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Proximal Humerus Fracture PDF Evidence

A hand-drawn illustration of a fractured upper arm bone just below the shoulder.
X-ray showing a fracture at the top of the upper arm bone, just below the shoulder joint. Kieran Hirpara 4.0

Proximal humerus fractures — Neer classification, sling management, and surgical options.

What you're feeling

You will likely feel pain in your upper arm and shoulder area. This pain often comes from a break in the bone near the shoulder joint. If your fracture is linked to weak bones, known as osteoporosis, the pain may be part of a larger pattern of fragility injuries. Nondisplaced fractures, where the bone pieces stay in place, are common in this group. Even when the bone does not shift, these breaks can still cause significant disability and lower your overall sense of health.

The pain tends to worsen with movement. You may find it difficult to lift your arm or reach overhead. Simple daily tasks become challenging. You might struggle to tuck in your shirt or reach behind your back to fasten a bra. Lifting objects, even light ones, can trigger sharp discomfort. Because the shoulder is unstable, any effort to use the arm can aggravate the injury.

Resting the arm usually helps reduce the pain. However, you may still experience flare-ups at night. Many patients report that sleeping on the affected side is painful or impossible. Waking up with a stiff or aching shoulder is common. Your surgeon will guide you on how to position yourself for comfort while protecting the healing bone.

If you are under 65, your surgeon may discuss whether surgery offers clear benefits over non-surgical care. For many adults in this age group, the evidence does not show a strong advantage for operation. Most one-part fractures heal well without surgery. Older adults also frequently receive nonoperative treatment. Regardless of your age, the goal is to manage your pain and protect the bone while it heals. Complications can occur at different stages, so your team will monitor you closely. You are not alone in this process; your care team is there to support your recovery and help you regain function safely.

What's actually happening

Your shoulder is a ball-and-socket joint where the upper arm bone meets your shoulder blade. The top of your arm bone has two small bumps called tuberosities. These bumps act like anchor points for the rotator cuff tendons. These tendons are strong ropes of fibers that lift and rotate your arm. When you fracture the top of your arm bone, these anchor points can shift out of place.

If the tuberosities move downward, the tendons lose their proper tension. This pulls the joint mechanics out of alignment. Even a small shift of 15 degrees can change how the joint moves and bears weight. This misalignment causes pain and limits your movement. It also makes it harder for the joint to heal in the correct position.

The joint capsule is the sleeve around the shoulder. It holds the joint together and produces fluid to keep things slippery. After a fracture, this capsule can become stiff or scarred. This stiffness, along with any damage to the tendons, reduces your strength and range of motion. Your surgeon needs to restore the anatomy so these tissues can work together again.

For many people, especially older adults, the bone fragments are too broken to fix with plates and screws. In these cases, your surgeon may recommend a joint replacement. This procedure replaces the damaged ball with a metal and plastic implant. This option is often chosen when getting your arm moving again is the top priority. It provides stable support and allows you to regain function even if the original bone structure is severely compromised.

What we can do about it

Most one-part fractures heal well without surgery. In fact, nonsurgical management is the standard for the vast majority of cases. Your surgeon will likely recommend a period of immobilization to let the bone knit. You can expect short and long periods of rest to yield similar results, regardless of the fracture pattern. This approach is especially common for older adults and children, whose bones have tremendous potential for remodeling.

During this time, physiotherapy plays a key role. Your therapist will guide you through gentle movements to restore range of motion. The goal is to prevent stiffness while protecting the healing bone. For displaced two-part fractures in patients aged 60 or older, studies show no significant difference in outcomes at two years between surgery and non-operative treatment. Therefore, your surgeon may advise you to give conservative care a fair chance before considering more invasive options.

Pain management is essential for your comfort. Your surgeon may prescribe pain medication or anti-inflammatories to control swelling and discomfort. While the evidence highlights the success of non-operative care, it does not detail specific injection protocols like cortisone or PRP for this fracture type. Instead, focus on adhering to your immobilization schedule and attending physiotherapy sessions. Consistent effort during these early weeks sets the foundation for your recovery.

Surgery is considered only when conservative care reaches its limit or when the fracture pattern is complex. This typically involves more severe breaks, such as three- or four-part fractures in older patients, where the bone fragments are significantly displaced. In these cases, your surgeon might recommend a procedure to stabilize the bone, such as using a nail and plate system or, in some instances, a reverse total shoulder replacement. These options aim to restore function and provide long-term durability when the bone cannot heal properly on its own. The decision depends on your age, the specific fracture pattern, and your overall health.

