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急性肱骨近端骨折的肩关节置换术

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Updated Aug 2026
插图：一个人休息，手臂用吊带支撑。
复杂肩关节骨折的治疗与关节置换术。 Kieran Hirpara 4.0

本页面由机器翻译，尚未经临床医生审核。英文版本为权威版本。

为何建议进行此手术

本页面反映了罗克汉普顿 Mater 私人医院上肢外科医生 Kieran Hirpara 博士在门诊中对此类病例的处理方式。患者通常由全科医生或物理治疗师转诊至我们门诊。门诊评估用于明确诊断。对于急性骨折，可能会立即建议手术治疗。

该手术通过替换受损的上臂骨来恢复稳定性。我们通常向伴有复杂骨折的老年患者提供此手术。其目的是缓解疼痛并改善肩关节活动度。现有证据表明，与半肩关节置换术相比，反式肩关节置换术能提供更好的长期功能。在这些病例中，非手术治疗往往导致较差的预后。我们通过共同决策，旨在实现令人满意的疼痛缓解和改善日常功能。

手术前

我们通过X线检查、血液检查和麻醉评估为您做好手术准备，以确保您的安全。您必须在手术前禁食，并遵照外科医生的指示停用某些药物。请携带所有当前用药的清单，并穿着舒适的衣物。安排专人开车送您回家，因为术后您不能独自乘车。我们采用肩部上方的单一传统切口进行这种开放入路手术。该方法使我们能够仔细修复骨碎片并恢复功能。您的外科医生将提供关于暂停哪些药物以及何时停止进食和饮水的具体指示。

手术当天

您将抵达医院办理入院并进行术前准备。本手术在全身麻醉联合区域神经阻滞下进行。手术期间您将完全处于睡眠状态，而神经阻滞（在苏醒前注射以麻木支配手臂的神经）可提供术后最初12至24小时的镇痛效果。麻醉医师将在手术前与您会面，并向您详细解释这两个部分。

我们采用开放入路，在手术部位做一个常规切口进行此手术。这可直接进入肩关节。术后，您将在复苏室苏醒，我们的团队将监测您的舒适度和稳定性。在神经阻滞的初始镇痛效果发挥作用期间，您将在医院接受观察。出院前，您的主刀医师将评估您的恢复情况，并提供清晰的术后最初几天康复指导。

手术过程

您的外科医生会在您肩部前方做一个长约 8 至 10 厘米的切口。这种开放入路可清晰暴露骨折骨块。我们仔细将周围组织移开，以清晰显露骨折部位。

如果进行反式肩关节置换术，我们将移除您肱骨头部受损的球状部分。随后，我们将一个新的金属盂杯固定于您的肩胛骨上。一个金属球状组件则固定于您肱骨的上端。这种新关节改变了肩部的运动方式，使您能够利用不同于常规的肌肉来抬起手臂。

如果进行自体骨修复，我们将骨折块重新复位至正确位置。我们使用接骨板和螺钉固定骨骼，直至其愈合。此步骤的关键部分是将肌腱和肌肉（大结节）重新附着于骨骼。我们将这些软组织缝合固定于植入物或骨块周围。正确完成此附着对于您未来的肩部活动至关重要。

骨骼稳定且组织固定后，我们缝合切口。我们使用皮内和皮外缝线对合切口边缘。无菌敷料覆盖该区域，以在您开始康复期间提供保护。

术后

您将在复苏室苏醒，手臂用吊带固定，伤口处覆盖敷料。大多数患者术后需住院一晚，但部分患者可在当天回家。我们将使用常规药物控制您的疼痛。术后24小时内需有人陪同照顾您。本手术采用开放入路，在手术部位做单一常规切口。任何肩部手术后至少六周内不得驾驶，无论哪侧手臂接受手术。请阅读我们关于上肢手术后驾驶的指南以获取更多信息。请按照外科医生的指示佩戴吊带。

恢复过程

您的肩部将有一个切口。在最初几天，疼痛和肿胀是正常的。我们通过处方药物和冰敷来管理这些症状。始终将手臂支撑在悬吊带中。这有助于保护正在愈合的骨骼和软组织。您将无法使用该手臂进行提举或推压动作。

起初睡眠可能会感到困难。尝试在躺椅上休息，或用枕头垫高身体。这种姿势可以减少关节的压力。随着肿胀消退，您将开始进行轻柔的活动。我们的物理治疗师将指导您完成这些练习。这些练习的重点是在不牵拉修复部位的情况下恢复基本活动度。您将学习如何使用另一只手穿衣和进食。

