Shoulder Fracture: Symptoms, Treatment & Recovery Guide

What Is a Shoulder Fracture?

A shoulder fracture is a break in one of the bones that form the shoulder joint, most commonly the proximal humerus (upper arm bone near the shoulder). These fractures account for approximately 5-6% of all fractures and are particularly common in elderly individuals with osteoporosis or young adults involved in high-energy trauma.

The shoulder is a complex ball-and-socket joint composed of three bones: the humerus (upper arm bone), the scapula (shoulder blade), and the clavicle (collarbone). When we refer to a shoulder fracture, we typically mean a fracture of the proximal humerus, which is the upper portion of the arm bone that forms the ball of the shoulder joint. This area includes the humeral head (the ball), the greater and lesser tuberosities (bony projections where muscles attach), and the surgical neck (a narrower region just below the head).

Shoulder fractures occur through two main mechanisms. In older adults, particularly those with osteoporosis, these fractures often result from low-energy trauma such as a simple fall from standing height. The weakened bone structure cannot withstand the forces generated when attempting to catch oneself during a fall, leading to fracture. In younger individuals, shoulder fractures typically require higher-energy trauma such as motor vehicle accidents, sports injuries, or falls from significant heights.

The severity of a shoulder fracture depends on several factors, including the number of bone fragments involved, the degree of displacement between fragments, and whether the blood supply to the humeral head has been disrupted. The Neer classification system, widely used by orthopedic surgeons, categorizes these fractures based on these factors. Two-part fractures involve one displaced fragment, three-part fractures involve two displaced fragments, and four-part fractures involve three or more displaced fragments. Understanding the fracture pattern is essential for determining the most appropriate treatment approach.

Anatomy of the Shoulder

To understand shoulder fractures, it helps to know the basic anatomy of the shoulder region. The proximal humerus is divided into four main parts: the humeral head, greater tuberosity, lesser tuberosity, and shaft. The rotator cuff muscles, which are crucial for shoulder movement and stability, attach to the tuberosities. When these attachment points fracture and become displaced, they can pull apart from each other, complicating healing and potentially requiring surgical intervention.

The blood supply to the humeral head is particularly important. The ascending branch of the anterior circumflex humeral artery provides most of the blood flow to the humeral head. In severely displaced fractures, this blood supply can be disrupted, leading to a condition called avascular necrosis where the bone tissue dies due to lack of blood flow. This complication is more common in four-part fractures and can significantly impact long-term outcomes.

Who Is at Risk for Shoulder Fractures?

Several factors increase the risk of sustaining a shoulder fracture. Osteoporosis is the most significant risk factor, particularly in postmenopausal women. Studies show that women are three times more likely than men to sustain proximal humerus fractures after age 50. Other risk factors include previous fractures, family history of osteoporosis, low body weight, smoking, excessive alcohol consumption, and certain medications such as long-term corticosteroids.

In younger populations, risk factors relate more to activity level and lifestyle. Athletes involved in contact sports, extreme sports, or activities with fall risk (skiing, snowboarding, cycling) face higher fracture risk. Occupations involving work at heights or with heavy machinery also increase risk. Additionally, conditions affecting balance or coordination, such as neurological disorders or inner ear problems, can increase fall risk and subsequently fracture risk.

What Are the Symptoms of a Shoulder Fracture?

Shoulder fracture symptoms include severe pain immediately after injury, significant swelling, bruising that extends to the chest and arm over 24-48 hours, inability to move the arm, and sometimes visible deformity. The arm is typically held close to the body, and any attempt to move it causes intense pain.

The symptoms of a shoulder fracture typically begin immediately following the injury and can be quite dramatic. Pain is usually severe and constant, centered around the shoulder but often radiating down the arm and into the neck. Unlike muscle strains or minor injuries where pain might be bearable, fracture pain is typically intense enough that most people instinctively protect the arm by holding it against their body with the opposite hand.

Swelling develops rapidly after a shoulder fracture, usually within the first few hours. The shoulder may appear noticeably larger than the uninjured side, and the normal contours of the shoulder joint may be obscured. This swelling results from bleeding at the fracture site and the body's inflammatory response to injury. In some cases, the swelling can extend into the upper arm and chest area.