What to expect

Your outlook depends largely on your age and how many bone fragments are involved. Most one-part fractures heal well without surgery. For older adults, nonoperative treatment often leads to good functional results. However, if you are over sixty, your surgeon may recommend surgery for complex three- or four-part fractures. In these cases, a new nail and plate system or a reverse shoulder replacement can provide better long-term function than leaving the fracture alone.

Recovery is a gradual process. For nonoperative cases, short and long periods of immobilization yield similar results. You do not need to worry about the exact length of rest changing your final outcome. If you have surgery, the timing of the operation beyond five days does not impact your final results. This gives your care team flexibility to plan safely. Most patients with complex fractures treated with surgery achieve good long-term outcomes, even though complication rates are high.

Be aware that your risk of serious health events is higher after this injury. The risk of death within one year is 9.8%. This risk continues to increase to 28.2% at five years. This elevated mortality risk exists regardless of other health factors. It is important to stay active and follow your surgeon’s advice to maintain your overall health during recovery.

If you undergo a reverse shoulder replacement, your function may improve significantly compared to nonoperative treatment. However, some patients notice a decrease in functionality and quality of life over time. This change occurs after the two-year mark but is generally not considered clinically relevant. Most pediatric patients recover fully with few complications. For adults under sixty-five, surgery does not always offer a clear benefit over nonoperative management. Your surgeon will weigh these factors to choose the path that best supports your daily life.

When to see someone

See your GP if pain does not improve with rest. Ask for a specialist review if you feel weakness or instability in your shoulder. Contact your surgeon if your arm locks or gives way. Seek care if symptoms interfere with your sleep or work. Sudden worsening of pain requires immediate attention. Most one-part fractures heal well without surgery. However, complications can occur at any stage. Mortality risk is high for fragility fractures in older adults. One-year mortality is 9.8%. Five-year mortality rises to 28.2%. Nonunion risk is higher than once thought. Do not ignore persistent symptoms. Early evaluation helps your surgeon choose the right path.

Reviewed by AI synthesis (v2) — pending human review · 2026-05-18 19:02:24.913419+00:00.

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For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

