Proximal Humerus Fracture Fixation

Overview

The proximal humerus is the upper end of the arm bone. It forms the ball of the shoulder joint. The bone has four main parts: the ball itself, two bony bumps (the tuberosities) where the rotator cuff tendons attach, and the narrowed neck just below, where most fractures occur. Because the rotator cuff attaches directly to the tuberosities, a fracture that shifts those pieces also disrupts the muscle forces acting on the shoulder.

Most proximal humerus fractures are minimally displaced: the bone has cracked, but the pieces have not moved much out of position. Those heal well with a sling and early supervised motion, without surgery. Surgery becomes necessary in three settings. The fragments have shifted enough to upset how the shoulder works. The bone will not heal reliably without fixation. Or the blood supply to the ball is at risk of being cut off, which can lead to avascular necrosis (bone death from loss of circulation).

Open reduction and internal fixation (ORIF) uses a plate placed along the outer surface of the bone. Screws lock into both the plate and the bone to hold the fragments in position. The repair is built to be stable enough for early shoulder motion. Too long in a sling leads to stiffness that can take months to resolve. The goal is to restore the shoulder's anatomy closely enough that the rotator cuff can work normally once healing is complete.

In older patients, or when the bone is badly fragmented, the rotator cuff is often damaged too, and the blood supply to the ball may not be savable. In those cases a reverse shoulder replacement is often chosen over fixation. It does not depend on an intact rotator cuff to function. Your surgeon will review your imaging, your age, your activity level, and the fracture pattern to recommend the right approach for you.

Why it's done

We consider proximal humerus ORIF when imaging and the exam together show that the fracture will not heal or function reliably without surgery. Common reasons include:

Displaced surgical-neck fracture
The pieces are tilted or shifted enough to affect how the shoulder works.
Displaced tuberosity fragments
The pull of the rotator cuff drags these pieces away from the bone.
Three- or four-part fractures in active patients
Fixation aims to preserve the native joint.
Head-splitting fracture
These usually need reconstruction or a shoulder replacement.

How it works

Through an incision on the front of the shoulder, the fracture pieces are realigned. A plate shaped to match the bone is then applied. Screws into the ball hold that piece without entering the joint surface. Heavy stitches through the plate secure the rotator cuff attachments.

For certain patterns, a rod passed down the hollow center of the bone through the top of the shoulder is an alternative. It is placed under live X-ray guidance.

Recovery

The arm is protected in a sling. Pendulum exercises (letting the arm hang and swing gently) and passive motion, where the arm is moved for you, start early. Motion with some help from the arm itself comes next, then fully active motion as healing allows. Strengthening waits until the bone is solidly healed. Stiffness and avascular necrosis (bone death from a disrupted blood supply) are the most common complications. Most people regain useful motion over time with consistent therapy.

Contact

For questions about this procedure or to schedule an evaluation, call the office at (830) 625-0009 or schedule an appointment online.

Physicians Who Perform Proximal Humerus ORIF

Michael S. Vrana, M.D.

David B. Templin, M.D.

Trent Twitero, M.D.

Weight-Bearing After Repair

Controlled load is part of how bone heals. Once the fracture is stabilized with hardware, gentle weight through the limb helps the bone heal. Taking all load off a fixed fracture for too long can actually slow healing and stiffen the joints above and below. Full body weight right away, however, can overload the repair before the bone has caught up. The right answer sits in between. Your surgeon sets a step-by-step weight-bearing plan based on your fracture pattern, the strength of the fixation, your bone quality, and how the repair looks on imaging after surgery. We tell you exactly how much weight the limb can take, when to advance, and what to watch for.

Risks & Why We Still Recommend It

Every operation carries risk. This procedure is offered because the condition, when left untreated, can cause a shoulder that heals out of line so the rotator cuff loses its leverage, and in severe patterns a ball that loses its blood supply. The decision to proceed weighs the risks of surgery against the limitations the condition places on daily function. Surgery does not remove risk; it addresses a problem that is otherwise progressive. Whether it is appropriate is determined for each patient in consultation with the surgeon.

The risks we discuss before proximal humerus ORIF include:

bleeding and infection
anesthesia risk
stiffness
loss of blood supply to the ball (avascular necrosis)
a screw working through the joint surface (cut-out)
hardware irritation
irritation of a shoulder nerve (the axillary nerve)
blood clot (rare in upper-extremity surgery)

We proceed when the fracture is displaced and your bone quality and fracture pattern favor fixation over replacement. If you do not need this operation, we will not recommend it.

Frequently Asked

questions we hear in clinic

Does every proximal humerus fracture need surgery?

No. Most are minimally displaced, meaning the bone has cracked but the pieces have not moved much, and those heal well with a sling and early supervised motion. Surgery becomes necessary when the fragments have shifted enough to upset how the shoulder works, when the bone will not heal reliably without fixation, or when the blood supply to the ball is at risk.

Why might a shoulder replacement be recommended instead of fixing the fracture?

In older patients, or when the bone is badly fragmented, the rotator cuff is often damaged too and the blood supply to the ball may not be savable. In those cases a reverse shoulder replacement, which does not depend on an intact rotator cuff to function, is often chosen over fixation. Your surgeon weighs your imaging, age, activity level, and the fracture pattern.

How is the fracture actually fixed?

Through an incision on the front of the shoulder, the pieces are realigned and a plate shaped to match the bone is applied. Screws into the ball hold that piece without entering the joint surface, and heavy stitches through the plate secure the rotator cuff attachments. For certain patterns, a rod passed down the hollow center of the bone under live X-ray guidance is an alternative.

How soon will my shoulder start moving after surgery?

Early. The repair is built to be stable enough for early shoulder motion, because too long in a sling leads to stiffness that can take months to resolve. Pendulum exercises and passive motion start early, motion with some help from the arm comes next, and strengthening waits until the bone is solidly healed.

What is avascular necrosis?

Bone death from a disrupted blood supply. Along with stiffness, it is one of the most common complications after this fracture, and in severe fracture patterns the ball is at substantial risk of losing its blood supply even without surgery.

Will I get my shoulder motion back?

Most people regain useful motion over time with consistent therapy. The goal of the repair is to restore the shoulder's anatomy closely enough that the rotator cuff can work normally once healing is complete.