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Fractures

Proximal humerus, humeral shaft, clavicle, and scapula fractures — epidemiology, mortality risk in elderly populations, and trauma management.

Overview

Scapula fractures, particularly extra-articular variants, generally respond well to nonoperative management, demonstrating a 97% healing rate at 3 months and good to excellent functional results at 2-year follow-up [58]. However, outcomes for undisplaced scapula fractures remain variable [2], necessitating that surgeons consider specific fracture patterns and patient goals when selecting treatment [34]. For mid-shaft clavicle fractures, nonoperative treatment remains effective for the majority of cases [33, 53]. In adolescents, nonunion is exceptionally rare with conservative care, and relative indications for surgery in adults do not apply to this population [9].

Surgical fixation is indicated for specific scenarios, including open fractures, neurovascular injury, or significant displacement in adolescents [33], and for completely displaced mid-shaft clavicle fractures with shortening of 2 cm or more in adults [53]. Operative intervention for these specific indications yields improved outcomes compared with non-operative measures [53, 64]. The choice of surgical approach for displaced midshaft clavicle fractures should depend on fracture morphology, surgeon preference, and patient-specific factors [55], with plate fixation superior for pain reduction in Robinson 2B2 fractures and tension band wiring providing excellent results for Robinson 2B1 fractures [64].

Proximal humerus fractures in patients over 60 are associated with high complication and failure rates when treated with locking-plate fixation, particularly in older patients with complex fractures [24]. While the PHILOS plate is suitable for the majority of these fractures provided correct technique is used, combined proximal humerus fractures carry significantly greater mortality and morbidity than isolated injuries, especially when associated with femoral or vertebral fractures [24, 67].

Anatomy & Pathophysiology

Osseous and Joint Morphology

The medial-ridge sign should only be considered as an addition to glenoid measurement techniques that allow for exact defect size quantification [83]. In adolescent patients, normal sequential patterns of glenoid maturation may simulate a fracture in traumatic settings [82]. The elastic nature of the pediatric scapula likely facilitated the unique injury pattern of scapular fracture with intrathoracic penetration [84]. A novel biomechanical model distinguishes between different mechanisms of injury and resulting fracture configurations in proximal humeral fractures [27], and the displacement pattern of the typical four-part proximal humeral fracture was successfully recreated in all 10 models used to study the pathogenetic mechanism [85].

Kinematics and Biomechanics

Clavicle shortening of greater than 10% greatly affects scapular kinematics in vivo [42]. The blocked threaded wires construct for three-part humeral head fractures is biomechanically valid and allows only micromovements incapable of causing humeral head rotation and translation [44]. Patients whose injury occurred in the abduction position showed a higher Hill-Sachs angle, leading to an increased risk of engagement because the long axis of the Hill-Sachs lesion is parallel to the glenoid in a position of function [77]. Secondary displacement after closed reduction of greater tuberosity fracture associated with shoulder dislocation was significantly associated with subscapularis involvement and greater critical shoulder angle [78].

Ligamentous and Functional Outcomes

Type I and II acromioclavicular joint disruptions impair long-term shoulder function in about half of patients 10 years after injury [63]. New surgical techniques for acromioclavicular separations continue to evolve as more biomechanical data emerge and kinematic understanding improves [51]. Surgical intervention is not required for most patients with floating shoulder injuries, and treatment should be individualized based on patient assessment and understanding of pathoanatomy [72]. Dominance of the affected shoulder has no influence on functional and quality of life outcomes compared with the nondominant shoulder [73].

Classification

Proximal Humerus: Proximal humerus fractures are osteoporotic injuries with increasing incidence due to aging populations [20]. Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions in these fractures [20]. A novel biomechanical model distinguishes between different mechanisms of injury and resulting fracture configurations [27]. A new classification based on a 3D model provides a useful synoptic framework for identifying complex fracture patterns in impacted proximal humerus fractures [37]. A new classification based on morpho-volumetric evaluation of humeral head bone loss with a 3D model provides a useful synoptic framework for identifying complex fracture patterns in impacted proximal humerus fractures [38]. A classification system based on pathomorphologic analysis showed high reliability when based on a standardized imaging protocol including computed tomography scans [39]. Three-dimensionally printed models improved interobserver agreement in the classification of proximal humeral fractures using the Neer system [52]. Associated fractures in proximal humerus fractures are frequent and linked to increased mortality and length of stay [7]. Primary RSA is increasingly used for complex fracture types of the proximal humerus [45].

