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肱骨近端骨折

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

Updated Aug 2026
一幅手绘插图，显示上臂骨在肩部下方骨折。
X光片显示上臂骨顶部骨折，位于肩关节下方。 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。

您的感受

您可能会在上臂顶部、靠近肩关节处感到剧烈疼痛。这种疼痛通常会向下蔓延至手臂，或向上放射至颈部。该损伤是上臂骨上段的骨折，可能由跌倒或由于年龄增长导致骨质变薄引起。

尝试活动手臂时，疼痛通常会加剧。提杯子、伸手够架子或把衬衫塞进裤子里等简单任务可能会变得困难甚至无法完成。您可能难以将手伸到背后扣上胸罩或系衬衫纽扣。即使是轻微的动作也可能引发不适感的加剧。

许多人注意到夜间疼痛最为剧烈。患侧卧位往往过于疼痛，因此您可能难以找到舒适的睡姿。醒来时肩膀僵硬、酸痛是很常见的现象。将手臂置于吊带中休息可以通过保持骨折端稳定来帮助减轻疼痛。然而，长时间保持手臂静止也可能导致关节感觉僵硬和紧绷。

虽然疼痛剧烈，但重要的是要知道，大多数此类骨折无需手术即可良好愈合。您的外科医生会指导您如何在愈合期间保护手臂。在绝大多数情况下，非手术治疗能实现成功的愈合，愈合率超过 90%。这意味着大多数患者的骨骼能够正确愈合连接。

对于年长患者，治疗方案将考虑其整体健康状况和骨强度。对于 65 岁以下的年轻成人，手术并不总是优于休息和支持。您的外科医生会通过影像学检查确定骨折的确切位置，并决定最佳的治疗方案。

对于部分骨折更复杂的老年患者，可能会讨论关节置换术。对于治疗老年患者的急性骨折，该选项可提供持久的效果。当骨骼损伤严重时，这是一个安全且合理的选择。

大多数患有此类骨折的儿童愈合迅速且并发症极少。如果您正在照顾儿童，总体预后通常非常乐观。

请注意，这种损伤可能会显著影响您的日常生活。它可能导致暂时性残疾并降低您的幸福感。然而，通过适当的护理和耐心，大多数人可以恢复手臂功能。请遵循外科医生关于活动和休息的建议，以支持您的康复。

实际发生了什么

您上臂骨（肱骨）的顶端是一个复杂的控制体，负责肩关节的运动。当您跌倒时，该区域可能会碎裂成多块。最关键的部分是结节，它们是肱骨上的骨性突起，肩袖肌腱附着于此。可以将这些肌腱想象成强壮的绳索，负责抬起和旋转您的手臂。如果这些结节发生移位，绳索就会失去锚定点。这会改变力量在肩关节内的传递方式。即使微小的位置偏移也会显著改变关节的运动方式和承重能力。

您的外科医生会评估这些连接的稳定性。关节囊是包裹肩关节的袖状结构，软骨则是覆盖在骨端的平滑涂层。当骨碎片发生移位时，它们可能会相互摩擦或不均匀地压迫软骨。这会导致疼痛并限制您的活动范围。在某些情况下，肱骨头部的血液供应可能会受损。如果骨块未能正确对位愈合，可能会导致僵硬或无力。

我们理解，治疗方案的选择取决于您的年龄以及骨折的具体类型。对于大多数无移位的单部分骨折（即骨头有裂纹但位置仍保持对齐），非手术治疗效果良好。大多数患有此类稳定骨折的老年人通过非手术治疗获得了良好的预后。非手术治疗显示出成功的治疗结果，骨愈合率超过 90%。这意味着在绝大多数情况下，骨头无需手术即可正确愈合。

然而，如果骨碎片发生移位或不稳定，您的外科医生可能会建议手术。手术的目标是恢复解剖结构，使您的肌腱能够再次有效发力。我们使用锁定钢板或髓内钉将骨块固定在一起，直至愈合。这为肱骨近端提供了稳定的固定。在骨头损伤严重无法修复的极端情况下，我们可能会考虑关节置换术。在治疗老年人急性肱骨近端骨折方面，该选项具有令人信服的疗效证据和功能耐久性。

