Scientific/Clinical Article| Volume 30, ISSUE 2, P158-166, April 2017

Download started.


Acute proximal humeral fractures in adults


      Study Design

      Clinical commentary.


      Proximal humeral fractures (PHF) are the third most common fracture in the elderly with an increased incidence expected in the coming years with the aging population, causing an important burden to the healthcare system. The management of PHF is challenging due to its complexity and the wide variety of fractures and treatment options.


      The objective of this clinical commentary is to update the available evidence on clinical presentation, classification, imaging, medical treatment, and rehabilitation of acute PHF.


      N/A for clinical commentary.


      The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. The Neer and OA classifications are commonly used and are based on the identification of the fractured parts of the humerus, as well as the displacement of the fragments. In case of non-displaced or minimally displaced fractures, a conservative treatment, consisting of initial immobilization and a rehabilitation program will be chosen. Displaced or unstable fractures will be managed operatively. Different surgical options exist and will vary according to the fracture type, patient's age, and functional needs, followed by rehabilitation.

      Level of Evidence



      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Hand Therapy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Bell J.E.
        • Leung B.C.
        • Spratt K.F.
        • et al.
        Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly.
        J Bone Joint Surg Am. 2011; 93: 121-131
        • Lanting B.
        • MacDermid J.
        • Drosdowech D.
        • Faber K.J.
        Proximal humeral fractures: a systematic review of treatment modalities.
        J Shoulder Elbow Surg. 2008; 17: 42-54
        • Court-Brown C.M.
        • Garg A.
        • McQueen M.M.
        The epidemiology of proximal humeral fractures.
        Acta Orthop Scand. 2001; 72: 365-371
        • Lee S.H.
        • Dargent-Molina P.
        • Breart G.
        Risk factors for fractures of the proximal humerus: results from the EPIDOS prospective study.
        J Bone Miner Res. 2002; 17: 817-825
        • Calvo E.
        • Morcillo D.
        • Foruria A.M.
        • Redondo-Santamaria E.
        • Osorio-Picorne F.
        • Caeiro J.R.
        Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception.
        J Shoulder Elbow Surg. 2011; 20: 795-801
        • Roux A.
        • Decroocq L.
        • El Batti S.
        • Bonnevialle N.
        • Moineau G.
        • Trojani C.
        • et al.
        Epidemiology of proximal humerus fractures managed in a trauma center.
        Orthop Traumatol Surg Res. 2012; 98: 715-719
        • Maier D.
        • Jaeger M.
        • Izadpanah K.
        • Strohm P.C.
        • Suedkamp N.P.
        Proximal humeral fracture treatment in adults.
        J Bone Joint Surg Am. 2014; 96: 251-261
        • Jordan R.W.
        • Modi C.S.
        A review of management options for proximal humeral fractures.
        Open Orthop J. 2014; 8: 148-156
        • Namdari S.
        • Voleti P.B.
        • Mehta S.
        Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment.
        J Shoulder Elbow Surg. 2012; 21: 1787-1795
        • Aaron D.
        • Shatsky J.
        • Paredes J.C.
        • Jiang C.
        • Parsons B.O.
        • Flatow E.L.
        Proximal humeral fractures: internal fixation.
        J Bone Joint Surg Am. 2012; 94: 2280-2288
        • Müller M.E.K.P.
        • Nazarian S.
        • Schatzker J.
        The comprehensive classification of fractures of long bones.
        New York, Springer-Verlag1990
        • Mutch J.
        • Laflamme G.Y.
        • Hagemeister N.
        • Cikes A.
        • Rouleau D.M.
        A new morphological classification for greater tuberosity fractures of the proximal humerus: validation and clinical implications.
        Bone Joint J. 2014; 96-B: 646-651
        • Brorson S.
        • Olsen B.S.
        • Frich L.H.
        • et al.
        Surgeons agree more on treatment recommendations than on classification of proximal humeral fractures.
        BMC Musculoskelet Disord. 2012; 13: 114
        • Carrerra Eda F.
        • Wajnsztejn A.
        • Lenza M.
        • Netto N.A.
        Reproducibility of three classifications of proximal humeral fractures.
        Einstein (Sao Paulo). 2012; 10: 473-479
        • Sukthankar A.V.
        • Leonello D.T.
        • Hertel R.W.
        • Ding G.S.
        • Sandow M.J.
        A comprehensive classification of proximal humeral fractures: HGLS system.
        J Shoulder Elbow Surg. 2013; 22: e1-e6
        • Shrader M.W.
        • Sanchez-Sotelo J.
        • Sperling J.W.
        • Rowland C.M.
        • Cofield R.H.
