuries may occur with significant displacement of mid to distal shaft fractures. Median and ulnar nerve injuries are uncommon.

EPIDEMIOLOGY AND RISK FACTORS — Proximal humeral fractures account for 4 to 5 percent of all fractures [3] and are the third most common fracture in older adult patients after those of the hip and distal radius. The incidence of proximal humeral fractures increases with age, with more than 70 percent occurring in patients over 60 years of age and the highest incidence among 73- to 78-year-olds [4]. Proximal humeral fractures are three to four times more common in females than males [5]. The major risk factors are frequent falls and low bone density [5-7]. In many older patients, proximal humeral fractures impair the ability to perform activities of daily living.

MECHANISM OF INJURY — In older adult individuals, falls are the most common cause of proximal humeral fractures; approximately 87 to 93 percent of fractures occur after a fall from standing [3,4,6,7]. Less often, these fractures occur from a direct blow or violent muscle contraction (eg, seizure). Anterior or posterior dislocations of the humeral head can occur in association with proximal humeral fractures.

SYMPTOMS AND EXAMINATION FINDINGS — Patients with proximal humeral fractures present with moderate to severe shoulder pain that increases with shoulder movement. Patients tend to hold the affected arm adducted against their side. Swelling and ecchymosis may be apparent shortly after injury. Gross shoulder deformities can occur, particularly if the fracture is associated with an anterior or posterior dislocation of the humeral head.

There are no specific examination tests for the diagnosis of proximal humeral fractures. Suspect this fracture in older adult patients who have fallen and present with the symptoms or findings described here. Although overlying musculature makes palpation difficult, patients typically have focal tenderness at the proximal humerus.

Distal pulses and nerve function must be evaluated, although assessment of motor function is often limited due to pain. Neurovascular injury occurs most often with displaced fractures or fracture-dislocations and usually involves the axillary or suprascapular nerve [2,8]. Axillary nerve injury manifests as deltoid muscle weakness and diminished sensation over the mid-deltoid region. Suprascapular nerve injury can manifest as supraspinatus and infraspinatus muscle weakness (ie, weakness with initiation of abduction and external shoulder rotation, respectively).

DIAGNOSTIC IMAGING — Plain radiographs of the shoulder that include a true anteroposterior (AP) view (image 1), an axillary view (image 2), and a scapular-Y view (image 3) should be obtained if a proximal humeral fracture is suspected. This is the standard trauma series of radiographs. A Velpeau view, in which the patient's arm is held in internal rotation and the radiograph is oriented superior to inferior while the patient leans backward, is acceptable if an axillary view is unobtainable (figure 15 and image 4).

A computed tomography (CT) scan with three-dimensional reconstructions is recommended if the trauma series of plain radiographs described above is nondiagnostic or if further information is necessary regarding the amount of displacement or rotation of a fracture fragment [9]. CT scans are also recommended for fracture dislocations, humeral head-splitting fractures, and comminuted fractures.

Fracture patterns — There are a number of classification systems used to describe proximal humeral fractures. Given the complexity and variety of fracture patterns involved, it is not surprising that both interobserver and intraobserver agreement for classification and treatment is relatively low, regardless of the imaging modality used or the experience of the physician. Of the many classification systems proposed for proximal humeral fractures, the AO and Neer classification schemes are used most often [10,11]. Of these, the Neer system is used most often in the United States.

The AO classification system distinguishes three basic groups of fractures (and divides these into 27 subtypes): (A) extra-articular unifocal, (B) extra-articular bifocal, and (C) articular. Type C fractures are considered to be higher risk due to the limited vascular supply to the articular segment and the increased risk of avascular necrosis [11]. The Neer classification scheme is based on the biomechanical forces involved and the resulting displacement patterns, and it is discussed below.

