Proximal Humerus Fracture Rehabilitation: Neer Classification and Elevation Milestones

Proximal humerus fractures are the third most common fracture in older adults, frequently resulting from a simple fall from standing height in osteoporotic bone, or high-energy trauma in younger patients. The definitive Neer classification categorizes these fractures based on the displacement (greater than 1 centimeter) or angulation (greater than 45 degrees) of four anatomical segments: the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft. One-part and minimally displaced two-part fractures are successfully managed non-operatively in a sling, whereas displaced two-part, three-part, and select four-part fractures often require open reduction and internal fixation (ORIF) with a proximal humeral locking plate (PHILOS) or reverse total shoulder arthroplasty in elderly patients. Physiotherapy must respect healing bone and rotator cuff insertions, progressing systematically from passive pendulum swings to active-assisted elevation and overhead function.

Domestic and Cultural Indian Realities

Living with a healing shoulder fracture in an Indian domestic setting requires practical modifications. Bathing traditionally with a bucket and mug (lota) involves bilateral lifting and overhead pouring; patients must use a lightweight plastic cup with the uninjured arm or install a handheld telephone shower at waist height. Dressing into traditional clothing like sarees, kurtas, or blouses requires reaching behind the torso; patients should always slip the injured arm into the sleeve first and avoid internal rotation behind the back for 8 weeks. Sleeping flat on a bed can cause posterior sagging of the humeral head and intense nocturnal pain; patients must sleep semi-recumbent in an armchair or use three wedge pillows supporting the back, with a small folded towel under the elbow to prevent arm extension. Reaching for high kitchen shelves, overhead temple bells, or clotheslines is strictly avoided until full active elevation is cleared.

Clinical Biomechanics and Anatomical Healing

The glenohumeral joint possesses the greatest range of motion of any joint in the body, sacrificing bony stability for mobility. In two-part surgical neck fractures, the pectoralis major pulls the shaft anteromedially, while in greater tuberosity fractures, the supraspinatus and infraspinatus displace the tuberosity superiorly and posteriorly. Uncontrolled active shoulder abduction creates powerful rotator cuff contraction that can avulse tuberosity fragments or pull screws out of soft osteoporotic bone. Passive elevation in the scapular plane (scaption: 30 to 45 degrees anterior to the coronal plane) aligns the humeral head with the glenoid fossa, minimizing capsular tension and shear across the tuberosities while preventing subacromial impingement.

Validated Special Tests and Differential Diagnosis

Clinical examination monitors axillary nerve integrity by evaluating skin sensation over the lateral deltoid (the regimental badge area) and checking for isometric deltoid contraction. Range of motion is measured using a goniometer in supine passive elevation and external rotation. Differential diagnosis rules out concomitant glenohumeral dislocation, rotator cuff tear, and brachial plexus injury using true AP, scapular Y, and axillary radiographs.

Stage-by-Stage Functional Recovery Protocol

Phase 1 (Weeks 0 to 3) immobilises the arm in a sling, permitting active elbow, wrist, and hand exercises, along with gentle Codman pendulum swings and passive external rotation limited to 20 degrees. Phase 2 (Weeks 3 to 6) introduces passive and active-assisted forward elevation in the scapular plane using a cane or overhead pulley, keeping elevation below 90 degrees until week 4, then progressing to 120 degrees. Phase 3 (Weeks 6 to 12) begins active unassisted elevation, isometric rotator cuff strengthening, and scapular stabilization exercises once radiographic union demonstrates bridging bone.

Red Flags and Urgent Surgical Indicators

Seek immediate orthopaedic assessment if you notice loss of sensation over the lateral deltoid badge area accompanied by weakness in lifting the arm, indicating axillary nerve neuropraxia. Sudden displacement or a grinding sensation in the shoulder accompanied by severe pain signals screw cut-out into the glenoid joint or fixation collapse. Spreading shoulder redness, fever, or fluid drainage from surgical portals indicates infection.

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