1 · SNAPSHOT
A straightforward rehab job attached to a much bigger clinical problem.
Illness script in one line: an older adult who fell onto an outstretched hand or onto the shoulder, with localised pain, swelling and bruising, and pain with any shoulder or arm movement.
Caseload frequency: common, and increasingly so with age. Read further: risk factors [1], outcomes in centenarians [2].
This is a fragility fracture. Treat it like one.
The usual teaching says "older adults or osteoporotic patients at higher risk" and then, correctly, gets on with the rehab. The thing it doesn't say is what that sentence implies.
Read further: proximal humeral fracture as a risk factor for subsequent hip fracture [3], mortality after proximal humeral fracture [4]. Secondary prevention of osteoporosis after non-neck-of-femur fragility fractures has been examined [5] — because it routinely doesn't happen.
You may be the only clinician who sees this person weekly for three months. Two questions — "has anyone talked to you about your bone health?" and "have you had a falls assessment?" — are inside your scope and may matter more than the shoulder.
2 · SE — THE SUBJECTIVE PATTERN
Acute and traumatic, so the UniSA order changes: MAIN PROBLEM → BODY CHART → HISTORY → BEHAVIOUR.
MAIN PROBLEM
"I fell and I can't move my arm."
BODY CHART
- Proximal humerus, anterolateral shoulder, into the deltoid.
- Bruising tracking down the arm and into the chest wall over the first week. Warn them — it looks alarming and it's expected.
- Any numbness, tingling or weakness, especially over the lateral deltoid. Section 4.
HISTORY — and this is where the extra value is
- The mechanism, and the height. A fall from standing height in an older adult is a fragility fracture by definition.
- WHY did they fall? Trip, or did they black out? Dizziness, medication, vision, home hazards. Nobody else is going to ask this.
- Previous fractures. Wrist, hip, spine, ribs.
- Bone health: any osteoporosis diagnosis, a DEXA scan, calcium, vitamin D, bisphosphonates.
- What they were managing before, and who's at home. The outcome that matters here is independence, not degrees of range.
BEHAVIOUR
- Aggs: any arm movement early; rolling in bed; dressing; the affected side at night.
- Eases: sling support, arm in.
- Severity: VAS 0–10 at best / at worst / right now.
- Irritability: high early, settling week by week. The trajectory is the thing to track — see section 4.
SPECIAL / SCREENING QUESTIONS
Neurovascular symptoms. Head strike or loss of consciousness with the fall. Anticoagulation. And the falls and bone-health questions above.
Assessing this region? Download the Shoulder assessment template →
3 · HYPOTHESIS RANKING
The diagnosis is usually made before you meet them. Your ranking is about what ELSE is going on.
| Question | What you're ranking |
|---|---|
| 1. Is this a stable fracture progressing normally? | The expected course: pain settling week on week, range returning, no neurological signs. |
| 2. Is there a neurovascular injury? | Axillary nerve, and more. Section 4. |
| 3. Is the fracture pattern actually stable? | Read further: Delphi consensus on radiographic characteristics that influence management [6]. You don't classify it — you ask what the treating team said. |
And then the complications, in order of when they show up
| Timing | Pattern |
|---|---|
| Any time | Axillary nerve, artery or plexus injury. |
| Weeks 0–6 | Loss of position, or a fracture more painful than last week. Re-image. |
| Weeks 6–12 | Nonunion. Read further: prediction of nonunion after nonoperative treatment [7]. |
| Weeks 6 onwards | Post-immobilisation stiffness and adhesive capsulitis. Read further: risk factors and prevention strategies for shoulder stiffness after this fracture [8]. |
| Months 3–12 | Avascular necrosis, malunion, cuff dysfunction. Read further: international consensus core set of unfavourable events [9]. |
| Any time after | The next fragility fracture. |
4 · RED FLAGS — DON'T MISS THIS
Free forever. Safety is never behind a paywall.
| Finding | What it means |
|---|---|
| Numbness over the lateral deltoid, or deltoid weakness | AXILLARY NERVE. Examine it, record it, escalate it. |
| Any other sensory or motor deficit in the arm or hand | Brachial plexus. Axillary artery and brachial plexus involvement has been reported in this fracture [10]. |
| Cold, pale, pulseless or discoloured hand; absent radial pulse | VASCULAR. EMERGENCY. |
| Pain that is worse at eight weeks than at four, or a shoulder that stops progressing | Loss of position or nonunion. Re-image. Don't push harder. |
| New deformity, crepitus with movement, or a sudden change | Escalate before you treat. |
| A fall with a head strike, loss of consciousness, or on anticoagulation | Medical review. |
| No bone health or falls assessment since the fracture | Not an emergency — but this is the flag most often missed, and it's the one you can act on. |
The screen, and it takes ninety seconds
Deltoid sensation. Deltoid power. Radial pulse. Full sensory and motor screen of the arm and hand. Recorded, both sides, every time the picture changes.