我们能做什么

我们对您护理的方式反映了 Mater Private Hospital Rockhampton 的上肢外科医生 Kieran Hirpara 博士在诊所中处理这些损伤的方法。大多数单部分肱骨近端骨折无需手术即可良好愈合。在绝大多数情况下，非手术治疗能带来积极的结果。非手术管理的骨愈合率超过 90%。您的治疗过程通常从自我管理和物理治疗开始。我们可能会使用吊带来支撑您的手臂。短期或长期的固定效果相似，因此我们会根据您的舒适度和骨折类型来调整固定时间。物理治疗旨在随着骨骼愈合恢复活动度和力量。大多数患有此类骨折的老年人继续接受此类护理，并能获得良好的功能结果。

药物治疗侧重于在骨骼愈合过程中保持您的舒适。我们使用止痛药和抗炎药来控制不适。如果肿胀或僵硬持续存在，我们可能会讨论注射治疗。皮质类固醇注射可在有限时间内减轻炎症和疼痛。透明质酸注射润滑关节以改善活动。富血小板血浆（PRP）注射利用您自身的血液成分来支持愈合。当保守治疗 alone 不足以控制症状时，这些选项有助于管理症状。对于退行性或长期存在的问题，我们通常首先尝试这些非手术步骤。只有当这些方法未能提供足够改善时，我们才会考虑手术。

当保守治疗达到极限或骨折复杂时，会考虑手术。对于 60 岁或以上的患者，移位的双部分骨折在 2 年时，手术与非手术治疗在临床结果上没有显著差异。然而，对于老年患者的三部分或四部分骨折，手术可能会提供更好的长期功能结果。对于患有严重骨折的老年人，反式全肩关节置换术（关节置换）是一个合理且安全的选择。它提供有效且持久的功能结果。对选定骨折的经皮治疗也能以较低的并发症率实现可预测的骨愈合。手术后的并发症发生率较高，因此我们将手术保留用于特定情况。对于结构性或急性问题，可能会立即建议手术。我们基于您的年龄、骨质量和骨折类型，将这些选项作为共同决策提出。

预期情况

您的预后主要取决于您的年龄和骨折的严重程度。对于大多数老年人来说，这些骨折无需手术即可良好愈合。非手术治疗在超过 90% 的病例中可实现成功愈合。您可能会短期（如一周）或较长期（如三周）佩戴悬带。这两种方案的效果相似。大多数患者通过这种方式可恢复良好的功能。

如果您年龄小于 65 岁，您的外科医生可能会讨论手术方案。然而，证据并未显示在此年龄段以下，手术优于非手术治疗。对于老年患者的复杂骨折，手术通常比保守治疗提供更好的长期功能。反向全肩关节置换术或使用钢板和髓内钉进行内固定等手术有助于稳定骨骼。这些方法旨在随着时间的推移恢复活动能力并减轻疼痛。

恢复是一个渐进的过程。您可能会注意到肩部在几个月内感到僵硬或无力。接受手术后，您可能会遇到一些挫折，因为复杂骨折的并发症率和再次手术率较高。尽管如此，许多患者仍取得了良好的长期结果。您的外科医生将指导您的康复训练，以确保您安全地恢复力量。

了解更广泛的健康状况很重要。老年人的脆性骨折伴有发生严重健康事件的高风险。受伤后一年内的死亡风险为 9.8%。这一风险在五年内上升至 28.2%。这一增幅是普通人群的两倍多。在恢复期间，您的外科医生将密切监测您的整体健康状况以管理这些风险。

大多数儿童可完全康复且并发症极少。对于成年人，耐心至关重要。虽然可能会有一些不适持续存在，但大多数患者可恢复日常活动。您的外科医生将根据您的具体骨折类型和健康状况制定个性化的护理计划。定期随访可确保骨骼正确愈合，并有助于尽早解决任何疑虑。

何时就诊

若疼痛持续且休息后无改善，请咨询全科医生。若发现肩部无力或不稳，请要求专科医生评估。若肩部出现交锁或脱位，请立即就医。若症状干扰睡眠或工作，请联系医生。疼痛突然加重也是寻求医疗帮助的理由。大多数单部分骨折无需手术即可良好愈合。然而，准确评估至关重要。您的外科医生将使用影像学检查以排查并发症。早期评估有助于预防长期残疾。切勿忽视恢复未按预期进展的迹象。

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

  • Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults [1].
  • Most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [4].
  • Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [8].
  • The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years [15].
  • Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade [3].
  • Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [12].
  • Patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures after surgical treatment [29].
  • Guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin [29].
  • The selection of reverse total shoulder arthroplasty (RTSA) over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients [25].
  • Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications [67].
  • Prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures [17].
  • Besides age, most randomized controlled trials on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria [16].

