Shoulder Fracture (Upper Humerus)

How does it typically present?

This is the situation after an injury: severe pain and marked difficulty moving the shoulder. Usually within hours a bruise appears that may spread to the arm, chest and back.

These fractures are typical of older people and are associated with osteoporosis, but they also occur at a young age after a significant injury to the shoulder. A fracture can be accompanied by a dislocation of the shoulder.

What types of fracture are there?

Fractures are usually classified by the number of parts and the degree of displacement of the fracture.

The parts of the humerus at the shoulder are:

• the joint surface
• the greater tuberosity
• the lesser tuberosity
• the shaft of the humerus

What matters is the degree of displacement of the fracture:

• The simplest fracture is one without displacement and with few parts.
• When the parts are displaced, the fracture becomes more complex.
• Naturally, the more parts there are and the more significant the displacement, the more complex the fracture.
• The most difficult situation is when the parts are completely separated, with dislocation of the head.

How are fractures of the proximal humerus diagnosed?

The initial diagnosis is made with a plain X-ray. When there is doubt about how complex the fracture is and how displaced, and also to plan surgery, a CT of the shoulder is used.

How are fractures of the proximal humerus treated?

Treatment depends on the complexity of the fracture, age, level of function before the fracture and general health:

1. Simple fractures

These usually do not require surgery. The arm is immobilized in a sling for about 3 weeks, and early movement is started in physiotherapy. The exceptions are fractures with marked displacement of the parts; in such cases, even though the fracture is simple, surgical repair is needed.

2. Complex fractures

In active people up to about age 65 (depending on the patient), we prefer surgical fixation of the fracture. This is usually done with a plate and screws, but there are also other techniques, such as an intramedullary nail.

3. Fractures that cannot be repaired

Mainly in older patients – for example when the head is completely detached and dislocated – we prefer a partial replacement of the joint.

Further treatment according to complexity and the patient's condition:

• The older the patient, and in cases where in addition to the fracture there is also a tear of the shoulder tendons, we prefer a total joint replacement with a reverse shoulder implant (see the separate entry).
• In people in poor health, with a low level of function even before the fracture, we prefer to avoid surgery, knowing that shoulder function will be very limited.

What is the treatment and rehabilitation after surgery?

After surgery, a rehabilitation period of 4–6 months is needed before returning to good activity.

Does the shoulder return to normal after surgery?

In most fractures, and especially complex fractures, the shoulder does not return to full function even after treatment, and some restriction of movement remains.

The goal of treatment is to allow the best possible function, with as little pain as possible, within the limits of the fracture.

During rehabilitation, the patient's cooperation and persistence with physiotherapy are critical to the success of treatment.