        Understanding proximal humerus fractures: image analysis, classification, and treatment.
        J Shoulder Elbow Surg. 2005; 14: 497-505
        • Berkes M.B.
        • Dines J.S.
        • Birnbaum J.F.
        • et al.
        The axillary view typically does not contribute to decision making in care for proximal humeral fractures.
        HSS J. 2015; 11: 192-197
        • Sandstrom C.K.
        • Kennedy S.A.
        • Gross J.A.
        Acute shoulder trauma: what the surgeon wants to know.
        Radiographics. 2015; 35: 475-492
        • Vachtsevanos L.
        • Hayden L.
        • Desai A.S.
        • Dramis A.
        Management of proximal humerus fractures in adults.
        World J Orthop. 2014; 5: 685-693
        • Song J.Q.
        • Deng X.F.
        • Wang Y.M.
        • Wang X.B.
        • Li X.
        • Yu B.
        Operative vs nonoperative treatment for comminuted proximal humeral fractures in elderly patients: a current meta-analysis.
        Acta Orthop Traumatol Turc. 2015; 49: 345-353
        • Xie L.
        • Ding F.
        • Zhao Z.
        • Chen Y.
        • Xing D.
        Operative versus non-operative treatment in complex proximal humeral fractures: a meta-analysis of randomized controlled trials.
        Springerplus. 2015; 4: 728
        • Handoll H.H.
        • Brorson S.
        Interventions for treating proximal humeral fractures in adults.
        Cochrane Database Syst Rev. 2015; : Cd000434
        • Guy P.
        • Slobogean G.P.
        • McCormack R.G.
        Treatment preferences for displaced three- and four-part proximal humerus fractures.
        J Orthop Trauma. 2010; 24: 250-254
        • Torrens C.
        • Corrales M.
        • Vila G.
        • Santana F.
        • Caceres E.
        Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively.
        J Orthop Trauma. 2011; 25: 581-587
        • Lefevre-Colau M.M.
        • Babinet A.
        • Fayad F.
        • et al.
        Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial.
        J Bone Joint Surg Am. 2007; 89: 2582-2590
        • Jeffcoach D.R.
        • Sams V.G.
        • Lawson C.M.
        • et al.
        Nonsteroidal anti-inflammatory drugs' impact on nonunion and infection rates in long-bone fractures.
        J Trauma Acute Care Surg. 2014; 76: 779-783
        • Court-Brown C.M.
        • Cattermole H.
        • McQueen M.M.
        Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment.
        J Bone Joint Surg Br. 2002; 84: 504-508
        • Court-Brown C.M.
        • McQueen M.M.
        The impacted varus (A2.2) proximal humeral fracture: prediction of outcome and results of nonoperative treatment in 99 patients.
        Acta Orthop Scand. 2004; 75: 736-740
        • Drosdowech D.S.
        • Faber K.J.
        • Athwal G.S.
        Open reduction and internal fixation of proximal humerus fractures.
        Orthop Clin North Am. 2008; 39 (vi): 429-439
        • Olsson C.
        • Petersson C.J.
        Clinical importance of comorbidity in patients with a proximal humerus fracture.
        Clin Orthop Relat Res. 2006; 442: 93-99
        • Hanson B.
        • Neidenbach P.
        • de Boer P.
        • Stengel D.
        Functional outcomes after nonoperative management of fractures of the proximal humerus.
        J Shoulder Elbow Surg. 2009; 18: 612-621
        • Hodgson S.
        Proximal humerus fracture rehabilitation.
        Clin Orthop Relat Res. 2006; 442: 131-138
        • Hodgson S.A.
        • Mawson S.J.
        • Saxton J.M.
        • Stanley D.
        Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up).
        J Shoulder Elbow Surg. 2007; 16: 143-145
        • Hodgson S.A.
        • Mawson S.J.
        • Stanley D.
        Rehabilitation after two-part fractures of the neck of the humerus.
        J Bone Joint Surg Br. 2003; 85: 419-422
        • Koval K.J.
        • Gallagher M.A.
        • Marsicano J.G.
        • Cuomo F.
        • McShinawy A.
        • Zuckerman J.D.
        Functional outcome after minimally displaced fractures of the proximal part of the humerus.
        J Bone Joint Surg Am. 1997; 79: 203-207
        • Basti J.J.
        • Dionysian E.
        • Sherman P.W.
        • Bigliani L.U.
        Management of proximal humeral fractures.
        J Hand Ther. 1994; 7: 111-121
        • Livesley P.J.
        • Mugglestone A.
        • Whitton J.
        Electrotherapy and the management of minimally displaced fracture of the neck of the humerus.
        Injury. 1992; 23: 323-327
        • Revay S.
        • Dahlstrom M.
        • Dalen N.
        Water exercise versus instruction for self-training following a shoulder fracture.
        Int J Rehabil Res. 1992; 15: 327-333
        • Burkhart K.J.
        • Dietz S.O.
        • Bastian L.
        • Thelen U.
        • Hoffmann R.
        • Müller L.P.
        The treatment of proximal humeral fracture in adults.
        Dtsch Ärztebl Int. 2013; 110: 591-597
