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Proximal Humerus Fracture

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

Updated Aug 2026

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

What you're feeling

You likely felt a sudden, sharp pain in your shoulder after a fall or a direct impact. This injury often happens when you try to break your fall with an outstretched arm. You may have heard or felt a snap or pop at the moment of impact. The pain is usually immediate and intense.

Your shoulder will swell quickly. Bruising may appear on the upper arm or chest within the first few days. You might notice a change in the shape of your shoulder, making it look squared off or uneven. Moving your arm will be difficult and painful. You will likely hold your injured arm close to your body to protect it. Simple tasks like reaching for a cup or putting on a shirt will feel impossible right away.

In the first few days, pain may be worse at night, making it hard to sleep on that side. As healing begins over the next few weeks, the sharp pain will gradually settle into a dull ache. You may still feel stiffness and discomfort when you try to move your shoulder. For most people with one-part fractures, this initial phase is managed without surgery. Your surgeon will guide you through this early period to ensure the bone starts to heal in the right position.

What's actually happening

The top of your upper arm bone is a complex control volume. It connects to your shoulder joint and anchors key muscles. When you fracture this area, you are breaking the foundation of that movement system. Think of it like a cracked tripod leg. If one leg shifts out of place, the whole structure becomes unstable and cannot bear weight or move smoothly.

Your shoulder relies on precise alignment to work. Small shifts in the bone position change how the joint moves. Even a shift of 15 degrees can alter the mechanics significantly. This displacement affects your range of motion and strength. The muscles pulling on the broken pieces can pull them further apart. This makes healing difficult without proper support.

Healing requires the bone to knit back together. For most one-part fractures, your body can heal this on its own. Nonoperative treatment leads to union rates greater than 90% in many cases. Your surgeon will guide you through this process. We focus on keeping the pieces stable while they fuse.

In more complex breaks, the bone fragments may not stay aligned naturally. Surgical options help hold the pieces in place. Locked plates and nails provide stable fixation. This allows the bone to heal in the correct position. For older patients with severe breaks, joint replacement may be necessary. This involves replacing the damaged bone surface with an artificial implant.

Reverse shoulder arthroplasty is a safe option for certain fractures. It demonstrates favorable medium- to long-term survivorship. The incidence of complications remains low. This approach restores function when the natural bone cannot be repaired. Proper technique is essential for success. We ensure the tuberosities, which are the attachment points for your rotator cuff, are managed carefully. If these do not heal correctly, it can limit your shoulder function.

Your recovery depends on how well the tissues heal. Bone knitting and tendon reattachment take time. Stiffness or rotator cuff tears can affect your outcome. We monitor your progress closely. Our goal is to restore your normal movement and strength.

What we can do about it

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, approaches this injury by matching the treatment to your specific fracture pattern and health needs. Most one-part fractures are stable and heal well without surgery. In these cases, we use a sling or splint to support your arm while the bone knits together. You will have repeat imaging to check the alignment. Nonsurgical management leads to union rates greater than 90%. For older adults, most fractures are treated this way with good functional outcomes. Children also heal well with non-operative care because their bones remodel quickly.

Surgery is recommended from the outset if your fracture is displaced, unstable, or involves multiple parts. We may suggest an intramedullary nail and plate system to hold the bone fragments in place. For older patients with complex three- or four-part fractures, we may recommend a reverse total shoulder replacement. This procedure aims to restore function and provide durable long-term results. The decision is shared. If non-operative care is an option but the pain or final arm position is unacceptable, surgery becomes the better choice for your quality of life.

Both paths share the same goals in the early weeks. You will need effective pain control to rest comfortably. We protect the injury while it heals, avoiding movements that could shift the bone. Once the initial healing phase passes, we guide you through staged physiotherapy to restore movement and strength. Short and long periods of immobilization yield similar results for nonoperatively treated fractures, so we tailor the timeline to your comfort and healing progress.

What to expect

Your recovery path depends on your age, the fracture pattern, and whether you have surgery. Most one-part fractures heal well without an operation. For older adults, nonoperative treatment is common and often successful. If your fracture involves three or four parts, your surgeon may recommend surgery to restore function.