Neer classification — The Neer classification system is based upon the anatomical relationship of the four major segments of the proximal humerus: the anatomical neck, the surgical neck (figure 4), the greater tuberosity, and the lesser tuberosity (figure 5 and figure 16) [1]. Fractures are classified according to whether one or more of these four segments (or fragments) have been displaced. Displacement exists when a segment is angulated more than 45 degrees or displaced more than one centimeter from a normal anatomic position.

One-part fractures are defined as fractures in which no fragments are displaced (image 5).

Two-part fractures are defined by one displaced fragment (image 6).

Three-part fractures are defined by two displaced fragments, but the humeral head remains in contact with the glenoid (image 7 and image 4).

Four-part fractures are defined by three or more displaced fragments and dislocation of the articular surface from the glenoid (image 8).

One- and two-part fractures occur most commonly. Two-part fractures of the surgical neck are the most common displaced fracture.

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Patients with two- to four-part proximal humeral fractures or those with anatomic neck fractures should be referred to an orthopedic surgeon to review treatment options, which are based upon the fracture type, patient characteristics, and surgeon experience. Emergency (ie, immediate) referral is indicated for all nerve and vascular injuries, open fractures, and fracture dislocations.

Approximately 80 percent of proximal humeral fractures are nondisplaced or minimally displaced (ie, one-part) and can be treated conservatively (ie, non-operatively) by primary care or other clinicians who are knowledgeable about fracture management [6,12]. However, fractures of the anatomic neck have a high rate of subsequent osteonecrosis, and patients with this type of fracture should be referred to an orthopedic surgeon even if there is no significant displacement of the fragments [13]. Whether surgery is the best treatment for anatomic neck and other complex proximal humeral fractures remains a matter of debate. (See 'Fracture patterns' above.)

Surgical intervention may be needed for significantly displaced, multi-part fractures; thus, all displaced fractures should be referred to an orthopedic surgeon for evaluation. Treatment options include minimally invasive osteosynthesis, percutaneous pinning, open reduction and internal fixation (image 9), primary hemiarthroplasty (image 10), and reverse shoulder arthroplasty. Further indications for referral include fracture-dislocations and joint instability [14].

A nonoperative approach to one-part fractures is supported by the findings of an observational study of 507 patients with minimally displaced humeral fractures treated conservatively [15]. At one-year follow-up, 88 percent of patients had good or excellent results according to the Neer criteria; no patients developed a nonunion. Another study of 54 patients with one-part humeral fractures treated conservatively found similar results [16]. All patients had clinical union of the fracture, and symptom scores at one year were similar to preinjury levels. Forward flexion was not diminished, but there was a 2- to 7-degree loss of internal and external rotation.

Conservative versus surgical management for complex fractures — The results of multiple randomized trials and observational studies suggest that conservative management may be as effective as surgery for many non- or minimally displaced two, three, and four-part surgical neck fractures and for non- or minimally displaced greater tuberosity fractures [17-24]. However, most evidence is of limited quality, and reviews of studies comparing conservative and surgical management of complex proximal humeral fractures have not reached uniform conclusions.

A 2001 systematic review of 24 studies limited to three- or four-part fractures found that patients treated conservatively experienced more pain and greater loss of motion [25]. A subsequent systematic review found high- to moderate-certainty evidence that surgery does not result in better functional outcomes at one and two years after injury compared with non-surgical treatment for people with displaced proximal humeral fractures (two-thirds were three- or four-part fractures) [17].

Both reviews determined that there is insufficient evidence from high-quality randomized trials to determine which interventions are best for the management of specific types of proximal humeral fractures. In addition, evidence is limited for patients under 60 years of age, two-part tuberosity fractures, less common fractures (eg, fracture dislocations, articular surface fractures), and injuries sustained from high-energy trauma. Therefore, the best approach in these clinical settings remains unclear.

Psychosocial issues and younger age may adversely affect patient-reported outcome measures, and these should be considered when extrapolating from studies to make management decisions [22]. Notable studies include the following:

A meta-analysis of 10 trials compared surgery and non-surgical management of proximal humerus fractures in 717 patients, two-thirds of whom had three- or four-part fractures. The meta-analysis found high-certainty evidence of no clinically important difference between groups in patient-reported shoulder function at one year (standardized mean difference [SMD] 0.10, 95% CI -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants) [17].

The Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) trial involving 250 patients with a displaced proximal humeral fracture reported no difference in overall shoulder function (as determined by the Oxford Shoulder Score [OSS]) at two- and five-year follow-up between patients treated surgically and those treated nonoperatively [19,20]. However, a high proportion of patients (188) with clear indications for surgery were excluded from the trial, rendering the results difficult to interpret. The trial results suggests that in a select group of patients without a clear indication for surgery, nonoperative management may be equivalent to surgery as determined by patient-important, functional outcomes.

In a study of 774 patients with complex proximal humerus fractures treated nonoperatively, a substantial number reported poor functional outcomes on validated assessment scores at one year [22]. Three demographic variables (higher level of dependency, higher level of social deprivation, and history of affective [mood] disorder) were most consistently associated with poor outcomes. Younger, more active patients also reported poorer outcomes.

INITIAL TREATMENT — Acute treatment for one-part fractures includes immobilization in a standard sling or collar and cuff sling (figure 17). A standard sling is recommended for impacted fractures. A collar and cuff sling may aid in reduction of minimally displaced fragments. Swathes (figure 18) can be used for pain control but are otherwise not necessary unless the shoulder is unstable. A coaptation splint, which wraps around the humerus lengthwise from the axilla to the top of the shoulder, may provide more support and reduce symptoms for the patient with severe pain. Ice can be used to reduce pain and swelling; pain medications are generally necessary for the first week of treatment. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Upper extremity splints' and "General principles of acute fracture management", section on 'Pain management'.)

Patients generally prefer to sleep semirecumbent (eg, in a reclining chair or propped up with pillows or a wedge in bed) with a sling. Repeat clinical evaluation and radiographs are performed at one week. Careful attention should be paid to the skin, especially in older adult patients with swelling and ecchymosis.

Several muscles have insertions on the proximal humerus, and the forces exerted by these muscles make it difficult to maintain reductions of proximal humeral fractures:

The supraspinatus and infraspinatus pull the greater tuberosity superiorly

The subscapularis pulls the lesser tuberosity medially

The pectoralis major adducts the humeral shaft

The deltoid abducts the humeral shaft

Therefore, closed reduction of fracture fragments is not recommended.

FOLLOW-UP CARE — Total healing time is typically 6 to 12 weeks for proximal humeral fractures. Early callus formation usually occurs at four to six weeks.

Duration of immobilization — Shoulder rehabilitation after proximal humeral fractures is important; however, the optimal timing for beginning rehabilitation remains uncertain. Multiple randomized trials report no significant harm and possibly improved mobility among patients whose initial immobilization is two weeks or less and who begin gentle mobility exercises at that time. For patients with nondisplaced or minimally displaced one- or two-part fractures, a shorter period of immobilization, perhaps as little as one week, does not adversely affect fracture healing and may be associated with better short-term pain control and shoulder function [26]. Early rehabilitation is supported by the following studies:

A study randomized 111 patients with nonoperative proximal humerus fractures to either one week or three weeks of immobilization in a sling followed by a comprehensive rehabilitation program. No differences were noted in pain scores or functional outcomes at any time point or in complications between the two groups [27].

A randomized trial of 74 patients compared aggressive early mobilization at 72 hours with standard mobilization at three weeks [28]. Initially, Constant scores (assessment of shoulder function), pain scores, and mobility were better in the early mobilization group, but at six months, no significant differences were noted.

In a subsequent study, 86 patients with two-part fractures of the proximal humerus were randomly assigned to begin range of motion exercises within the first week after injury or to continue shoulder immobilization for three weeks before beginning rehabilitation [29]. The group that started early therapy had significantly less pain and better function four months after the fractures occurred. However, there was no statistically significant difference between the two groups at one year.