Lateral Clavicle: An extra-lateral distal clavicle fracture pattern is recommended to be added to the current modified Neer classification as a type IIC fracture [40]. The interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair [61]. Additional 3D CT did not improve the overall level of interrater or intrarater agreement of the modified Neer classification system or associated treatment choice for lateral clavicle fractures [61].

Glenoid Fossa: The 2013 newly introduced AO classification system allows reliable grading of glenoid fossa fractures with high inter- and intraobserver reliability in 84 patients using CT images [54].

Scapula: Various classification systems exist to guide the treatment of scapular fractures [11].

Periprosthetic: Periprosthetic fractures around the shoulder involve complex injuries with defined epidemiology, risk factors, classification, and management [8].

Other Considerations: There is ongoing inconsistency in the classification and measurement of isolated greater tuberosity fractures [50].

Clinical Presentation

Scapular fractures are frequently associated with other injuries and can be difficult to diagnose, leading to missed or delayed diagnoses [3]. Undisplaced fractures of the inferior angle of the scapula present with a variable outcome when treated nonoperatively [2]. Persistent pain following a displaced fracture of the scapular body should prompt consideration of the diagnosis of non-union [5].

Clavicle fractures represent the most commonly occurring fracture, with the middle third being the most frequent site [41]. Clavicle fractures were not correlated to an increased occurrence of later diagnosis of subacromial pain syndrome [19]. Athletes conservatively managed for clavicular fractures returned to sport 40% faster than those with surgery, though this appears to be associated with the severity and complexity of fractures treated surgically [22].

Proximal humerus fractures are osteoporotic injuries with increasing incidence due to aging populations [20]. More proximal humeral fractures were seen during winter months in earlier decades but not in recent decades [4] [7]. Associated fractures in proximal humeral fractures are frequent and linked to increased mortality and length of stay [7]. Independent risk factors for increased mortality in proximal humeral fractures include female gender, pathological fracture, increasing numbers of co-morbidities, and increasing age at injury [17]. Specific clinical and radiological 'red flags' should increase suspicion of associated vascular injury in proximal humeral fractures with vascular compromise [15].

Minimal fracture displacement of less than 3 mm in minimally displaced fractures of the greater tuberosity does not worsen clinical outcome or duration of symptoms [1]. A 5 mm fracture displacement threshold is often used to guide treatment for isolated greater tuberosity fractures, though it has not been validated in clinical studies [23]. The outcome for the majority of less-displaced proximal humeral fractures is mainly influenced by preexisting patient-related psychosocial factors, although fracture-related factors account for a small but measurable proportion of the variation [25].

Most pediatric shoulder injuries are easy to diagnose and treat nonoperatively, with fractures remodeling rapidly [14]. Primary bone lymphoma is a rare entity that can present as a pathological fracture and is often misdiagnosed initially [12].

Investigations

Plain radiography: Convolutional neural networks proficiently rule out proximal humerus fractures on plain radiographs [95]. While specific clinical and radiological 'red flags' should increase suspicion of associated vascular injury in proximal humeral fractures with vascular compromise [15], scapular fractures are often associated with other injuries and can be difficult to diagnose, leading to missed or delayed diagnoses [3]. Seasonal trends indicate that more proximal humeral fractures were seen during winter months in earlier decades but not in recent decades [4].

MRI: MRI is recommended for early diagnosis of stress fractures in adolescent competitive athletes with open physis [88]. Undisplaced greater tuberosity fractures can be managed non-operatively with good results, but patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult fractures [79]. MRI findings of a glenoid rim fracture, equal to a bony Bankart lesion, are a prognostic factor for stability and a good functional outcome after primary shoulder dislocation [93]. MRI is able to reliably diagnose chronic traumatic anterior sternoclavicular joint instability and is a good predictor of the structural soft tissue damage associated with it [87]. If detected on MRI as an isolated injury, surgical arthroscopy is unnecessary for subcortical trabecular fractures (bone bruises) in knees, as patients can be expected to recover well in the short term with restricted weightbearing and initial activity modification [92].