"Neurovascular screen essential (axillary nerve)" is the usual line. Keep it, and widen it — the axillary nerve is the commonest, not the only.
Any red flag: stop, escalate, and check it with your educator.
5 · OE — THE OBJECTIVE
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
Sign in or join free6 · MX — MANAGEMENT ESSENTIALS
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Sign in or join free7 · CLINICAL PEARLS + RETRIEVAL CHECK
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The objective exam, management and pearls, plus the six-minute lesson and the debrief. Free with an account.
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Twelve slides on this pattern: what you'll hear, what to examine, what to do. Free with an account.
Sign in or join freeGuideline anchor
No Australian guideline for managing the fracture. For bone health, the Australian anchor is the 2024 RACGP and Healthy Bones Australia osteoporosis guideline (PMID 40134107): any minimal-trauma fracture after age 50 is presumptive osteoporosis.
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The treatment anchor is the Cochrane review of interventions for treating proximal humeral fractures in adults (Handoll et al. 2022, PMID 35727196), with surgical versus non-surgical treatment systematically reviewed and meta-analysed since (Hernandes Júnior et al. 2025, PMID 39775965) and the cost-effectiveness question addressed in the Bone & Joint Journal (Corbacho et al. 2016, PMID 26850418). The rehabilitation anchors are a systematic review of rehabilitation protocols in Shoulder & Elbow (Budharaju et al. 2024, PMID 39346799), a review of how long the arm is immobilised after a conservatively managed displaced fracture (Tunnicliffe et al. 2024, PMID 39552671) and a study of early versus delayed mobilisation for non-surgically treated fractures (Challoumas et al. 2025, PMID 40016664).
The Cochrane review addresses interventions including surgery. There is no physiotherapy management guideline for this fracture — the rehabilitation literature is systematic reviews of protocols, which vary.
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Verified diagnostic accuracy, where the evidence stands and what it doesn't settle. Free with an account.
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Every source on this page resolves and title-verifies against PubMed. Newest first.
- 2004Chu et al. (2004). Risk factors for proximal humerus fracture. American journal of epidemiology, 160(4), 360-7. https://doi.org/10.1093/aje/kwh224
- 2025Koeppe et al. (2025). Centenarians with proximal humeral fracture. BMC geriatrics, 26(1), 19. https://doi.org/10.1186/s12877-025-06820-w
- 2009Clinton et al. (2009). Proximal humeral fracture as a risk factor for subsequent hip fractures. The Journal of bone and joint surgery. American volume, 91(3), 503-11. https://doi.org/10.2106/JBJS.G.01529
- 2020Bergdahl et al. (2020). Mortality after a proximal humeral fracture. The bone & joint journal, 102-B(11), 1484-1490. https://doi.org/10.1302/0301-620X.102B11.BJJ-2020-0627.R1
- 2013Mettyas & Carpenter (2013). Secondary prevention of osteoporosis in non-neck of femur fragility fractures: is it value for money? A retrospective, prospective and cross-sectional cohort study. Journal of orthopaedic surgery and research, 8, 44. https://doi.org/10.1186/1749-799X-8-44
- 2025Floyd et al. (2025). Delphi method consensus on radiographic characteristics influencing management decisions for proximal humerus fracture. Journal of orthopaedic surgery and research, 20(1), 1041. https://doi.org/10.1186/s13018-025-06465-w
- 2021Goudie & Robinson (2021). Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture. The Journal of bone and joint surgery. American volume, 103(8), 668-680. https://doi.org/10.2106/JBJS.20.01139
- 2025Liu et al. (2025). Analysis of risk factors and prevention strategies of shoulder joint stiffness after traumatic proximal humeral fracture in patients with osteoporosis. Frontiers in medicine, 12, 1641583. https://doi.org/10.3389/fmed.2025.1641583