Healing takes time. Most proximal humerus fractures heal within a few months. If you have surgery, your surgeon will use plates, nails, or a joint replacement to hold the bone in place. You will wear a sling for a period of time to protect the repair. Short and long periods of immobilization yield similar results for nonoperatively treated fractures. Your physical therapist will guide you through gentle movements to prevent stiffness.

Return to daily tasks varies. Most people resume light activities as pain allows. Return to work and sport depends on the nature of your job and your healing speed. Surgery for complex fractures leads to overall good long-term outcomes, though complication rates are higher than for simple breaks. You may experience stiffness or soreness for several months.

Be aware of potential complications. The rate of complications following operative treatment is high. These can include slow healing, nonunion (where the bone fails to knit), or healing in a poor position. Infection and nerve irritation are also possible risks. For older patients, surgery carries an increased risk of major adverse events during hospitalization.

Mortality risk is a serious consideration for fragility fractures in older adults. Proximal humeral fractures confer a more than two-fold increase in mortality at 1 year (9.8%). This risk continues to increase to 28.2% mortality at 5 years. This statistic reflects the overall health burden of such injuries in the elderly population, not a direct result of the fracture itself.

Most pediatric patients have favorable results with infrequent complications. For adults under 65, the clinical benefit of surgery over nonoperative management is not always clear. Your surgeon will discuss which path offers the best chance for you to regain strength and mobility. Follow your specific post-operative instructions closely to support your healing journey.

When to see someone

Seek urgent care if you have visible deformity, an open wound, numbness or tingling, or cannot use your arm. These signs need immediate assessment.

If pain is not settling, or if swelling, movement, and function are not improving week on week as healing progresses, see your GP. They can arrange a specialist review. Most simple fractures heal well without surgery, but persistent issues need checking. Your surgeon will guide you based on how your arm is recovering. Do not wait if symptoms worsen. Early advice helps prevent long-term stiffness or disability.

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Reviewed by AI synthesis (v2) — pending human review · 18 May 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

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

Evidence & references

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. [1] (10.5312/wjo.v5.i5.685)
• [L4] In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. [2] (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. [3] (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. [4] (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. [6] (10.1080/17453670510041295)
• [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. [7] (10.1016/j.jse.2024.12.005)
• [L3] These results are pertinent when deciding on the treatment of proximal humerus fracture sequelae. [9] (10.1080/17453674.2020.1793548)
• [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [12] (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. [13] (10.1016/j.xrrt.2023.01.002)
• [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [14] (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. [15] (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. [16] (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. [17] (10.1016/j.injury.2013.08.024)
• [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. [18] (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. [19] (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. [20] (10.1007/s00590-021-03099-6)
• [L4] They are indicated for complex proximal humerus fractures in patients no younger than 70 years of age. [21] (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. [22] (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. [23] (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. [24] (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. [25] (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. [26] (10.1016/j.jse.2006.09.006)
• [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [27] (10.2106/jbjs.l.01293)
• [L4] The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs. [28] (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. [29] (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). [30] (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. [31] (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. [32] (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. [33] (10.1016/j.jse.2007.02.110)
• [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. [35] (10.1016/j.jhsa.2020.03.022)
• [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. [36] (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. [37] (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. [38] (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. [39] (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. [40] (10.1016/j.jse.2007.02.027)
• [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. [41] (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. [44] (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. [45] (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. [46] (10.5397/cise.2022.00885)
• [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. [48] (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. [49] (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. [50] (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. [51] (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. [52] (10.1097/corr.0000000000002895)
• [L2] However, the changed position of the humeral head on coronal plane does not affect the final functional results. [54] (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. [57] (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. [58] (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. [59] (10.1016/j.jseint.2024.02.005)
• [Paper] Rotator cuff tears are a detrimental factor and a major cause of painful shoulders. [63] (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. [64] (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. [65] (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. [67] (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. [69] (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. [72] (10.1177/17585732231190038)
• [L4] Glenoid loosening and severe scapular notching are related to poor positioning and/or incorrect orientation of the glenosphere. [74] (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. [75] (10.1016/j.jse.2023.08.022)
• [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. [76] (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. [79] (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. [83] (10.1097/md.0000000000008977)
• [L3] Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures. [84] (10.1016/j.jse.2025.02.019)

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