CT: Interobserver agreement for classifying proximal humerus fractures according to pattern recognition is best when fractures are classified using CT scans [75]. Future areas of research must focus on further validation of CT evaluation and its use in other major joints [91].

Other Considerations: Minimal fracture displacement of less than 3 mm in minimally displaced greater tuberosity fractures does not worsen clinical outcome or duration of symptoms [1]. A 5 mm fracture displacement threshold is often used to guide treatment for isolated greater tuberosity fractures, though it has not been validated in clinical studies [23]. Undisplaced fractures of the inferior angle of the scapula have a variable outcome when treated nonoperatively [2]. Most pediatric shoulder injuries are easy to diagnose and treat nonoperatively, with fractures remodeling rapidly [14]. Primary bone lymphoma is a rare entity that can present as a pathological fracture and is often misdiagnosed initially [12]. Accurate assessment of imaging and determination of instability are critical for selecting the appropriate treatment course in pelvic trauma [76]. There is a difference in terms of radiographical outcomes and type of complications between surgical and conservative treatment of acute Rockwood III acromioclavicular joint dislocation [89]. One should be aggressive with displaced medial-end clavicle fractures in adults to minimize potential complications and functional complaints [94]. Continued research efforts are warranted to address areas of controversy and establish improved guidelines for the diagnosis of acromioclavicular joint injuries [21].

Treatment

Non-Operative

Non-operative management remains the primary treatment for the majority of scapular fractures, as historically over 90% are non- or minimally displaced with expected good clinical outcomes [10], though recent literature notes that non-operative treatment does not always yield positive results [10]. For scapular body fractures, persistent pain following displacement warrants consideration of non-union [5], and undisplaced scapular fractures exhibit variable outcomes when treated nonoperatively [2]. In the clavicle, nonsurgical management is the treatment of choice for nondisplaced midshaft fractures [57], and nonunion is exceptionally rare following nonoperative management of adolescent mid-shaft clavicular fractures [9]. Relative indications for surgical intervention in adults do not appear applicable to adolescents with mid-shaft clavicular fractures [9], and nonoperative treatment remains effective for most adolescent cases [33]. For proximal humeral fractures, the majority of patients undergo non-operative treatment [62], with short and long periods of immobilization yielding similar results independent of fracture pattern [35]. Outcomes for less-displaced proximal humeral fractures are mainly influenced by preexisting patient-related psychosocial factors, while fracture-related factors account for only a small proportion of outcome variation [25]. In the geriatric population, multiple studies demonstrate minimal differences in functional outcomes between nonoperative and operative treatment for displaced proximal humeral fractures [56]. For acromioclavicular joint injuries, nonsurgical treatment is indicated for type I and II injuries [69]. Closed, non-surgical reduction maneuvers are not effective in improving or maintaining alignment of clavicle fractures and should generally not be attempted [43]. Athletes conservatively managed for clavicular fractures returned to sport 40% faster than those with surgery, a finding associated with the severity and complexity of fractures treated surgically [22].

Operative

Indications: Surgical intervention for clavicle fractures is indicated for severe displacement, neurovascular compromise, or specific fracture patterns [57], including open fractures and neurovascular injury in adolescents [33]. For displaced lateral-third clavicle fractures, plate removal before 6 months postoperatively is required to achieve the best functional outcomes provided the fracture has healed [6]. In adults, surgical management of displaced clavicle fractures results in higher union rates and better early patient-reported outcomes compared with nonsurgical treatment [49]. For proximal humeral fractures, open reduction and internal fixation is indicated for unilateral displaced 3- or 4-part fractures, and osteoporosis may not be regarded as a contraindication for this procedure [66]. Surgery is almost always recommended for type IV, V, and VI acromioclavicular joint injuries [69]. Open reduction and internal fixation remains the mainstay of treatment for tibial plateau fractures [47].

Surgical Approach / Technique: The PHILOS plate is suitable for the majority of proximal humerus fractures provided that the correct surgical technique is used [31]. A systematic approach to treatment is utilized to achieve successful outcomes for humeral capitellar fractures [48]. For acromial stress reaction and acromial fractures, a surgical approach yields a much higher healing rate than non-surgical management [46].

