Overview
The proximal humerus is the ball of the shoulder and the flared bone beneath it: the head, which articulates with the socket; the greater and lesser tuberosities, where the rotator cuff tendons attach; and the shaft below. A fracture here is described by how many of those pieces have separated and by how far. Most are cracked but not displaced and heal in a sling; the difficult ones are those in which the tuberosities pull away with their tendons, the head tilts, or the bone splits into several pieces.
Treatment is decided by displacement, bone quality and the patient. About three quarters of these fractures are stable enough to treat without surgery. For the rest, the choice is between fixing the pieces with a plate, which works well in good bone, and replacing the joint, which is more reliable when the head is in pieces or the bone is too soft to hold screws. A 35-year-old cyclist and a 78-year-old who fell in the kitchen are treated very differently.
Common Symptoms
- Severe pain at the shoulder immediately after a fall, with the patient holding the arm against the body
- Swelling, followed over two to three days by extensive bruising that tracks down the arm and across the chest
- Inability to lift or rotate the arm; any attempt to move it is painful
- Numbness over the outer shoulder or weakness of the deltoid, which indicates an axillary nerve stretch
Bruising that appears down the arm days after a fall is characteristic. Pain and deformity along the collarbone instead is a clavicle fracture. A shoulder that went out of joint and had to be put back is a dislocation. A fall that leaves weakness lifting the arm with a normal X-ray is treated as a rotator cuff tear.
Causes & Risk Factors
Over 65 the cause is almost always a fall from standing height onto the outstretched arm or the side of the shoulder, and the underlying problem is osteoporosis; this is one of the three classic osteoporotic fractures, with wrist and hip, and a first one is a reason to check bone density. Women are affected about twice as often as men. In younger patients it takes more energy: a cycling or motorcycle crash, a ski fall, a contact-sport collision, or a dislocation that takes a piece of the tuberosity with it.
How It Is Diagnosed
Dr. O'Donnell examines the whole arm. He checks the deltoid for sensation and contraction because the axillary nerve wraps around the neck of the humerus exactly where it breaks, examines the pulse and hand function, and looks for a dislocated head, which changes the urgency. Once healing has begun, the rotator cuff is tested to confirm the tuberosities are attached and working.
A trauma X-ray series is the first step: an AP view, a scapular Y view and an axillary view, which shows whether the head is in the socket. Together they show how many parts there are and how far each has displaced. CT is ordered for displaced or multi-part fractures and whenever surgery is being planned, because it shows the fragments in three dimensions and decides between fixation and replacement. MRI is rarely needed. Out-of-town patients can upload images through mymedicalimages.com for an opinion before traveling.
Treatment Options
Non-operative care
Fractures that are not displaced, or displaced by less than about 1 cm and angled less than 45 degrees, are treated in a sling, and that is the majority. The risk here is not that the bone will fail to heal but that the shoulder will freeze while it does, so motion starts early: pendulums within the first week, passive shoulder motion at one to two weeks, and active-assisted motion at four to six weeks when X-rays show healing. The sling is worn for three to four weeks and strengthening begins around eight to twelve weeks. Most patients regain useful function by three months and continue to improve for a year.
Proximal humerus fracture fixation (ORIF)
Dr. O'Donnell recommends open reduction and plate fixation for fractures displaced more than 1 cm or angled more than 45 degrees in patients with good bone, for greater tuberosity fragments displaced more than 5 mm because they carry the rotator cuff with them, for fracture-dislocations, and for most displaced fractures in patients under about 65. The fragments are repositioned, the tuberosities are sutured through the cuff tendons, and a locking plate holds the construct while it heals. Fixation preserves the patient's own joint. Its limitation is soft bone: screws cut out and the head can lose its blood supply, which is why it is chosen selectively in older patients.
Reverse shoulder replacement
For three- and four-part fractures in patients over about 65, head-split fractures, and fractures where the head has lost its blood supply, a reverse shoulder replacement is the more predictable operation. It does not depend on the tuberosities healing or the cuff working; the trade-off is a permanent lifting limit. Both operations are performed under a nerve block and general anesthesia; fixation is usually outpatient at Bayside Surgery Center.
Recovery & What to Expect
After fixation the plate holds the fragments, but the bone still has to heal before the arm is used actively. Passive motion starts early to prevent stiffness; active motion and strengthening wait for healing on X-ray.
| Phase | Timing | What happens |
|---|---|---|
| Passive motion | Weeks 0–4 | Sling except for exercise. Pendulums; passive forward flexion and external rotation in a comfortable range set by Dr. O'Donnell. No weight through the arm, no active shoulder motion. |
| Active-assisted to active motion | Weeks 4–8 | Sling weaned at 3 to 4 weeks. Active motion begins only once X-rays confirm adequate healing, usually about 6 weeks; sub-maximal cuff and scapular isometrics late in the phase. |
| Strengthening | Weeks 8–12 | Begins after radiographic union. Progressive rotator cuff, deltoid and scapular strengthening and endurance. Advance at 70 to 80% strength of the other side. |
| Return to activity | Months 3–6 | Advanced strengthening and sport- or job-specific progression. Full loading on surgeon clearance with symmetric strength and motion. |
Desk work is possible within one to two weeks, driving once the sling is off and the arm can control the wheel at 4 to 6 weeks, and golf, tennis, cycling and manual work at 3 to 6 months depending on the fracture. The full protocol is available as a PDF: Proximal Humerus Fracture ORIF rehabilitation protocol. Patients treated with a reverse replacement follow the reverse shoulder replacement protocol.
Frequently Asked Questions
Can a proximal humerus fracture heal without surgery?
Most do. About three quarters are minimally displaced and heal in a sling over 6 to 8 weeks, with motion started early so the shoulder does not stiffen. Surgery is reserved for fractures displaced more than about 1 cm or angled more than 45 degrees, tuberosity fragments carrying the rotator cuff, and fracture-dislocations.
How long does a broken upper arm bone take to heal?
The fracture is usually stable enough for passive motion at 1 to 2 weeks, shows healing on X-ray at about 6 weeks, and is solid at 8 to 12 weeks. Function keeps improving for a year. Older patients often keep a small loss of overhead reach; younger patients generally regain full motion.
Should I move my shoulder after a proximal humerus fracture?
Yes, early and within the limits set at each visit. The main risk in a fracture treated in a sling is a frozen shoulder, not a bone that fails to heal. Pendulums and elbow, wrist and hand motion begin in the first week; passive shoulder motion at 1 to 2 weeks and active motion at about 6 weeks when the X-ray shows healing.
Plate fixation or shoulder replacement, which is better?
It depends on the bone. In a younger patient with strong bone, plate fixation preserves the natural joint. Over about 65 with a three- or four-part fracture in osteoporotic bone, screws can cut out and the head can lose its blood supply, so a reverse replacement is more predictable, at the cost of a permanent lifting limit.
When can I drive after a proximal humerus fracture?
Once the sling is off and the arm can steer and brake without pain, usually 4 to 6 weeks after either surgery or non-operative treatment. Driving one-handed with the arm in a sling is not advised. Desk work with the arm supported is usually possible within 1 to 2 weeks.
This page is for general education and is not a substitute for a medical evaluation. Treatment recommendations depend on your individual diagnosis and goals. Kevin O'Donnell, MD sees patients from Coral Gables, Miami, Brickell, Pinecrest and Coconut Grove at 475 Biltmore Way, and out-of-town patients by telemedicine.