Overview
Proximal humerus fractures (PHFs) are increasingly common, especially among older adults. These fractures occur near the top of the upper arm bone (humerus), close to the shoulder. While many can be treated without surgery, certain types require fixation—surgical procedures to realign and stabilize the broken bones. Choosing the right treatment depends on the fracture pattern, patient age, bone quality, and overall health.
Who Gets These Fractures?
Proximal humerus fractures follow a bimodal distribution:
- Younger individuals often suffer them through high-energy trauma (e.g., car accidents, sports injuries).
- Older adults, particularly women with osteoporosis, tend to experience these fractures from low-energy incidents like falls.
Complications from PHFs can include:
- Malunion or non-union (bones not healing properly)
- Avascular necrosis (bone tissue death)
- Traumatic arthritis
- Long-term pain and loss of shoulder function
How Are These Fractures Evaluated?
Clinical Assessment
A thorough clinical evaluation includes:
- Medical history and lifestyle assessment (e.g., smoking, physical activity, handedness)
- Checking for nerve or vascular injuries, especially in more severe fractures or dislocations
- Neurovascular exam to assess limb function and blood flow
In some cases, a CT angiogram is used if vascular injury is suspected—most commonly in patients over 50, due to vascular stiffening.
Radiological Assessment
Initial imaging includes:
- X-rays (front, side, and angled views)
- CT scans with 3D reconstruction for complex fractures
- MRI scans when rotator cuff damage is suspected
Notably, about 40% of PHFs involve rotator cuff tears, which can impact both function and treatment choice.
How Are PHFs Classified?
The most commonly used system is the Neer classification, dividing fractures into:
- 2-part
- 3-part
- 4-part fractures
This classification helps guide treatment but is known to have poor consistency between observers. Other systems, like the AO classification or Hertel’s 12-pattern binary system, attempt to offer more detailed breakdowns.
Non-Operative Management
About 85% of PHFs can be treated without surgery. This is especially true for stable fractures and elderly patients. Management includes:
- Short-term immobilization
- Early supervised physiotherapy (often started within 2 weeks)
The UK’s PROFHER study, a major clinical trial, showed no significant difference in outcomes between surgical and non-surgical treatment for many PHFs, especially in cases where doctors were uncertain about whether surgery was needed.
Operative Management
Surgical intervention is considered when:
- The fracture is severely displaced
- The humeral head is split
- There’s a fracture-dislocation
- Bone fragments are completely separated
Surgical fixation options include:
1. Percutaneous Fixation
A minimally invasive method using screws or pins:
- Best for specific 3- or 4-part fractures
- Preserves soft tissue and vascularity
- Not ideal for unstable or complex fractures
2. Locking Plate Fixation
The most common method for displaced PHFs:
- Offers rigid fixation using locking screws
- Useful in 2- or 3-part fractures, and sometimes 4-part fractures
- Requires soft tissue dissection and has risks like screw penetration and varus collapse
- Complication rate (screw penetration, collapse, AVN) varies from 4–10%
3. Intramedullary Nailing (IM Nail)
A nail is inserted into the bone’s canal:
- Less invasive than plating
- Preserves blood supply and avoids extensive dissection
- Entry through the rotator cuff can sometimes lead to dysfunction
- Better suited for 2-part and select 3-part fractures
Arthroplasty (Shoulder Replacement)
1. Hemiarthroplasty (HA)
Replaces the humeral head only:
- Best for younger patients with good rotator cuff function
- Heavily depends on the healing of tuberosities (bony attachments for muscles)
- Failure of tuberosity healing leads to poor outcomes
2. Reverse Shoulder Arthroplasty (RSA)
Reverses ball-and-socket orientation of the joint:
- Increasingly favored for elderly patients or those with rotator cuff tears
- Offers reliable pain relief and good shoulder function
- Does not depend on rotator cuff integrity
- More costly and technically demanding
RSA vs Other Treatments
- RSA has better outcomes than HA in elderly patients with complex fractures
- RSA is increasingly used over open reduction and internal fixation (ORIF) due to lower re-operation rates and better function in select populations
Key Surgical Decision Factors
| Factor | Influence on Treatment |
|---|---|
| Age and activity level | Younger → ORIF/HA; Elderly → RSA or non-operative |
| Bone quality | Poor quality → Avoid ORIF, favor RSA |
| Rotator cuff integrity | Intact → HA possible; Torn/dysfunctional → RSA preferred |
| Tuberosity involvement | Essential for HA; less crucial for RSA |
| Fracture pattern | 2-part → ORIF/IM Nail; 3-/4-part → Consider RSA |
| Surgeon experience | Influences complication rate and outcomes |
Conclusion
Proximal humerus fractures require personalized care. While many fractures can be managed without surgery, fixation or even shoulder replacement is warranted for unstable or complex injuries. Modern fixation techniques such as locking plates and intramedullary nails have improved outcomes for specific patterns. However, reverse shoulder arthroplasty has emerged as the leading treatment in elderly patients with poor bone quality or failed rotator cuffs. The decision depends on a careful balance of patient needs, fracture characteristics, and surgeon expertise.