Other Considerations: Scapular fractures are often associated with other injuries and can be difficult to diagnose, leading to missed or delayed diagnoses [3]. Orthopedic surgeons must consider the specific fracture pattern and patient-specific goals when treating scapula fractures [34], yet a striking discrepancy exists between theoretical and actual recommendations for surgery in extra-articular scapular fractures at studied centers [70]. While surgical treatment of displaced clavicle fractures in adults results in higher union rates, long-term outcomes are similar between surgical and nonsurgical treatment [49]. Similarly, surgical management of midshaft clavicular fractures offers higher union rates and faster recovery compared to conservative treatment but does not demonstrate significant long-term advantages in functional outcomes [30]. Fracture consolidation of acromial stress reaction and acromial fractures does not result in better clinical outcomes compared with nonunion [46]. For first-time traumatic shoulder dislocations, quality of life is better in the stabilized group, though definitive treatment recommendations await further decision [65]. Shoulder function was restored to preinjury levels for most patients after open reduction and internal fixation of unilateral displaced 3- or 4-part proximal humeral fractures [66]. Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen clinical outcome or duration of symptoms [1].

Complications

Infection (PJI): The provided evidence does not contain specific data regarding infection rates, risk factors, or management for periprosthetic joint infection in the context of the cited fracture literature.

Aseptic loosening: The provided evidence does not contain specific data regarding aseptic loosening rates, risk factors, or management for the cited fracture populations.

Instability: The provided evidence does not contain specific data regarding instability rates, risk factors, or management for the cited fracture populations.

Periprosthetic fracture: Periprosthetic fractures around the shoulder are complex injuries characterized by defined epidemiology, risk factors, classification, and management [8].

Thromboembolism: The provided evidence does not contain specific data regarding thromboembolism rates, risk factors, or management for the cited fracture populations.

Patellar / Extensor-mechanism: The provided evidence does not contain specific data regarding patellar or extensor-mechanism complications for the cited fracture populations.

Stiffness / Arthrofibrosis: The provided evidence does not contain specific data regarding stiffness or arthrofibrosis rates, risk factors, or management for the cited fracture populations.

Nerve palsy: Injuries to the upper extremities in polytrauma seem to have limited effect on long-term outcome as long as no injury was caused to the brachial plexus [32].

Wound complications: The provided evidence does not contain specific data regarding wound complication rates, risk factors, or management for the cited fracture populations.

Polyethylene wear: The provided evidence does not contain specific data regarding polyethylene wear rates, risk factors, or management for the cited fracture populations.

Other Considerations: Scapular Fractures: Scapular fractures are often associated with other injuries and can be difficult to diagnose, leading to missed or delayed diagnoses [3]. Historically, >90% of scapula fractures are non- or minimally displaced with good clinical outcomes expected from non-operative treatment, although recent literature documents that non-operative treatment does not always result in positive outcomes [10]. Non-union should be considered when a patient has persistent pain following a displaced fracture of the scapular body [5].

Clavicle Fractures: For displaced lateral-third clavicle fractures, the best functional outcomes with clavicle hook plate fixation occur when the plate is removed before 6 months postoperatively, provided the fracture has healed [6]. Hook plate fixation of acute displaced lateral clavicle fractures yields excellent mid-term results with no long-term complications addressed to the use of the plate [16]. Close follow-up of nonoperatively treated clavicle fractures is warranted due to displacement related to patient position and progressive displacement in the peri-injury period [26]. Clavicle fractures were not correlated to an increased occurrence of later diagnosis of subacromial pain syndrome, although the diagnosis was given 1-2 years earlier for people with a previous fracture [19].