Anatomy & Pathophysiology

  • Inferior tuberosity displacement after prosthetic reconstruction of shoulder fractures is associated with diminished functional results [33].
  • Inferior tuberosity positioning after hemiarthroplasty for proximal humerus fractures is associated with diminished function [40].
  • Range of motion and strength thresholds can identify subjects with normal shoulder function [36].
  • Shoulder flexion, extension, and abduction are only moderately correlated with patient-reported outcome measures (PROMs) [57].
  • Holistic assessment of outcomes requires both subjective and objective outcomes [57].
  • The changed position of the humeral head on the coronal plane does not affect final functional results in conservatively treated displaced proximal humerus fractures in the elderly [54].
  • Bone quality significantly impacts implant anchorage in osteosynthesis for proximal humerus fractures [58].
  • Positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures [46].
  • Rotator cuff tears are a detrimental factor and a major cause of painful shoulders in proximal humeral fractures with minimal displacement treated conservatively [63].
  • The double plate strategy can increase the stability of the medial column of the proximal humerus and enhance the overall biomechanical property of the repaired proximal humerus [64].
  • Reverse shoulder arthroplasty could be considered primary treatment for proximal humerus fractures, especially when optimal range of motion is of great importance to the patient [72].
  • Glenoid loosening and severe scapular notching in reverse shoulder arthroplasty for proximal humerus fractures are related to poor positioning and/or incorrect orientation of the glenosphere [74].

Classification

  • Proximal humerus fractures are osteoporotic injuries with increasing incidence due to aging populations [5].
  • Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions [5].
  • Evaluation of classification systems for fractures of the proximal humerus with plain radiographs has yielded low interobserver reliability [32].
  • The Mayo-FJD classification system for proximal humerus fractures allows high intraobserver and interobserver agreement using both radiographs and computed tomography [45].
  • The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [28].
  • Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized [50].
  • Current diagnosis coding practices (ICD-10) do not adequately capture the fracture complexity needed to conduct subgroup analysis for proximal humerus fractures [75].
  • There is clear evidence of specific characteristics which differentiate proximal third humeral shaft fractures from those of midshaft and distal third [69].

Clinical Presentation

  • Proximal humerus fractures are now typically osteoporotic fractures in women over 70, with prevalence increasing due to an aging population in poor general condition [19].
  • There is a substantial mortality in patients with a proximal humerus fracture [6].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [14].
  • Surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year [6].
  • Complications associated with proximal humerus fractures are varied and can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [11].
  • Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population [13].
  • Surgical treatment of proximal humerus fractures remains far from straightforward, with unpredictable outcomes where factors associated with poor results include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension [37].
  • Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae [18].
  • Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae [18].

Investigations

  • Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions in proximal humerus fractures [5].
  • Computed tomography improves the diagnostic accuracy of the Boileau classification of proximal humerus fracture sequelae [18].
  • Computed tomography does not improve the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae [18].
  • Computed tomography scan is more specific than radiographs in the assessment of proximal humerus fracture sequelae [18].
  • Artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [28].
  • Convolutional neural networks proficiently rule out proximal humerus fractures on plain radiographs [76].
  • The routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities [79].
  • The routine use of 3D-printed models should be avoided as the sole determinant for recommending surgical intervention in proximal humeral fractures [79].
  • In children with shoulder dislocation combined with proximal humerus fracture, bilateral anteroposterior shoulders x-ray is suggested routinely to confirm shoulder location in addition to palpation and anteroposterior and lateral humeral x-ray [83].