Bruising is another hallmark symptom of shoulder fractures, though it may not appear immediately. Over the first 24-48 hours, bruising typically develops and can be extensive. It's common for bruising to extend down the arm toward the elbow and across the chest wall. The discoloration may appear dark purple or blue initially, then transition through various shades of green and yellow as healing progresses over the following weeks.

Visible Deformity and Abnormal Position

In more severe or displaced fractures, there may be visible deformity of the shoulder. The normal rounded contour of the shoulder may be lost, replaced by an abnormal shape. In some cases, a step-off or depression can be felt through the skin where the bone fragments have separated. The affected arm may hang slightly lower than the uninjured side, and the shoulder may appear flattened or squared off rather than having its normal rounded appearance.

The position of the arm itself can be telling. Most people with a shoulder fracture naturally hold their arm close to their body, often supporting it with their opposite hand. This protective posture reduces pain by minimizing movement at the fracture site. Any attempt to raise the arm away from the body or rotate it typically causes severe pain, and patients often describe a feeling of instability or that the shoulder "isn't right."

Neurological and Vascular Symptoms

Nerve and blood vessel damage can occur with shoulder fractures, particularly with severely displaced fractures or high-energy injuries. The brachial plexus (a network of nerves controlling arm movement and sensation) and the axillary artery (main blood supply to the arm) pass close to the proximal humerus and can be injured during fracture.

Warning signs of nerve involvement include numbness or tingling in the arm, hand, or fingers; weakness in specific movements; or areas of decreased sensation. The most commonly affected nerve is the axillary nerve, which can cause numbness over the outer aspect of the upper arm and weakness in raising the arm away from the body.

What Causes Shoulder Fractures?

Shoulder fractures are most commonly caused by falls onto an outstretched arm or direct trauma to the shoulder. In elderly individuals, even low-energy falls from standing height can cause fractures due to osteoporosis. Younger patients typically sustain fractures from high-energy trauma such as motor vehicle accidents, sports injuries, or falls from heights.

Understanding the mechanism of injury helps healthcare providers predict the fracture pattern and potential complications. Falls are by far the most common cause of shoulder fractures, accounting for approximately 75% of all cases. The typical scenario involves falling forward or sideways and instinctively reaching out to catch oneself. When the hand contacts the ground with the arm extended, forces are transmitted up through the arm to the shoulder. If these forces exceed the bone's strength, a fracture occurs.

The pattern of fracture depends on how the arm is positioned at the time of impact and the direction of the applied force. Falls onto an outstretched arm with the shoulder in neutral position typically cause fractures at the surgical neck of the humerus. Falls with the arm in an abducted (raised away from the body) position may result in greater tuberosity fractures. Direct blows to the outside of the shoulder, such as in contact sports, can cause various fracture patterns depending on the force and point of impact.

Age-Related Differences in Causes

The causes of shoulder fractures differ significantly between age groups, reflecting differences in bone quality, activity patterns, and lifestyle factors. In older adults (typically over 65), osteoporosis plays a central role. Osteoporotic bone has reduced density and structural integrity, meaning it cannot withstand the same forces as healthy bone. As a result, elderly individuals may sustain fractures from relatively minor trauma that would not injure a younger person.

Common scenarios in older adults include falling while walking on uneven surfaces, tripping over obstacles in the home, losing balance while getting out of bed or a chair, or slipping on wet or icy surfaces. These are all considered low-energy mechanisms, yet they can produce significant fractures when bone quality is compromised. Studies show that hip, spine, and proximal humerus fractures are the three most common osteoporotic fractures, often referred to as fragility fractures.

In contrast, younger adults typically sustain shoulder fractures only with high-energy trauma. Motor vehicle accidents (including motorcycle and bicycle accidents), falls from significant heights, and high-impact sports injuries are common causes in this population. The healthy bone in younger individuals can withstand greater forces, so when fractures do occur, they often involve more complex patterns with greater displacement and potentially more soft tissue damage.

Sports and Activity-Related Causes

Athletic activities and recreational sports contribute to a significant number of shoulder fractures, particularly in young and middle-aged adults. Contact sports such as football, rugby, hockey, and martial arts carry inherent risk of direct shoulder trauma or falls. The high speeds and unpredictable nature of these sports mean that even protective equipment may not prevent fractures from significant impacts.

