Fracture of the shoulder and proximal humerus: symptoms and treatment

By Cristiano Antonino On Jun 6, 2022

Fracture of the proximal humerus is a very common shoulder fracture. Particularly common in elderly individuals due to osteoporosis, the proximal humerus is among the most frequently broken bones in a shoulder

In fact, in patients over the age of 65, proximal humerus fractures rank third in frequency (after hip fractures and wrist fractures).

A fracture of the proximal humerus occurs when the ball of the shoulder joint, the head of the humerus (the arm bone), breaks

The fracture then localises at the top of the arm bone (humerus).

Most proximal humerus fractures are non-displaced (not out of position), but about 15-20% of these fractures are decomposed and these may require more invasive treatment.

Another important aspect is that in these fractures, there may be an associated injury of the ‘rotator cuff’ tendons, which may worsen the healing prognosis.

The most significant problem regarding the treatment of proximal humerus fractures is that, regardless of the type of treatment, the outcomes are sometimes not very satisfactory in terms of functional recovery.

Many patients who experience this injury do not regain full strength or full mobility of the shoulder, even with proper treatment.

Compound fractures of the proximal humerus

When the fragments of the broken bone are not properly aligned, the fracture is called a ‘decomposed’ fracture.

In proximal humerus fractures, the severity often depends on how many pieces of this bone are broken and how many are decomposed.

The proximal humerus is divided into four ‘parts’ that can break into ‘fragments’, so a fracture can be decomposed into 2 fragments, 3 fragments, or 4 main fragments (a non-decomposed fracture, by definition is in 2 fragments).

In general, the more numerous the fragments of the fracture and the more they are broken up, the worse is the prognosis, i.e. the ability to heal, and the greater is the possibility that the fractured pieces will go into necrosis, i.e. die and possibly have to be replaced with joint replacements.

The portions that make up the proximal humerus are called the tuberosities (major and minor tuberosities), the humeral head (the shoulder ball), and the humeral diaphysis.

The tuberosities are close to the head of the humerus, and are those parts of the bone where the main muscles of the rotator cuff fit.

For a fragment to be considered dislocated, it must be separated from its normal position by more than 2 millimetres or be rotated by more than 15 degrees.

Causes of humerus and shoulder fracture

Normally, these fractures are caused either by a direct blow to the shoulder or by an indirect blow that occurs after a fall on the hand with the limb outstretched.

In young people, these fractures are observed in high-energy traumas (road or sports accidents) to the shoulder, which most often result in a decomposed multi-fragmentary fracture associated, in some cases, with a dislocation of the joint heads.

In elderly patients with osteoporotic bone, even low-energy trauma (a trivial fall to the ground) is sometimes sufficient.

Other additional traumatic mechanisms are: violent comitial muscle contractions and/or electric shocks.

Symptoms

Fractures of the proximal humerus can be very painful and can make it difficult even to simply move the arm.

Other symptoms include:

Drooping shoulder (down and forward).
Inability to lift the arm due to pain.
Paresthesias, i.e. disturbance of sesnsitivity, tingling, in the hand.
A characteristic haematoma in the inner region of the arm that can reach up to the elbow (called Hennequin haematoma).

Medical examination

During the examination, the doctor will ask questions about how the fracture occurred.

After discussing the injury and discussing the symptoms, the doctor will examine your shoulder.

The doctor will carefully examine your shoulder to make sure that no nerves or blood vessels have been damaged by the fracture.

In order to identify the location and severity of the fracture, the doctor will have an X-ray taken.

X-rays of the entire shoulder will often be taken to check for further injuries.

In some cases, especially in anticipation of surgery, your doctor may order a CT scan to see the fracture in more detail and plan the appropriate treatment for your case.

Other examinations such as echo-colour Doppler or contrastographic investigations will be performed if vascular involvement is suspected.

Treatment of proximal humerus fracture

Non-surgical treatment

Approximately 80% of proximal humerus fractures are non-displaced (not out of position), and these can almost always be treated with a simple brace fitted with an anti-rotator band.

The typical treatment is to rest the shoulder in the brace for 3-4 weeks, and then begin some gentle range of motion exercises.

As healing progresses, which will be monitored by monthly X-rays, more aggressive shoulder strengthening exercises can be started, and complete healing will typically take about 3 months.

The limitation of non-surgical treatment is the possibility that the shoulder, after being immobilised for a long time to allow the fracture to heal, may become stiff and lose mobility.

Sometimes the resulting stiffness is disabling and requires surgical treatment to try to resolve the situation.

Surgical treatment

In the case of more serious injuries, when the fracture consists of several fragments and is disjointed (out of position), or even in simpler fractures in young people who need to return to an active life sooner, surgery may be required to fix the fracture, realign it, or in complex cases replace the damaged bone with a joint replacement.

Deciding on the best surgical treatment depends on many factors, including:

The age of the patient.
Whether the limb is dominant or not.
The patient’s activity level.
The amount of fracture fragments.
The degree of displacement of the fracture fragments.
The experience of the surgeon.

Surgery involves realigning the bone fragments manually and holding them in place using various metal systems, or a shoulder replacement procedure is performed using a joint replacement.

Osteosynthesis

Bone fragments can be fixed with:

Plates and screws: this procedure is considered the golden standard and is the procedure that, when the indication exists, is preferred in our OTB department. It allows an optimal reduction of fragments but above all a very solid stabilisation. Sometimes, however, it is a complex operation and therefore requires expert hands for its correct execution.
Endomedicular nails (nails driven into the hollow bone). The advantage of this operation is its simpler execution for the surgeon and less exposure (it can be performed through small cuts in the skin and without exposing the fracture). The disadvantage, which in our opinion is intolerable, is that in order to insert this metal device, the surgeon must necessarily damage the tendons of the rotator cuff, which are the main motors of the shoulder, which is why in our department it is an operation that is almost never proposed.
Simple screws and Kirschner wires are sometimes combined. This system does not guarantee adequate stability and therefore does not allow early mobilisation of the shoulder. This option is generally reserved for the elderly or people in poor general condition.
Joint prostheses: When the bone is badly damaged, and especially in the elderly, it may happen that the vascularisation of certain fragments is irreparably impaired, which is why it may be decided to replace all or part of the joint with a shoulder prosthesis. If such a procedure is recommended, the options include a standard anatomical prosthesis, an endoprosthesis, or a reverse prosthesis. In young people, this intervention should only be envisaged in cases where osteosynthesis has no hope of success, and this must be considered very carefully due to the fact that prostheses have a limited lifespan (10-15 years on average) and do not guarantee a particularly active life.

Fracture of the humerus and shoulder: advantages and disadvantages of surgical treatment

The advantage of surgery, when the fracture is fixed stably with, for example, plates and screws, or with intramedullary nails, is that it allows the patient to start moving the joint immediately.

This allows an earlier return to an active life and reduces the risk of stiffness, and the patient is therefore more likely to regain more shoulder movement at the end of treatment than with non-surgical treatment.

The disadvantages, however, even if they occur very infrequently, are those common to surgery (anaesthesiological complications) and those specific to orthopaedic surgery such as infections, haemorrhages, vascular and nerve injuries.

These complications are more frequent in the elderly, which is why non-surgical treatment is generally opted for in these patients whenever possible.

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