Proximal Humeral Fractures

Proximal humeral fractures are most commonly caused by falling on an outstretched arm. Patients present with shoulder pain and inability to move the arm. About 80% of proximal humeral fractures are minimally displaced, with < 45° angulation and < 0.5 cm (< 0.2 inches) displacement of any fragment. Anteroposterior x-ray views of the proximal humerus may show as many as four main fragments--eg, of the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft. These fragments are prone to displacement because of the pull of the rotator cuff, deltoid, and pectoral muscles. If no fracture is apparent on anteroposterior x-ray views, a patient with an acute shoulder injury should be examined for a glenohumeral dislocation and a rotator cuff tear. An axillary or Y-view lateral x-ray shows a dislocation if present. Large rotator cuff tears cause a feeling of painful weakness when the patient elevates and rotates the arm.

The most common complication after a proximal humoral fracture is adhesive capsulitis, which results when the inflamed surfaces of the joint capsule scar and adhere to one another. Capsulitis restricts motion, causing chronic pain and functional disability.

Prognosis and Treatment

Prognosis and treatment depend on the number of fragments and the extent of displacement. Regaining the ability to perform overhead activities (eg, combing hair) may take several months.

If the alignment and position of fragments are satisfactory, the arm may be immobilized in a sling. If they are unsatisfactory, an orthopedist may attempt closed reduction. If closed reduction is unsuccessful, open reduction with internal fixation or insertion of a prosthesis may be indicated. Patients should be told to expect considerable swelling and discoloration, which will spread to the lower arm and hand.

For stable fractures, the patient should be encouraged to use the hand and wrist immediately. Range-of-motion exercises are begun as soon as possible. A physical therapist can teach the patient how to perform range-of-motion exercises and monitors their performance. At 1 week, the patient should begin pendulum exercises in the sling; the patient leans forward and uses the noninjured arm to help swing the injured arm like a pendulum, making circles with the elbow. The sling may be removed daily to allow bathing and elbow motion. By 3 weeks, passive and active arm elevation should be begun.