Winter sports present particular risk for shoulder fractures. Skiing and snowboarding falls can generate tremendous forces, and the typical fall pattern often involves landing on an outstretched arm. Cycling accidents, whether mountain biking on trails or road cycling, frequently result in shoulder injuries when riders are thrown from their bicycles. Equestrian sports, particularly jumping and eventing, also carry significant fracture risk due to the potential for high-speed falls.

When Should You Seek Medical Care?

All suspected shoulder fractures require medical evaluation. Seek emergency care immediately if you experience numbness or tingling in the arm, inability to move the fingers, pale or blue discoloration of the hand, severe deformity, or if the injury resulted from high-energy trauma. For other suspected fractures, urgent care within 24 hours is recommended.

Determining when and where to seek care for a shoulder injury can be challenging. While not every shoulder injury is a fracture, certain symptoms strongly suggest bone injury and warrant prompt medical attention. The decision between emergency care and urgent care depends on the severity of symptoms and the mechanism of injury.

Emergency department care is appropriate when there are signs of serious injury that could threaten the limb or require immediate intervention. These include any signs of nerve or blood vessel damage (numbness, weakness, color changes in the hand), open fractures where the bone has penetrated the skin, injuries from high-energy trauma such as motor vehicle accidents, or severe deformity suggesting significant displacement. In these situations, time-sensitive evaluation and treatment may be necessary to prevent permanent damage.

For injuries without emergency warning signs but with symptoms suggesting possible fracture (moderate to severe pain, swelling, difficulty moving the arm, bruising), seeking care within 24 hours at an urgent care center, orthopedic clinic, or emergency department is appropriate. While not immediately life-threatening, delayed diagnosis and treatment of fractures can lead to complications including malunion (bone healing in wrong position), increased stiffness, and prolonged recovery.

How Is a Shoulder Fracture Diagnosed?

Shoulder fractures are diagnosed through a combination of physical examination and imaging studies. X-rays are the primary diagnostic tool, typically taken from multiple angles to assess the fracture pattern. CT scans may be ordered for complex fractures to plan surgical treatment. The doctor will also assess nerve and blood vessel function.

The diagnostic process begins with a thorough history and physical examination. The doctor will ask about how the injury occurred, the timing and nature of symptoms, previous shoulder problems or injuries, and relevant medical history including osteoporosis, medications, and allergies. This information helps guide the evaluation and treatment planning.

Physical examination includes inspection of the shoulder for swelling, bruising, and deformity, followed by gentle palpation to identify areas of tenderness and assess for crepitus (a grinding sensation that can indicate bone fragments). Range of motion testing is typically limited due to pain but provides information about the injury's severity. Crucially, the examination includes assessment of neurovascular status: checking pulses at the wrist, testing sensation in different areas of the arm and hand, and evaluating muscle strength to identify any nerve or blood vessel injury.

Imaging Studies

X-rays are the cornerstone of shoulder fracture diagnosis. A standard series includes multiple views: an anteroposterior (front-to-back) view, a lateral (side) view, and often an axillary view (taken with the arm positioned away from the body). These different angles allow the physician to visualize the fracture pattern, assess displacement, and identify how many bone fragments are present.

For complex fractures or when surgical treatment is being considered, computed tomography (CT) scanning provides detailed three-dimensional information. CT scans are particularly valuable for evaluating multi-part fractures, assessing the extent of displacement, identifying small fracture fragments that may not be visible on X-rays, and planning surgical approaches. The reconstructed three-dimensional images allow surgeons to understand the exact configuration of bone fragments and plan how to reassemble them.

Magnetic resonance imaging (MRI) is occasionally used but is not routine for most shoulder fractures. MRI may be helpful when there is concern about associated soft tissue injuries (rotator cuff tears, labral injuries) or when evaluating for complications such as avascular necrosis in follow-up imaging.

How Is a Shoulder Fracture Treated?

Treatment for shoulder fractures depends on the fracture pattern, displacement, and patient factors. Approximately 80% are treated non-surgically with sling immobilization for 2-6 weeks followed by physical therapy. Surgery (open reduction internal fixation or shoulder replacement) is reserved for severely displaced fractures, fractures with multiple fragments, or when conservative treatment fails.

