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Fratura do Húmero Proximal

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

Updated Jun 2026
Uma ilustração desenhada à mão de um osso do braço superior fraturado logo abaixo do ombro.
Raio-X mostrando uma fratura na parte superior do osso do braço, logo abaixo da articulação do ombro. Kieran Hirpara 4.0

Esta página foi traduzida automaticamente e ainda não foi verificada por um médico. A versão em inglês é a versão oficial.

O que você está sentindo

É provável que sinta dor no braço superior e na região do ombro. Essa dor frequentemente decorre de uma fratura do osso próximo à articulação do ombro. Se sua fratura estiver associada a ossos enfraquecidos, conhecida como osteoporose, a dor pode fazer parte de um padrão maior de lesões por fragilidade. Fraturas não desviadas, nas quais os fragmentos ósseos permanecem em seu lugar, são comuns nesse grupo. Mesmo quando o osso não se desloca, essas fraturas ainda podem causar incapacidade significativa e reduzir sua sensação geral de bem-estar.

A dor tende a piorar com o movimento. Você pode encontrar dificuldade para levantar o braço ou alcançar acima da cabeça. Tarefas diárias simples tornam-se desafiadoras. Você pode ter dificuldade para guardar a camisa ou alcançar as costas para fechar um sutiã. Levantar objetos, mesmo os leves, pode desencadear desconforto agudo. Como o ombro é instável, qualquer esforço para usar o braço pode agravar a lesão.

Descansar o braço geralmente ajuda a reduzir a dor. No entanto, você ainda pode experimentar crises noturnas. Muitos pacientes relatam que dormir do lado afetado é doloroso ou impossível. Acordar com o ombro rígido ou dolorido é comum. Seu cirurgião orientará você sobre como se posicionar para conforto, enquanto protege o osso em cicatrização.

Se você tiver menos de 65 anos, seu cirurgião pode discutir se a cirurgia oferece benefícios claros em relação ao tratamento não cirúrgico. Para muitos adultos nesse grupo etário, as evidências não mostram uma vantagem significativa para a operação. A maioria das fraturas de um fragmento cicatriza bem sem cirurgia. Idosos também frequentemente recebem tratamento não operatório. Independentemente da sua idade, o objetivo é controlar sua dor e proteger o osso enquanto ele cicatriza. Complicações podem ocorrer em diferentes estágios, portanto, sua equipe o monitorará de perto. Você não está sozinho nesse processo; sua equipe de cuidados está lá para apoiar sua recuperação e ajudá-lo a recuperar a função com segurança.

O que está realmente acontecendo

O ombro é uma articulação do tipo bola e soquete onde o osso do braço se encontra com a escápula. A parte superior do osso do braço possui dois pequenos protuberâncias chamadas tuberosidades. Essas protuberâncias atuam como pontos de ancoragem para os tendões do manguito rotador. Esses tendões são cordas fortes de fibras que levantam e rotacionam o braço. Quando você fratura a parte superior do osso do braço, esses pontos de ancoragem podem se deslocar.

Se as tuberosidades se movem para baixo, os tendões perdem sua tensão adequada. Isso desalinha a mecânica da articulação. Mesmo um pequeno deslocamento de 15 graus pode alterar como a articulação se move e suporta peso. Essa desalinhamento causa dor e limita o movimento. Também torna mais difícil para a articulação cicatrizar na posição correta.

A cápsula articular é a capa ao redor do ombro. Ela mantém a articulação unida e produz fluido para manter as superfícies deslizantes. Após uma fratura, essa cápsula pode ficar rígida ou cicatrizada. Essa rigidez, junto com qualquer dano aos tendões, reduz sua força e amplitude de movimento. Seu cirurgião precisa restaurar a anatomia para que esses tecidos possam trabalhar juntos novamente.

Para muitas pessoas, especialmente adultos mais velhos, os fragmentos ósseos estão muito quebrados para serem reparados com placas e parafusos. Nesses casos, seu cirurgião pode recomendar uma substituição articular. Este procedimento substitui a bola danificada por um implante de metal e plástico. Esta opção é frequentemente escolhida quando a prioridade máxima é retomar o movimento do braço. Ela fornece suporte estável e permite que você recupere a função mesmo se a estrutura óssea original estiver severamente comprometida.