您的恢复进度取决于身体的愈合情况。有些日子感觉较好，有些则较差。这是正常现象。在随访期间，我们会密切监测您的愈合情况。一旦您的外科医生批准（通常在六周复查时），您可以恢复驾驶。请注意，在佩戴悬吊带或疼痛限制您的控制能力时，不得驾驶。更多详情，请参阅上肢手术后的驾驶指南。

恢复过程因人而异。您的时间线可能有所不同；您的外科医生和物理治疗师将为您提供指导。我们将在此过程中支持您，陪伴您度过每一步。

可能发生的问题

大多数患者恢复良好，但偶尔也会出现并发症。您的外科医生和医疗团队会密切监测您的情况，以便尽早发现任何问题。

疼痛与愈合问题 术后您可能会发现肩关节活动度仍然受限或不可预测。这很常见，因为愈合过程因人而异。对于老年患者，大结节等骨块的适当愈合有助于改善肩关节功能。如果您感到剧烈、搏动性疼痛，且普通止痛药无法缓解，请告知我们。这可能意味着骨骼愈合不良。

全身健康风险 老年人的骨折常发生于体质虚弱的患者。无论是否接受手术，这一群体在受伤后一年内面临更严重的健康问题甚至死亡的风险较高。您可能需要因全身医疗问题住院，而不仅仅是针对肩部的治疗。大多数再入院是由于全身内科原因，而非肩部本身的问题。如果您感到全身不适、呼吸急促或意识模糊，请立即寻求紧急医疗救助。

手术部位并发症

与钢板内固定相比，此类关节置换术后发生并发症的可能性更高。您可能会看到伤口周围出现红斑扩散、突然肿胀或出现引流液。这些迹象可能提示感染或其他愈合问题。如果发现这些变化，请立即致电诊所。不要等到下次预定复诊时间。

长期预后

虽然疼痛缓解效果通常良好，但关节活动度的改善结果可能不太可预测。您可能会感到肩关节僵硬或出现弹响感。部分患者可能需要进一步手术来纠正这些问题。如果肩关节出现新的不稳定或疼痛，请在复诊时告知我们。我们将评估是否需要进一步治疗。

如需具体数据，请参阅本页的并发症表格，其中列出了典型的发生率。

何时联系我们

如果您出现发热、伤口红肿加重或渗出，或突发剧烈疼痛，请立即联系我们。若发现小腿肿胀、呼吸困难、感觉丧失或无法活动肢体，请前往急诊。这些症状需要紧急评估。我们致力于帮助您在康复期间保持安全。如出现上述任何症状，请立即联系我们的诊所。

Reviewed by Dr Kieran Hirpara · 7 August 2026.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

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

Evidence & references

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

  • Patients undergoing arthroplasty for acute proximal humeral fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • In elderly patients undergoing reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [2].
  • Clinical results at 1-year follow-up confirm the advantage of applying a new intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [3].
  • Elderly patients requiring admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age [4].
  • Patients who undergo initial nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures [5].
  • Patients with acute proximal humeral fractures who undergo reverse shoulder arthroplasty appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty [6].
  • The study cited represents the largest long-term follow-up of acute proximal humeral fractures treated with hemiarthroplasty [9].
  • 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 [16].
  • The increased in-hospital risk for major adverse events and surgical complications may moderate enthusiasm for reverse total shoulder arthroplasty (RTSA) for proximal humeral fractures in patients 65 years and older [21].
  • Available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication [26].
  • Reverse total shoulder arthroplasty (RTSA) performed for acute 3- and 4-part proximal humeral fractures yields overall worse clinical outcomes and active range of motion compared with RTSA performed for elective indications [66].
  • No clear benefits were observed in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment [67].