- 2021Audigé et al. (2021). Core set of unfavorable events of proximal humerus fracture treatment defined by an international Delphi consensus process. BMC musculoskeletal disorders, 22(1), 1002. https://doi.org/10.1186/s12891-021-04887-1
- 2025Parkar & Thangarajah (2025). Radiological Diagnosis of Axillary Artery and Brachial Plexus Involvement in a Proximal Humerus Fracture-Dislocation: A Case Report. Cureus, 17(9), e92425. https://doi.org/10.7759/cureus.92425
- 2024Tunnicliffe et al. (2024). How long is the arm immobilised after a conservatively managed displaced proximal humerus fracture and does early mobilisation effect complication rates: A systematic review. Shoulder & elbow, 16(6), 654-666. https://doi.org/10.1177/17585732241239011
- 2025Challoumas et al. (2025). Early versus delayed mobilisation for non-surgically treated proximal humerus fractures: a systematic review and meta-analysis of randomised trials. BMC musculoskeletal disorders, 26(1), 203. https://doi.org/10.1186/s12891-025-08371-y
- 2024Budharaju et al. (2024). Rehabilitation protocols in proximal humerus fracture management: A systematic review. Shoulder & elbow, 16(4), 449-458. https://doi.org/10.1177/17585732231182374
- 2006Hodgson (2006). Proximal humerus fracture rehabilitation. Clinical orthopaedics and related research, 442, 131-8. PubMed 16394751
- 2022Handoll et al. (2022). Interventions for treating proximal humeral fractures in adults. The Cochrane database of systematic reviews, 6(6), CD000434. https://doi.org/10.1002/14651858.CD000434.pub5
- 2025Hernandes Júnior et al. (2025). Is surgical treatment better than non-surgical treatment for proximal humeral fracture in elderly people? A meta-analysis and meta-regression. European journal of orthopaedic surgery & traumatology : orthopedie traumatologie, 35(1), 51. https://doi.org/10.1007/s00590-024-04170-8
- 2016Chen et al. (2016). Effectiveness and Safety of Interventions for Treating Adults with Displaced Proximal Humeral Fracture: A Network Meta-Analysis and Systematic Review. PloS one, 11(11), e0166801. https://doi.org/10.1371/journal.pone.0166801
- 2016Corbacho et al. (2016). Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus: economic evaluation alongside the PROFHER trial. The bone & joint journal, 98-B(2), 152-9. https://doi.org/10.1302/0301-620X.98B2.36614
- 2023Rangan et al. (2023). Reverse shoulder arthroplasty versus hemiarthroplasty versus non-surgical treatment for older adults with acute 3- or 4-part fractures of the proximal humerus: study protocol for a randomised controlled trial (PROFHER-2: PROximal Fracture of Humerus Evaluation by Randomisation - Trial Number 2). Trials, 24(1), 270. https://doi.org/10.1186/s13063-023-07259-3
- 2025Migliorini et al. (2025). Reverse arthroplasty compared to hemiarthroplasty and open reduction and internal fixation for displaced proximal humerus fracture in patients above 60: a Bayesian network meta-analysis. Archives of orthopaedic and trauma surgery, 145(1), 481. https://doi.org/10.1007/s00402-025-06067-5
Mapped to this pattern
Generic measures that also apply
- Borg RPE
Borg Rating of Perceived Exertion Scale (6-20)
perceived exertion · 1 items · 1 min
- GROC
Global Rating of Change Scale
perceived change since baseline · 1 items · 1 min
- NPRS
Numeric Pain Rating Scale
pain intensity · 1 items · 1 min
- PGIC
Patient Global Impression of Change
perceived change since baseline · 1 items · 1 min
- PSFS
Patient-Specific Functional Scale
patient-generated function · 3 items · 2 min
- SANE
Single Assessment Numeric Evaluation
patient-rated function as a percentage of normal · 1 items · 1 min
- VAS
Visual Analogue Scale
pain intensity · 1 items · 1 min
- Borg CR10
Borg Category Ratio 10 Scale
perceived exertion or symptom intensity, ratio scale · 1 items · 1 min
- GAS
Goal Attainment Scaling
individualised goal achievement · 10 min
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