February 2026

ORTHOPAEDICS

CASE REPORT: ACUTE 4-PART PROXIMAL HUMERUS FRACTURE TREATED WITH REVERSE TOTAL SHOULDER ARTHROPLASTY

Featuring: Matthew D Saltzman, MD
A 63-year-old woman sustained a traumatic shoulder injury after a fall in her home. Prior to the incident, she had no history of shoulder problems.

Case Presentation
The patient presented approximately one week after the fall with significant pain and an inability to use her arm effectively. Initial radiographs demonstrated a comminuted, displaced proximal humerus fracture. Further evaluation confirmed that this was a four-part fracture, representing the most severe pattern of proximal humerus injury, with multiple misaligned fragments and compromised vascularity to the humeral head.

Diagnostic Workup
The diagnostic evaluation included standard shoulder X-rays and a CT scan with 3D reconstruction. The CT imaging clearly showed the severity of displacement, fragmentation and loss of structural integrity. The 3D reconstruction visualized the relationship of the fracture fragments and helped clinicians determine that fixation would be unreliable due to poor vascularity and the extent of comminution.


Surgical Strategy and Procedure
Given the degree of displacement and compromised blood supply to the bone fragments, reverse total shoulder arthroplasty was recommended as the most predictable treatment.

The humeral head was removed because it no longer had adequate soft tissue attachments to maintain viability. A fracture-specific reverse shoulder prosthesis was implanted. The greater and lesser tuberosities were anatomically repositioned and secured using heavy, permanent sutures to ensure stability during the six-week healing period.

Intraoperative fluoroscopy was used to confirm alignment, reduction of fracture fragments and proper placement of the prosthesis. The surgery proceeded without complications, and the patient remained overnight due to being far from home.
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​Post-op
The patient was placed in a sling for six weeks with permission for light activities. She experienced normal post-op discomfort but progressed well, eventually discontinuing narcotic pain medication. At her six-week follow-up visit, she will begin physical therapy, including controlled overhead motion. Full recovery is expected to take six to 12 months.

Clinical Significance
  • This case highlights the need for timely surgical intervention, within three to four weeks, for severe proximal humerus fractures.
  • Reverse total shoulder arthroplasty offers a reliable reconstructive approach when blood supply is compromised and fracture fragments are not viable.
  • High‑quality imaging plays a pivotal role in both diagnosis and surgical planning.
Dr. Salzman recently joined WGN Radio to explain the complex fracture sustained by the patient and the successful reverse shoulder arthroplasty performed.
Listen now >
Matthew D. Saltzman, MD
Professor, Orthopaedic Surgery ​at Northwestern Medicine

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