        • Gaudelli C.
        • Menard J.
        • Mutch J.
        • Laflamme G.Y.
        • Petit Y.
        • Rouleau D.M.
        Locking plate fixation provides superior fixation of humerus split type greater tuberosity fractures than tension bands and double row suture bridges.
        Clin Biomech (Bristol, Avon). 2014; 29: 1003-1008
        • Lee B.G.
        • Cho N.S.
        • Rhee Y.G.
        Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: aggressive versus limited early passive exercises.
        Arthroscopy. 2012; 28: 34-42
        • Sheps D.M.
        • Bouliane M.
        • Styles-Tripp F.
        • et al.
        Early mobilisation following mini-open rotator cuff repair: a randomised control trial.
        Bone Joint J. 2015; 97-B: 1257-1263
        • Gracitelli M.E.
        • Malavolta E.A.
        • Assuncao J.H.
        • et al.
        Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial.
        J Shoulder Elbow Surg. 2016; 25: 695-703
        • Apivatthakakul T.
        • Arpornchayanon O.
        • Bavornratanavech S.
        Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report.
        Injury. 2005; 36: 530-538
        • Saran N.
        • Bergeron S.G.
        • Benoit B.
        • Reindl R.
        • Harvey E.J.
        • Berry G.K.
        Risk of axillary nerve injury during percutaneous proximal humerus locking plate insertion using an external aiming guide.
        Injury. 2010; 41: 1037-1040
        • Kathrein S.
        • Joeris A.
        • Kralinger F.
        • Blauth M.
        • Goldhahn J.
        Significant differences between local reporting and central assessment of radiographic complications in a prospective, multicenter study about locking plate fixation of proximal humerus fractures.
        J Orthop Trauma. 2016; 30: e336-e339
        • Newman J.
        • Kahn M.
        • Gruson K.I.
        Reducing postoperative fracture displacement after locked plating of proximal humerus fractures: current concepts.
        Am J Orthop (Belle Mead NJ). 2015; 44: 312-320
        • Gardner M.J.
        • Weil Y.
        • Barker J.U.
        • Kelly B.T.
        • Helfet D.L.
        • Lorich D.G.
        The importance of medial support in locked plating of proximal humerus fractures.
        J Orthop Trauma. 2007; 21: 185-191
        • Schliemann B.
        • Wahnert D.
        • Theisen C.
        • et al.
        How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data.
        Injury. 2015; 46: 1207-1214
        • Robinson C.M.
        • Page R.S.
        Severely impacted valgus proximal humeral fractures. Results of operative treatment.
        J Bone Joint Surg Am. 2003; 85-a: 1647-1655
        • Robinson C.M.
        • Page R.S.
        Severely impacted valgus proximal humeral fractures.
        J Bone Joint Surg Am. 2004; 86-A: 143-155
        • Gavaskar A.S.
        • Tummala N.C.
        Locked plate osteosynthesis of humeral head-splitting fractures in young adults.
        J Shoulder Elbow Surg. 2015; 24: 908-914
        • Sirveaux F.
        • Roche O.
        • Mole D.
        Shoulder arthroplasty for acute proximal humerus fracture.
        Orthop Traumatol Surg Res. 2010; 96: 683-694
        • Gallinet D.
        • Clappaz P.
        • Garbuio P.
        • Tropet Y.
        • Obert L.
        Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: a comparative study of 40 cases.
        Orthop Traumatol Surg Res. 2009; 95: 48-55
        • Shukla D.R.
        • McAnany S.
        • Kim J.
        • Overley S.
        • Parsons B.O.
        Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis.
        J Shoulder Elbow Surg. 2016; 25: 330-340
        • Wall B.
        • Walch G.
        Reverse shoulder arthroplasty for the treatment of proximal humeral fractures.
        Hand Clin. 2007; 23 (v-vi): 425-430
        • Young S.W.
        • Segal B.S.
        • Turner P.C.
        • Poon P.C.
        Comparison of functional outcomes of reverse shoulder arthroplasty versus hemiarthroplasty in the primary treatment of acute proximal humerus fracture.
        ANZ J Surg. 2010; 80: 789-793
        • Wang J.
        • Zhu Y.
        • Zhang F.
        • Chen W.
        • Tian Y.
        • Zhang Y.
        Meta-analysis suggests that reverse shoulder arthroplasty in proximal humerus fractures is a better option than hemiarthroplasty in the elderly.
        Int Orthop. 2016; 40: 531-539
        • Agorastides I.
        • Sinopidis C.
        • El Meligy M.
        • Yin Q.
        • Brownson P.
        • Frostick S.P.
        Early versus late mobilization after hemiarthroplasty for proximal humeral fractures.
        J Shoulder Elbow Surg. 2007; 16: S33-S38
      1. Godges J. Proximal Humeral Fracture Repair and Rehabilitation Loma Linda University and University of Pacific Doctorate in Physical Therapy Programs. Available at: Accessed January 01, 2017.

