Overview
Open reduction and internal fixation of a proximal humerus fracture realigns the broken ball and neck of the upper arm bone and holds the pieces with a locking plate and screws, or with a nail passed down the inside of the bone. Most of these fractures will heal in some position on their own; the reason to fix a displaced one is to restore the tuberosities, where the rotator cuff attaches, to their correct place so the cuff can lift and rotate the arm, and to make the fracture stable enough that motion can start early. A shoulder immobilized while a displaced fracture heals crooked is permanently stiff and weak.
The expected result is a shoulder with functional overhead reach and rotation for daily life, and for younger patients a return to sport. Fixation is usually outpatient at Bayside Surgery Center; older patients with other medical conditions may stay one night.
Who It's For
Fixation is recommended when a tuberosity is displaced by more than about 5 mm, when the head is angled more than 45° from the shaft or displaced by more than a centimeter, when the fracture enters the joint surface, or when the shaft has separated from the head. Younger and active patients are fixed more readily because their bone holds screws well and they need the strength that anatomic healing provides; fracture-dislocations are usually treated surgically, by fixation or replacement. See proximal humerus fracture for how the fracture pattern is classified.
About three quarters of proximal humerus fractures are minimally displaced and heal in a sling with early pendulum motion, without surgery. In osteoporotic bone a plate can cut out of the soft head, so a displaced three- or four-part fracture in a patient over about 70 is often better treated with a reverse shoulder replacement, which does not depend on the fracture healing. A head that has split or lost its blood supply is usually replaced rather than fixed. The decision is made on CT, bone quality and the patient's demands.
Displacement measured on an X-ray or CT is not by itself the reason to fix a proximal humerus fracture. Dr. O'Donnell recommends fixation when the displacement on imaging, the patient's bone quality and demands, and the expected function in a sling together favor it; the majority heal without surgery. The proximal humerus fracture page describes how the pattern is classified.
What the Procedure Involves
Surgery is performed under general anesthesia with a nerve block. Dr. O'Donnell uses the deltopectoral approach, between the deltoid and pectoralis muscles at the front of the shoulder, which reaches the fracture without cutting muscle. Heavy sutures through the rotator cuff at each tuberosity give a way to control the fragments and, later, a way to tie the cuff down to the plate.
The head is levered back onto the shaft and the tuberosities brought around it. Bone defects under the head are filled with bone graft or a calcium phosphate substitute so the head does not settle. A pre-contoured locking plate is placed on the outer surface of the bone below the cuff insertion; locking screws thread into the plate itself and form a fixed-angle scaffold that holds the head even in soft bone. Screw length is checked on X-ray in several positions so that none can penetrate the joint. The cuff sutures are tied to the plate, sharing the pull of the tendons across the fixation rather than through the fracture. A locked intramedullary nail is chosen instead for some two-part neck fractures and for fractures extending down the shaft.
The operation takes about 90 minutes to two hours. The arm is placed in a sling, and most patients go home the same day.
Risks & How They Are Minimized
The most important risks come from the fracture rather than the surgery. Avascular necrosis, in which the head loses its blood supply and collapses over one to two years, is most likely in four-part fractures and dislocations; it is reduced by minimal stripping of soft tissue from the fragments, and if it occurs the shoulder can be converted to a replacement. Screw penetration into the joint follows collapse of the head onto fixed-angle screws and is guarded against by grafting bone defects and checking screw length on multiple X-ray views. Loss of fixation in osteoporotic bone is why older patients with complex fractures are advised to have replacement.
Stiffness is common after any proximal humerus fracture, which is why passive motion begins in the first week. Nonunion is uncommon after plating; strengthening waits until X-rays show healing. Infection is rare and is guarded against with preoperative antibiotics. The axillary nerve wraps around the humerus below the joint and is protected by keeping the plate above it; block numbness resolves in a day. Blood clots are unusual after upper-limb surgery; patients walk the same day and take aspirin if they have risk factors.
Recovery & Rehabilitation
Dr. O'Donnell's protocol starts passive motion early to prevent stiffness and delays active motion and strengthening until the fracture shows healing. Comminuted fractures are progressed more slowly.
| Phase | Timing | What happens |
|---|---|---|
| Passive motion | Weeks 0–4 | Sling except for exercise. Pendulums, passive flexion and external rotation in a range set by the surgeon, scapular setting, ice. Passive motion only; no weight bearing through the arm. |
| Active-assisted to active motion | Weeks 4–8 | Sling weaned at 3–4 weeks. Active-assisted then active motion once healing is confirmed, sub-maximal cuff and scapular isometrics late in the phase, posture work. |
| Strengthening | Weeks 8–12 | Progressive rotator cuff, deltoid and scapular strengthening, endurance work. Advance at radiographic union and 70–80% strength. |
| Return to activity | Months 3–6 | Advanced strengthening and sport- or job-specific progression. Full loading with surgeon clearance once strength and motion are symmetric. |
Desk work is possible within one to two weeks, driving at four to six weeks once active motion is cleared, swimming and golf from about three months, and heavy lifting or contact sport between four and six months depending on healing.
Protocol summary
The sling is worn for about three to four weeks. Early motion is passive only, within a range set by Dr. O'Donnell at surgery; active motion is delayed until healing has progressed, at about six weeks, and no lifting, pushing or weight bearing through the arm is allowed until cleared. Forceful end-range stretching is avoided early.
Active motion starts only when the surgeon confirms healing on X-ray, strengthening requires radiographic union, and full loading requires symmetric strength and motion with surgeon clearance, typically between three and six months.
Physical Therapy Protocol
Proximal Humerus Fracture — Open Reduction & PDF ↗Frequently Asked Questions
Does a proximal humerus fracture need surgery?
Most do not. About three quarters are minimally displaced and heal in a sling with early pendulum exercises. Dr. O'Donnell recommends fixation when a tuberosity is displaced more than about 5 mm, the head is angled more than 45°, the fracture enters the joint, or the head and shaft have separated, and a reverse replacement for complex fractures in osteoporotic bone.
Plate or shoulder replacement for a broken shoulder?
A plate is chosen when the bone is strong enough to hold screws and the head has a good blood supply, usually younger patients with two- or three-part fractures. A reverse replacement is chosen for displaced three- and four-part fractures in patients over about 70, a split head, and fracture-dislocations with a high risk of the head losing its blood supply.
How long does a proximal humerus fracture take to heal after surgery?
Healing is usually visible on X-ray at about six weeks, when active motion begins. Strengthening starts at eight weeks once union is confirmed, and full loading is cleared between three and six months. Motion often keeps improving for a year.
When can I drive after shoulder fracture surgery?
Usually at four to six weeks, once the sling is off, active motion has been cleared on X-ray and you can turn the wheel comfortably without prescription pain medication. Until then, arrange rides; a sudden steering correction loads the fixation before the bone has healed.
Will I get full motion back after a proximal humerus fracture?
Some loss of end-range elevation and rotation is common after these fractures, fixed or not; early passive motion keeps that loss small. Most patients regain the motion they need for daily activities and recreation. The phases are in the proximal humerus ORIF protocol.
This page is for general education and is not a substitute for a medical evaluation. The right procedure depends on your individual diagnosis, anatomy, 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.