Anatomy & Pathophysiology

  • Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic [8].
  • Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion [28].
  • Greater tuberosity healing affects reverse shoulder arthroplasty biomechanics during external rotation [28].
  • With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly [30].
  • Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics [40].
  • The control volume is an important anatomic and functional area of the proximal humerus [44].
  • Vertical abduction has the greatest effect on axillary nerve position during the split lateral deltoid approach [43].
  • Horizontal glenohumeral forward flexion and humeral rotation have little effect on axillary nerve position during the split lateral deltoid approach [43].
  • The study demonstrates variability in the glenopolar angle with increased AP rotational offset of the shoulder radiograph [38].
  • The study reveals inaccuracies in glenopolar angle measurement even at an institution with an established protocol [38].
  • Range of motion and strength thresholds can identify subjects with normal shoulder function [29].
  • The authors recommend performing the measurement of objective strength at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane [35].
  • Dominance of the affected shoulder has no influence on functional and quality of life outcome compared with the nondominant shoulder [37].
  • Dominance of the affected shoulder should not be used to make treatment decisions [37].

Classification

  • The Neer classification system covers 98% of all proximal humeral fractures and is appropriate for clinical practice [58].
  • Classifications of proximal humeral fractures using the Neer system based on CT scans and plain radiographs are not very reliable or reproducible due to difficulty in determining which segments are fractured [60].
  • The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems [56].
  • A 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 [49].
  • Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [11].

Clinical Presentation

  • Patients undergoing arthroplasty for acute proximal humerus fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • Patients undergoing initial nonoperative management have worse functional outcomes and higher complication rates than those undergoing acute reverse total shoulder arthroplasty for proximal humeral fractures [5].
  • Fractures of the proximal humerus follow characteristic patterns [7].
  • A majority of patients with proximal humeral fractures undergo non-operative treatment [10].
  • Consensus on managing proximal humerus fractures is limited to specific scenarios, while a lack of consensus exists in others [11].
  • There is significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [12].
  • Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, with a substantial proportion of patients having poor perceived functional outcomes [13].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [15].
  • The majority of unplanned hospital readmissions after surgical treatment of proximal humerus fractures are associated with medical diagnoses [19].
  • In patients presenting with a traumatic shoulder injury and normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify occult greater tuberosity fractures [22].
  • Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [23].
  • Patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury compared with the general population [25].
  • Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [50].
  • Reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae when joint-preserving options are not optimal, provided there is careful management of the tuberosities and understanding of associated pearls and pitfalls [54].
  • Prevention of local complications, particularly those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture [55].
  • Factors associated with poor results after internal fixation of three-part and four-part proximal humerus fracture-dislocations include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension [57].
  • A wide range of outcome measures are used in proximal humeral fracture studies, but there is limited evidence regarding their psychometric properties in this specific population [59].

Investigations

  • Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced lesser tuberosity fracture can be successful and enhance overall shoulder function [17].
  • Undisplaced greater tuberosity fractures can be managed non-operatively with good results [72].
  • Patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult greater tuberosity fractures [72].
  • In patients presenting with a traumatic shoulder injury with normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify patients with an occult greater tuberosity fracture [22].
  • There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane [73].
  • Nearly 30% of cases suggesting surgical treatment on radiographs are reclassified for conservative treatment based on CT findings [73].
  • The inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes [71].
  • 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 [74].
  • The routine use of 3D-printed models should be avoided as the sole determinant for recommending surgical intervention at this time [74].
  • Convolutional neural networks (CNNs) proficiently rule out proximal humerus fractures on plain radiographs [76].
  • Missed posterior dislocation of the shoulder after intramedullary fixation of proximal humeral fractures is an extremely rare injury that can be missed due to inadequate initial and postoperative x-ray images and incorrect interpretation [79].

Treatment

  • Patients undergoing shoulder hemiarthroplasty for acute proximal humerus fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • Patients undergoing initial nonoperative management have worse functional outcomes and higher complication rates than those undergoing acute reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures [5].
  • Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant in complex shoulder fractures treated by reverse shoulder arthroplasty, provided their consolidation is anatomic [8].
  • A majority of patients with proximal humeral fractures underwent non-operative treatment [10].
  • Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [12].
  • Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years [14].
  • Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [20].
  • Nonsurgical management of proximal humerus fractures decreased during the study period [46].
  • Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [47].
  • 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 [48].
  • Nonsurgical management of proximal humerus fractures demonstrates successful outcomes and union rates greater than 90% [51].
  • Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures compared to locking plate fixation [52].
  • Osteoporosis may not be regarded as a contraindication for open reduction and internal fixation of unilateral displaced 3- or 4-part fractures, as shoulder function was restored to preinjury levels for most patients at 12-month follow-up [53].
  • Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [62].
  • With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8 years after hemiarthroplasty for primary nonreconstructable humeral head fractures [65].

