A proximal humerus fracture is a break in the upper part of the humerus, the long bone in the upper arm, near the shoulder joint. This type of injury is common, particularly among older adults, often linked to conditions like osteoporosis. It also affects active individuals due to high-energy trauma. These fractures represent a significant percentage of all adult fractures, accounting for approximately 4-7%.
Understanding Proximal Humerus Fractures
These fractures can occur at the anatomical neck, surgical neck, greater tuberosity, or lesser tuberosity, either alone or in combination. Common causes include low-energy falls in older patients with osteoporosis. In younger individuals, high-energy trauma, such as car accidents or direct blows to the upper arm, can cause these fractures.
Symptoms include immediate and severe pain, swelling, and bruising around the shoulder, which may extend down the arm or across the chest. Movement of the affected arm is often decreased, and a snapping or crunching sensation may be felt when attempting to move it.
Diagnosis begins with a medical history and physical examination to assess pain and range of motion. X-rays confirm the fracture’s presence, location, and severity. For complex fractures or to assess soft tissue injuries, a CT scan or MRI may be ordered for more detailed images.
Immobilization and Treatment Options
While full plaster casts are less frequently used for proximal humerus fractures in adults, due to the importance of early shoulder mobility to prevent stiffness, various immobilization methods are common. These include simple arm slings, shoulder immobilizers, or a sling and swathe, which provides additional stability. Coaptation splints and functional braces may also be used depending on the fracture pattern.
Non-surgical management is often preferred for non-displaced or minimally displaced fractures. This approach involves immobilization, typically for 2-3 weeks for stable fractures, extending to 4-6 weeks for more complex cases. Pain management and gradual initiation of gentle exercises, such as pendulum exercises, are part of the non-surgical treatment plan to prevent stiffness.
Surgical intervention is considered for displaced fractures, open fractures, or those with nerve or blood vessel injuries. Procedures include Open Reduction Internal Fixation (ORIF), where bone fragments are realigned and secured with plates and screws. For severe cases, especially in older patients with complex fractures or risk of avascular necrosis (loss of blood supply), shoulder replacement may be performed. This can be a hemiarthroplasty (humeral head replacement) or a reverse total shoulder arthroplasty (reversing joint orientation to improve deltoid function).
Life During Recovery
Living with a proximal humerus fracture involves managing pain and adapting daily activities. Pain is often intense initially, gradually lessening after about three weeks, with noticeable improvement by six weeks. Pain medication as prescribed and comfortable sleeping positions, such as propped up with pillows, can help manage discomfort. Bruising and swelling are common, sometimes extending down the arm or across the chest.
Daily activities like dressing and hygiene require adaptation while the arm is immobilized. Simple tasks may be challenging, and assistance might be needed initially. Healing typically ranges from 6 to 12 weeks, though full recovery can extend beyond a year.
Physical therapy and rehabilitation exercises restore range of motion and strength. Gentle pendulum exercises may begin 1-2 weeks post-injury, as directed by a physician, to prevent shoulder stiffness. As healing progresses, a physical therapist guides the patient through range of motion and strengthening exercises, gradually increasing activity. Patience and consistent adherence to medical and physical therapy advice are important for the best functional outcome.
Recognizing Potential Complications
Complications can occur despite appropriate treatment. Shoulder stiffness is common, sometimes progressing to frozen shoulder or adhesive capsulitis, where movement becomes severely restricted. This can happen even in non-displaced fractures treated conservatively.
Nerve damage, particularly to the axillary nerve, can occur at the time of injury or during surgery, potentially leading to sensory loss or reduced arm abduction. Blood vessel injury, though less common, is a serious complication. Other problems include malunion (fracture heals incorrectly) and nonunion (failure of the bone to heal). Malunion can lead to mechanical limitations or post-traumatic arthritis. Signs warranting immediate medical attention include increased pain, new numbness or tingling, changes in skin color, or a sudden inability to move the arm.