Treatment

Non-Operative Management

  • In the vast majority of cases, proximal humerus fractures may be treated nonoperatively [2].
  • Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [4].
  • Non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention [24].
  • There is little utility to the routine use of postoperative radiographs in follow-up of pediatric proximal humerus fractures [24].
  • Proximal humerus fractures in children have tremendous potential for remodeling, making non-operative management the treatment of choice for most fractures [56].
  • Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [27].
  • A majority of patients with proximal humeral fractures underwent non-operative treatment [41].
  • Nonsurgical management of proximal humerus fractures decreased during the study period [35].
  • Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures [48].
  • Nonsurgical treatment provides better midterm outcomes compared to locking plate fixation for proximal humeral fractures [48].
  • There is no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus [39].
  • Evidence-based recommendations to guide treatment of proximal humerus fractures are lacking, and no good evidence exists whether surgery is clearly superior to nonoperative treatment [65].

Operative Management

  • Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [7].
  • Most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria [16].
  • Hemiarthroplasty and reverse prosthesis are indicated for complex proximal humerus fractures in patients no younger than 70 years of age [21].
  • Reverse total shoulder replacement is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [22].
  • The selection of RTSA over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients [25].
  • Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [26].
  • No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [38].
  • Minimally invasive plate osteosynthesis (MIPO) with PHILOS plate is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent [49].
  • There are no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in reverse shoulder arthroplasty (RSA) for proximal humerus fractures [51].

Complications

  • Proximal humerus fractures are associated with substantial mortality [6].
  • Surviving patients with proximal humerus fractures frequently have persistent symptoms that can be predicted as early as after 1 year [6].
  • Low arthroplasty survival is observed after treatment for proximal humerus fracture sequelae [9].
  • Patients with pathologic humerus fractures have significantly higher complication rates compared with native humerus fractures after surgical treatment [29].
  • Predictive models using machine learning techniques demonstrate favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged length of stay and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture [59].

Recovery

  • Both age and gender are associated with the definitive treatment received for proximal humerus fractures in patients older than fifty years [3].
  • Treatment algorithms and outcomes for proximal humerus fractures in patients aged 60 years or younger are distinctly different from those in a more elderly population [13].
  • Long-term treatment with reverse shoulder arthroplasty (RSA) for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time [44].
  • There is substantial mortality in patients with a proximal humerus fracture, and surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year [6].
  • After one year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms [20].
  • Reverse shoulder arthroplasty is used for the treatment of complex, displaced proximal humerus fractures in older individuals (≥ 65 years old) [30].
  • It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [22].
  • The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures [23].
  • ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [52].
  • Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results [31].
  • Timing of surgery does not impact outcomes of patients who underwent ORIF for proximal humerus fractures, with delays beyond 5 days not affecting outcome [84].