The goal of treatment for shoulder fractures is to restore the best possible shoulder function while minimizing complications. This requires achieving adequate fracture healing in good alignment, maintaining range of motion, and preventing stiffness. The treatment approach must balance these sometimes competing goals while considering individual patient factors including age, activity level, bone quality, and overall health.

The decision between conservative (non-surgical) and surgical treatment depends primarily on the fracture pattern. Non-displaced or minimally displaced fractures, where the bone fragments remain in good alignment, typically heal well with conservative management. The bone has excellent healing potential when the fragments are in contact, and the surrounding muscles and soft tissues help maintain alignment during healing.

Conservative Treatment

Conservative treatment is appropriate for most shoulder fractures and forms the foundation of care even when surgery is ultimately needed. The key components include immobilization, pain management, and rehabilitation.

Immobilization typically involves a sling or shoulder immobilizer that holds the arm against the body. This reduces pain by limiting movement at the fracture site and helps maintain alignment while early healing occurs. The duration of sling use varies but is typically 2-6 weeks, depending on the fracture pattern and radiographic evidence of healing. During this period, patients are usually instructed to remove the sling several times daily for gentle elbow, wrist, and hand exercises to prevent stiffness in these joints.

Pain management includes ice application, elevation when possible, and medications. Over-the-counter pain relievers such as acetaminophen (paracetamol) and non-steroidal anti-inflammatory drugs (NSAIDs) are usually sufficient for most patients. Stronger prescription medications may be needed initially for severe pain but are typically weaned as pain improves. Sleep can be challenging in the first few weeks; many patients find it more comfortable to sleep in a recliner or propped up on pillows rather than lying flat.

Surgical Treatment

Surgery is recommended when conservative treatment is unlikely to achieve satisfactory results. Indications for surgery include severely displaced fractures where bone fragments have moved significantly apart, multi-part fractures (especially 4-part fractures), fractures where the blood supply to the humeral head is disrupted, associated injuries requiring surgical repair, and fractures that fail to heal or heal in poor alignment despite conservative treatment.

The most common surgical procedure is open reduction and internal fixation (ORIF). This involves making an incision to directly visualize the fracture, manipulating the bone fragments back into their proper positions (reduction), and holding them in place with metal hardware (internal fixation). Hardware options include plates and screws, which are most commonly used for proximal humerus fractures. The plate is contoured to fit the shape of the bone and secured with multiple screws that capture each major fracture fragment.

Shoulder replacement (arthroplasty) may be recommended for certain complex fractures, particularly in older patients. Hemiarthroplasty involves replacing only the humeral head with a metal prosthesis while preserving the natural socket (glenoid). Reverse total shoulder arthroplasty, which has become increasingly popular, replaces both the ball and socket with prosthetic components configured in a reversed orientation. This design compensates for rotator cuff deficiency, which is common in complex fractures, and can provide reliable pain relief and function even when the fracture pattern is not reconstructable.

What Is the Recovery Process for a Shoulder Fracture?

Recovery from a shoulder fracture takes 3-6 months for most patients. Bone healing occurs in 6-12 weeks, but regaining full range of motion and strength requires ongoing physical therapy. Early gentle movement is important to prevent stiffness. Most patients achieve good functional recovery, though some permanent limitation of overhead motion is common.

Understanding the recovery timeline helps set realistic expectations and ensures appropriate progress through each phase of healing. Recovery occurs in overlapping phases, each with specific goals and activities. While the timeline varies based on fracture severity, treatment type, and individual factors, most patients follow a similar general pattern.

The first phase, spanning roughly the first two weeks, focuses on pain control and protection. The fracture site is most vulnerable during this period, and the priority is allowing initial healing to begin. Pain is usually at its worst during this phase but should gradually improve. Activities are limited to gentle movements of the hand, wrist, and elbow to maintain mobility in these joints, while the shoulder itself is immobilized.

Physical Therapy and Rehabilitation

Physical therapy is essential for optimal recovery from shoulder fractures and typically begins within the first few weeks. Early therapy focuses on preventing stiffness while respecting healing constraints. As healing progresses, therapy advances through increasingly challenging exercises to restore range of motion, strength, and function.

