Shoulder fractures, and more specifically fractures of the proximal humerus, are common skeletal injuries, accounting for 4–6% of all fractures. Among patients over the age of 65, they are the third most frequent type of non-vertebral fracture. These injuries cause intense pain, swelling, and limited mobility, typically resulting from trauma or falls.
The incidence of shoulder fractures is about twice as high in women compared to men, and the complexity of the fractures increases with age. Well-known predisposing factors include osteoporosis, diabetes mellitus, epilepsy, and female sex. These fractures can occur after low-energy falls, which are more common in elderly, osteoporotic patients, but also after high-energy trauma, more often seen in younger individuals.
A critical parameter in shoulder fractures of the proximal humerus is the blood supply to the humeral head. Depending on factors such as fracture complexity, displacement, and angulation of bone fragments, as well as the presence of an associated shoulder dislocation, the vascular supply may be compromised, leading to ischemia of the humeral head and, in some cases, osteonecrosis. This consideration is crucial in planning the management of such injuries. In addition, because the shoulder region lies anatomically close to major nerves and vessels supplying the entire upper limb, associated neurovascular injuries must always be ruled out.
Shoulder fractures of the proximal humerus are classified according to the Neer system, which is based on the fact that this region develops embryologically from four distinct segments that later fuse into one. These parts are the humeral head, the greater tuberosity, the lesser tuberosity, and the humeral shaft. Fractures are therefore categorized as two-part, three-part, or four-part, depending on the number of separate fragments. Other important parameters for classification include the presence of a concomitant shoulder dislocation or an intra-articular fracture of the humeral head.
Patients with shoulder fractures present with pain, swelling, and inability to move the shoulder. Within hours of the injury, extensive hematoma and bruising often develop in the axilla, chest, upper arm, and elbow. Standard imaging includes a full series of trauma radiographs with at least two or three different views. Complex fractures or those extending into the articular surface of the humeral head may also require CT scans for better visualization of the fragments and their spatial relationship, which helps guide surgical planning.
When deciding on the management plan for a shoulder fracture, several factors must be taken into account. These include the patient’s biological age and dominant hand, activity level, overall health, specific fracture characteristics (number and displacement of fragments, fracture type/classification), bone quality, and associated injuries. For the majority of cases, conservative treatment is appropriate, since the healing potential of this anatomical region is high, and displacements of less than 0.5–1 cm are generally well tolerated without functional deficit. Conservative management involves oral analgesics, immobilization with a sling for about three weeks, followed by early physiotherapy. Early range-of-motion exercises are associated with faster recovery.
When the characteristics of the patient or the fracture exclude conservative management, surgical options must be considered. In some two-part fractures, and in selected three- and four-part fractures, closed reduction with percutaneous pinning may be used. This technique requires good bone quality and minimal comminution to reduce the risk of loss of fixation, but it offers the advantages of minimal surgical trauma and short operative time, making it useful in frail patients.
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In biologically younger patients with good or moderate bone quality and displaced shoulder fractures, or in cases of intra-articular fractures of the humeral head, open reduction and internal fixation with plates and screws is usually required to achieve healing in anatomic alignment. Bone grafting may also be used when bone quality is poor or comminution is severe, reducing the risk of fixation failure. Fracture healing is typically expected in six weeks, though physiotherapy may begin as early as two to three weeks postoperatively. Rehabilitation starts with passive mobilization exercises, progresses to active mobilization and strengthening, and eventually includes stretching and advanced strengthening after healing has been confirmed.
Another minimally invasive option for selected cases in younger patients with good bone stock is intramedullary nailing. This involves inserting a titanium rod into the humerus, locked with screws proximally and distally, which can also secure individual fracture fragments. This technique provides good healing rates with less surgical trauma compared to open techniques, but it is only suitable for selected fracture types.
In cases of fracture-dislocation of the shoulder, non-constructible intra-articular fractures in younger patients, or highly comminuted and complex fractures in elderly individuals, shoulder arthroplasty becomes the preferred treatment. Options include hemiarthroplasty, typically reserved for younger patients, and reverse shoulder arthroplasty, more commonly used in elderly patients with low demands and often with pre-existing rotator cuff disease.
Shoulder fractures of the proximal humerus are a heterogeneous group of relatively common injuries that can affect patients of different ages and activity levels. They can result from both low-energy and high-energy trauma, and diagnosis is relatively straightforward. Management ranges from conservative therapy, which is often the preferred option in certain age groups and fracture types, to various surgical interventions, depending on the characteristics of both the fracture and the patient. Functional outcomes rely heavily on the patient’s pre-injury activity level and on matching the safest and most effective treatment option to each case.
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