title: "Proximal Humerus Fracture" slug: proximal-humerus-fracture region: shoulder audience: patient mesh_terms: ["Shoulder Fractures", "Bone Plates", "Humerus", "Humeral Fractures", "Fracture Fixation, Intramedullary", "Fracture Fixation", "Bone Nails", "Fracture Healing"] article_count: 1090 model_used: Qwen3.6-35B-A3B-Q8_0.gguf generated_at: '2026-06-16T19:38:31+00:00' key_articles: - title: "Management of proximal humerus fractures in adults" ref_num: 1 evidence_tier: paper evidence_level: 4 doi: 10.5312/wjo.v5.i5.685 year: 2014 - title: "Evaluation and Management of Proximal Humerus Fractures" ref_num: 2 evidence_tier: paper evidence_level: 4 doi: 10.1155/2012/861598 year: 2012 - title: "How age and gender influence proximal humerus fracture management in patients older than fifty years" ref_num: 3 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jseint.2021.11.007 year: 2022 - title: "Trending a decade of proximal humerus fracture management in older adults" ref_num: 4 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jseint.2021.08.006 year: 2022 - title: "Long-term outcome of a proximal humerus fracture predicted after 1 year" ref_num: 6 evidence_tier: paper evidence_level: 3 doi: 10.1080/17453670510041295 year: 2005 - title: "Consensus statement on the treatment of proximal humerus fractures: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons" ref_num: 7 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2024.12.005 year: 2025 - title: "Low arthroplasty survival after treatment for proximal humerus fracture sequelae: 3,245 shoulder replacements from the Nordic Arthroplasty Register Association" ref_num: 9 evidence_tier: paper evidence_level: 3 doi: 10.1080/17453674.2020.1793548 year: 2020 - title: "Evaluation and Management of Pediatric Proximal Humerus Fractures" ref_num: 12 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-14-00033 year: 2015 - title: "Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review" ref_num: 13 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.xrrt.2023.01.002 year: 2023 - title: "Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center" ref_num: 14 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2022.03.006 year: 2022 - title: "Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis" ref_num: 15 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.xrrt.2021.04.014 year: 2021 - title: "Randomized controlled trials investigating proximal humerus fractures lack consensus in inclusion criteria" ref_num: 16 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.xrrt.2025.07.023 year: 2025 - title: "A comprehensive update on current fixation options for two-part proximal humerus fractures" ref_num: 17 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.injury.2013.08.024 year: 2014 - title: "Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae" ref_num: 18 evidence_tier: paper evidence_level: 2 doi: 10.1177/17585732221150785 year: 2023 - title: "Epidemiology of proximal humerus fractures managed in a trauma center" ref_num: 19 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.otsr.2012.05.013 year: 2012 - title: "No change in outcome ten years following locking plate repair of displaced proximal humerus fractures" ref_num: 20 evidence_tier: paper evidence_level: 3 doi: 10.1007/s00590-021-03099-6 year: 2021 - title: "Three or four parts complex proximal humerus fractures: Hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases" ref_num: 21 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.otsr.2008.09.002 year: 2009 - title: "Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures – a propensity score matched comparison" ref_num: 22 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-023-06669-3 year: 2023 - title: "Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up" ref_num: 23 evidence_tier: paper evidence_level: 4 doi: 10.1007/s00590-010-0655-z year: 2010 - title: "Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures" ref_num: 24 evidence_tier: paper doi: 10.1016/j.otsr.2016.09.022 year: 2017 - title: "CORR Insights®: Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database" ref_num: 25 evidence_tier: paper evidence_level: 5 doi: 10.1097/corr.0000000000002430 year: 2022 - title: "Outcomes after percutaneous reduction and fixation of proximal humeral fractures" ref_num: 26 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2006.09.006 year: 2007 - title: "Proximal Humeral Fracture Treatment in Adults" ref_num: 27 evidence_tier: paper evidence_level: 5 doi: 10.2106/jbjs.l.01293 year: 2014 - title: "Automated detection and classification of the proximal humerus fracture by using deep learning algorithm" ref_num: 28 evidence_tier: paper evidence_level: 4 doi: 10.1080/17453674.2018.1453714 year: 2018 - title: "Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures" ref_num: 29 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2020.10.024 year: 2021 - title: "Reverse Shoulder Arthroplasty for Proximal Humerus Fracture" ref_num: 30 evidence_tier: paper evidence_level: 4 doi: 10.1007/s12178-020-09597-0 year: 2020 - title: "Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock" ref_num: 31 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.injury.2015.05.017 year: 2015 - title: "Classification and Imaging of Proximal Humerus Fractures" ref_num: 32 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.ocl.2008.05.002 year: 2008 - title: "Biomechanical Assessment Of Inferior Tuberosity Placement During Hemiarthroplasty For 4-Part Proximal Humerus Fractures G." ref_num: 33 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2007.02.110 year: 2007 - title: "Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures" ref_num: 35 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2020.03.022 year: 2020 - title: "Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures" ref_num: 36 