A proximal humerus fracture is a fracture of the humeral head, tuberosities or surgical neck, usually a fragility fracture in an older person after a fall. The ST3 T&O interview asks when to operate, and the answer is anchored in PROFHER and NICE NG38: non-surgical treatment for the uncomplicated displaced injury, surgery for the complicated one.

Key takeaways

  • Neer's classification counts displaced segments among the head, greater tuberosity, lesser tuberosity and shaft; a segment is displaced at 1 cm of translation or 45 degrees of angulation.
  • PROFHER (JAMA 2015) randomised 250 adults with displaced surgical neck fractures across 32 NHS hospitals: Oxford Shoulder Score over two years was 39.07 for surgery and 38.32 for a sling, a difference of 0.75 points.
  • The five-year PROFHER follow-up (Bone Joint J 2017) found no statistically or clinically significant difference at three, four or five years.
  • NICE NG38 states: offer non-surgical management for uncomplicated displaced low-energy proximal humerus fractures; consider surgery for an open wound, skin tenting, vascular injury, fracture-dislocation or head split.
  • The May 2019 BOAST on the older or frail trauma patient applies to every fragility fracture admission, with a geriatric assessment (CGA) starting within 72 hours and a bone health and falls review.

What is a proximal humerus fracture and how is the Neer classification applied?

A proximal humerus fracture is described with Neer's 1970 classification, which divides the proximal humerus into four segments: the articular head, the greater tuberosity, the lesser tuberosity and the shaft.

A segment counts as displaced when it is translated by 1 cm or angulated by 45 degrees; the fracture is then two-part, three-part or four-part by the number of displaced segments.

Fracture-dislocations and head-splitting fractures of the proximal humerus sit outside the simple part count and are named separately, because they are the injuries the guidance sends to theatre.

In practice the panel wants the segments named on the radiograph, the displacement judged against the 1 cm or 45 degree rule, and a clear statement of whether the head is dislocated or split.

How should you assess a proximal humerus fracture?

Assessment of a proximal humerus fracture starts with the patient: why they fell, their frailty, cognition and function, because the May 2019 frailty BOAST puts every fragility fracture into a frailty pathway.

Examine the skin over the fracture for tenting or an open wound, the radial pulse, and the axillary nerve by sensation over the regimental badge area and deltoid contraction where pain allows.

Radiographs of a proximal humerus fracture are a trauma series: an anteroposterior view in the scapular plane, a scapular Y view and an axillary or modified axillary view to confirm the head is located.

CT is for surgical planning when the head may be split, the tuberosities are comminuted, or the radiographs cannot settle whether the joint is dislocated.

What is the initial management of a proximal humerus fracture?

Initial management of a proximal humerus fracture is a collar and cuff or sling, analgesia, and early enrolment in the frailty pathway, with a fracture-dislocation reduced promptly and re-imaged.

NICE NG38 states that for adults with displaced low-energy proximal humerus fractures, non-surgical management should be offered for the definitive treatment of uncomplicated injuries.

The frailty BOAST states that a geriatric assessment (CGA) should commence within 72 hours of injury, and that all patients should have a falls risk assessment and a bone health review.

The BOAST also states that pain management should limit opioids, use regional blockade when appropriate, and avoid non-steroidal drugs in this population.

What did the PROFHER trial show about proximal humerus fractures?

PROFHER showed that surgery did not improve patient-reported outcome over a sling for displaced proximal humerus fractures involving the surgical neck. It is the trial the panel expects you to know.

According to the JAMA 2015 report, PROFHER recruited 250 patients aged 16 or older (mean 66, 77% female) from 32 acute NHS hospitals between September 2008 and April 2011.

Surgery was fixation or head replacement by experienced surgeons; the non-surgical arm was sling immobilisation, and both arms had standardised rehabilitation.

The Oxford Shoulder Score averaged over two years was 39.07 for surgery and 38.32 for the sling, a difference of 0.75 points (95% CI -1.33 to 2.84, P=.48), against a five-point minimal clinically important difference.

Complications did not differ significantly (30 versus 23 patients), secondary shoulder surgery was 11 in each arm, and mortality was 9 versus 5, all non-significant.

