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    Move Forward Guide

    Physical Therapist's Guide to Proximal Humerus Fractures

    A proximal humerus fracture is a serious injury to the humerus bone in the shoulder joint that requires immediate treatment to preserve function of the shoulder. A fracture to the humerus bone is a possible consequence of a traumatic event, such as a fall or forceful collision. Depending on the specific location and type of fracture to the proximal humerus, surgical intervention may be required. Whether surgical or nonsurgical treatment is needed, physical therapy treatment is essential to safely and effectively restore shoulder function, and return an individual to normal activity.


     

    What is a Proximal Humerus Fracture?

    The humerus is one of the long bones of the arm. The distal, or bottom, end contributes to the elbow joint. The proximal, or top, end contributes to the shoulder joint. During a traumatic event, like a fall, any part of the humerus is susceptible to injury. Other bones, including the clavicle (collarbone) or scapula (shoulder blade) can also be injured. However, a fracture to the proximal humerus is especially concerning due to its location and proximity to other important structures, such as the rotator cuff muscles, the brachial plexus (a web of nerves from the neck that supplies the arm), and certain tissues within the shoulder-joint capsule.

    Fractures of the proximal humerus typically occur as the result of a trauma, such as a fall where the individual lands directly on the shoulder, a forceful collision, or a more complicated event, such as a car accident. Typically, the position of the arm and body at the time of the trauma will determine how the bone fractures. Individuals of any age and gender may suffer this type of fracture. Individuals who suffer from osteoporosis, or the weakening of bone tissue, may have an increased risk of fracture during any traumatic event.

     

    How Does it Feel?

    An individual with a proximal humerus fracture may experience the following symptoms immediately following the injury:

    • Pain
    • Swelling
    • Bruising
    • Severely restricted movement of the shoulder
    • Numbness and tingling in the arm, forearm, or hand
    • Deformity (an unusual appearance) of the upper arm
     

    How Is It Diagnosed?

    Proximal humerus fractures are diagnosed by a thorough physical examination and diagnostic imaging. An x-ray is often taken to confirm the fracture. If further information is needed, such as investigating if any soft tissues are also injured, an MRI or CT scan may be required.

    Fractures to the proximal humerus are typically classified as:

    • Nondisplaced. The pieces of bone at the fracture site are separated, but not out of position. This type of fracture may not require surgery.
    • Displaced. The pieces of bone at the fracture site are separated and shifted out of position. This type of fracture typically requires surgery.

    Surgical intervention for proximal humerus fractures involves realigning and fixing the fractured bone segments using screws, plates, or rods. If there is more severe damage to the shoulder joint, a more advanced surgical procedure may be needed. If your injury requires surgery, your orthopedic surgeon will review your injury, diagnostic imaging findings, and surgical plan with you in detail.

     

    How Can a Physical Therapist Help?

    Following a proximal humerus fracture, physical therapy will be crucial to restore proper function of your shoulder and arm. If surgery is required, physical therapy will typically begin 1 to 4 weeks following the surgery, depending on the specific surgical intervention required.

    If surgery is not required, your physician and physical therapist will determine when the best time is to begin physical therapy, based on your bone healing and symptoms. After a traumatic injury like a fracture, individuals lose range of motion, strength, and often develop different movement patterns caused by injury limitations. Your physical therapist will develop an individualized treatment plan to address your specific condition, and help you return to your desired activities.

    Your physical therapy treatment may include:

    Range of Motion Exercises. Due to their limited movement following a proximal humerus fracture, individuals lose their range of shoulder motion and may develop stiffness of the shoulder joint. Your physical therapist will assess your shoulder motion compared to expected normal motion and the motion of shoulder of your noninjured arm, and lead you through a program of motion exercises to restore shoulder function.

    Strengthening Exercises. The muscles of the shoulder and upper back work together to allow for normal upper-body motion. Based on the way the shoulder joint is designed (a ball-and-socket joint, like a golf ball on a golf tee), there are many directions in which the shoulder may move. Therefore, balanced strength of all the upper body muscles is crucial to make sure that the shoulder joint is protected and efficient with its movements. When there is a fracture to the proximal humerus (near the “ball” segment of the joint), the muscles around the shoulder girdle weaken, as they are not being used normally; this process is called "atrophy." There are many exercises that can be done to strengthen the muscles around the shoulder, so that each muscle is able to properly perform its job. Often, building strength after a fracture can take weeks to months due to atrophy. Your physical therapist will help you develop a strengthening program that is safe and comprehensive.

    Manual Therapy. Physical therapists are trained in manual (hands-on) therapy. When appropriate, based on the stage of healing at your fracture site, your physical therapist will gently move your shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.

    Modalities. Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.

    Functional Training. Whether you work in a factory, are a mother of a young child, work as a secretary, or are an older adult, the ways in which you perform your normal daily activities are important. Improper movement patterns after a fracture may come back to haunt you, as they may lead to future secondary injuries. Physical therapists are experts in assessing movement quality. Your physical therapist will be able to point out and correct faulty movements, so you are able to regain use of, and maintain, a pain-free shoulder.

     

    Can this Injury or Condition be Prevented?

