A broken shoulder is one of the most common fractures in adults — especially after a fall. Most heal without surgery. For those that require operative treatment, Dr. Graham offers locking plate fixation or reverse total shoulder arthroplasty — selected based on fracture pattern, bone quality, and your activity level. Complex and revision cases accepted.
Previously treated elsewhere? Malunions, nonunions, and failed prior fixations are accepted. Second opinions welcome.
Understanding the Injury
The proximal humerus is the ball-shaped top of the upper arm bone — the part that forms the shoulder joint. Fractures here are among the three most common fractures in adults over 65, typically occurring after a fall on an outstretched hand or a direct blow to the shoulder. In younger patients, higher-energy mechanisms — motor vehicle accidents, sports collisions — produce more complex fracture patterns.
The proximal humerus consists of four anatomic segments: the humeral head (the articular ball), the greater tuberosity (where the rotator cuff attaches), the lesser tuberosity, and the surgical neck. The Neer classification system organizes fractures by how many of these segments are displaced, which guides treatment decisions.
The good news is that the majority of proximal humerus fractures — roughly 80% — are minimally displaced and can be treated successfully without surgery. The shoulder joint's inherent stability and the surrounding muscle envelope make non-operative management effective for most patients when fracture alignment is acceptable.
In Dr. Graham's experience, the most important initial question is not whether surgery is technically possible, but whether it will actually produce a better result than careful non-operative management. For displaced fractures in younger patients with good bone, the answer is often yes. For the same fracture in an elderly, low-demand patient with osteoporotic bone, the calculus is different — and honest counseling about realistic expectations matters more than the surgical options on the table.
The four segments: humeral head, greater tuberosity (red — rotator cuff attaches here), lesser tuberosity (amber), and surgical neck. When tuberosities displace, the rotator cuff pulls them further from the head — a key driver of fracture pattern complexity.
The blood supply to the humeral head enters through the surgical neck. Severely displaced fractures and 4-part patterns risk disrupting this supply, leading to avascular necrosis — a key factor in the decision between fixation and replacement.
Fracture Classification
The Neer system classifies proximal humerus fractures by the number of displaced segments. Each part must be displaced more than 1 cm or angulated more than 45° to count as a separate part.
Treatment Options
Dr. Graham does not offer hemiarthroplasty. When the shoulder needs replacement, he uses reverse total shoulder arthroplasty — a more reliable option for fracture cases.
The majority of proximal humerus fractures — including all 1-part fractures and many 2-part fractures — are treated without surgery. The shoulder's muscular envelope and the fracture's inherent stability allow reliable healing with protected immobilization followed by progressive rehabilitation.
Protocol: sling for 2 to 3 weeks for comfort, early pendulum exercises to prevent stiffness, followed by formal physical therapy beginning at 4 to 6 weeks as fracture healing progresses on X-ray.
Open reduction and internal fixation with a proximal humerus locking plate restores the anatomy of the shoulder without replacing the joint. A low-profile plate is positioned on the lateral humeral shaft, and locking screws are placed into the humeral head in a fixed-angle construct that resists pullout — particularly important in osteoporotic bone.
ORIF is preferred when the fracture is displaced enough to warrant surgery but the humeral head has adequate blood supply and bone quality to support fixation and heal reliably. The goal is anatomic restoration of the tuberosities and head-neck relationship.
Reverse total shoulder arthroplasty replaces the shoulder joint entirely, inverting the normal ball-and-socket geometry. In a reverse design, the ball is fixed to the glenoid (socket) and the socket is on the humeral side — allowing the deltoid muscle to power shoulder elevation even when the rotator cuff and tuberosities are not reconstructable.
Dr. Graham does not perform hemiarthroplasty for fractures. When replacement is the right choice, RSA produces more predictable and durable results — particularly in elderly patients or when tuberosity healing cannot be relied upon to restore rotator cuff function.
Hemiarthroplasty — replacing only the humeral head without the glenoid socket — was historically the standard surgical option for complex proximal humerus fractures. The results were often disappointing: outcomes depended heavily on tuberosity healing, which is unpredictable in osteoporotic bone, and many patients were left with significant pain and limited function.
Reverse total shoulder arthroplasty has largely replaced hemiarthroplasty for fracture indications. Because RSA does not rely on tuberosity healing or rotator cuff function to achieve shoulder elevation, it produces more consistent and durable results — particularly in elderly patients where these structures are least reliable. In Dr. Graham's experience, when a proximal humerus fracture cannot be adequately managed with fixation, RSA is the better replacement option. He does not offer hemiarthroplasty for fracture indications.
