Quick answer: Most fractures of the top of the arm bone (proximal humerus) in older adults heal well in a sling, followed by physical therapy. Even for many displaced fractures, a large randomized trial found no difference in outcomes between surgery and nonsurgical care at two and five years [1, 2]. For severe, multi-fragment fractures in older patients, a reverse shoulder replacement can be a good option when surgery is needed [3, 4]. Just as important, a shoulder fracture after a simple fall is a warning sign for osteoporosis [5].
What Is a Proximal Humerus Fracture?
The proximal humerus is the ball-shaped top of the upper arm bone. Fractures here are among the most common fractures in older adults and typically happen after a fall from standing height onto an outstretched arm or the side of the shoulder. Their incidence is highest in women in their 80s, and about half are minimally displaced [6].
Symptoms
- Pain and swelling at the shoulder after a fall
- Extensive bruising that can spread down the arm and chest over several days
- Difficulty moving the arm
X-rays confirm the diagnosis. A CT scan is sometimes used to better understand complex fractures.
Most Fractures Heal Without Surgery
When the bone fragments are not severely displaced, most of these fractures can be treated without surgery [7], typically with a sling for comfort followed by gentle motion and progressive physical therapy [1].
The strongest evidence comes from the UK PROFHER trial, which randomized 250 adults (average age 66) with displaced fractures involving the surgical neck of the humerus to surgery (plate fixation or replacement) or a sling. At two years, patient-reported shoulder function was essentially identical between the groups, and complications and repeat surgeries were similar [1]. At five years, there was still no meaningful difference [2]. These results do not support routine surgery for most of these fractures.
When Is Surgery Recommended?
Surgery may be considered for:
- Severely displaced fractures, especially in younger or very active patients
- Fractures combined with a dislocation of the shoulder
- Head-splitting fractures or those that cut off the blood supply to the humeral head
- Open fractures or fractures with nerve or blood vessel injury
The options include fixation with plates, screws, or pins, which preserves the patient's own bone, and shoulder replacement [7].
Reverse Shoulder Replacement for Complex Fractures
For older patients with complex fractures, especially those where the rotator cuff attachments are broken off, reverse shoulder replacement has become a standard option [8] and has largely replaced older partial replacements. In a randomized trial of patients over 70, reverse replacement produced better function, better overhead motion, and fewer revisions than hemiarthroplasty [3].
But surgery is not always better than a sling, even for complex fractures. In a randomized trial of patients 80 or older with three- or four-part fractures, reverse replacement and nonsurgical treatment produced similar function at one year, with somewhat less pain after replacement [4]. The decision is individualized based on your fracture pattern, activity level, and overall health.
Don't Ignore Bone Health
A shoulder fracture from a simple fall often signals osteoporosis. In a large study of older women, a proximal humerus fracture increased the risk of a hip fracture more than fivefold during the following year [5]. If you've had a shoulder fracture, ask your doctor about a bone density test and osteoporosis treatment, and consider a home fall-risk review.
Recovery Timeline
Whether treated with or without surgery, recovery usually involves:
- Weeks 0–3: Sling for comfort; elbow, wrist, and hand motion; gentle pendulum exercises as instructed
- Weeks 3–6: Progressive passive and active-assisted shoulder motion as the fracture stabilizes
- Months 2–4: Strengthening and return to daily activities
- Up to 12 months: Continued gains in motion and strength
Your surgeon will adjust this timeline based on X-rays and how the fracture is healing.
Frequently Asked Questions
Will my shoulder ever be normal again?
Many patients regain good, pain-free function for daily activities, though some loss of overhead motion is common, particularly after severe fractures.
Is surgery safer if I'm healthy?
Not necessarily. In the PROFHER trial, surgery did not improve outcomes for most displaced fractures, and it adds surgical risks [1]. Fracture pattern matters more than general health alone.
When should I see a shoulder specialist?
Any shoulder fracture should be followed with serial X-rays. A specialist evaluation is especially valuable for displaced or multi-part fractures, fractures with a dislocation, or if healing seems slow.
Getting Care
Dr. Tej Joshi treats shoulder fractures, including fracture fixation and reverse shoulder replacement, at NYU Langone offices in Manhattan, Lake Success, and Bay Ridge, Brooklyn.
References
- Rangan A, Handoll H, Brealey S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-1047. PubMed 25756440 · doi:10.1001/jama.2015.1629
- Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017;99-B(3):383-392. PubMed 28249980 · doi:10.1302/0301-620X.99B3.BJJ-2016-1028
- Sebastiá-Forcada E, Cebrián-Gómez R, Lizaur-Utrilla A, Gil-Guillén V. Reverse shoulder arthroplasty versus hemiarthroplasty for acute proximal humeral fractures. A blinded, randomized, controlled, prospective study. J Shoulder Elbow Surg. 2014;23(10):1419-1426. PubMed 25086490 · doi:10.1016/j.jse.2014.06.035
- Lopiz Y, Alcobía-Díaz B, Galán-Olleros M, et al. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial. J Shoulder Elbow Surg. 2019;28(12):2259-2271. PubMed 31500986 · doi:10.1016/j.jse.2019.06.024
- Clinton J, Franta A, Polissar NL, et al. Proximal humeral fracture as a risk factor for subsequent hip fractures. J Bone Joint Surg Am. 2009;91(3):503-511. PubMed 19255209 · doi:10.2106/JBJS.G.01529
- Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001;72(4):365-371. PubMed 11580125 · doi:10.1080/000164701753542023
- American Academy of Orthopaedic Surgeons. Shoulder Trauma (Fractures and Dislocations). OrthoInfo. orthoinfo.org
- American Academy of Orthopaedic Surgeons. Reverse Total Shoulder Replacement. OrthoInfo. orthoinfo.org