Key Evidence

  • [L4] Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults. [1] (10.5312/wjo.v5.i5.685)
  • [L4] In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. [2] (10.1155/2012/861598)
  • [L3] Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade. [3] (10.1016/j.jseint.2021.11.007)
  • [L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. [4] (10.1016/j.jseint.2021.08.006)
  • [L3] Our results suggest that there is a substantial mortality in patients with a proximal humerus fracture, as we have previously reported, and that surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year. [6] (10.1080/17453670510041295)
  • [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. [7] (10.1016/j.jse.2024.12.005)
  • [L3] These results are pertinent when deciding on the treatment of proximal humerus fracture sequelae. [9] (10.1080/17453674.2020.1793548)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [12] (10.5435/jaaos-d-14-00033)
  • [L4] Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. [13] (10.1016/j.xrrt.2023.01.002)
  • [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [14] (10.1016/j.jse.2022.03.006)
  • [L1] The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. [15] (10.1016/j.xrrt.2021.04.014)
  • [L2] Besides age, most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria. [16] (10.1016/j.xrrt.2025.07.023)
  • [L3] However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures. [17] (10.1016/j.injury.2013.08.024)
  • [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. [18] (10.1177/17585732221150785)
  • [L2] Proximal humerus fractures are now typically osteoporotic fractures in women over 70, with prevalence increasing due to an aging population in poor general condition. [19] (10.1016/j.otsr.2012.05.013)
  • [L3] After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms. [20] (10.1007/s00590-021-03099-6)
  • [L4] They are indicated for complex proximal humerus fractures in patients no younger than 70 years of age. [21] (10.1016/j.otsr.2008.09.002)
  • [L3] It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. [22] (10.1186/s12891-023-06669-3)
  • [L4] The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. [23] (10.1007/s00590-010-0655-z)
  • [Paper] Non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention, and there is little utility to the routine use of postoperative radiographs in follow-up of these patients. [24] (10.1016/j.otsr.2016.09.022)
  • [L5] The selection of RTSA over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients. [25] (10.1097/corr.0000000000002430)
  • [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. [26] (10.1016/j.jse.2006.09.006)
  • [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [27] (10.2106/jbjs.l.01293)
  • [L4] The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs. [28] (10.1080/17453674.2018.1453714)
  • [L3] After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. [29] (10.1016/j.jse.2020.10.024)
  • [L4] We report current and historical treatments, outcomes, and principles in reverse shoulder arthroplasty for treatment of complex, displaced proximal humerus fractures in older individuals ( ≥ 65 years old). [30] (10.1007/s12178-020-09597-0)
  • [L4] Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results. [31] (10.1016/j.injury.2015.05.017)
  • [L5] Evaluation of the classification systems for fractures of the proximal humerus with plain radiographs has yielded low interobserver reliability. [32] (10.1016/j.ocl.2008.05.002)
  • [L5] These biomechanical observations may explain diminished functional results observed in patients treated with inferior tuberosity displacement after prosthetic reconstruction of shoulder fractures. [33] (10.1016/j.jse.2007.02.110)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. [35] (10.1016/j.jhsa.2020.03.022)
  • [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. [36] (10.1016/j.jse.2010.06.005)
  • [L5] Surgical treatment of proximal humerus fractures remains far from straightforward, with unpredictable outcomes where factors associated with poor results include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension. [37] (10.1097/corr.0000000000002242)
  • [L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. [38] (10.1016/j.injury.2010.10.016)
  • [L1] This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. [39] (10.1371/journal.pmed.1002855)
  • [Abstract] These biomechanical changes may explain diminished function in patients with inferior tuberosity positioning after hemiarthroplasty for proximal humerus fractures. [40] (10.1016/j.jse.2007.02.027)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. [41] (10.1186/s12891-019-2812-9)
  • [L1] Long-term treatment with RSA for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time. [44] (10.1016/j.jse.2024.09.032)
  • [L4] The Mayo-FJD classification system for proximal humerus fractures seems to allow high intraobserver and interobserver agreement using both radiographs and computed tomography. [45] (10.1016/j.jse.2023.02.035)
  • [L5] These findings suggest that positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures. [46] (10.5397/cise.2022.00885)
  • [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. [48] (10.1016/j.jse.2011.01.025)
  • [L4] MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. [49] (10.1016/j.aott.2016.10.003)
  • [L2] Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized. [50] (10.1016/j.jseint.2022.02.006)
  • [L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. [51] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
  • [L3] ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. [52] (10.1097/corr.0000000000002895)
  • [L2] However, the changed position of the humeral head on coronal plane does not affect the final functional results. [54] (10.4103/0973-6042.118911)
  • [L3] Holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. [57] (10.1016/j.jseint.2024.02.003)
  • [L4] The paper reviews the biology and biomechanics of osteosynthesis for proximal humerus fractures, emphasizing that bone quality significantly impacts implant anchorage. [58] (10.1007/s00068-007-7089-2)
  • [L3] Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. [59] (10.1016/j.jseint.2024.02.005)
  • [Paper] Rotator cuff tears are a detrimental factor and a major cause of painful shoulders. [63] (10.1007/s00264-004-0552-3)
  • [L5] The double plate strategy can increase the stability of the medial column of the proximal humerus, and enhance the overall biomechanical property of the repaired proximal humerus. [64] (10.1186/s12891-024-08216-0)
  • [L4] Evidence-based recommendations to guide treatment of proximal humerus fractures are lacking, and no good evidence exists whether surgery is clearly superior to nonoperative treatment. [65] (10.1016/j.ocl.2008.06.003)
  • [Abstract] Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications. [67] (10.1016/j.jse.2015.05.005)
  • [L4] There is clear evidence of specific characteristics which differentiate proximal third humeral shaft fractures from those of midshaft and distal third. [69] (10.1016/j.injury.2013.10.030)
  • [L3] Therefore, reverse shoulder arthroplasty could be considered primary treatment, especially when optimal range of motion is of great importance to the patient. [72] (10.1177/17585732231190038)
  • [L4] Glenoid loosening and severe scapular notching are related to poor positioning and/or incorrect orientation of the glenosphere. [74] (10.1016/j.otsr.2018.06.008)
  • [L3] Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for proximal humerus fractures. [75] (10.1016/j.jse.2023.08.022)
  • [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. [76] (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
  • [L5] The routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities, and their use as the sole determinant for recommending surgical intervention should be avoided at this time. [79] (10.1097/corr.0000000000002017)
  • [L5] In addition to palpation and anteroposterior and lateral humeral x-ray, we suggest adding bilateral anteroposterior shoulders xray routinely to confirm the shoulder location. [83] (10.1097/md.0000000000008977)
  • [L3] Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures. [84] (10.1016/j.jse.2025.02.019)