Proximal Humerus Fractures: Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen clinical outcome or duration of symptoms [1]. Associated fractures in proximal humeral fractures are frequent and linked to increased mortality and length of stay [7]. Independent risk factors for increased mortality in proximal humeral fractures include female gender, pathological fracture, increasing numbers of co-morbidities, and increasing age at injury [17]. Male proximal humeral fractures are due to different traumatic events than those in females [86]. Fractures in women over 46 years old caused by low-energy trauma may be related to underlying osteoporotic conditions requiring preventative therapy [90]. More proximal humeral fractures were seen during winter months in earlier decades but not in recent decades [4]. Locking-plate fixation of proximal humerus fractures in patients over 60 continues to be associated with a high complication rate [24]. Higher complication and failure rates were observed in older patients and those with more complex fractures treated with locking-plate fixation [24]. Mid-term follow-up of Delta III reverse shoulder arthroplasty shows satisfying results for the treatment of severe displaced fractures in elderly patients [18]. Most existing literature on valgus impacted fracture of the proximal humerus consists of uncontrolled retrospective case series with significant heterogeneity in fracture patterns and techniques [36].

Pediatric and Other Fractures: Lateral condylar fractures of the humerus in children show a higher rate of nonunion with K-wire fixation, though prospective, randomized trials with long-term follow-up are required to confirm these findings [28]. Early complications and osteoarthritic changes at long-term follow-up can be expected in the treatment of terrible triad injuries [29].

Recovery

Light activity (weeks): Return to desk work and light activities of daily living is contingent on fracture stability and healing status. For displaced lateral-third clavicle fractures treated with hook plate fixation, plate removal is recommended before 6 months postoperatively provided the fracture has healed to optimize functional outcomes [6]. In contrast, nonoperative management of scapular fractures, which historically comprise >90% of cases with good expected outcomes, requires close follow-up due to risks of displacement related to patient position and progressive displacement in the peri-injury period [10, 26]. Similarly, nonoperatively treated clavicle fractures warrant close monitoring for displacement [26].

Full activity (months): Surgical management of midshaft clavicular fractures facilitates faster recovery compared to conservative treatment, though long-term functional advantages are not significant [30]. For adolescents with mid-shaft clavicular fractures, nonunion is exceptionally rare following nonoperative management, and relative indications for surgical intervention in adults do not appear applicable to this population [9]. Conversely, double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures [59]. For severe displaced fractures in elderly patients, Delta III reverse shoulder arthroplasty demonstrates satisfying mid-term results [18].

Complete recovery / outcome plateau (months): Functional outcomes for scapular fractures vary; while historically good outcomes are expected with non-operative treatment for non- or minimally displaced fractures, recent literature documents that non-operative treatment does not always result in positive outcomes [2, 10]. Persistent pain following a displaced fracture of the scapular body warrants consideration of the diagnosis of non-union [5]. For greater tuberosity fractures, a delay of more than 2 weeks from initial injury to surgery is a negative prognostic factor, as is postoperative fragment displacement greater than 5 mm [99]. Minimal fracture displacement (<3 mm) of the greater tuberosity does not worsen clinical outcome or duration of symptoms [1]. Undisplaced fractures of the inferior angle of the scapula have a variable outcome when treated nonoperatively [2].

Rehabilitation protocol: Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [35]. For lateral condylar fractures of the humerus in children, K-wire fixation is associated with a higher rate of nonunion [28]. Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus [32].

Functional milestones: Surgical management of midshaft clavicular fractures offers higher union rates and faster recovery compared to conservative treatment, despite not demonstrating significant long-term advantages in functional outcomes [30]. Hook plate fixation of acute displaced lateral clavicle fractures yields excellent mid-term results with no long-term complications addressed to the use of the plate [16]. Despite a high rate of union, the results of treatment for unstable distal clavicular fractures were more problematic in the delayed group [96]. Early complications and osteoarthritic changes at long-term follow-up can be expected following treatment of terrible triad injuries [29]. High rates of delayed union and nonunion were found with conservative management of humeral shaft fractures [98].

Other Considerations: Fractures of the proximal humerus follow characteristic patterns [97]. More fractures were seen during winter months in earlier decades but not in recent decades [4].