O que podemos fazer a respeito

A maioria das fraturas em um único fragmento cicatriza bem sem cirurgia. De fato, o manejo não cirúrgico é o padrão para a grande maioria dos casos. Seu cirurgião provavelmente recomendará um período de imobilização para permitir a consolidação óssea. Você pode esperar que períodos curtos e longos de repouso produzam resultados semelhantes, independentemente do padrão da fratura. Essa abordagem é especialmente comum em adultos mais velhos e crianças, cujos ossos têm um potencial tremendo de remodelação.

Durante esse período, a fisioterapia desempenha um papel fundamental. Seu fisioterapeuta irá guiá-lo por meio de movimentos suaves para restaurar a amplitude de movimento. O objetivo é prevenir a rigidez, protegendo ao mesmo tempo o osso em cicatrização. Para fraturas em dois fragmentos deslocadas em pacientes com 60 anos ou mais, os estudos não mostram diferença significativa nos resultados aos dois anos entre a cirurgia e o tratamento não operatório. Portanto, seu cirurgião pode aconselhá-lo a dar uma chance justa ao tratamento conservador antes de considerar opções mais invasivas.

O controle da dor é essencial para o seu conforto. Seu cirurgião pode prescrever analgésicos ou anti-inflamatórios para controlar o inchaço e o desconforto. Embora as evidências destaquem o sucesso do tratamento não operatório, elas não detalham protocolos específicos de injeção, como cortisona ou PRP, para este tipo de fratura. Em vez disso, concentre-se em seguir o cronograma de imobilização e comparecer às sessões de fisioterapia. O esforço consistente durante essas primeiras semanas estabelece a base para a sua recuperação.

A cirurgia é considerada apenas quando o tratamento conservador atinge seu limite ou quando o padrão da fratura é complexo. Isso geralmente envolve fraturas mais graves, como fraturas em três ou quatro fragmentos em pacientes mais velhos, nas quais os fragmentos ósseos estão significativamente deslocados. Nesses casos, seu cirurgião pode recomendar um procedimento para estabilizar o osso, como o uso de um sistema de haste e placa ou, em algumas instâncias, uma artroplastia total reversa do ombro. Essas opções visam restaurar a função e proporcionar durabilidade a longo prazo quando o osso não consegue cicatrizar adequadamente por conta própria. A decisão depende da sua idade, do padrão específico da fratura e da sua saúde geral.

O que esperar

Seu prognóstico depende em grande parte da sua idade e de quantos fragmentos ósseos estão envolvidos. A maioria das fraturas em um único fragmento cicatriza bem sem cirurgia. Para adultos mais velhos, o tratamento não operatório frequentemente leva a bons resultados funcionais. No entanto, se você tiver mais de sessenta anos, seu cirurgião pode recomendar cirurgia para fraturas complexas de três ou quatro fragmentos. Nesses casos, um novo sistema de pino e placa ou uma artroplastia reversa do ombro pode proporcionar melhor função a longo prazo do que deixar a fratura sem tratamento.

A recuperação é um processo gradual. Nos casos não operatórios, períodos curtos e longos de imobilização produzem resultados semelhantes. Você não precisa se preocupar com o comprimento exato do repouso alterando seu resultado final. Se você tiver cirurgia, o momento da operação além de cinco dias não impacta seus resultados finais. Isso dá flexibilidade à sua equipe de cuidados para planejar com segurança. A maioria dos pacientes com fraturas complexas tratadas com cirurgia alcança bons resultados a longo prazo, embora as taxas de complicações sejam altas.

Esteja ciente de que seu risco de eventos de saúde graves é maior após essa lesão. O risco de morte dentro de um ano é de 9,8%. Esse risco continua a aumentar para 28,2% aos cinco anos. Esse risco elevado de mortalidade existe independentemente de outros fatores de saúde. É importante manter-se ativo e seguir as orientações do seu cirurgião para manter sua saúde geral durante a recuperação.

