Overview
Proximal humerus fractures account for approximately 4–6% of all fractures and are among the most common upper extremity injuries in the elderly population. The incidence increases significantly with age due to osteoporosis and low-energy falls. In contrast, younger patients usually sustain these fractures following high-energy trauma.
Treatment decisions are influenced by fracture displacement, stability, bone quality, patient age, comorbidities, and functional expectations. While most proximal humerus fractures can be treated non-operatively, surgical intervention is required in selected patients with displaced or unstable fracture patterns. The Neer classification remains the most commonly used system; however, it should be interpreted in conjunction with patient-specific factors rather than as a sole determinant of treatment.
Clinical Presentation
Patients typically present with acute shoulder pain, limited range of motion, and functional impairment following trauma. Swelling and ecchymosis around the shoulder and proximal arm are common clinical findings. In cases with significant displacement, visible deformity may be observed.
A thorough clinical examination is mandatory and should always include neurovascular assessment, particularly evaluation of the axillary nerve. Signs of open fracture must be ruled out, and associated injuries such as glenohumeral dislocation or rotator cuff tears should be actively assessed. In elderly patients, low-energy trauma should raise suspicion for fragility fractures.
Imaging
Standard shoulder radiographs are usually sufficient for the initial evaluation of proximal humerus fractures. A complete radiographic assessment should include three orthogonal views to accurately evaluate fracture displacement, alignment, and associated glenohumeral instability.
The recommended radiographic views are:
Anteroposterior (Grashey) view: allows assessment of the humeral head, tuberosities, and overall fracture displacement.
Scapular Y view: is useful for evaluating sagittal plane alignment and excluding associated shoulder dislocation.
Axillary view: provides critical information regarding anterior or posterior displacement and glenohumeral congruency.
Computed tomography (CT) is reserved for complex fracture patterns, suspected articular surface involvement, or preoperative planning. CT imaging improves visualization of fracture morphology, tuberosity displacement, and comminution, and assists in estimating the risk of humeral head ischemia.
Treatment
Treatment selection is primarily guided by fracture displacement and stability, in addition to patient-related factors such as age, bone quality, and functional demands.
Non-operative Management
Non-operative treatment is appropriate for minimally displaced fractures, stable two-part fractures, and patients with low functional demands or high surgical risk. Management typically involves short-term sling immobilization followed by early passive range-of-motion exercises.
Operative Management
Surgical options include locking plate fixation, intramedullary nailing, hemiarthroplasty, and reverse shoulder arthroplasty. In younger patients, joint-preserving fixation techniques are preferred. In elderly patients with osteoporotic bone or complex fracture patterns, reverse shoulder arthroplasty has become increasingly favored due to predictable functional outcomes.
Surgical Indications
Surgical intervention is generally indicated in fractures with significant displacement or instability, three- and four-part fractures, head-splitting fractures, glenohumeral instability, and open fractures or those associated with neurovascular injury.
Prognosis
Clinical outcomes depend on fracture severity, treatment modality, and rehabilitation adherence. Many patients achieve satisfactory functional recovery, although complications such as avascular necrosis, nonunion, malunion, and implant failure may occur. Early mobilization and appropriate patient selection are essential for optimal outcomes.
Differential Diagnosis
Conditions that may mimic proximal humerus fractures include glenohumeral dislocation, acute rotator cuff tears, pathological fractures, and metastatic bone disease. In elderly patients without a clear traumatic mechanism, pathological fractures should always be excluded.
References
Court-Brown CM, Caesar B. Epidemiology of adult fractures. Injury. 2006;37(8):691–697. DOI: 10.1016/j.injury.2006.04.130
Neer CS. Displaced proximal humeral fractures. J Bone Joint Surg Am. 1970;52(6):1077–1089.
Fraser AN et al. Reverse shoulder arthroplasty versus angular stable plate fixation. Bone Joint J. 2020;102-B(4):442–450.
Boileau P et al. Reverse shoulder arthroplasty for acute fractures. J Shoulder Elbow Surg. 2019;28(11):e370–e381.