மேல் பகுதி மூலக்கோல் முறிவு ORIF (தகடு மற்றும் நெயில் ஃபிக்ஸேஷன்)

This is the clinical evidence summary written for health professionals. It is technical, and it lists the research this page was built from. You do not need to read it to understand your treatment or to make a decision about it.

Overview¶

• Modern proximal humeral nail designs and techniques demonstrate promising outcomes and provide stable fixation [1].
• Intramedullary nailing and locked plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults [2].
• Intramedullary nailing is superior to locking plates in reducing total complications, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rates [3].
• Both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures [6].
• There is unclear superiority of intramedullary nails versus locking plates for the treatment of displaced proximal humeral fractures [6].
• Limited evidence suggests that both locking plates and intramedullary nails are valuable options for the treatment of proximal humeral fractures [13].
• Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages [7].
• Reported outcomes for intramedullary fixation are comparable with other techniques [7].
• Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation [9].
• Augmentation of plate fixation for proximal humeral fractures mechanically increases construct stability and reduces complication rates while improving patient outcomes [18].
• Augmentation of plate fixation for proximal humeral fractures is a reliable and safe procedure [18].
• No single fixation method is a panacea for proximal humeral fractures [21].
• The choice of implant and method for proximal humeral fractures should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [21].
• Treatment for proximal humerus fractures remains controversial [5].
• Nonsurgical management of proximal humerus fractures demonstrates successful outcomes and union rates greater than 90% [5].

Anatomy & Pathophysiology¶

• Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy [29].

Classification¶

• Intramedullary nailing of the proximal humerus can provide stable fixation [1].
• Intramedullary nailing is superior to locking plate in reducing total complications, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [3].
• There is unclear superiority of intramedullary nails versus locking plates for displaced proximal humeral fractures [6].
• Reported outcomes with intramedullary fixation are comparable with other techniques [7].
• Plate fixation was associated with a higher risk of avascular necrosis (AVN) development than conservative treatment in patients with proximal humeral fractures [11].
• Limited evidence suggests that locking plate and intramedullary nail are both valuable options for the treatment of proximal humeral fractures [13].
• No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures [14].
• Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics [16].
• Treatment options for displaced proximal humerus fractures range from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty [16].
• The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status [25].

Clinical Presentation¶

• Intramedullary nailing is superior to locking plate in reducing total complication rate, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [3].
• Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [4].
• Both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method [6].
• Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques [7].
• Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [8].
• Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [12].
• Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [15].
• Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics, with a general evolution toward humeral head preservation using options ranging from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty [16].
• Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging [17].
• Hemiarthroplasty for the treatment of complex proximal humerus fractures yields variable long-term clinical outcomes and high rates of failure, with the majority due to greater tuberosity malunion or nonunion [38].
• Optimal management of osteoporotic proximal humeral fractures has evolved to include the use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft [43].

Investigations¶

• Intramedullary nailing and plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults [2].
• Intramedullary nailing is superior to locking plate in reducing total complication rates, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [3].
• Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation [1].
• Patients undergoing ORIF for proximal humerus fracture dislocations have relatively high avascular necrosis and reoperation rates [4].
• Preoperative CT is extremely valuable for careful analysis of fracture type, fragment displacement, and bone quality in the surgical treatment of three and four-part proximal humeral fractures [54].
• Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries [52].

Treatment¶

Non-Operative Management¶

• Most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [15].
• Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes [27].
• Non-operative treatment is advocated for the majority of non-displaced and minimally displaced proximal humerus fractures, which generally yield good outcomes [41].

Operative Management: General Considerations¶

• No single fixation method is a panacea for proximal humerus fractures; the choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [21].
• Surgical management of proximal humeral fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results [19].
• Technical strategies to maximize the success of surgical treatment for proximal humerus fractures emphasize innovations in technique and implant design to mitigate high complication rates [39].
• Modern management controversies surrounding adult proximal humerus fractures include surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty [53].

Intramedullary Nailing vs. Locking Plate Fixation¶

• The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of proximal humerus fractures [3].

Augmentation Techniques¶

• Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure that mechanically increases construct stability and reduces complication rates while improving patient outcomes [18].
• Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone [26].

Specific Fracture Patterns and Populations¶

Anesthesia¶

• Regional anesthesia is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anesthesia alone [44].

Complications and Definitions¶

• Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures, calling for standardized definitions to improve evidence synthesis [20].