An uncontrolled study of 104 patients with minimally displaced (one-part) proximal humeral fractures found no difference in fracture healing but significantly better overall function and external rotation in those patients who started supervised physical therapy by day 14 compared with those who started after day 14 [30]. The mean duration of follow-up was 41 months.

Reevaluation — Patients are seen again within four to seven days of their initial visit, and plain radiographs are obtained to reevaluate for significant displacement. If pain is well controlled and no displacement of fragments is noted, pendulum exercises can be initiated in the sling to avoid loss of shoulder motion (figure 19). Passive elbow range of motion as well as isometric strengthening exercises for the biceps and triceps should be initiated early.

Subsequent visits — The first of a series of two-week follow-up visits focuses on pain control and upper extremity range of motion. Patients are encouraged to discontinue their sling within two to four weeks of the injury and to perform gentle, passive range of motion exercises of the elbow and shoulder. Pendulum (figure 19) and wall climb (figure 20) exercises should be done at least twice daily. If patients are unable to perform these exercises, a referral to physical therapy for assistance improving passive range of motion is necessary.

The goal of shoulder rehabilitation is to restore strength and mobility, including abduction, flexion, extension, and rotation. Exercises in which the patient places their hand on a wall or holds a ball against a wall to improve motion can begin within two to four weeks. Patients can initiate these motions against gravity at four weeks and progress to elastic band or resistance exercises once adequate motion has been achieved and there is sufficient evidence of healing by radiographs. The details of rehabilitation for proximal humeral fractures are beyond the scope of this monograph, but the systematic review cited here emphasizes the importance of early mobilization and outlines a program suitable for most patients [31].

After eight weeks, the time between visits may be increased to every three to four weeks. The focus of these visits is to further improve shoulder range of motion and overall function. Functional measures of motion include the ability to touch the neck and lower back and to abduct the arm overhead.

Over subsequent weeks, the patient follows a progression of exercises designed to maximize shoulder mobility and strength. Most patients with nondisplaced or minimally displaced fractures of the proximal humerus who adhere to a well-designed rehabilitation program regain over 90 percent of the function and 85 percent of the motion of their unaffected shoulder [30].

Complications — Loss of shoulder mobility is among the more common complications of proximal humeral fractures. The decrease in motion ranges from the clinically insignificant to adhesive capsulitis (frozen shoulder), in which shoulder movement is painful and limited in all orientations. (See "Frozen shoulder (adhesive capsulitis)".)

Loss of shoulder motion and function is more likely to develop in patients who do not perform range of motion exercises during recovery. (See 'Subsequent visits' above.)

Severely displaced or angulated fractures can cause neurovascular injury, most commonly to the circumflex artery and the axillary or suprascapular nerve. One prospective study of 142 patients with proximal humeral fractures found evidence of some denervation using an electromyogram in 67 percent of patients [2]. Injury to the axillary nerve accounted for 58 percent of cases, while injury to the suprascapular nerve accounted for 48 percent. All patients recovered full function of the nerve and muscles.

Proximal humeral fractures are sometimes associated with dislocations of the humeral head or rotator cuff tears, which can cause significant loss of motion or instability. Studies using dynamic ultrasound have found that 20 to 50 percent of patients with proximal humeral fractures have associated rotator cuff tears [32,33]. A prospective study involving magnetic resonance imaging (MRI) reported that 71 percent of patients had rotator cuff abnormalities and 40 percent had at least one torn or avulsed tendon [34]. (See "Presentation and diagnosis of rotator cuff tears".)

Although osteonecrosis of the humeral head is not common, it can occur, especially in fractures involving the anatomic neck or severely displaced fractures. Other complications include nonunion and impingement from avulsed fracture fragments. A study of 160 patients managed nonoperatively reported delayed union or nonunion in 7 percent of patients [21].