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2010.06.005 year: 2011 - title: "CORR Insights®: What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?" ref_num: 37 evidence_tier: paper evidence_level: 5 doi: 10.1097/corr.0000000000002242 year: 2022 - title: "New trends in fixation of proximal humeral fractures: A review" ref_num: 38 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.injury.2010.10.016 year: 2011 - title: "Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial" ref_num: 39 evidence_tier: paper evidence_level: 1 doi: 10.1371/journal.pmed.1002855 year: 2019 - title: "Biomechanical Assessment Of Inferior Tuberosity Placement During Hemiarthroplasty For 4-Part Proximal Humerus Fractures" ref_num: 40 evidence_tier: abstract evidence_level: 5 doi: 10.1016/j.jse.2007.02.027 year: 2007 - title: "Readmissions, revisions, and mortality after treatment for proximal humeral fractures in three large states" ref_num: 41 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-019-2812-9 year: 2019 - title: "Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humerus fractures in elderly patients: results from a prior randomized clinical trial" ref_num: 44 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2024.09.032 year: 2025 - title: "The Mayo-FJD Classification System For Proximal Humerus Fractures: Intra And Interobserver Agreement" ref_num: 45 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2023.02.035 year: 2023 - title: "Biomechanical investigation of arm position on deforming muscular forces in proximal humerus fractures" ref_num: 46 evidence_tier: paper evidence_level: 5 doi: 10.5397/cise.2022.00885 year: 2022 - title: "Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment" ref_num: 48 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2011.01.025 year: 2011 - title: "Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures" ref_num: 49 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.aott.2016.10.003 year: 2020 - title: "The reliability of the Neer classification for proximal humerus fractures: a survey of orthopedic shoulder surgeons" ref_num: 50 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jseint.2022.02.006 year: 2022 - title: "Standard compared with fracture-specific components in reverse shoulder arthroplasty for proximal humerus fractures" ref_num: 51 evidence_tier: paper evidence_level: 1 doi: 10.1302/0301-620x.107b9.bjj-2024-1508.r2 year: 2025 - title: "What Are the Long-term Outcomes of Locking Plates for Nonosteoporotic Three-part and Four-part Proximal Humeral Fractures With a Minimum 10-year Follow-up Period?" ref_num: 52 evidence_tier: paper evidence_level: 3 doi: 10.1097/corr.0000000000002895 year: 2023 - title: "Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: A prospective study" ref_num: 54 evidence_tier: paper evidence_level: 2 doi: 10.4103/0973-6042.118911 year: 2013 - title: "Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores" ref_num: 57 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jseint.2024.02.003 year: 2024 - title: "Biology and Biomechanics in Osteosynthesis of Proximal Humerus Fractures" ref_num: 58 evidence_tier: paper evidence_level: 4 doi: 10.1007/s00068-007-7089-2 year: 2007 - title: "Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database" ref_num: 59 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jseint.2024.02.005 year: 2024 - title: "Proximal humeral fractures with minimal displacement treated conservatively" ref_num: 63 evidence_tier: paper doi: 10.1007/s00264-004-0552-3 year: 2004 - title: "Biomechanical study of two different fixation methods for the treatment of Neer III proximal humerus fractures" ref_num: 64 evidence_tier: paper evidence_level: 5 doi: 10.1186/s12891-024-08216-0 year: 2024 - title: "Open Reduction and Internal Fixation of Proximal Humerus Fractures" ref_num: 65 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.ocl.2008.06.003 year: 2008 - title: "Reverse Total Shoulder Arthroplasty Patients with a Proximal Humerus Fracture Have Significantly Worse Perioperative Outcomes than Other Indications: An Analysis of 5644 Cases" ref_num: 67 evidence_tier: abstract evidence_level: 3 doi: 10.1016/j.jse.2015.05.005 year: 2015 - title: "Proximal third humeral shaft fractures—A fracture entity not fully characterized by conventional AO classification" ref_num: 69 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.injury.2013.10.030 year: 2014 - title: "Does primary treatment of proximal humerus fractures show favourable functional outcomes over secondary treatment with reverse shoulder arthroplasty?" ref_num: 72 evidence_tier: paper evidence_level: 3 doi: 10.1177/17585732231190038 year: 2023 - title: "Reverse shoulder arthroplasty for proximal humerus fractures: Is the glenoid implant problematic?" ref_num: 74 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.otsr.2018.06.008 year: 2018 - title: "ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures" ref_num: 75 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2023.08.022 year: 2024 - title: "Detection, classification, and characterization of proximal humerus fractures on plain radiographs" ref_num: 76 evidence_tier: paper evidence_level: 3 doi: 10.1302/0301-620x.106b11.bjj-2024-0264.r1 year: 2024 - title: "CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures" ref_num: 79 evidence_tier: paper evidence_level: 5 doi: 10.1097/corr.0000000000002017 year: 2021 - title: "Shoulder dislocation combined with proximal humerus fracture in children" ref_num: 83 evidence_tier: paper evidence_level: 5 doi: 10.1097/md.0000000000008977 year: 2017 - title: "Delays beyond 5 days to surgery does not affect outcome following plate and screw fixation of proximal humerus fractures" ref_num: 84 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2025.02.019 year: 2025 synthesis_version: "v2" verifier_status: skipped

