Proximal Humerus Fractures:
The Shoulder Break After a Fall

What is a proximal humerus fracture?

The humerus is the long bone of the upper arm. Its top end — the proximal humerus — includes the rounded head that sits in the shoulder socket, two bony bumps called the greater and lesser tuberosities where the rotator cuff tendons attach, and the narrower surgical neck just below them. A break anywhere in this region is called a proximal humerus fracture, or, more loosely, a "shoulder fracture". In Japanese it is called jōwankotsu kin’itan kossetsu (上腕骨近位端骨折).

Doctors often describe these fractures by how many main fragments the bone has broken into and whether they have shifted — "one-part" (cracked but not displaced), "two-part", "three-part" or "four-part" — a system known as the Neer classification. Some fractures also involve a dislocation of the shoulder joint, or a split through the joint surface.

Who gets it and how

In a five-year prospective study of 1,027 proximal humerus fractures in Edinburgh, these injuries mostly occurred in otherwise fit older people. The rate rose steadily with age and was highest in women aged 80 to 89. The single most common pattern was an impacted fracture, in which the head is pushed down onto the shaft and the fragments are wedged together, and about half of all fractures were minimally displaced (Court-Brown et al., Acta Orthopaedica Scandinavica, 2001).

The usual mechanism is a fall onto an outstretched hand or directly onto the side of the shoulder. In older adults this is often a low-energy fall at home or on the street; in younger adults the same fracture usually needs much more force — a cycling or motorbike crash, a ski fall, or contact sport. Because the bone involved is often thinned by osteoporosis, a proximal humerus fracture in later life is regarded as a fragility fracture, in the same family as wrist, spine and hip fractures.

Symptoms and warning signs

Typical symptoms are pain at the top of the arm, difficulty lifting or rotating the arm, and swelling. A large bruise often appears a day or two later and can spread down the arm to the elbow and even onto the chest wall — this looks alarming but is common and usually harmless. People often hold the arm close to the body with the other hand.

Diagnosis

Diagnosis is made with an examination and X-rays of the shoulder taken from more than one angle, which show the fracture lines, how far fragments have moved, and whether the joint is dislocated. A CT scan is often added for complex or displaced fractures, because it shows the fragments and the joint surface in three dimensions and helps when surgery is being considered. The examining doctor will also check the nerves and circulation of the arm — particularly the axillary nerve, which supplies sensation to the outer upper arm and runs close to the fracture.

Treatment options

Treatment depends on the fracture pattern, the quality of the bone, the person's age, general health, hand dominance and daily demands, and personal preferences. The overview below is simplified — individual decisions are made with the treating surgeon.

Fracture type	Usual first approach	When surgery may be considered
Minimally displaced	Sling for comfort, early gentle movement	Rarely
Displaced, older adults	Often a sling, after shared decision-making	Depends on pattern, bone quality, health and preferences
Displaced, younger adults	Frequently discussed for surgery	Good-quality bone; high-energy injuries; evidence from trials is limited in this group
Fracture-dislocation	Specialist assessment	Usually, because the joint must be put back in place
Displaced greater tuberosity	Depends on displacement	When the fragment, with its rotator cuff attachment, has moved significantly

Non-operative treatment

Non-operative care means a sling for comfort, pain relief, and a structured exercise programme, usually guided by a physiotherapist. Hand, wrist and elbow movement starts immediately. Gentle shoulder exercises — often pendulum-type swinging movements first — are begun once pain allows, and progressed gradually as the bone heals. Regular X-rays in the first weeks check that the fragments have not shifted further.

Surgical options

When surgery is chosen, the main options are fixation — holding the fragments with a locking plate and screws or with a rod (intramedullary nail) inside the bone — or replacement of the top of the humerus. Replacement may be a hemiarthroplasty (replacing only the ball) or a reverse shoulder replacement, in which the ball and socket positions are swapped so that the deltoid muscle can lift the arm even if the rotator cuff attachments do not heal. Replacement is generally reserved for complex fractures in older adults where fixation is unlikely to hold or the blood supply to the head is threatened.

Surgery or sling? What the trials show

Over the past two decades surgery for displaced fractures became increasingly common, but several well-designed trials have since compared it directly with sling treatment.

Displaced fracture, older adult	Sling	Surgery
Function at 1–2 years	Similar on average in randomised trials
Further operations	Less common	More common (e.g. hardware problems, screw cut-out)
Main downsides	Healing in a shifted position; stiffness; occasional non-union	Anaesthetic and operative risks, infection, implant complications
Where it may suit best	Most displaced fractures in older adults	Fracture-dislocations, some younger or high-demand patients, selected patterns

These results do not mean surgery is never helpful. Trials largely studied older adults with common fracture patterns, and a sling can leave a visibly healed but shifted bone and some lasting loss of overhead reach. Younger adults with good-quality bone, people with fracture-dislocations, and those whose work or sport makes particular demands of the shoulder are often advised differently. Research continues — for example, the UK PROFHER-2 trial was designed to compare reverse shoulder replacement, hemiarthroplasty and non-surgical care for three- and four-part fractures in people over 65 (Rangan et al., Trials, 2023).

Recovery

Recovery from a proximal humerus fracture is gradual, whichever treatment is chosen. Pain usually eases noticeably over the first few weeks, but shoulder movement and strength often keep improving for many months, and some stiffness — especially when reaching overhead or behind the back — may persist. Follow-up from PROFHER suggested that most people reach close to their best function by around six months, with further modest gains after that (Norman et al., Bone & Joint Journal, 2020). Practical points in the early weeks include sleeping propped up in a reclining position, loose front-opening clothing, and help with tasks such as bathing and shopping. Driving and cycling should wait until you can control the vehicle safely with both arms.

Don't forget bone health and falls

For many older adults, the most important long-term step after a shoulder fracture is not about the shoulder at all. A fracture from a simple fall is a warning sign that bone strength may be reduced and that further fractures — including hip fractures — are more likely. It is reasonable to ask your doctor about a bone density (DXA) scan, vitamin D and calcium intake, whether osteoporosis medication is appropriate, and a review of fall risks such as medications that cause dizziness, eyesight, footwear and hazards at home. Our column on osteoporosis and bone health covers this in more detail.

When to see a doctor

Any shoulder injury with significant pain, swelling or inability to lift the arm after a fall should be examined and X-rayed. Go to an emergency department straight away if the shoulder looks dislocated, the arm or hand is numb or weak, the skin is broken, or there was a head injury. Otherwise, an orthopaedic clinic (整形外科) can usually make the diagnosis on the same day. For displaced fractures, ask about the options and their trade-offs, and whether a review with a shoulder or trauma specialist would help. Bring any X-ray images or reports from a previous visit.