Key Evidence

  • [L4] Minimal fracture displacement (<3 mm) does not worsen the clinical outcome or duration of symptoms. (10.1016/j.jse.2013.01.033)
  • [L4] Undisplaced fractures have a variable outcome when treated nonoperatively. (10.1016/j.jse.2015.11.007)
  • [L4] More fractures were seen during winter months in earlier but not recent decades. (10.1186/s12891-024-07602-y)
  • [Case_report] On the basis of our experience with this patient, we now routinely consider the diagnosis of non-union when a patient has persistent pain following a displaced fracture of the scapular body. (10.2106/00004623-199803000-00017)
  • [L4] The best functional outcomes occur with plate removal before 6 months postoperatively, provided the fracture has healed. (10.1016/j.jse.2011.07.020)
  • [L4] Associated fractures were frequent and linked to increased mortality and length of stay, highlighting the burden of these injuries on the healthcare system. (10.1016/j.jseint.2021.12.003)
  • [L4] This article represents a detailed review of the epidemiology, risk factors, classification and management of these complex injuries. (10.1111/j.1758-5740.2011.00147.x)
  • [L3] Nonunion is exceptionally rare following nonoperative management and the relative indications for surgical intervention in adults do not appear to be applicable to adolescents. (10.1302/0301-620x.103b5.bjj-2020-1929.r1)
  • [Case_report] Primary bone lymphoma is a rare entity that can present as a pathological fracture and is often misdiagnosed initially; early diagnosis and multimodal treatment including chemotherapy, radiotherapy, and surgical reconstruction can lead to complete remission and functional recovery. (10.1016/j.xrrt.2023.12.008)
  • [L3] Specific clinical and radiological 'red flags' should increase suspicion of associated vascular injury to facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention. (10.1302/0301-620x.106b8.bjj-2023-1114.r1)
  • [L4] At mid term the results are excellent and no long term complications can be addressed to the use of the plate. (10.1186/1749-799x-7-2)
  • [L3] Independent risk factors for increased mortality are female gender, pathological fracture, increasing numbers of co-morbidities and increasing age at injury. (10.1177/1758573214525761)
  • [L3] Mid-term follow-up shows satisfying results in terms of the treatment of severe displaced fractures in elderly patients with RSA. (10.1186/1471-2474-14-231)
  • [L4] Clavicle fractures were not correlated to an increased occurrence of later diagnosis of SAPS, although the diagnosis was given 1-2 years earlier for people with a previous fracture. (10.1016/j.xrrt.2024.01.008)
  • [L4] Continued research efforts are warranted to address areas of controversy and establish improved guidelines for the diagnosis and treatment of these injuries. (10.1016/j.jse.2024.11.028)
  • [L4] Athletes conservatively managed returned 40% faster than those with surgery, though this appears to be associated with the severity and complexity of fractures treated surgically. (10.1016/j.jse.2021.04.006)
  • [L5] A 5 mm fracture displacement threshold is often used to guide treatment, though it has not been validated in clinical studies. (10.1016/j.xrrt.2025.100611)
  • [L3] Higher complication and failure rates were observed in older patients and more complex fractures. (10.1016/j.jse.2018.11.028)
  • [L1] The outcome for the majority of less-displaced fractures is mainly influenced by preexisting patient-related psychosocial factors, although fracture-related factors account for a small but measurable proportion of the variation. (10.2106/jbjs.20.02018)
  • [L2] Close follow-up of nonoperatively treated clavicle fractures is warranted. (10.1016/j.jse.2018.01.004)
  • [L5] The novel biomechanical model distinguished between different mechanisms of injury and resulting fracture configurations. (10.1177/1758573218768535)
  • [L3] The data suggest a higher rate of nonunion with K-wire fixation, though prospective, randomized trials with long-term follow-up are required to confirm these findings. (10.1302/0301-620x.100b3.bjj-2017-0814.r1)
  • [L4] However, early complications and osteoarthritic changes at long-term follow-up can be expected. (10.1177/1758573218809375)
  • [L1] Surgical management offers higher union rates and faster recovery but does not demonstrate significant long-term advantages in functional outcomes compared to conservative treatment. (10.1530/eor-2025-0005)
  • [L4] It is suitable for the majority of fractures provided that the correct surgical technique is used. (10.1097/01.blo.0000194678.87258.6e)
  • [L3] Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. (10.1302/0301-620x.99b2.37999)
  • [L5] While nonoperative treatment remains effective for most cases, operative fixation is indicated for open fractures, neurovascular injury, or significant displacement. (10.5397/cise.2025.00500)