Se você se submeter a uma artroplastia reversa do ombro, sua função pode melhorar significativamente em comparação com o tratamento não operatório. No entanto, alguns pacientes notam uma diminuição na funcionalidade e na qualidade de vida ao longo do tempo. Essa mudança ocorre após o segundo ano, mas geralmente não é considerada clinicamente relevante. A maioria dos pacientes pediátricos se recupera completamente com poucas complicações. Para adultos com menos de sessenta e cinco anos, a cirurgia nem sempre oferece um benefício claro em relação ao manejo não operatório. Seu cirurgião ponderará esses fatores para escolher o caminho que melhor apoie sua vida diária.

Quando procurar atendimento

Procure seu médico de família se a dor não melhorar com o repouso. Solicite uma avaliação especializada se sentir fraqueza ou instabilidade no ombro. Entre em contato com seu cirurgião se o braço travar ou ceder. Procure atendimento se os sintomas interferirem no seu sono ou no trabalho. A piora súbita da dor requer atenção imediata. A maioria das fraturas unipartidas cicatriza bem sem cirurgia. No entanto, complicações podem ocorrer em qualquer fase. O risco de mortalidade é alto para fraturas por fragilidade em adultos mais velhos. A mortalidade em um ano é de 9,8%. A mortalidade em cinco anos aumenta para 28,2%. O risco de não consolidação é maior do que se pensava anteriormente. Não ignore os sintomas persistentes. A avaliação precoce ajuda seu cirurgião a escolher o caminho adequado.

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

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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)

