Proximal Humerus Fracture Fixation

Proximal humerus fractures (PHFs) are increasingly common, especially among older adults. These fractures occur near the top of the upper arm bone (humerus), close to the shoulder. While many can be treated without surgery, certain types require fixation—surgical procedures to realign and stabilize the broken bones. Choosing the right treatment depends on the fracture pattern, patient age, bone quality, and overall health.

How Common It Is and Who Gets It? (Epidemiology)

Proximal humerus fractures follow a bimodal distribution:

• Younger individuals often suffer them through high-energy trauma (e.g., car accidents, sports injuries).
• Older adults, particularly women with osteoporosis, tend to experience these fractures from low-energy incidents like falls.
  Complications from PHFs can include:
• Malunion or non-union (bones not healing properly)
• Avascular necrosis (bone tissue death)
• Traumatic arthritis
• Long-term pain and loss of shoulder function

Why It Happens – Causes (Etiology and Pathophysiology)

Clavicle fractures typically occur due to high-energy trauma or falls, while in older adults, they are often related to the degenerative effects of osteoporosis. The humerus may break when significant force is applied to the upper arm, particularly when it is abducted or externally rotated during a fall or direct blow. As the bone breaks, surrounding soft tissue, including muscles and ligaments, may also be damaged, contributing to instability and poor healing without intervention.

How the Body Part Normally Works? (Relevant Anatomy)

The proximal humerus is the top part of the upper arm bone, which connects with the shoulder blade to form the shoulder joint. It provides support for arm movement and plays a critical role in daily activities. The rotator cuff muscles help stabilize the humerus within the glenoid cavity of the shoulder joint. The humeral head is important for movement like lifting, reaching, and pushing, while the neck of the humerus helps facilitate rotation.

What You Might Feel – Symptoms (Clinical Presentation)

Patients with PHFs typically report:

• Pain in the shoulder or upper arm, especially when moving the arm
• Swelling, bruising, or deformity over the fracture site
• Difficulty lifting the arm or reaching overhead
• Decreased range of motion
• Tenderness and a sensation of grinding or crepitus with arm movements

How Doctors Find the Problem? (Diagnosis and Imaging)

PHFs are diagnosed through a thorough physical examination and imaging studies, including:

• X-rays: Standard front, side, and angled views to assess the fracture pattern.
• CT scans: To evaluate complex fractures with better 3D reconstructions, particularly for comminuted fractures.
• MRI: Used if there’s a concern for rotator cuff involvement, as up to 40% of PHFs involve rotator cuff tears.

Classification

The most commonly used system for classifying PHFs is the Neer classification, which divides fractures into:

• 2-part fractures: Single fracture with displacement of the head or neck.
• 3-part fractures: Includes fractures of the head, neck, and tuberosities.
• 4-part fractures: Involves fractures of the humeral head, neck, and both tuberosities.

This system helps guide treatment and gives insight into the stability of the fracture. Other systems like the AO classification or Hertel’s binary system provide more detailed breakdowns of fracture patterns.

Treatment Options

Non-Surgical Care
About 85% of PHFs can be treated non-operatively, especially when fractures are stable:

• Rest and immobilization with a sling or brace for several weeks
• Ice, pain medications, and anti-inflammatory drugs
• Early physical therapy to restore movement and prevent stiffness
• PROFHER study (UK-based trial) showed no significant difference in long-term outcomes between surgical and non-surgical treatment for many fractures, especially when surgery wasn’t clearly necessary.

Surgical Care
Surgical intervention is considered when:

• The fracture is severely displaced
• The bone is split or comminuted
• Bone fragments are widely separated
• The patient has significant functional demands, such as athletes or active individuals
  Surgical options include:

1. Percutaneous Fixation: Minimally invasive technique using screws or pins for specific fractures.
2. Locking Plate Fixation: The most common method for displaced fractures, using locking screws to stabilize the bone.
3. Intramedullary Nailing (IM Nail): A less invasive approach using a rod inserted into the bone canal, suitable for 2-part or select 3-part fractures.
4. Arthroplasty (Shoulder Replacement):
   • Hemiarthroplasty (HA): Replaces the humeral head, typically in younger patients.
   • Reverse Shoulder Arthroplasty (RSA): More common in elderly patients, especially those with rotator cuff tears, providing stability and pain relief.

