Shoulder

Proximal Humerus Fracture

Proximal humerus fractures — breaks at the top of the upper arm bone — are among the most common fractures seen in adults, particularly following falls in older patients. Their management requires careful consideration of fracture pattern, bone quality, patient age, and functional demands. At Maryland Orthopedic Specialists, our shoulder specialists apply a comprehensive, evidence-driven approach to guide each patient — from non-operative management of stable fractures to advanced surgical reconstruction — toward the best possible shoulder function.

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What is proximal humerus fracture?

The proximal humerus comprises the humeral head (the ball of the shoulder joint) and two bony prominences called tuberosities — the greater tuberosity (attachment of supraspinatus, infraspinatus, and teres minor) and the lesser tuberosity (subscapularis attachment). These structures articulate with the glenoid and are separated from the humeral shaft by the surgical neck.

The proximal humerus comprises the humeral head (the ball of the shoulder joint) and two bony prominences called tuberosities — the greater tuberosity (attachment of supraspinatus, infraspinatus, and teres minor) and the lesser tuberosity (subscapularis attachment). These structures articulate with the glenoid and are separated from the humeral shaft by the surgical neck.

Proximal humerus fractures are the second most common upper extremity fracture in the elderly (after distal radius fracture), and account for approximately 5–6% of all fractures in adults. Incidence increases sharply with age and is three times higher in women than men, reflecting the role of osteoporosis.

The most common mechanism is a low-energy fall on an outstretched hand or directly on the lateral shoulder. High-energy mechanisms (motor vehicle accidents, athletic collisions) are responsible in younger patients.

Neer Classification

The Neer classification (1970) organizes proximal humerus fractures by the number of displaced segments (parts). A "part" is considered displaced if it is separated by >1 cm or angulated >45°:

1-part fracture: Any number of fracture lines, but no part is displaced beyond threshold criteria. Accounts for >80% of proximal humerus fractures. Managed non-operatively in the vast majority.
2-part fracture: One segment is displaced. Surgical neck 2-part fractures are most common; greater tuberosity 2-part fractures, even with modest displacement (≥ 5 mm), are increasingly treated operatively.
3-part fracture: Two segments displaced; the remaining tuberosity stays with the head.
4-part fracture: Both tuberosities and the humeral head are each displaced; the head is often devascularized (risk of avascular necrosis). These are the most complex fractures.

Neurovascular Injury Risk

The axillary nerve — which innervates the deltoid muscle — courses around the surgical neck of the humerus and is the most commonly injured nerve in proximal humerus fractures and shoulder dislocations. A formal deltoid function assessment and sensory check over the lateral deltoid (axillary nerve territory) is mandatory in every patient. Most axillary nerve injuries from fracture are neurapraxias (contusions) that recover spontaneously. The axillary artery may be injured in high-energy fractures, especially in elderly patients with atherosclerotic vessels — absent radial pulse warrants urgent vascular assessment.

Treatment options

Non-Operative Management (> 80% of Fractures)

The vast majority of 1-part and many 2-part proximal humerus fractures are managed with a sling for 3–6 weeks, followed by supervised physical therapy. Non-operative treatment achieves satisfactory outcomes because most proximal humerus fractures are either minimally displaced or impacted in a stable configuration. Pendulum exercises begin early to prevent stiffness.

Open Reduction and Internal Fixation (ORIF)

ORIF using a locking proximal humerus plate is the surgical standard for most displaced fractures in younger, bone-healthy patients:

Reverse Total Shoulder Arthroplasty (RSA) for 3–4-Part Fractures in the Elderly

In elderly patients with osteoporotic bone, 3-part and 4-part proximal humerus fractures present a significant reconstructive challenge. Reverse shoulder arthroplasty is the gold standard if ORIF is not a good option.

Frequently Asked Questions

Does everyone with a broken shoulder need surgery?

No — more than 80% of proximal humerus fractures are treated successfully without surgery using a sling and physical therapy. Surgery is reserved for displaced fractures in appropriate candidates.

What is the risk of avascular necrosis (bone death)?

AVN occurs when the fracture disrupts the blood supply to the humeral head. It is most common with 4-part fractures and head-splitting injuries. In the elderly, reverse shoulder replacement avoids this risk entirely by replacing the humeral head.

Why might my doctor recommend a reverse shoulder replacement instead of a traditional repair?

In elderly patients with osteoporotic bone and complex fracture patterns, RSA provides more reliable functional recovery than attempting to fix the fragments with plates and screws, which may fail in poor bone quality.

How long does recovery from a broken shoulder take?

Recovery from a proximal humerus fracture depends on fracture severity and whether surgery was required. Non-operative fractures typically require 4–6 weeks in a sling followed by physical therapy, with most patients regaining functional motion by 3–4 months and continuing to improve for up to a year. Surgically treated fractures — whether with a plate, nails, or shoulder replacement — follow a similar or slightly longer timeline, and full strength and motion recovery can take 6–12 months. At MOS, your surgeon will set realistic expectations based on your fracture pattern, age, and bone quality.

What are the signs that my broken shoulder is healing properly?

Healing is monitored through a combination of decreasing pain, improving range of motion, and serial X-rays showing progressive bone bridging at the fracture site. Most patients notice meaningful pain reduction within the first 4–6 weeks, and X-ray evidence of healing typically appears at 6–8 weeks in younger patients, though it may take longer in older adults or those with osteoporosis. One important warning sign to watch for is persistent severe pain or sudden loss of shoulder movement weeks after injury, which could indicate avascular necrosis (loss of blood supply to the humeral head). Your MOS care team will follow up with you regularly to ensure your recovery is progressing on track.