Fracture

Proximal Humerus Fracture

Common shoulder fracture (5% of fractures). Neer classification to guide conservative or surgical treatment.

The proximal humerus fracture accounts for approximately 5% of all fractures and is the third most common fracture in the elderly after hip and wrist (Court-Brown & Caesar, 2006). It typically occurs from a fall onto an abducted arm or direct shoulder trauma. The Neer classification is the reference system, distinguishing fractures by the number of displaced fragments (2, 3 or 4 parts: humeral head, greater tuberosity, lesser tuberosity, shaft). 80% of fractures are non-displaced and managed conservatively. Displaced fractures require surgery (plate fixation, nail, or shoulder replacement for complex fractures in the elderly).

Characteristics

  • Sudden severe shoulder pain, rapid swelling, brachial bruising descending toward the elbow (Hennequin's sign). Complete functional impairment of the upper limb.
  • Systematic radiographic assessment: AP in neutral rotation + Neer profile (scapular Y view) + axillary profile. 3D CT scan recommended for complex fractures and surgical planning.
  • Greater tuberosity fracture associated in 20% of cases: direct impact on the supraspinatus and infraspinatus insertion. Displacement > 5 mm = surgical indication.
  • Complications: shoulder stiffness (very common), avascular necrosis of the humeral head (5-35% depending on fragment count), axillary nerve injury (5-10%), frozen shoulder.

Medical and surgical management

  • Non-displaced fractures (80%): conservative treatment. Arm sling for 3-4 weeks with early pendular mobilization. Follow-up X-rays at 1, 3 and 6 weeks.
  • Displaced 2-3 part fractures: surgical fixation by locking plate (PHILOS) or intramedullary nail. Early passive mobilization post-operatively.
  • Complex 4-part fractures in the elderly: reverse shoulder replacement (Grammont concept). Provides pain relief and functional recovery despite the fracture complexity.

Physiotherapy rehabilitation

  • Early passive mobilization from day 3-5: Codman pendular exercises to prevent stiffening. Passive mobilization in flexion and external rotation from 3 weeks.
  • Active-assisted mobilization from 6 weeks: pulley therapy, rehabilitation stick, self-assisted movements in flexion, abduction and rotations.
  • Progressive strengthening from 8-10 weeks: rotator cuff (external and internal rotators), deltoid, scapular stabilizers. Proprioceptive training.
  • Functional reintegration: overhead activities, professional and sports tasks. Gradual return to sports at 4-6 months depending on radiographic consolidation.

Classification

  1. Neer 1 part — Non-displaced

    No fragment displaced > 1 cm or angulated > 45°. Conservative treatment.

  2. Neer 2 parts — One displaced fragment

    One displaced segment (surgical neck, greater or lesser tuberosity). Surgery if significant displacement.

  3. Neer 3 parts — Two displaced fragments

    Two displaced segments. Plate or nail fixation recommended.

Average duration

8 to 16 weeks of rehabilitation

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Scientific sources

General information only: this content cannot provide a diagnosis or prescription. A healthcare professional must assess your situation.