Recovery and What to Expect After Treatment

Recovery varies depending on the severity and type of fracture and treatment:

• First 2 weeks: Sling immobilization, controlling pain and swelling.
• 2–6 weeks: Sutures removed, light motion exercises start under guidance.
• 6 months: Full return to activities, including sports, may be achieved after rehabilitation.
  Physical therapy plays a crucial role in regaining shoulder strength and mobility.

Possible Risks or Side Effects (Complications)

• Infection, especially in surgical patients
• Nerve or vascular injury, particularly in more complex fractures or surgeries
• Nonunion or malunion, where bones fail to heal properly
• Avascular necrosis, where the bone loses its blood supply
• Shoulder stiffness or weakness

Long-Term Outlook (Prognosis)

With appropriate treatment, most patients achieve good functional recovery, especially when the fracture is adequately stabilized. However, in elderly patients or those with poor bone quality, the risk of complications such as nonunion or arthritis increases. Reverse shoulder arthroplasty has become increasingly favored in patients with poor bone quality or rotator cuff deficiency.

Out-of-Pocket Costs

Medicare

CPT Code 23615 – Percutaneous Fixation & Locking Plate Fixation (ORIF for Shoulder Fracture): $210.24

CPT Code 24516 – Intramedullary Nailing (Fixation Using Intramedullary Implant for Humeral Fracture): $204.20

CPT Code 23470 – Hemiarthroplasty (Replacement of Humeral Head Only for Shoulder Joint): $282.66

CPT Code 23472 – Reverse Shoulder Arthroplasty (Total Reverse Shoulder Replacement): $340.19

Medicare Part B typically covers 80% of the approved cost for these procedures once your annual deductible has been met, leaving you responsible for the remaining 20%. Supplemental Insurance plans such as Medigap, AARP, or Blue Cross Blue Shield generally cover the remaining 20%, reducing or eliminating out-of-pocket expenses for Medicare-approved surgeries. These plans coordinate with Medicare to fill the coverage gap and reduce the patient’s financial responsibility.

If you have Secondary Insurance, such as TRICARE, an Employer-Based Plan, or Veterans Health Administration coverage, it acts as a secondary payer. These plans typically cover any remaining balance, including coinsurance or small deductibles, which generally range between $100 and $300, depending on your plan and provider network.

Workers’ Compensation

If your shoulder fracture or joint replacement is required due to a work-related injury, Workers’ Compensation will cover all associated medical expenses, including surgery, rehabilitation, and follow-up care. You will not have any out-of-pocket expenses, as the employer’s insurance carrier directly covers all approved treatments.

No-Fault Insurance

If your shoulder injury requiring surgery is related to an automobile accident, No-Fault Insurance will typically cover the full cost of treatment, including surgery and postoperative care. The only potential out-of-pocket cost may be a small deductible or co-payment depending on your insurance policy.

Example

Lisa Evans required a reverse shoulder arthroplasty (CPT 23472) due to a severe shoulder injury. Her estimated Medicare out-of-pocket cost was $340.19 for the shoulder replacement. Since Lisa had supplemental insurance through Blue Cross Blue Shield, her remaining balance was fully covered, leaving her with no out-of-pocket expenses for the surgery.

Frequently Asked Questions (FAQ)

Q. What is a proximal humerus fracture?
A. A proximal humerus fracture is a break in the upper part of the arm bone near the shoulder, often resulting from trauma such as a fall.

Q. What are common causes of proximal humerus fractures?
A. These fractures often occur due to falls, especially in older adults with osteoporosis, or from high-impact injuries like car accidents.

Q. What are the symptoms of a proximal humerus fracture?
A. Symptoms include shoulder pain, swelling, bruising, limited motion, and visible deformity in some cases.

Q. How is a proximal humerus fracture diagnosed?
A. Diagnosis is made through a physical exam and imaging tests like X-rays and CT scans to assess the fracture pattern and displacement.

Q. What determines the treatment approach for a proximal humerus fracture?
A. Treatment depends on the fracture type, displacement, patient’s age, activity level, and bone quality.

Q. When is surgery recommended for a proximal humerus fracture?
A. Surgery is considered when the fracture is significantly displaced, involves multiple parts, or if conservative treatment would not lead to optimal healing.

Q. What surgical methods are used for proximal humerus fracture fixation?
A. Common methods include open reduction and internal fixation (ORIF) with plates and screws or intramedullary nailing.