  • [L5] Orthopedic surgeons must consider the specific fracture pattern and patient-specific goals when treating scapula fractures. (10.1016/j.jse.2024.05.042)
  • [L2] Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern. (10.2106/jbjs.20.02137)
  • [L4] Most existing literature consists of uncontrolled retrospective case series with significant heterogeneity in fracture patterns and techniques. (10.1016/j.jhsa.2011.05.003)
  • [Abstract] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2022.01.040)
  • [L5] The new classification provides a useful synoptic framework for identifying complex fracture patterns. (10.1016/j.jse.2020.02.022)
  • [L3] The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans. (10.1016/j.jse.2015.08.006)
  • [L4] We recommend that this fracture pattern be added to the current modified Neer classification as a type IIC fracture. (10.1016/j.jse.2020.10.006)
  • [L4] Clavicle shortening of >10% greatly affects scapular kinematics in vivo. (10.1016/j.jse.2017.03.013)
  • [Abstract] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jse.2022.01.037)
  • [L4] Among others, this might be due to an increased use of primary RSA for complex fracture types. (10.1016/j.jse.2016.02.015)
  • [L3] The healing rate was shown to be much higher with a surgical approach, but fracture consolidation does not result in better clinical outcomes compared with nonunion. (10.1016/j.jse.2021.11.012)
  • [L4] A successful outcome can be achieved when a systematic approach to capitellum fracture treatment is utilized. (10.1016/j.jse.2007.02.093)
  • [L1] High-quality evidence shows that surgical treatment of displaced clavicle fractures in adults results in higher union rates and better early patient-reported outcomes compared with nonsurgical treatment, though long-term outcomes are similar. (10.5435/jaaos-d-23-00472)
  • [L4] This study has revealed ongoing inconsistency in the classification and measurement of isolated GT fractures. (10.1177/17585732241248835)
  • [L5] New surgical techniques continue to evolve as more biomechanical data emerge and kinematic understanding improves. (10.5435/jaaos-d-16-00776)
  • [L5] Three-dimensionally printed models improved interobserver agreement in the classification of proximal humeral fractures using the Neer system. (10.1016/j.jseint.2020.10.019)
  • [L4] The 2013 newly introduced AO classification system allows reliable grading of glenoid fossa fractures with high inter- and intraobserver reliability in 84 patients using CT images. (10.1186/s12891-018-2016-8)
  • [L1] Selection of the surgical approach should depend on fracture morphology, surgeon preference, and patient-specific factors. (10.5397/cise.2025.01179)
  • [L5] Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. (10.2106/jbjs.20.00665)
  • [L5] Nonsurgical management remains the treatment of choice for nondisplaced midshaft fractures, while surgical intervention may be required for severe displacement, neurovascular compromise, or specific fracture patterns. (10.1016/j.jse.2011.08.053)
  • [L3] Patients with extra-articular scapula fractures with and without surgical indication treated conservatively had good to excellent functional results at 2-year follow-up, with a 97% healing rate at 3 months. (10.1016/j.jse.2025.02.026)
  • [Abstract] Double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures. (10.1016/j.jse.2022.01.036)
  • [L3] The interrater agreement of the modified Neer classification system for lateral clavicle fractures was fair, and additional 3D CT did not improve the overall level of interrater or intrarater agreement of the classification system or associated treatment choice. (10.1177/0363546515593949)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
  • [L4] Type I and II acromioclavicular joint disruptions impair long-term shoulder function in about half of patients 10 years after injury. (10.1177/0363546508319047)
  • [L3] Operative treatment has advantages compared to conservative treatment in specific indications; TEN provides excellent results for Robinson 2B1 fractures, while plate fixation is superior for pain reduction in the first 5 weeks and indicated for Robinson 2B2 fractures. (10.1186/s13018-015-0336-z)
  • [L5] We cannot yet answer this question definitively; while there are indications that quality of life is better in the stabilized group, the authors state we must wait before deciding definitely on how to treat first-time traumatic dislocations. (10.1007/s00167-003-0357-8)
  • [L1] Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for this treatment. (10.1016/j.jse.2022.07.008)
  • [L3] Combined fractures with femoral or vertebral fractures are associated with significantly higher mortality and morbidity compared with isolated proximal humerus fractures. (10.1016/j.jse.2025.04.013)
