Proximal Humerus Fractures

What is a proximal humerus fracture?

The humerus is the long bone of the arm, extending from the shoulder to the elbow. The upper portion of the humerus, which is part of the shoulder joint, is referred to as the “proximal” humerus.

Proximal humerus fractures account for 5 to 10% of all fractures. Their incidence increases with age and is associated with greater bone fragility in the elderly, making it the third most common fracture after age 65, affecting women three times more often than men. In 90% of cases, the fractures result from low-energy trauma, such as falls from standing height.

Young adults (ages 25 to 45) can also be affected, though less frequently than older adults. In these cases, the fracture is usually related to traffic accidents (motorcycle falls, being hit by a vehicle, car crashes, etc.) or sports-related trauma.

Symptoms

The main symptom is intense pain in the shoulder area and difficulty moving the joint. It is very difficult to lift the arm with this type of fracture. Within the first 72 hours, bruising may also appear around the shoulder, arm, and part of the chest due to bone bleeding.

Diagnosis

In cases of clinical suspicion, the doctor will request X-rays in 2 or 3 different positions of the shoulder region. A CT scan may also be recommended to better define the type of fracture. In addition to diagnosis, it is important to assess the degree of displacement of the fracture fragments.

The fracture is called “non-displaced” when there is no significant separation of the bone fragments—in other words, “the bone is broken but still in place.” In a “displaced” fracture, the fracture site opens due to separation or angulation of the bone fragments, altering the bone’s original anatomy. Differentiating between “non-displaced” and “displaced” fractures is important for determining the appropriate treatment plan with your orthopedics specialist.

Treatment

• conservative treatment: This refers to non-surgical treatment. In 80% of cases, proximal humerus fractures do not show significant displacement and can be treated conservatively by immobilizing the shoulder with a sling for approximately 4 weeks. A cast is not necessary to immobilize proximal humerus fractures.
• surgical treatment: Several factors are considered when recommending surgery: clinical condition, physician preference, presence of other fractures, and the degree of displacement and instability of the fragments. Although there is no consensus on what constitutes an acceptable displacement, many orthopedic surgeons consider surgery for separations greater than 1.0 cm (0.5 cm for the greater tuberosity) or angulation greater than 45 degrees between fragments.

The type of surgical treatment depends on the fracture and may involve the use of plates and screws, rods inserted into the bone canal, steel wires to fix the bones, suturing of fragments, or in more severe cases, replacement of the fractured bone with a prosthesis (arthroplasty).

Possible Complications

• infection: this is the proliferation and growth of bacteria at the fracture site, leading to pus formation. Incidence varies widely in the medical literature, with scientific articles reporting infection rates from 0 to 10% in operated patients
• osteonecrosis: this is the death of bone tissue due to loss of blood supply caused by the fracture. It occurs in 3 to 35% of cases, and symptoms may appear later
• nonunion (Pseudoarthrosis): this is the failure of the bone fragments to heal. It occurs in approximately 1.1% to 13% of cases
• joint stiffness: some degree of shoulder stiffness is expected after 3 to 4 weeks of sling use. A lack of progressive improvement in range of motion, even with proper physical therapy, may be related to the formation of adhesions in the joint capsule or inadequate reduction of the bone fragments

By Einstein Editorial Board