Locking Plate ORIF
When ORIF is the right choice, Dr. Graham uses a proximal humerus locking plate system — a low-profile implant designed specifically for the complex three-dimensional anatomy of the proximal humerus. The locking screw-plate interface provides angular stability that is particularly valuable in osteoporotic bone, where conventional screws can pull out under load.
The critical technical goals are restoration of the head-neck shaft angle, anatomic reduction of the tuberosities so that the rotator cuff heals in the correct position, and placement of screws that support the humeral head without penetrating the articular surface. Intraoperative fluoroscopy is used throughout to confirm reduction and hardware position.
Surgery is performed under general anesthesia or regional block at Baptist Beaches Hospital. Most patients are home the same day or within 24 hours. The arm is placed in a sling post-operatively, and the rehabilitation protocol mirrors the non-operative protocol — early pendulum exercises followed by progressive formal therapy.
General anesthesia or interscalene block. Beach-chair positioning provides excellent access to the shoulder without requiring arm traction. Fluoroscopy available throughout.
Standard deltopectoral interval — the interval between the deltoid and pectoralis major muscles — provides direct access to the proximal humerus while protecting the axillary nerve and anterior circumflex vessels.
Fracture fragments are reduced anatomically. Tuberosities are repositioned to restore rotator cuff insertion geometry. Reduction is confirmed on fluoroscopy before plate placement.
The proximal humerus locking plate is positioned on the lateral cortex below the greater tuberosity. Locking screws are placed into the humeral head in a fixed-angle construct. Articular penetration is confirmed not to have occurred on fluoroscopy.
Layered closure. Arm placed in sling. Pendulum exercises begin within the first week. Formal physical therapy starts at 4 to 6 weeks as healing progresses on follow-up X-ray.
Reverse Shoulder Arthroplasty
For 4-part fractures, fracture-dislocations with humeral head devascularization, and complex patterns in elderly patients with poor bone quality, the likelihood that ORIF will produce a functional shoulder is low. In these cases, replacing the joint with a reverse total shoulder arthroplasty is the more reliable path to a pain-free, functional shoulder.
The reverse design is particularly well-suited to fracture cases because it does not require tuberosity healing or intact rotator cuff function to achieve shoulder elevation. The deltoid becomes the primary elevator, and its biomechanical advantage is dramatically improved by the reverse ball-and-socket geometry.
In Dr. Graham's experience, properly selected patients — particularly those over 65 with complex fracture patterns — achieve reliable pain relief and functional shoulder use after RSA for fracture. The operation is more predictable in this population than either hemiarthroplasty or attempted ORIF in compromised bone.
Dr. Graham accepts revision RSA cases and patients referred after failed prior fixation or prior hemiarthroplasty that has not performed as expected.
Recovery Timeline
Recovery milestones are similar whether you had surgery or not — the shoulder demands patience regardless of how the fracture was managed.
Sling worn for 2 to 3 weeks for comfort. Pendulum exercises begin early to prevent stiffness. X-rays at follow-up confirm healing progress.
Structured PT begins once early healing is confirmed. Passive and active-assisted range of motion, progressing to active motion as strength and healing allow.
Most patients regain functional shoulder use for daily activities. Overhead use and heavy lifting continue to improve through 6 to 12 months.
Shoulder motion and strength continue improving for up to a year. Most patients achieve satisfactory function for their pre-fracture activity level.
Sling worn continuously. Pendulum exercises typically begin within the first week. Wound check and suture removal at 10 to 14 days.
Sling discontinued or transitioned to nighttime use. Formal PT with passive and active-assisted range of motion. X-rays confirm healing and hardware position.
Progressive strengthening begins. Rotator cuff and deltoid exercises. Return to light functional activities. Most ADLs restored by 3 months.
Most patients return to full activity within 4 to 6 months after ORIF, or 3 to 6 months after RSA. Heavy labor and contact sports are discussed individually.
Not every proximal humerus fracture is treated correctly the first time — and not every treated fracture heals the way it should. Dr. Graham accepts referrals for malunions, nonunions, failed ORIF with hardware failure, and prior hemiarthroplasty that has not performed as expected. Second opinions are always welcome.
"I had a complex shoulder fracture that two other surgeons said was too complicated to fix. Dr. Graham took one look at my X-rays and had a plan. He was honest about what to expect, and the result was better than I hoped for. He's the real deal."
Common Questions
What patients and families ask most often after a shoulder fracture.