Overview

  • Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults [1].
  • Most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [4].
  • Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [8].
  • The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years [15].
  • Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade [3].
  • Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [12].
  • Patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures after surgical treatment [29].
  • Guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin [29].
  • The selection of reverse total shoulder arthroplasty (RTSA) over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients [25].
  • Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications [67].
  • Prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures [17].
  • Besides age, most randomized controlled trials on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria [16].

Anatomy & Pathophysiology

  • Inferior tuberosity displacement after prosthetic reconstruction of shoulder fractures is associated with diminished functional results [33].
  • Inferior tuberosity positioning after hemiarthroplasty for proximal humerus fractures is associated with diminished function [40].
  • Range of motion and strength thresholds can identify subjects with normal shoulder function [36].
  • Shoulder flexion, extension, and abduction are only moderately correlated with patient-reported outcome measures (PROMs) [57].
  • Holistic assessment of outcomes requires both subjective and objective outcomes [57].
  • The changed position of the humeral head on the coronal plane does not affect final functional results in conservatively treated displaced proximal humerus fractures in the elderly [54].
  • Bone quality significantly impacts implant anchorage in osteosynthesis for proximal humerus fractures [58].
  • Positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures [46].
  • Rotator cuff tears are a detrimental factor and a major cause of painful shoulders in proximal humeral fractures with minimal displacement treated conservatively [63].
  • The double plate strategy can increase the stability of the medial column of the proximal humerus and enhance the overall biomechanical property of the repaired proximal humerus [64].
  • Reverse shoulder arthroplasty could be considered primary treatment for proximal humerus fractures, especially when optimal range of motion is of great importance to the patient [72].
  • Glenoid loosening and severe scapular notching in reverse shoulder arthroplasty for proximal humerus fractures are related to poor positioning and/or incorrect orientation of the glenosphere [74].

Classification

  • Proximal humerus fractures are osteoporotic injuries with increasing incidence due to aging populations [5].
  • Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions [5].
  • Evaluation of classification systems for fractures of the proximal humerus with plain radiographs has yielded low interobserver reliability [32].
  • The Mayo-FJD classification system for proximal humerus fractures allows high intraobserver and interobserver agreement using both radiographs and computed tomography [45].
  • The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [28].
  • Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized [50].
  • Current diagnosis coding practices (ICD-10) do not adequately capture the fracture complexity needed to conduct subgroup analysis for proximal humerus fractures [75].
  • There is clear evidence of specific characteristics which differentiate proximal third humeral shaft fractures from those of midshaft and distal third [69].

Clinical Presentation

  • Proximal humerus fractures are osteoporotic injuries with increasing incidence due to aging populations [5].
  • Proximal humerus fractures are now typically osteoporotic fractures in women over 70, with prevalence increasing due to an aging population in poor general condition [19].
  • There is a substantial mortality in patients with a proximal humerus fracture [6].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [14].
  • Surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year [6].
  • Complications associated with proximal humerus fractures are varied and can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [11].
  • Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [12].
  • Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population [13].
  • Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade [3].
  • Surgical treatment of proximal humerus fractures remains far from straightforward, with unpredictable outcomes where factors associated with poor results include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension [37].
  • Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae [18].
  • Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae [18].

Investigations

  • Proximal humerus fractures are osteoporotic injuries with increasing incidence due to aging populations [5].
  • Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions in proximal humerus fractures [5].
  • Computed tomography improves the diagnostic accuracy of the Boileau classification of proximal humerus fracture sequelae [18].
  • Computed tomography does not improve the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae [18].
  • Computed tomography scan is more specific than radiographs in the assessment of proximal humerus fracture sequelae [18].
  • Artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [28].
  • Convolutional neural networks proficiently rule out proximal humerus fractures on plain radiographs [76].
  • The routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities [79].
  • The routine use of 3D-printed models should be avoided as the sole determinant for recommending surgical intervention in proximal humeral fractures [79].
  • In children with shoulder dislocation combined with proximal humerus fracture, bilateral anteroposterior shoulders x-ray is suggested routinely to confirm shoulder location in addition to palpation and anteroposterior and lateral humeral x-ray [83].

Treatment

Non-Operative Management

  • Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults [1].
  • In the vast majority of cases, proximal humerus fractures may be treated nonoperatively [2].
  • Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [4].
  • Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [8].
  • Non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention [24].
  • There is little utility to the routine use of postoperative radiographs in follow-up of pediatric proximal humerus fractures [24].
  • Proximal humerus fractures in children have tremendous potential for remodeling, making non-operative management the treatment of choice for most fractures [56].
  • Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [27].
  • A majority of patients with proximal humeral fractures underwent non-operative treatment [41].
  • Nonsurgical management of proximal humerus fractures decreased during the study period [35].
  • Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures [48].
  • Nonsurgical treatment provides better midterm outcomes compared to locking plate fixation for proximal humeral fractures [48].
  • There is no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus [39].
  • The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years [15].
  • Evidence-based recommendations to guide treatment of proximal humerus fractures are lacking, and no good evidence exists whether surgery is clearly superior to nonoperative treatment [65].