References

[1] Management of proximal humerus fractures in adults. World Journal of Orthopedics. 2014. DOI: 10.5312/wjo.v5.i5.685 [2] Evaluation and Management of Proximal Humerus Fractures. Advances in Orthopedics. 2012. DOI: 10.1155/2012/861598 [3] How age and gender influence proximal humerus fracture management in patients older than fifty years. JSES International. 2022. DOI: 10.1016/j.jseint.2021.11.007 [4] Trending a decade of proximal humerus fracture management in older adults. JSES International. 2022. DOI: 10.1016/j.jseint.2021.08.006 [5] 1. Clinical Evaluation, Imaging, and Classification of Proximal Humerus Fractures. n.d.. [6] Long-term outcome of a proximal humerus fracture predicted after 1 year. Acta Orthopaedica. 2005. DOI: 10.1080/17453670510041295 [7] Consensus statement on the treatment of proximal humerus fractures: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.005 [8] 2. Non-operative Management of Proximal Humerus Fractures: Indications, Protocols, and Outcomes. n.d.. [9] Low arthroplasty survival after treatment for proximal humerus fracture sequelae: 3,245 shoulder replacements from the Nordic Arthroplasty Register Association. Acta Orthopaedica. 2020. DOI: 10.1080/17453674.2020.1793548 [11] 6. Complications of Proximal Humerus Fractures: Evaluation and Management. n.d.. [12] Evaluation and Management of Pediatric Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00033 [13] Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.01.002 [14] Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.03.006 [15] Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2021.04.014 [16] Randomized controlled trials investigating proximal humerus fractures lack consensus in inclusion criteria. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.023 [17] A comprehensive update on current fixation options for two-part proximal humerus fractures. Injury. 2014. DOI: 10.1016/j.injury.2013.08.024 [18] Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae. Shoulder & Elbow. 2023. DOI: 10.1177/17585732221150785 [19] Epidemiology of proximal humerus fractures managed in a trauma center. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.05.013 [20] No change in outcome ten years following locking plate repair of displaced proximal humerus fractures. European Journal of Orthopaedic Surgery & Traumatology. 2021. DOI: 10.1007/s00590-021-03099-6 [21] Three or four parts complex proximal humerus fractures: Hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2008.09.002 [22] Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures – a propensity score matched comparison. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06669-3 [23] Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. European Journal of Orthopaedic Surgery & Traumatology. 2010. DOI: 10.1007/s00590-010-0655-z [24] Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.09.022 [25] CORR Insights®: Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002430 [26] Outcomes after percutaneous reduction and fixation of proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.006 [27] Proximal Humeral Fracture Treatment in Adults. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.l.01293 [28] Automated detection and classification of the proximal humerus fracture by using deep learning algorithm. Acta Orthopaedica. 2018. DOI: 10.1080/17453674.2018.1453714 [29] Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.024 [30] Reverse Shoulder Arthroplasty for Proximal Humerus Fracture. Current Reviews in Musculoskeletal Medicine. 2020. DOI: 10.1007/s12178-020-09597-0 [31] Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock. Injury. 2015. DOI: 10.1016/j.injury.2015.05.017 [32] Classification and Imaging of Proximal Humerus Fractures. Orthopedic Clinics of North America. 2008. DOI: 10.1016/j.ocl.2008.05.002 [33] Biomechanical Assessment Of Inferior Tuberosity Placement During Hemiarthroplasty For 4-Part Proximal Humerus Fractures G.. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.110 [35] Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.03.022 [36] Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.06.005 [37] 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?. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002242 [38] New trends in fixation of proximal humeral fractures: A review. Injury. 2011. DOI: 10.1016/j.injury.2010.10.016 [39] Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLOS Medicine. 2019. DOI: 10.1371/journal.pmed.1002855 [40] Biomechanical Assessment Of Inferior Tuberosity Placement During Hemiarthroplasty For 4-Part Proximal Humerus Fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.027 [41] Readmissions, revisions, and mortality after treatment for proximal humeral fractures in three large states. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2812-9 [44] 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. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.032 [45] The Mayo-FJD Classification System For Proximal Humerus Fractures: Intra And Interobserver Agreement. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.035 [46] Biomechanical investigation of arm position on deforming muscular forces in proximal humerus fractures. Clinics in Shoulder and Elbow. 2022. DOI: 10.5397/cise.2022.00885 [48] Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.01.025 [49] Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures. Acta Orthopaedica et Traumatologica Turcica. 2020. DOI: 10.1016/j.aott.2016.10.003 [50] The reliability of the Neer classification for proximal humerus fractures: a survey of orthopedic shoulder surgeons. JSES International. 2022. DOI: 10.1016/j.jseint.2022.02.006 [51] Standard compared with fracture-specific components in reverse shoulder arthroplasty for proximal humerus fractures. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b9.bjj-2024-1508.r2 [52] 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?. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002895 [54] Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: A prospective study. International Journal of Shoulder Surgery. 2013. DOI: 10.4103/0973-6042.118911 [56] 24. Proximal Humerus Fractures in the Adolescent Patient: Diagnosis, Management, and Complications. n.d.. [57] Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores. JSES International. 2024. DOI: 10.1016/j.jseint.2024.02.003 [58] Biology and Biomechanics in Osteosynthesis of Proximal Humerus Fractures. European Journal of Trauma and Emergency Surgery. 2007. DOI: 10.1007/s00068-007-7089-2 [59] 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. JSES International. 2024. DOI: 10.1016/j.jseint.2024.02.005 [63] Proximal humeral fractures with minimal displacement treated conservatively. International Orthopaedics. 2004. DOI: 10.1007/s00264-004-0552-3 [64] Biomechanical study of two different fixation methods for the treatment of Neer III proximal humerus fractures. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08216-0 [65] Open Reduction and Internal Fixation of Proximal Humerus Fractures. Orthopedic Clinics of North America. 2008. DOI: 10.1016/j.ocl.2008.06.003 [67] Reverse Total Shoulder Arthroplasty Patients with a Proximal Humerus Fracture Have Significantly Worse Perioperative Outcomes than Other Indications: An Analysis of 5644 Cases. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.05.005 [69] Proximal third humeral shaft fractures—A fracture entity not fully characterized by conventional AO classification. Injury. 2014. DOI: 10.1016/j.injury.2013.10.030 [72] Does primary treatment of proximal humerus fractures show favourable functional outcomes over secondary treatment with reverse shoulder arthroplasty?. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231190038 [74] Reverse shoulder arthroplasty for proximal humerus fractures: Is the glenoid implant problematic?. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.06.008 [75] ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.022 [76] Detection, classification, and characterization of proximal humerus fractures on plain radiographs. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0264.r1 [79] CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000002017 [83] Shoulder dislocation combined with proximal humerus fracture in children. Medicine. 2017. DOI: 10.1097/md.0000000000008977 [84] Delays beyond 5 days to surgery does not affect outcome following plate and screw fixation of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.019

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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.

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