Proximal humerus (upper arm) fracture rehabilitation: sling to strength

A proximal humerus fracture is a break in the upper end of the arm bone. It usually follows a fall from standing height in an older adult with weakened bone, and so belongs with fragility fractures. The NHS advises over-50s with a broken arm to ask their GP about a fracture liaison service, which looks at bone health to prevent further breaks.

The PROFHER-2 protocol summarises the earlier PROFHER trial, which found that surgery was not superior to non-surgical treatment for the majority of adults with displaced fractures. That finding is why many people go home with a sling and a physiotherapy referral rather than an operation.

In the PROFHER-2 pathway a sling is worn for 3 weeks, mainly for comfort, and participants receive a sling-care leaflet at the start. The aim is to settle pain while the break begins to stabilise. The clinician study explains the biology: about a week after the break the blood clot organises and a soft callus forms, a stage often associated with reduced pain and the opportunity to begin gentle movement.

Your fracture clinic will say which other joints to keep moving in the meantime, and the NHS recommends following any exercise advice you are given. The NHS also advises that a broken arm with numbness, tingling, a changed shape or bone showing through the skin needs A&E or 999, and that worsening pain, a large amount of swelling or bruising, or an arm that is very stiff or hard to move needs NHS 111.

After the sling period the arm is mobilised gently under a physiotherapist's supervision, with the aim of increasing range of movement and performing active exercises as tolerated. PROFHER-2 describes sessions tailored to the person, with a home programme based mainly on daily functional tasks, and a combination of exercise, soft tissue techniques, joint mobilisation, stretching and relaxation.

The number of sessions reflects the severity of the fracture. The protocol allows a median of 12 sessions for 3- and 4-part fractures, higher than the eight used in the PROFHER trial. Your own course will depend on your physiotherapy service, and timings are individual.

The clinician study describes what happens in practice: sling use is still often recommended for up to six weeks, and the term early sling removal has no standard definition. Its focus groups of UK surgeons, therapists and nurses identified pain and fear of harm as barriers, along with limited evidence and surgeon-led decision making.

A systematic review brought together six randomised trials comparing movement within one week of injury with movement after three or four weeks of immobilisation. Patient-reported function and pain were similar at all time points except a modest advantage for early movement in combined function scores at three months. Secondary displacement and complications were not significantly different. The authors conclude that early mobilisation is safe for non-surgically managed fractures, although the pooled studies were few and could not be split by fracture type.

Some complex 3- and 4-part fractures in older adults are treated by reverse shoulder replacement or hemiarthroplasty, and PROFHER-2 is testing these against non-surgical care. After either operation the trial protocol provides a supportive sling for comfort and a graduated programme, based on guidance agreed by British Elbow and Shoulder Society physiotherapists.

That guidance recommends supervised physiotherapy to build range of movement and function gradually. Because a reverse replacement is more prone to dislocation, the movement of placing the hand behind the back is avoided in the early stage. Our guide to rehabilitation after shoulder replacement covers the stages in more detail.

The PROFHER-2 protocol notes that if pain stays severe or function remains poor after non-surgical treatment, delayed surgery can be considered at the clinician's discretion, and that this would not usually be considered before six months. That timeframe gives rehabilitation a fair chance, because much improvement happens slowly after this kind of break.

Ask your team about sleeping positions, help with dressing and washing while the arm is in the sling, and when driving is acceptable. Because the injury often follows a fall, it is also reasonable to ask about a falls assessment, and about the fracture liaison service and bone health if you are over 50.