Proximal Humerus Fracture (Broken Shoulder)

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Physical Therapy Videos - Shoulder

Basic Anatomy

Your shoulder is made up of three bones, the clavicle (collarbone), the scapula (shoulder blade) and the humerus (upper arm bone). The top part of your humerus is called the proximal part of the bone. Many muscles surround your shoulder. They include your rotator cuff muscles, deltoid muscle, pectorals muscle, and several strong muscles from your back. The arteries and nerves that supply your arm come out from under your clavicle bone and go down the arm in front of the shoulder.

A patient with a proximal humerus fracture.
Figure 1: A patient with a proximal humerus fracture. Front and side pictures show the swelling and bruising down the arm.

 

Skeleton model showing the proximal humerus and three other bones of the shoulder.
Figure 2: Skeleton model showing the proximal humerus and three other bones of the shoulder.

 

X-ray of a normal shoulder.
Figure 3: X-ray of a normal shoulder. The shoulder joint is between part of the scapula or shoulder blade (blue line) and the proximal humerus (green line).

Mechanism and Epidemiology

The proximal humerus is one of the most commonly broken bones in older people. It can occur after a normal fall or trip. Due to it being weaker in older people, the bone often breaks in multiple pieces.

For children and younger adults, a higher energy injury (like motor vehicle crashes, falls from height, and sports) is needed to break the proximal humerus. Because of the many muscles that attach to this part of the humerus, it can break in many different ways, and you need to talk to your doctor about the specific type of fracture you have.

Fracture lines separating the proximal humerus into 2, 3 or 4 parts.
Figure 4: Fracture lines separating (breaking) the proximal humerus into 2, 3, or 4 parts.

Initial Treatment

Proximal humerus fractures usually hurt a lot, especially when you try to move your arm. Simple breathing will cause pain. There may be a lot of swelling and bruising in your armpit, your chest, and down your arm. You may even have bruising in your hand or even fingers. When you first see a doctor, he or she will examine your shoulder and arm, and x-rays will be taken. Unless you have other injuries, most of the time you will be able to go home and will not be admitted to the hospital. You will likely be given a sling to use. Lying flat in a bed after a proximal humerus fracture can cause pain, so it may be more comfortable to sleep in a recliner chair. It is important to move your elbow, wrist, and hand to prevent stiffness. You should make an appointment with an orthopaedist or your primary care doctor for follow-up.

General Treatment

Most proximal humerus fractures can be treated without surgery. The broken bone will take 3 to 4 months to heal. During this time, you will need to perform exercises to regain range of motion, strength, and return to normal activities. Even if surgery is performed, recovery of full function often takes as long as 18 months. If surgery is not needed, there may be a time during which movement and lifting is limited. This decision will be made by your doctor based on your specific fracture.

Some proximal humerus fractures benefit from surgery. An orthopaedic surgeon can discuss your specific injury and the pros and cons of surgery vs. non-surgical treatment. Surgery is required if the bone came through your skin (open fracture) or is close to breaking through the skin. You may also need surgery if your shoulder is dislocated. Otherwise, there are few absolute reasons to do surgery. If surgery is chosen, the surgeon will make a cut over your shoulder, realign your bones, and use metal plates and screws to repair the broken bone. If your shoulder has broken into too many pieces and is unlikely to heal even if put back together, your surgeon may recommend replacing your shoulder instead of repairing it.

X-rays of a 2-part proximal humerus fracture treated without surgery.
Figure 5: X-rays of a 2-part proximal humerus fracture treated without surgery. The image on the left was taken 2 weeks after injury and the image on the right shows the fracture healed 9 months later.

 

Figure 6: X-rays of a 3-part proximal humerus fracture before and after surgery.
Figure 6: X-rays of a 3-part proximal humerus fracture before and after surgery.

Post-operative Care

While your proximal humerus fracture is healing, you will likely not be able to fully move your shoulder or lift objects that weigh more than 1 or 2 pounds. This may be due to pain and/or instructions from your surgeon. Many surgeons will ask you to avoid certain movements after surgery until the bone has begun to heal. Often, you will be prescribed physical therapy to help with motion, lifting, and pain after surgery. A sling may also be used for comfort. It is important to remove the sling several times a day and to move your elbow, wrist, and hand to prevent stiffness. Your ability to move your shoulder and lift more weight will improve as your bone heals. For best results, it is important to follow instructions from your surgeon.

Long Term

Long-term issues after fracture of the proximal humerus can include stiffness, soreness, and an inability to regain full, pre-injury strength. You may require several months of physical therapy to be able to return to your prior activities. Your shoulder may always feel and move differently compared to your uninjured side.

While most proximal humerus fractures heal, some may not heal or may heal in a position that causes discomfort or limits motion. Some people may develop arthritis and this can result in increasing pain and stiffness. These complications can occur with or without surgery. In older patients, shoulder replacement may be recommended if pain becomes too severe. In younger patients, your surgeon may recommend removal of the hardware or other surgery.

X-ray of a shoulder replacement.
Figure 7: X-ray shows a shoulder replacement, which may be performed if the fracture is irreparable, or after complications following non-operative treatment or surgical repair.

 

Physical Therapy Videos - Shoulder

More Information

Adults:

Children:

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Babar Shafiq, MD
Edited by the OTA Patient Education Committee and Steven Papp, MD (section lead)
X-rays and images from the personal collections of Dr. Shafiq and Christopher Domes, MD

 

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