Operative Management

  • Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population [13].
  • Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [7].
  • Most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria [16].
  • Hemiarthroplasty and reverse prosthesis are indicated for complex proximal humerus fractures in patients no younger than 70 years of age [21].
  • Reverse total shoulder replacement is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [22].
  • The selection of RTSA over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients [25].
  • Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [26].
  • No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [38].
  • Minimally invasive plate osteosynthesis (MIPO) with PHILOS plate is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent [49].
  • There are no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in reverse shoulder arthroplasty (RSA) for proximal humerus fractures [51].

Complications

  • Proximal humerus fractures are associated with substantial mortality [6].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [14].
  • Surviving patients with proximal humerus fractures frequently have persistent symptoms that can be predicted as early as after 1 year [6].
  • Complications associated with proximal humerus fractures are varied and can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [11].
  • Low arthroplasty survival is observed after treatment for proximal humerus fracture sequelae [9].
  • Patients with pathologic humerus fractures have significantly higher complication rates compared with native humerus fractures after surgical treatment [29].
  • Guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin [29].
  • Predictive models using machine learning techniques demonstrate favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged length of stay and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture [59].
  • Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [12].

Recovery

  • Both age and gender are associated with the definitive treatment received for proximal humerus fractures in patients older than fifty years [3].
  • Most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [4].
  • Treatment algorithms and outcomes for proximal humerus fractures in patients aged 60 years or younger are distinctly different from those in a more elderly population [13].
  • Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [27].
  • Long-term treatment with reverse shoulder arthroplasty (RSA) for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time [44].
  • There is substantial mortality in patients with a proximal humerus fracture, and surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year [6].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [14].
  • Complications associated with proximal humerus fractures are varied and can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [11].
  • Low arthroplasty survival is observed after treatment for proximal humerus fracture sequelae [9].
  • Prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures [17].
  • After one year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms [20].
  • Reverse shoulder arthroplasty is used for the treatment of complex, displaced proximal humerus fractures in older individuals (≥ 65 years old) [30].
  • It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [22].
  • The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures [23].
  • ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [52].
  • Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [26].
  • Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results [31].
  • Timing of surgery does not impact outcomes of patients who underwent ORIF for proximal humerus fractures, with delays beyond 5 days not affecting outcome [84].