In a study of 2230 older adult patients with a proximal humeral fracture, researchers evaluated a tool with 19 elements (proximal humeral assessment of risk of nonunion model; PHARON) to assess healing and the risk for nonunion [35]. The overall nonunion rate was 10.4 percent at 24 weeks. A head-shaft angle (HSA) of >140 degrees or a valgus malalignment of the fracture were independent variables associated with a low nonunion rate (0.8 percent; n = 3). If the HSA was <140 degrees, the risk of nonunion was increased among patients who were smokers or whose fractures had increased head-shaft translation (HST) or varus alignment. The prevalence of nonunion was low (1 percent) in cohorts with both an HSA of 90 to 140 degrees and HST of <50 percent, whereas the risk was much higher (83.7 percent) in the 8.3 percent with an HSA of <90 degrees and HST of >50 percent. Further validation of this assessment tool is warranted.

RETURN TO SPORT OR WORK — Return to work typically occurs two to three weeks after a proximal humeral fracture, provided the patient can return in the sling and the job does not require full use of the affected arm. Patients whose jobs include two-handed labor or lifting will likely not be able to return for 8 to 12 weeks.

Criteria for return to work include adequate range of motion and strength as well as stable callus formation on radiographs. The same criteria are used to determine the return to sports. Cardiovascular fitness after a proximal humeral fracture can be maintained by low-impact activities such as walking or use of an elliptical trainer or stationary bike.

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

(See "General principles of fracture management: Bone healing and fracture description".)

(See "General principles of fracture management: Fracture patterns and description in children".)

(See "General principles of definitive fracture management".)

(See "General principles of acute fracture management".)

(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Fractures of the skull, face, and upper extremity in adults" and "Society guideline links: Acute pain management".)

SUMMARY AND RECOMMENDATIONS

Epidemiology and mechanism – Proximal humeral fractures account for 4 to 5 percent of all fractures, and the incidence increases with advancing age. They often occur as a result of falling from a standing height. (See 'Epidemiology and risk factors' above and 'Mechanism of injury' above.)

Presentation and examination – Swelling and ecchymosis may be apparent soon after the injury. Gross deformity of the shoulder suggests an associated anterior or posterior dislocation. Concomitant neurologic or vascular injury should be suspected and neurovascular integrity carefully assessed. (See 'Symptoms and examination findings' above.)

Classification – The Neer classification system (figure 16) is often used for proximal humeral fractures. (See 'Neer classification' above.)

Initial care and indications for orthopedic referral – Complex proximal humeral fractures (ie, Neer two-part to four-part fractures; (figure 16)) and fractures that involve the anatomical neck should be referred to an orthopedic surgeon. These are initially managed with immobilization using a standard sling or, if unstable, a sling and swathe. Closed reduction of the fracture is NOT recommended prior to orthopedic referral.

Orthopedic referral is not required for one-part fractures unless the fracture involves the anatomic neck, there are neurovascular complications, there is a concomitant shoulder dislocation, or the treating clinician is not experienced in fracture management. (See 'Indications for orthopedic consultation or referral' above.)

Nonoperative management of one-part fractures – Approximately 80 percent of proximal humeral fractures are impacted or nondisplaced (Neer one-part fractures) and are amenable to closed, nonoperative management. Initial care consists of immobilization with a standard or collar and cuff sling, ice, and analgesics. Neither splinting nor casting is required. We suggest that early mobilization with gentle pendulum exercises be performed in the sling beginning one to two weeks after the injury. (See 'Initial treatment' above.)

Follow up care of one-part fractures – Periodic follow-up visits allow assessment of range of motion, strength, and function. Generally, the first appointment occurs one week following the injury, with subsequent follow-up every two weeks for two months, followed by visits every three to four weeks until complete radiographic healing is documented. (See 'Follow-up care' above.)

Return to activity – Return to work can be expected in two to three weeks if the patient can perform the required duties while in a sling. Return to occupations that require full use of the shoulder or to sports is not advised until strength and range of motion are acceptable and stable healing is apparent on radiographs. (See 'Return to sport or work' above.)

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References

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