Complications

  • Patients undergoing arthroplasty for acute proximal humeral fractures may achieve satisfactory long-term pain relief, but overall shoulder motion results are less predictable [1].
  • Patients with acute proximal humeral fractures who undergo reverse shoulder arthroplasty (RSA) appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty [6].
  • In-hospital complications are more likely to occur after reverse shoulder arthroplasty than after locked plating for proximal humeral fractures [21].
  • Surgery for complex proximal humeral fractures leads to overall good long-term outcomes but is associated with high overall complication and reoperation rates [24].
  • Short-term complication rates for fixation and arthroplasty alike have decreased compared with recent historic norms [27].

Recovery

  • This study represents the largest long-term follow-up of acute proximal humeral fractures treated with hemiarthroplasty [9].
  • Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced lesser tuberosity fracture was successful and enhanced overall shoulder function in two adolescent patients [17].
  • Surgery for complex proximal humeral fractures leads to overall good long-term outcomes despite high overall complication and reoperation rates [24].
  • The increasing utilization of reverse total shoulder arthroplasty (RTSA) and decreasing short-term complication rates for fixation and arthroplasty represent a substantial change compared with recent historic norms in the management of proximal humerus fractures [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 [63].
  • Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type [80].

Key Evidence

  • [L3] Patients undergoing arthroplasty as treatment of an acute fracture of the proximal humerus may achieve satisfactory long-term pain relief; however, the result for overall shoulder motion is less predictable. [1] (10.1016/j.jse.2007.06.025)
  • [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. [2] (10.1016/j.jse.2018.05.030)
  • [L3] Clinical results at 1-year follow-up confirmed the advantage of applying it to 3- or 4-part proximal humeral fractures in older patients. [3] (10.1186/s12891-022-05998-z)
  • [L3] Elderly patients who require admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age. [4] (10.1016/j.jse.2019.05.030)
  • [L3] Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. [5] (10.1016/j.jse.2021.06.020)
  • [L3] Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty. [6] (10.1016/j.jse.2012.03.006)
  • [L4] Fractures of the proximal humerus follow characteristic patterns. [7] (10.1016/j.jse.2017.05.014)
  • [L3] Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic. [8] (10.1016/j.jse.2012.03.011)
  • [L3] This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty. [9] (10.1302/0301-620x.103b6.bjj-2020-1753.r1)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. [10] (10.1186/s12891-019-2812-9)
  • [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. [11] (10.1016/j.jse.2024.12.005)
  • [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. [12] (10.1186/s12891-019-2459-6)
  • [L1] Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. [13] (10.2106/jbjs.20.02018)
  • [L2] Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years. [14] (10.2106/jbjs.l.01115)
  • [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [15] (10.1016/j.jse.2022.03.006)
  • [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. [16] (10.1016/j.jse.2022.01.141)
  • [L4] Despite a delayed diagnosis of more than one year, osteotomy and realignment of the displaced fracture of the lesser tuberosity was successful and enhanced the overall function of the shoulder in these two patients. [17] (10.2106/00004623-199509000-00020)
  • [L3] As the majority of unplanned hospital readmissions were associated with medical diagnoses, it is important to consider patient medical comorbidities before surgical treatment of proximal humerus fractures and during the postoperative care phase. [19] (10.1007/s11999-014-3613-y)
  • [L2] Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern. [20] (10.2106/jbjs.20.02137)
  • [L3] The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. [21] (10.1097/corr.0000000000001776)
  • [L2] In patients presenting with a traumatic shoulder injury with normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify patients with an occult greater tuberosity fracture. [22] (10.1016/j.jse.2023.07.044)
  • [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [23] (10.2106/jbjs.l.01293)
  • [L5] Surgery for complex proximal humeral fractures leads to overall good long-term outcomes with high overall complication and reoperation rates. [24] (10.2106/jbjs.19.01109)
  • [L3] Compared with the general population, patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury. [25] (10.1302/0301-620x.102b11.bjj-2020-0627.r1)
  • [L1] The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication. [26] (10.1016/j.jse.2015.08.030)
  • [L3] The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. [27] (10.1097/corr.0000000000002391)
  • [L5] Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. [28] (10.1016/j.jse.2019.07.022)
  • [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. [29] (10.1016/j.jse.2010.06.005)
  • [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. [30] (10.1016/j.jse.2007.06.017)
  • [L3] The authors recommend performing the measurement at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane. [35] (10.1186/s12891-019-2795-6)