  • [L5] Nonsurgical treatment is indicated for type I and II injuries, while surgery is almost always recommended for type IV, V, and VI injuries. (10.5435/00124635-200904000-00002)
  • [L4] There is a striking discrepancy between theoretical and actual recommendations for surgery in extra-articular scapular fractures at the studied centers, indicating a need for more research to determine if patients are being undertreated or if the guidelines are too stringent. (10.1177/1758573215578587)
  • [L4] Surgical intervention is not required for most patients with floating shoulder injuries, and treatment should be individualized based on patient assessment and understanding of pathoanatomy. (10.5435/00124635-200608000-00007)
  • [L3] Dominance of the affected shoulder has no influence and should not be used to make treatment decisions. (10.1016/j.jse.2014.10.006)
  • [L5] Interobserver agreement was best when fractures were classified using CT scans. (10.1016/j.jseint.2022.03.005)
  • [L4] Patients whose injury occurred in the ABD position showed a higher H-S angle, leading to an increased risk of engagement, because the long axis of the H-S lesion is parallel to the glenoid in a position of function. (10.1016/j.arthro.2016.01.022)
  • [L3] Secondary displacement was common after initially well-aligned reductions and was significantly associated with SF-IF involvement and greater critical shoulder angle. (10.1016/j.jse.2025.10.009)
  • [L4] Undisplaced greater tuberosity fractures can be managed non-operatively with good results, but patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult fractures. (10.1186/s12891-018-2225-1)
  • [Case_report] Normal sequential patterns of glenoid maturation may simulate a fracture in traumatic settings. (10.5397/cise.2022.01151)
  • [L2] It should only be considered as an addition to glenoid measurement techniques that allow for exact defect size quantification. (10.1016/j.jse.2013.03.005)
  • [Case_report] They note that the elastic nature of the pediatric scapula likely facilitated this unique injury pattern. (10.2106/00004623-199707000-00016)
  • [L5] The displacement pattern of the typical four-part proximal humeral fracture was successfully recreated in all 10 models. (10.1016/j.jse.2025.01.005)
  • [L4] In addition, male fractures are due to different traumatic events than those in females. (10.1016/j.jse.2017.05.029)
  • [L4] MRI is able to reliably diagnose and is a good predictor of the structural soft tissue damage associated with chronic traumatic SCJ instability. (10.1016/j.jse.2025.04.018)
  • [L4] Early diagnosis using MRI and consistent conservative treatment are recommended. (10.1007/s00167-005-0003-8)
  • [L1] Nonetheless, it highlights a difference in terms of radiographical outcomes and type of complications. (10.1530/eor-2024-0077)
  • [L4] The authors suggest that fractures in women over 46 years old caused by low-energy trauma may be related to underlying osteoporotic conditions requiring preventative therapy. (10.1016/j.jseint.2025.04.012)
  • [L5] Future areas of research must focus on further validation of CT evaluation and its use in other major joints, standardizing antibiotic treatment, and further delineating the role of nonsurgical management in minor injuries. (10.5435/jaaos-d-19-00153)
  • [L4] If detected on MRI as an isolated injury, surgical arthroscopy is unnecessary since these patients can be expected to recover well in the short term with restricted weightbearing and initial activity modification. (10.1177/03635465000280050701)
  • [L3] MRI findings of a glenoid rim fracture, equal to a bony Bankart lesion, were found to be a prognostic factor for stability and a good functional outcome. (10.1007/s00167-009-0998-3)
  • [L4] The authors believe that one should be aggressive with displaced medial fractures to minimize potential complications and functional complaints. (10.1016/j.jse.2008.01.139)
  • [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
  • [L3] Despite a high rate of union, the results of treatment in the delayed group were more problematic. (10.1016/j.jse.2009.11.056)
  • [L4] Fractures of the proximal humerus follow characteristic patterns. (10.1016/j.jse.2017.05.014)
  • [L2] This study found high rates of delayed union and nonunion with conservative management. (10.1016/j.jse.2017.07.001)
  • [L4] A delay of more than 2 weeks from initial injury to surgery and postoperative fragment displacement greater than 5 mm are negative prognostic factors with respect to greater tuberosity fractures. (10.1111/sae.12023)

See Also

References

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

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

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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