Key Evidence

  • [L4] Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults. (10.5312/wjo.v5.i5.685)
  • [L4] In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. (10.1155/2012/861598)
  • [L3] Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade. (10.1016/j.jseint.2021.11.007)
  • [L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. (10.1016/j.jseint.2021.08.006)
  • [L3] Our results suggest that there is a substantial mortality in patients with a proximal humerus fracture, as we have previously reported, and that surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year. (10.1080/17453670510041295)
  • [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. (10.1016/j.jse.2024.12.005)
  • [L3] These results are pertinent when deciding on the treatment of proximal humerus fracture sequelae. (10.1080/17453674.2020.1793548)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. (10.5435/jaaos-d-14-00033)
  • [L4] Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. (10.1016/j.xrrt.2023.01.002)
  • [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. (10.1016/j.jse.2022.03.006)
  • [L1] The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. (10.1016/j.xrrt.2021.04.014)
  • [L2] Besides age, most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria. (10.1016/j.xrrt.2025.07.023)
  • [L3] However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures. (10.1016/j.injury.2013.08.024)
  • [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. (10.1177/17585732221150785)
  • [L2] Proximal humerus fractures are now typically osteoporotic fractures in women over 70, with prevalence increasing due to an aging population in poor general condition. (10.1016/j.otsr.2012.05.013)
  • [L3] After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms. (10.1007/s00590-021-03099-6)
  • [L4] They are indicated for complex proximal humerus fractures in patients no younger than 70 years of age. (10.1016/j.otsr.2008.09.002)
  • [L3] It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. (10.1186/s12891-023-06669-3)
  • [L4] The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. (10.1007/s00590-010-0655-z)
  • [Paper] Non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention, and there is little utility to the routine use of postoperative radiographs in follow-up of these patients. (10.1016/j.otsr.2016.09.022)
  • [L5] The selection of RTSA over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients. (10.1097/corr.0000000000002430)
  • [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. (10.1016/j.jse.2006.09.006)
  • [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. (10.2106/jbjs.l.01293)
  • [L4] The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs. (10.1080/17453674.2018.1453714)
  • [L3] After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. (10.1016/j.jse.2020.10.024)
  • [L4] We report current and historical treatments, outcomes, and principles in reverse shoulder arthroplasty for treatment of complex, displaced proximal humerus fractures in older individuals ( ≥ 65 years old). (10.1007/s12178-020-09597-0)
  • [L4] Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results. (10.1016/j.injury.2015.05.017)
  • [L5] Evaluation of the classification systems for fractures of the proximal humerus with plain radiographs has yielded low interobserver reliability. (10.1016/j.ocl.2008.05.002)
  • [L5] These biomechanical observations may explain diminished functional results observed in patients treated with inferior tuberosity displacement after prosthetic reconstruction of shoulder fractures. (10.1016/j.jse.2007.02.110)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
  • [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. (10.1016/j.jse.2010.06.005)
  • [L5] Surgical treatment of proximal humerus fractures remains far from straightforward, with unpredictable outcomes where factors associated with poor results include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension. (10.1097/corr.0000000000002242)
  • [L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. (10.1016/j.injury.2010.10.016)
  • [L1] This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. (10.1371/journal.pmed.1002855)
  • [Abstract] These biomechanical changes may explain diminished function in patients with inferior tuberosity positioning after hemiarthroplasty for proximal humerus fractures. (10.1016/j.jse.2007.02.027)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
  • [L1] Long-term treatment with RSA for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time. (10.1016/j.jse.2024.09.032)
  • [L4] The Mayo-FJD classification system for proximal humerus fractures seems to allow high intraobserver and interobserver agreement using both radiographs and computed tomography. (10.1016/j.jse.2023.02.035)
  • [L5] These findings suggest that positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures. (10.5397/cise.2022.00885)
  • [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. (10.1016/j.jse.2011.01.025)
  • [L4] MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. (10.1016/j.aott.2016.10.003)
  • [L2] Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized. (10.1016/j.jseint.2022.02.006)
  • [L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
  • [L3] ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. (10.1097/corr.0000000000002895)
  • [L2] However, the changed position of the humeral head on coronal plane does not affect the final functional results. (10.4103/0973-6042.118911)
  • [L3] Holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. (10.1016/j.jseint.2024.02.003)
  • [L4] The paper reviews the biology and biomechanics of osteosynthesis for proximal humerus fractures, emphasizing that bone quality significantly impacts implant anchorage. (10.1007/s00068-007-7089-2)
  • [L3] Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. (10.1016/j.jseint.2024.02.005)
  • [Paper] Rotator cuff tears are a detrimental factor and a major cause of painful shoulders. (10.1007/s00264-004-0552-3)
  • [L5] The double plate strategy can increase the stability of the medial column of the proximal humerus, and enhance the overall biomechanical property of the repaired proximal humerus. (10.1186/s12891-024-08216-0)
  • [L4] Evidence-based recommendations to guide treatment of proximal humerus fractures are lacking, and no good evidence exists whether surgery is clearly superior to nonoperative treatment. (10.1016/j.ocl.2008.06.003)
  • [Abstract] Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications. (10.1016/j.jse.2015.05.005)
  • [L4] There is clear evidence of specific characteristics which differentiate proximal third humeral shaft fractures from those of midshaft and distal third. (10.1016/j.injury.2013.10.030)
  • [L3] Therefore, reverse shoulder arthroplasty could be considered primary treatment, especially when optimal range of motion is of great importance to the patient. (10.1177/17585732231190038)
  • [L4] Glenoid loosening and severe scapular notching are related to poor positioning and/or incorrect orientation of the glenosphere. (10.1016/j.otsr.2018.06.008)
  • [L3] Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for proximal humerus fractures. (10.1016/j.jse.2023.08.022)
  • [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
  • [L5] The routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities, and their use as the sole determinant for recommending surgical intervention should be avoided at this time. (10.1097/corr.0000000000002017)
  • [L5] In addition to palpation and anteroposterior and lateral humeral x-ray, we suggest adding bilateral anteroposterior shoulders xray routinely to confirm the shoulder location. (10.1097/md.0000000000008977)
  • [L3] Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures. (10.1016/j.jse.2025.02.019)

References

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Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.