  • [L3] Dominance of the affected shoulder has no influence and should not be used to make treatment decisions. [37] (10.1016/j.jse.2014.10.006)
  • [L4] The study demonstrates variability in the glenopolar angle with increased AP rotational offset of the shoulder radiograph, revealing inaccuracies even at an institution with an established protocol. [38] (10.1302/0301-620x.95b8.30631)
  • [L5] Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics. [40] (10.5435/jaaos-d-20-00555)
  • [L5] Vertical abduction has the greatest effect on axillary nerve position, while horizontal glenohumeral forward flexion and humeral rotation have little effect. [43] (10.1016/j.jse.2008.12.001)
  • [L5] The control volume is an important anatomic and functional area of the proximal humerus. [44] (10.1016/j.jse.2017.12.004)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. [46] (10.1016/j.jhsa.2020.03.022)
  • [L1] Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. [47] (10.1016/j.jse.2024.02.023)
  • [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. [48] (10.1371/journal.pmed.1002855)
  • [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. [49] (10.1016/j.jse.2015.08.006)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [50] (10.5435/jaaos-d-14-00033)
  • [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. [51] (10.5435/jaaos-d-24-01073)
  • [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. [52] (10.1016/j.jse.2011.01.025)
  • [L1] Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for this treatment. [53] (10.1016/j.jse.2022.07.008)
  • [L5] Reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae when joint-preserving options are not optimal, provided there is careful management of the tuberosities and understanding of associated pearls and pitfalls. [54] (10.5435/jaaos-d-23-00740)
  • [L2] Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture. [55] (10.1016/j.jse.2011.06.009)
  • [L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. [56] (10.1016/j.jse.2012.09.018)
  • [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. [57] (10.1097/corr.0000000000002242)
  • [L4] The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice. [58] (10.1016/j.jse.2009.01.018)
  • [L1] The review identified a wide range of outcome measures used in proximal humeral fracture studies, but found limited evidence regarding their psychometric properties in this specific population. [59] (10.1016/j.jse.2010.10.028)
  • [L4] Classifications of proximal humeral fractures using the Neer system based on CT scans and plain radiographs are not very reliable or reproducible due to difficulty in determining which segments are fractured. [60] (10.2106/00004623-199609000-00012)
  • [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. [62] (10.1016/j.jse.2006.09.006)
  • [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. [63] (10.1016/j.jse.2024.09.032)
  • [L4] With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8 years after hemiarthroplasty for primary nonreconstructable humeral head fractures. [65] (10.1016/j.jse.2023.02.118)
  • [L1] RTSA performed for acute 3- and 4-part proximal humeral fractures yields overall worse clinical outcomes and active ROM compared with RTSA performed for elective indications. [66] (10.1016/j.jse.2021.07.014)
  • [L1] We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment. [67] (10.1007/s11999-012-2531-0)
  • [L3] This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes. [71] (10.1186/s13018-022-03337-5)
  • [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. [72] (10.1186/s12891-018-2225-1)
  • [L3] There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane, with nearly 30% of cases suggesting surgical treatment on radiographs being reclassified for conservative treatment based on CT findings. [73] (10.1016/j.jse.2016.05.016)
  • [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. [74] (10.1097/corr.0000000000002017)
  • [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. [76] (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
  • [L4] Missed posterior dislocation of the shoulder after intramedullary fixation of proximal humeral fractures is an extremely rare injury that can be missed due to inadequate initial and postoperative x-ray images and incorrect interpretation. [79] (10.1016/j.jse.2008.10.020)
  • [L1] Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type. [80] (10.1302/0301-620x.102b1.bjj-2020-0546.r1)

References

[1] Shoulder hemiarthroplasty for acute fractures of the proximal humerus: A minimum five-year follow-up. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.06.025

[2] How the greater tuberosity affects clinical outcomes after reverse shoulder arthroplasty for proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2018.05.030

[3] Technique and clinical results of a new intramedullary support nail and plate system for fixation of 3- or 4- part proximal humeral fractures in older adults. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05998-z

[4] Mortality after inpatient stay for proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.05.030

[5] Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.06.020

[6] Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.03.006

[7] Fracture line morphology of complex proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2017.05.014

[8] Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.03.011

[9] Ten-year follow-up of stemmed hemiarthroplasty for acute proximal humeral fractures. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b6.bjj-2020-1753.r1