Complications¶

• Intramedullary fixation represents an alternative treatment option with reported outcomes comparable with other techniques [7].
• Fixation of proximal humeral fractures in elderly patients using locked plates with cement augmentation may have lesser implant failure and total complication rates than using a locked plate alone [26].
• Standard components and fracture-specific components in reverse shoulder arthroplasty (RSA) for proximal humerus fractures show no significant differences in complication rates [47].
• Venous thromboembolism (VTE) was the most frequently reported complication after shoulder arthroplasty (SA) compared to ORIF, with RSA having the highest VTE rate [50].
• Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty [57].
• Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures [58].
• Open fractures and 4-part proximal humerus fractures had the highest complication rates following intramedullary nailing [59].
• Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures [60].
• Proximal humerus fractures treated with a locking compression plate (LCP) augmented with a fibular allograft have decreased odds of a major complication when compared with patients treated with an LCP alone [61].

Recovery¶

• Modern proximal humeral nail designs and techniques can provide stable fixation [1].
• In most studies of proximal humerus fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied [24].
• Patients 65 years of age with 3- or 4-part proximal humerus fractures achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing reverse total shoulder arthroplasty (rTSA) with a noncemented stem and early postoperative ROM compared to rTSA with cemented stem and delayed rehabilitation [48].
• Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management [49].

Key Evidence¶

• [L5] Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation. [1] (10.1016/j.jse.2015.11.016)
• [L1] Intramedullary nailing and plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults. [2] (10.1016/j.jse.2026.02.016)
• [L1] The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. [3] (10.1186/s13018-019-1345-0)
• [L4] Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. [4] (10.1016/j.jse.2022.04.018)
• [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. [5] (10.5435/jaaos-d-24-01073)
• [L5] The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. [6] (10.1016/j.xrrt.2024.01.001)
• [L4] Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques. [7] (10.5435/jaaos-d-18-00360)
• [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [8] (10.2106/jbjs.l.01293)
• [L4] Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. [9] (10.1016/j.injury.2010.11.058)
• [L1] Plate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures. [11] (10.1186/1749-799x-9-31)
• [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [12] (10.5435/jaaos-d-14-00033)
• [L1] Limited evidence suggests that locking plate and intramedullary nail are both valuable options for the treatment of proximal humeral fractures. [13] (10.1186/s13018-015-0242-4)
• [L1] No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures. [14] (10.1007/s00264-017-3683-z)
• [L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. [15] (10.1016/j.jseint.2021.08.006)
• [L5] Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics, with a general evolution toward humeral head preservation using options ranging from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty. [16] (10.5435/00124635-200701000-00003)
• [L4] Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. [17] (10.1016/j.jse.2020.04.006)
• [L1] Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure that mechanically increases construct stability and reduces complication rates while improving patient outcomes. [18] (10.1007/s00402-019-03162-2)
• [L5] The paper concludes that surgical management of proximal humeral fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results. [19] (10.1016/j.jse.2010.12.006)
• [L1] This systematic review highlights significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures, calling for standardized definitions to improve evidence synthesis. [20] (10.1186/s12891-019-2459-6)
• [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. [21] (10.1016/j.injury.2010.10.016)
• [L2] In most studies of proximal humeral fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied. [24] (10.1016/j.jse.2022.01.141)
• [L4] The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status. [25] (10.5435/jaaos-d-15-00240)
• [L1] Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. [26] (10.1186/s12891-024-07502-1)
• [L5] Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. [27] (10.2106/jbjs.20.00665)
• [L5] Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy, with biomechanical studies showing that locked plating provides stable fixation. [29] (10.5435/jaaos-d-20-00558)
• [L5] Hemiarthroplasty for the treatment of complex proximal humerus fractures yields variable long-term clinical outcomes and high rates of failure, with the majority due to greater tuberosity malunion or nonunion. [38] (10.1016/j.xrrt.2025.100616)
• [L5] This review highlights various technical strategies to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates. [39] (10.5435/jaaos-d-22-01211)
• [L4] Non-operative treatment is advocated for the majority of non-displaced and minimally displaced fractures with generally good outcomes, while displaced fractures may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors. [41] (10.1016/j.injury.2007.09.022)
• [L4] Optimal management of osteoporotic proximal humeral fractures has evolved to include the use of locking plates and augmentation with intramedullary fibular grafts, calcium phosphate or sulfate cement, and iliac crest bone graft. [43] (10.1016/j.jse.2012.04.003)
• [L1] This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. [44] (10.1007/s00402-019-03253-0)
• [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. [47] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
• [L1] Patients 65 years of age with 3- or 4-part proximal humerus fractures achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM compared to rTSA with cemented stem and delayed rehabilitation. [48] (10.1016/j.jse.2024.03.040)
• [L4] Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management. [49] (10.1177/17585732231182374)
• [L4] Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate. [50] (10.1016/j.xrrt.2023.06.003)
• [L5] Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries. [52] (10.1530/eor-2026-0043)
• [L5] This review discusses modern management controversies surrounding adult proximal humerus fractures, including surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty to assist surgeons in making evidence-based decisions. [53] (10.1016/j.jhsa.2025.07.009)
• [L4] All available ORIF techniques require careful analysis of fracture type, fragment displacement, and bone quality, making preoperative CT extremely valuable. [54] (10.1016/j.otsr.2012.12.006)
• [L5] Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty. [57] (10.5435/jaaos-d-17-00051)
• [L4] Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures. [58] (10.1016/j.xrrt.2025.100625)
• [L4] Open fractures and 4-part proximal humerus fractures had the highest complication rates. [59] (10.1016/j.jse.2024.07.049)
• [L1] Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. [60] (10.1016/j.jse.2020.09.044)
• [L1] The pooled WMD and prediction interval suggest that 95% of patients with proximal humerus fractures treated with an LCP augmented with a fibular allograft will have improved radiographic outcomes, improved ASES clinical outcome scores, and decreased odds of a major complication when compared with patients treated with an LCP alone. [61] (10.1016/j.jse.2021.11.004)