The five-year follow-up (Handoll, Bone Joint J 2017) found no statistically or clinically significant difference at three, four or five years, and no secondary surgery for a new complication.

When should you operate on a proximal humerus fracture?

You operate on a proximal humerus fracture when NICE NG38 says to consider it: an open wound, tenting of the skin, vascular injury, a fracture-dislocation or a split of the humeral head.

PROFHER excluded fracture-dislocations and open fractures, so its result does not speak to those injuries; the trial supports a sling for the displaced surgical neck fracture, not for everything.

That said, a young patient with a high-energy, multi-part proximal humerus fracture is also outside the frail, low-energy population PROFHER mostly enrolled, and fixation is discussed on its merits.

The interviewer will accept surgery for a complicated injury and will push back on surgery for an uncomplicated displaced fracture in an older patient, because the evidence does not support it.

Which operation is used for a proximal humerus fracture?

The operation for a proximal humerus fracture is either fixation, usually with a locking plate or an intramedullary nail, or replacement with a hemiarthroplasty or a reverse shoulder arthroplasty.

Fixation suits a reconstructable fracture with good bone and intact tuberosities; replacement is considered for a head split, a fracture-dislocation with a non-viable head, or a four-part injury in poor bone.

In PROFHER the surgical arm received fixation or humeral head replacement at the treating surgeon's discretion, and neither approach produced a measurable advantage over the sling.

The frailty BOAST states that surgery in the frail patient should allow full weight-bearing for activities of daily living and take place within 36 hours of admission, in line with hip fracture care.

What do the NICE and BOAST standards say about proximal humerus fractures?

NICE NG38 recommendation 1.4.8 is the standard to quote for a proximal humerus fracture: offer non-surgical treatment for uncomplicated displaced low-energy injuries and consider surgery only for the five named complications.

The May 2019 BOAST on the older or frail orthopaedic trauma patient includes all patients admitted with a fragility fracture, not just hip fractures, and requires a frailty pathway with orthogeriatric collaboration.

BESS publishes patient care pathways for instability, frozen shoulder and subacromial pain, but none for proximal humerus fractures, so NG38 and PROFHER carry the weight here.

What are the complications of a proximal humerus fracture?

The complications of a proximal humerus fracture are stiffness, malunion of the tuberosities, avascular necrosis of the head, nonunion of the surgical neck, and after fixation, screw penetration and implant failure.

PROFHER recorded 30 surgical-arm and 23 non-surgical-arm patients with a complication related to surgery or the fracture, plus ten medical complications in hospital after surgery.

Axillary nerve injury and vascular injury are the acute complications to examine for at presentation and to document before any manipulation, in line with the December 2021 BOAST on peripheral nerve injury.

What is the interviewer listening for on proximal humerus fractures?

The interviewer is listening for a candidate who treats the proximal humerus fracture as a frailty presentation, quotes PROFHER accurately and names the NG38 indications for surgery without hedging.

They want to hear the Neer segments, the 1 cm or 45 degree rule, an axillary nerve examination, an axillary view, and the sling as the default with a reason.

A strong candidate adds the five-year data and the trial's exclusions, showing they know what PROFHER does and does not settle.

What are the common mistakes with proximal humerus fractures?

The commonest mistake with a proximal humerus fracture is reaching for a locking plate because the radiograph looks displaced, which is the trend PROFHER was designed to test and did not support.

Others are missing a posterior fracture-dislocation because no axillary view was taken, skipping the axillary nerve, and forgetting the bone health and falls work that the frailty BOAST requires.

Candidates also misquote PROFHER as showing surgery is harmful; it showed no significant benefit, which is a different and more defensible statement.

How this comes up at the ST3 interview

A proximal humerus fracture arrives at the ST3 T&O clinical station as a radiograph of a three-part fracture in a 74-year-old who lives alone, with the question of what you would offer her.

The follow-ups are how you classify it, what PROFHER showed, what would change your mind, which operation and why, and what else this admission needs beyond the shoulder.

orthointerview's question bank covers this in station form, with model answers and AI-marked spoken practice across 782 questions and 100 scenarios, so the PROFHER numbers are said aloud before they are needed.