Early Mobilization for Proximal Humerus Fractures
For nonoperatively managed proximal humerus fractures, initiate passive mobilization within 1-3 days of injury rather than immobilizing for 3 weeks, as this approach significantly improves shoulder function, reduces pain, and does not compromise fracture healing.
Evidence-Based Mobilization Protocol
Immediate Phase (Days 1-3 Post-Injury)
Begin passive range of motion exercises within 1-3 days for impacted, minimally displaced proximal humerus fractures managed nonoperatively, as this produces superior Constant scores at 6 weeks (difference of 10.1 points, p=0.02) and 3 months (difference of 9.9 points, p=0.02) compared to 3-week immobilization 1
Start pendulum exercises on post-injury day 1, as this is the most common timing reported across rehabilitation protocols 2
Use sling immobilization for comfort only during the first 1-3 weeks, not as a strict immobilization device, since 1 week of immobilization produces better pain scores and equivalent functional outcomes compared to 3 weeks 3
Early Active Phase (Weeks 1-3)
Progress to active-assisted range of motion at 3 weeks post-injury, as this is the most commonly reported timing in systematic reviews of rehabilitation protocols 2
Patients beginning immediate physiotherapy experience significantly less pain (between-group difference of 15.7 on visual analog scale, p=0.04) and better active forward elevation (28.1 degrees better at 6 weeks, p=0.01) compared to delayed mobilization 1, 4
Progressive Strengthening Phase (Weeks 4-6)
Initiate strengthening exercises at 6 weeks post-injury, as this is the most common timing across published protocols 2
Remove all activity restrictions at 6 weeks for uncomplicated fractures, as this timing aligns with typical fracture healing and is most commonly reported 2
Critical Safety Considerations
This early mobilization approach is safe for impacted, nonoperatively treated fractures, with no complications in displacement or nonhealing documented in randomized trials 1
Ensure CT imaging has been obtained to accurately characterize the fracture pattern before initiating early mobilization, as CT changes management in up to 41% of cases by revealing complexity not apparent on radiographs 5, 6
Assess for associated rotator cuff tears, which occur in up to 40% of proximal humerus fractures, as these may require modified rehabilitation or surgical intervention 5, 7
Surgical Management Considerations
For fractures requiring surgical fixation (displaced, comminuted, or unstable patterns):
Early passive mobilization starting on postoperative day 2 is safe when modern locked intramedullary nailing with proximal angular stability is used, producing better Constant scores at 3 and 6 months without loss of reduction 8
Three-week delayed mobilization after plate fixation remains common practice, though emerging evidence suggests earlier mobilization may be beneficial if fixation is stable 2
Common Pitfalls to Avoid
Do not routinely immobilize stable proximal humerus fractures for 3 weeks, as this produces worse pain and functional outcomes at 3-6 months with no benefit in fracture healing 1, 4, 3
Do not rely solely on radiographs to determine fracture stability before initiating early mobilization, as CT is superior for characterizing fracture patterns and displacement 5, 6
Do not assume all proximal humerus fractures can be mobilized early—displaced fractures, fracture-dislocations, and those with significant comminution require individualized assessment and often surgical stabilization before mobilization 7, 9