Pendulum exercises, also called Codman exercises, are usually the first shoulder-specific exercises introduced, often starting around 1-2 weeks post-injury. These involve leaning forward and letting the arm hang, then gently swinging it in small circles using body momentum rather than active muscle contraction. This provides motion to the shoulder joint without putting stress on the healing fracture.

Passive and active-assisted range of motion exercises follow, typically starting around 4-6 weeks. In passive exercises, the therapist or patient's other arm moves the injured shoulder through its range of motion. Active-assisted exercises involve the patient contributing some muscle effort while still receiving assistance. These exercises gradually restore flexibility that would otherwise be lost due to immobilization.

Strengthening exercises begin once adequate healing has occurred, usually around 8-12 weeks for conservatively treated fractures or as directed by the surgeon for operative cases. Initial strengthening uses isometric exercises (muscle contraction without movement) and light resistance, progressing to more demanding exercises using bands, weights, and functional activities.

Expected Outcomes and Long-Term Results

Most patients with shoulder fractures achieve satisfactory functional outcomes, particularly those with less complex fracture patterns treated conservatively. However, it's important to have realistic expectations: many patients experience some permanent limitation, particularly in overhead reaching and rotation. Studies show that patient satisfaction is generally high when expectations are appropriately set, even if some limitation remains.

Factors associated with better outcomes include younger age, non-displaced or minimally displaced fractures, good bone quality, absence of associated injuries, adherence to rehabilitation, and non-smoking status. Factors associated with poorer outcomes include complex multi-part fractures, significant displacement, delayed treatment, osteoporosis, diabetes, and other medical conditions affecting healing.

Complications, while not common, can affect recovery. Shoulder stiffness (adhesive capsulitis or frozen shoulder) is the most frequent complication, occurring in up to 30% of patients. This usually improves with continued physical therapy but can occasionally require additional intervention. Malunion (healing in an abnormal position), nonunion (failure to heal), and avascular necrosis of the humeral head are less common but more serious complications that may require additional surgery.

How Can Shoulder Fractures Be Prevented?

Preventing shoulder fractures involves two main strategies: reducing fall risk and maintaining bone health. Fall prevention includes improving balance, removing home hazards, using appropriate footwear, and managing medications that affect balance. Bone health is maintained through adequate calcium and vitamin D intake, weight-bearing exercise, and treating osteoporosis when present.

Prevention of shoulder fractures is particularly important for older adults at risk of osteoporotic fractures. Since falls are the leading cause of these fractures, fall prevention strategies are paramount. Home safety modifications include removing loose rugs, improving lighting, installing grab bars in bathrooms, and keeping walkways clear of obstacles. Using appropriate footwear with non-slip soles both indoors and outdoors reduces slip risk.

Balance and strength training programs have been shown to reduce fall risk in older adults. Tai chi, in particular, has strong evidence for fall prevention and is recommended by many health organizations. Regular physical activity also helps maintain muscle mass, coordination, and reaction time, all of which help prevent falls. Vision and hearing should be checked regularly, as deficits in these senses increase fall risk.

Bone Health and Osteoporosis Management

Maintaining strong bones is crucial for preventing fragility fractures. Adequate calcium intake (1000-1200 mg daily from diet and supplements if needed) and vitamin D (600-800 IU daily, higher doses for those with deficiency) support bone health. Weight-bearing exercise stimulates bone formation and helps maintain bone density. This includes walking, jogging, dancing, and resistance training.

For individuals diagnosed with osteoporosis, medication treatment can significantly reduce fracture risk. Bisphosphonates, denosumab, and other osteoporosis medications have been proven to reduce fracture rates. Those who have already had a fragility fracture are at high risk for additional fractures and should be evaluated for osteoporosis treatment if not already receiving it.

Lifestyle factors also affect bone health. Smoking accelerates bone loss and should be avoided. Excessive alcohol consumption (more than 2 drinks daily) increases fracture risk both through effects on bone and increased fall risk. Maintaining a healthy body weight is also important, as both underweight and obesity are associated with increased fracture risk.