[10] 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

[11] 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

[12] 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

[13] Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.02018

[14] Comparison of Hemiarthroplasty and Reverse Arthroplasty for Treatment of Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2013. DOI: 10.2106/jbjs.l.01115

[15] 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

[16] 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

[17] Isolated avulsion fracture of the lesser tuberosity of the humerus in adolescents. A report of two cases.. The Journal of Bone & Joint Surgery. 1995. DOI: 10.2106/00004623-199509000-00020

[19] Hospital Readmissions After Surgical Treatment of Proximal Humerus Fractures: Is Arthroplasty Safer Than Open Reduction Internal Fixation?. Clinical Orthopaedics & Related Research. 2014. DOI: 10.1007/s11999-014-3613-y

[20] One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.02137

[21] In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001776

[22] A new clinical sign to detect radiologically occult greater tuberosity fractures. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.07.044

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

[24] Proximal Humeral Fractures: “Damned If You Operate, and Damned If You Don’t”. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.01109

[25] Mortality after a proximal humeral fracture. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b11.bjj-2020-0627.r1

[26] Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.08.030

[27] 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.0000000000002391

[28] The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.022

[29] 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

[30] Neer Award 2006: Biomechanical assessment of inferior tuberosity placement during hemiarthroplasty for four-part proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.06.017

[35] Evaluation of the Constant score: which is the method to assess the objective strength?. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2795-6

[37] Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder?. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.10.006

[38] The assessment of scapular radiographs. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b8.30631

[40] Altered Glenohumeral Biomechanics in Proximal Humeral Fracture Malunion. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00555

[43] Effects of shoulder position on axillary nerve positions during the split lateral deltoid approach. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.12.001

[44] A morphovolumetric study of head malposition in proximal humeral fractures based on 3-dimensional computed tomography scans: the control volume theory. Journal of Shoulder and Elbow Surgery. 2018. DOI: 10.1016/j.jse.2017.12.004

[46] 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

[47] Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.02.023

[48] 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

[49] Classification of proximal humeral fractures based on a pathomorphologic analysis. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.08.006

[50] Evaluation and Management of Pediatric Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-14-00033

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

[52] 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

[53] Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2022.07.008

[54] Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review. Journal of the American Academy of Orthopaedic Surgeons. 2024. DOI: 10.5435/jaaos-d-23-00740

[55] Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.06.009

[56] A comprehensive classification of proximal humeral fractures: HGLS system. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.09.018

[57] 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

[58] Four-segment classification of proximal humeral fractures revisited: A multicenter study on 509 cases. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2009.01.018

[59] Outcome measures in the management of proximal humeral fractures: a systematic review of their use and psychometric properties. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.10.028

[60] Evaluation of the Neer System of Classification of Proximal Humeral Fractures with Computerized Tomographic Scans and Plain Radiographs. The Journal of Bone & Joint Surgery*. 1996. DOI: 10.2106/00004623-199609000-00012

[62] 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

[63] 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

[65] Is there still a place for anatomic hemiarthroplasty in patients with high functional demands in primary, nonreconstructable proximal humeral fractures? A clinical and radiographic assessment. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.118

[66] Clinical outcomes of reverse total shoulder arthroplasty for elective indications versus acute 3- and 4-part proximal humeral fractures: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.07.014

[67] Hemiarthroplasty for Humeral Four-part Fractures for Patients 65 Years and Older: A Randomized Controlled Trial. Clinical Orthopaedics & Related Research. 2012. DOI: 10.1007/s11999-012-2531-0

[71] The effect of medial calcar support on proximal humeral fractures treated with locking plates. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-022-03337-5

[72] Missed fractures of the greater tuberosity. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2225-1

[73] Coronal displacement in proximal humeral fractures: correlation between shoulder radiographic and computed tomography scan measurements. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.05.016

[74] 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

[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] Missed posterior dislocation of the shoulder after intramedullary fixation of humeral fractures: A report of three cases. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2008.10.020

[80] Does time to surgery affect patient-reported outcome in proximal humeral fractures? A subanalysis of the PROFHER randomized clinical trial. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b1.bjj-2020-0546.r1

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

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

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

Section 6 -- Term and Termination.

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

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

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

2. upon express reinstatement by the Licensor.

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

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

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

Section 7 -- Other Terms and Conditions.

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

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

Section 8 -- Interpretation.

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

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

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

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

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

Creative Commons may be contacted at creativecommons.org.