Q. What is the goal of surgical fixation for proximal humerus fractures?
A. The goal is to realign the bone fragments, stabilize the fracture, and allow early shoulder movement to restore function.

Q. What is open reduction and internal fixation (ORIF)?
A. ORIF is a surgical procedure where the bone fragments are repositioned and fixed in place with hardware like plates and screws.

Q. What type of anesthesia is used for this surgery?
A. The procedure is typically performed under general anesthesia or regional anesthesia with a nerve block.

Q. How long does proximal humerus fracture fixation surgery take?
A. The surgery usually takes one to two hours depending on the complexity of the fracture.

Q. What is the typical recovery time after surgery?
A. Recovery time varies but generally includes several weeks of immobilization followed by physical therapy, with most patients improving over a few months.

Q. What are the possible complications of surgical fixation?
A. Complications may include infection, nerve injury, hardware problems, nonunion or malunion of the bone, and shoulder stiffness.

Q. What is the role of physical therapy after surgery?
A. Physical therapy helps restore shoulder movement, strength, and function through a structured rehabilitation program.

Q. Can elderly patients undergo surgery for proximal humerus fractures?
A. Yes, elderly patients can undergo surgery if they are medically stable and the fracture would benefit from fixation to preserve function.

Q. Are there alternatives to surgical fixation?
A. Non-surgical treatment options include immobilization with a sling or brace for less complex, non-displaced fractures.

Q. What happens if the fracture doesn’t heal properly?
A. Improper healing can lead to chronic pain, limited shoulder function, and may require additional surgery for correction.

Q. Will the hardware used in fixation need to be removed later?
A. In most cases, the hardware remains in place unless it causes discomfort or complications, in which case it may be removed.

Summary and Takeaway

Proximal humerus fractures require personalized treatment based on fracture severity, patient health, and lifestyle needs. For many patients, non-surgical management is sufficient, but surgery may be necessary for more severe fractures or those involving displacement or multiple fragments. Techniques like locking plate fixation and intramedullary nailing offer promising outcomes, while reverse shoulder arthroplasty remains an excellent option for elderly patients or those with rotator cuff tears.

Clinical Insight & Recent Findings

A recent study compared the outcomes of latissimus dorsi tendon transfer (LDTT) and muscle advancement (MA) for irreparable rotator cuff tears (IRCTs), focusing on functional recovery and complication rates.

The study found that both techniques significantly improved shoulder function, but LDTT resulted in greater improvements in external rotation. However, MA had higher complication rates (25.7%) and a higher retear rate (20.8%) compared to LDTT, which had lower retear rates (8.9%). While both approaches were effective, LDTT was preferred for patients needing biomechanical compensation, especially those with severe tendon degeneration.

MA, however, was beneficial in patients with preserved muscle quality and fewer retear risks. The study suggests that the choice between these two techniques should be individualized based on the patient’s specific needs and the severity of the rotator cuff tear. (“Study on LDTT vs. MA for irreparable rotator cuff tears – see PubMed.”)

Who Performs This Treatment? (Specialists and Team Involved)

Orthopedic surgeons specializing in trauma or shoulder reconstruction typically perform the ORIF procedure. Physical therapists assist in postoperative rehabilitation to restore strength and mobility.

When to See a Specialist?

If you experience severe shoulder pain or deformity following an injury, consult an orthopedic specialist to assess for fractures or other shoulder conditions.

When to Go to the Emergency Room?

Seek emergency care if you have difficulty moving the shoulder, significant swelling or bruising, or if the shoulder appears deformed following an injury.

What Recovery Really Looks Like?

Recovery involves initial immobilization, followed by physical therapy to restore shoulder strength and function. Full recovery may take several months, depending on the severity of the injury.

What Happens If You Ignore It?

If left untreated, proximal humerus fractures can result in chronic pain, shoulder instability, and long-term dysfunction, potentially leading to arthritis or the need for shoulder replacement surgery.

How to Prevent It?

Preventing PHFs involves strengthening shoulder muscles, using proper lifting techniques, and avoiding high-risk activities that may lead to falls or trauma.

Nutrition and Bone or Joint Health

Adequate nutrition with a focus on calcium, vitamin D, and omega-3 fatty acids supports bone healing and overall joint health, aiding in recovery after surgery.

Activity and Lifestyle Modifications

Avoiding excessive strain on the shoulder and strengthening the muscles around the shoulder joint can help prevent future injuries and improve long-term health.