References¶

[1] Intramedullary nailing of the proximal humerus: evolution, technique, and results. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.016

[2] Effectiveness of intramedullary nailing vs. locked plating (open reduction and internal fixation) in adult displaced proximal humerus fractures: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.016

[3] Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1345-0

[4] Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.04.018

[5] Contemporary Management of Proximal Humeral Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01073

[6] Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2024.01.001

[7] Intramedullary Fixation for Proximal Humeral Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-18-00360

[8] Proximal Humeral Fracture Treatment in Adults. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.l.01293

[9] A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011. DOI: 10.1016/j.injury.2010.11.058

[11] Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/1749-799x-9-31

[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] Meta-analysis of locking plate versus intramedullary nail for treatment of proximal humeral fractures. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0242-4

[14] Locking plates versus intramedullary nails in the management of displaced proximal humeral fractures: a systematic review and meta-analysis. International Orthopaedics. 2017. DOI: 10.1007/s00264-017-3683-z

[15] Trending a decade of proximal humerus fracture management in older adults. JSES International. 2022. DOI: 10.1016/j.jseint.2021.08.006

[16] Innovations in the Management of Displaced Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200701000-00003

[17] Outcome measures reported for the management of proximal humeral fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.006

[18] Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies. Archives of Orthopaedic and Trauma Surgery. 2019. DOI: 10.1007/s00402-019-03162-2

[19] Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.12.006

[20] Complications after non-surgical management of proximal humeral fractures: a systematic review of terms and definitions. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2459-6

[21] New trends in fixation of proximal humeral fractures: A review. Injury. 2011. DOI: 10.1016/j.injury.2010.10.016

[24] Fragility of randomized controlled trials on treatment of proximal humeral fracture. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.141

[25] Management of Acute Proximal Humeral Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00240

[26] Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07502-1

[27] Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.00665

[29] Principles of Locking Plate Fixation of Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00558

[38] Long-term outcomes of hemiarthroplasty for complex proximal humerus fractures: a systematic review of clinical studies with minimum 10-year follow-up. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100616

[39] Technical Tips for Reduction and Stable Fixation of Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-01211

[41] Isolated tuberosity fractures of the proximal humerus: Current concepts. Injury. 2008. DOI: 10.1016/j.injury.2007.09.022

[43] Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2012.04.003

[44] Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal. Archives of Orthopaedic and Trauma Surgery. 2019. DOI: 10.1007/s00402-019-03253-0

[47] 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

[48] Optimal combination of arthroplasty type, fixation method, and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: a network meta-analysis. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.040

[49] Rehabilitation protocols in proximal humerus fracture management: A systematic review. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231182374

[50] Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.06.003

[52] Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2026-0043

[53] Controversies in the Management of Proximal Humerus Fractures. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.07.009

[54] Surgical treatment of three and four-part proximal humeral fractures. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2012.12.006

[57] Management of the Failed Arthroplasty for Proximal Humerus Fracture. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00051

[58] Use of locking humeral stems in reverse total shoulder arthroplasty for complex proximal humerus fractures: a scoping review. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100625

[59] Complications following intramedullary nailing of proximal humerus and humeral shaft fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.049

[60] Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.044

[61] Improved outcomes for proximal humerus fracture open reduction internal fixation augmented with a fibular allograft in elderly patients: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.11.004