An Overview of Proximal Humeral Fractures

Doctor fixing hand of a young patient in an arm sling

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A proximal humeral fracture is a broken bone that occurs near your shoulder joint. "Proximal" refers to being close to your body, and "humeral" refers to the arm bone known as the humerus. 

A proximal humeral fracture can be a painful injury that limits your ability to move your arm and shoulder. This can have a significant impact on your ability to work, perform household duties, or enjoy recreational activities.

Proximal humeral fractures can be treated conservatively with an arm sling, pain management, and supportive care. Surgery may be needed for severe open fractures. A physical therapy program after a proximal humeral fracture can help you return to normal activity quickly and safely.

Symptoms

The symptoms of a proximal humeral fracture can vary by the location of the fracture, the complexity of the fracture, and your general health. Common symptoms include:

  • Shoulder pain or upper arm pain
  • Difficulty moving your arm and shoulder
  • Swelling around your shoulder
  • Bruising or discoloration around your shoulder and upper arm

Causes

A fracture of your proximal humerus usually involves significant trauma to your arm or shoulder. The elderly are vulnerable to these fractures due to an increased risk of osteopenia (bone loss). Proximal humeral fractures are typically the result of:

  • Falling onto your outstretched hand
  • A forceful pull to your arm and shoulder
  • Falling onto your side or shoulder

If you suspect that you have a proximal humeral fracture, it is important to see your doctor or emergency room as soon as possible. Failure to do so may result in the significant (and possibly permanent) loss of arm function.

Chief among the concerns is avascular necrosis (AVN) in which the localized loss of blood flow results in bone death. A 2018 study from Germany found that no less than 33% of people with proximal humeral fractures developed AVN.

Diagnosis

If your doctor suspects that you have a fracture, an X-ray will likely be taken to confirm the diagnosis. Occasionally, more advanced pictures of your shoulder will be taken with a computed tomography (CT) scan. These images help your doctor see the severity of your injury and help decide on the best way to manage your injury.

Treatment

If a proximal humeral fracture is confirmed, the fracture may need to be reduced. Most often, the fractured pieces of bone are close together will not require much to reduce the fracture.

For severe fractures where the bone pieces are far apart, a surgical procedure called an open reduction internal fixation (ORIF) may need to be performed. Your doctor will discuss with you the options and best treatment strategy for your specific condition.

According to a 2019 study in the Journal of Orthopaedic Surgery and Research, the vast majority of proximal humeral fractures (85.4%) are treated conservatively. Indications for surgery include open fractures, pathologic fractures, or injury to major nerves or blood vessels.

There is currently no clear evidence that surgery improves outcomes in people with uncomplicated proximal humeral fractures compared to conservative therapies.

Physical Therapy

Your first encounter with a physical therapist may take place immediately after injury in the hospital. The physical therapy may start with a lesson on how to properly wear your sling. You may also be taught gentle pendulum exercises to help keep your shoulder mobile as it heals. Your doctor will let you know if it is safe to perform these exercises.

In four to six weeks, you may be ready to partake in active physical therapy. After a thorough evaluation, your physical therapist will provide you an outline of exercises and treatments to aid in your recovery. This will typically focus on five things:

  • Range of motion: After a proximal humeral fracture, you will almost invariably have a decreased range of motion (ROM) of your shoulder and elbow. Your physical therapist may prescribe progressive exercises to help improve the rotational range of your arm in every direction.
  • Strength: The four- to six-weeks immobilization of your shoulder will result in a significant loss of arm strength. Strengthening exercises will focus largely on the rotator cuff and the biceps and triceps muscles. This may involve isometric exercises, resistant bands, and, eventually, resistance-training machines and free weights.
  • Pain: Your physical therapist can help you manage your pain treatments like heat application, ice application, or transcutaneous electrical nerve stimulation (TENS). Oral anti-inflammatory drugs and transdermal anti-inflammatory patches may also be used.
  • Function: Your physical therapist can help you engage in functional activities to help improve the way your shoulder and arm moves so your injury does not limit your normal activities. This overlaps with occupational therapy and may involve tools and devices to help overcome functional limitations.
  • Scar mobility: If you had an ORIF procedure, small adhesions (abnormal fusions of membranes) may have developed in scar tissues, resulting in a loss of arm mobility. Your physical therapist may perform scar massage and mobilization or teach you how to perform them yourself.

Eight to 12 weeks after the injury, your strength and mobility should have improved enough to return to full activity. Your pain level should be minimal as well.

If you underwent an ORIF procedure, you can expect to be fully restored to work in an average of 48 days if you are an office worker and 118 days if you are a physical laborer, according to a 2014 study in Open Orthopaedics Journal.

A Word From Verywell

If you have suffered a fracture of your proximal humerus, you may benefit from the skilled services of a PT to help you fully recover. By understanding what to expect during rehab, you can have all the necessary information to participate fully in your humerus fracture rehab and ensure you have the best possible recovery.

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Article Sources

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  1. Schnetzke M, Bockmeyer J, Loew M, Studier-Fischer S, Grützner PA, Guehring T. Rate of avascular necrosis after fracture dislocations of the proximal humerus: timing of surgery. Obere Extrem. 2018;13(4):273-8. doi:10.1007/s11678-018-0452-6

  2. Floyd SB, Campbell J, Chapman CG, et al. Geographic variation in the treatment of proximal humerus fracture: an update on surgery rates and treatment consensusJ Orthop Surg Res. 2019;14:22. doi:10.1186/s13018-018-1052-2

  3. Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database System Rev. 2015;11(11);(11):CD000434. doi:10.1002/14651858.cd000434.pub4

  4. Dietrich M, Wasmer M, Platz A, Spross C. Return-to-work following open reduction and internal fixation of proximal humerus fractures. Open Orthop J. 2014;8:281-7. doi:10.2174/1874325001408010281