        • Dietrich M.
        • Wasmer M.
        • Platz A.
        • Spross C.
        Return-to-work following open reduction and internal fixation of proximal humerus fractures.
        Open Orthop J. 2014; 8: 281-287
        • Gosch M.
        • Druml T.
        • Nicholas J.A.
        • et al.
        Fragility non-hip fracture patients are at risk.
        Arch Orthop Trauma Surg. 2015; 135: 69-77
        • Papaioannou A.
        • Morin S.
        • Cheung A.M.
        • et al.
        2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary.
        CMAJ. 2010; 182: 1864-1873

      JHT Read for Credit

      Quiz: #484

      Record your answers on the Return Answer Form found on the tear-out coupon at the back of this issue or to complete online and use a credit card, go to There is only one best answer for each question.
      • #1.
        Management of PHF is initially based on
        • a.
          the age and general health of the patient
        • b.
          the therapist's evaluation
        • c.
          classification via X-ray
        • d.
          pain and AROM on the first visit to therapy
      • #2.
        The distinction between _____________ and ______________ fractures is critical in setting the plan of treatment
        • a.
          displaced and non-displaced
        • b.
          dominant and non-dominant arm
        • c.
          longitudinal and horizontal
        • d.
          non-displaced and stress
      • #3.
        There is a steep rise in the incidence of PHF after the age of
        • a.
        • b.
        • c.
        • d.
      • #4.
        Results of conservative treatment have been shown to be best when mobilization has been initiated at about ____ week(s) post fracture
        • a.
        • b.
        • c.
        • d.
      • #5.
        The vast majority of non-displaced PHFs can be successfully treated conservatively
        • a.
        • b.
      When submitting to the HTCC for re-certification, please batch your JHT RFC certificates in groups of 3 or more to get full credit.