    Unfortunately, the unexpected traumatic events that are responsible for proximal humerus fractures cannot be directly prevented. However, based on the individual, certain precautionary measures can be taken to decrease the risk of any fracture:

    • For older individuals or individuals with known balance problems, removing fall-risk hazards in the home, such as loose rugs is beneficial. It is also important to encourage the use of handrails, assistive devices, and proper shoes.
    • For athletes participating in contact sports, it is important to always use proper protective equipment, as required by the rules and regulations of the specific sport.
    • For individuals with low bone density, following prescribed guidelines for appropriate vitamins and minerals, such as calcium and vitamin D, is helpful to maximize healthy bone composition.
     

    Real Life Experiences

    Mary is an energetic 60-year-old receptionist working full-time at a dental office. Outside of work, Mary attends fitness classes at her gym 3 days a week (she especially loves yoga and step classes), walks with her neighbors every weekend, and serves meals at the local soup kitchen several times a month. She is also the proud grandmother of 2 busy and growing grandchildren. Fortunately for Mary, all members of her family live in the same town; as a result, she finds that she spends time babysitting just about every week.

    One recent evening, Mary was babysitting her daughter's toddlers, while their parents attended a work function. It was nearing bedtime and Mary was rushing, trying to clean up the dinner dishes, and getting the kids ready for bed. As she was carrying dishes from the table back into the kitchen, she didn’t see that 1 of the toddler’s small plastic trucks was in the middle of the floor. She slipped on the truck, the dishes went flying, and Mary fell awkwardly onto her right shoulder. Writhing in pain, she was unable to move her right arm. Fortunately, her older grandson had been taught how to call his parent’s cell phone. The parents rushed home and took Mary to the emergency room.

    X-rays revealed that Mary had fractured the proximal humerus of her right arm, and 2 bone segments were displaced. Her arm was painful, swollen, and beginning to bruise. She was placed in a sling to immobilize the entire arm. The next day, Mary met with an orthopedic surgeon, who scheduled surgery for the following morning. During surgery, everything went well; the surgeon was able to realign the displaced fracture fragments, and fix them together with several screws and a plate. Mary's arm and shoulder were placed in a padded sling. Her surgeon told her she would begin physical therapy in 2 weeks.

    Two weeks later, Mary met with her physical therapist and told him that she was still having quite a bit of pain, and was afraid to move her shoulder. They talked about her goals; her physical therapist developed a rehabilitation plan, outlined what they would work on, and estimated timelines for her recovery. He assured Mary that it was reasonable that she was still experiencing some pain and apprehension, as it was still fairly soon after her surgery. He and Mary had a great discussion regarding expectations for healing, and a return to full function.

    Over the next few months, Mary went to physical therapy several times a week and grew to love her sessions. Her physical therapist used gentle manual (hands-on) therapy and guided exercises to help Mary restore the motion in her shoulder. After about a month of treatment, they started working on basic muscle-activation exercises, which led into a strengthening program. Mary was impressed that her physical therapist even knew the different arm positions in yoga, and included these in her treatments. He also discussed the importance of appropriate supplementation of calcium and vitamin D, particularly because Mary was postmenopausal, which can result in decreased bone density.

    After about 3 months, Mary was able to carry light items, perform some of her yoga moves, and return to work with nearly normal use of her right arm. She continued to work diligently on the home exercises prescribed by her physical therapist.

    At her 6-month follow-up appointment with her physician, the doctor was especially impressed with Mary's functional ability. She said that she had received excellent progress reports from Mary's physical therapist on her motion, strength, and function, and cleared her for a full

    Today, Mary is back to her regular, busy schedule, and able to perform all her normal right-arm movements. However, she always double-checks where she’s stepping when she’s with the grandchildren!

     

    What Kind of Physical Therapist Do I Need?

    All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:

    • A physical therapist who is experienced in treating people with orthopedic or musculoskeletal injuries.
    • A physical therapist who is a board-certified specialist, or who has completed a residency in orthopedic or sports physical therapy, as they will have advanced knowledge, experience, and skills that apply to an active population.

    You can find physical therapists who have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

    General tips when you're looking for a physical therapist (or any other health care provider):

    • Get recommendations from family and friends or from other health care providers.
    • When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people with shoulder pain and injury.
    • During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
     

    Further Reading

    The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.

    The following articles provide some of the best scientific evidence related to physical therapy treatment of humerus fractures. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.

    Canbora MK, Kose O, Polat A, Konukoglu L, Gorgec M, et al. Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: a prospective study. Int J Shoulder Surg. 2013;7(3):105-109. Free Article. Article Summary in PubMed.

    Hauschild O, Konrad G, Audige L, et al. Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch Orthop Trauma Surg. 2013;133(10):1385-1393. Article Summary in PubMed.

    Handoll HH, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2012;(12):CD000434. Free Article. Article Summary in PubMed.

    Ribinik P, Calmels P, Edouard P, Gentry M, Yelnnick AP. Care pathways in physical and rehabilitation medicine (PRM): the patient after proximal humeral fracture and shoulder hemi-arthroplasty. Ann Phys Rehabil Med. 2012;55(8):557-564. Article Summary in PubMed.

    * PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine’s MEDLINE database.

    Authored by Laura Stanley, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.