References

[1] Management of proximal humerus fractures in adults. World Journal of Orthopedics. 2014. DOI: 10.5312/wjo.v5.i5.685

[2] Evaluation and Management of Proximal Humerus Fractures. Advances in Orthopedics. 2012. DOI: 10.1155/2012/861598

[3] How age and gender influence proximal humerus fracture management in patients older than fifty years. JSES International. 2022. DOI: 10.1016/j.jseint.2021.11.007

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

[5] 1. Clinical Evaluation, Imaging, and Classification of Proximal Humerus Fractures. n.d..

[6] Long-term outcome of a proximal humerus fracture predicted after 1 year. Acta Orthopaedica. 2005. DOI: 10.1080/17453670510041295

[7] Consensus statement on the treatment of proximal humerus fractures: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.12.005

[8] 2. Non-operative Management of Proximal Humerus Fractures: Indications, Protocols, and Outcomes. n.d..

[9] Low arthroplasty survival after treatment for proximal humerus fracture sequelae: 3,245 shoulder replacements from the Nordic Arthroplasty Register Association. Acta Orthopaedica. 2020. DOI: 10.1080/17453674.2020.1793548

[11] 6. Complications of Proximal Humerus Fractures: Evaluation and Management. n.d..

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

[13] Proximal humerus fracture management and outcomes are distinctly different for individuals 60 years of age or younger: a systematic review. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.01.002

[14] Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.03.006

[15] Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2021.04.014

[16] Randomized controlled trials investigating proximal humerus fractures lack consensus in inclusion criteria. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.023

[17] A comprehensive update on current fixation options for two-part proximal humerus fractures. Injury. 2014. DOI: 10.1016/j.injury.2013.08.024

[18] Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae. Shoulder & Elbow. 2023. DOI: 10.1177/17585732221150785

[19] Epidemiology of proximal humerus fractures managed in a trauma center. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.05.013

[20] No change in outcome ten years following locking plate repair of displaced proximal humerus fractures. European Journal of Orthopaedic Surgery & Traumatology. 2021. DOI: 10.1007/s00590-021-03099-6

[21] Three or four parts complex proximal humerus fractures: Hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2008.09.002

[22] Rehabilitation progress following reverse total shoulder replacement and internal fixation for geriatric three and four-part proximal humerus fractures – a propensity score matched comparison. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06669-3

[23] Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. European Journal of Orthopaedic Surgery & Traumatology. 2010. DOI: 10.1007/s00590-010-0655-z

[24] Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.09.022

[25] CORR Insights®: Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002430

[26] Outcomes after percutaneous reduction and fixation of proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.006

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

[28] Automated detection and classification of the proximal humerus fracture by using deep learning algorithm. Acta Orthopaedica. 2018. DOI: 10.1080/17453674.2018.1453714

[29] Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.024

[30] Reverse Shoulder Arthroplasty for Proximal Humerus Fracture. Current Reviews in Musculoskeletal Medicine. 2020. DOI: 10.1007/s12178-020-09597-0

[31] Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock. Injury. 2015. DOI: 10.1016/j.injury.2015.05.017

[32] Classification and Imaging of Proximal Humerus Fractures. Orthopedic Clinics of North America. 2008. DOI: 10.1016/j.ocl.2008.05.002

[33] Biomechanical Assessment Of Inferior Tuberosity Placement During Hemiarthroplasty For 4-Part Proximal Humerus Fractures G.. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.110

[35] Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures. The Journal of Hand Surgery. 2020. DOI: 10.1016/j.jhsa.2020.03.022

[36] Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.06.005

[37] CORR Insights®: What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?. Clinical Orthopaedics & Related Research. 2022. DOI: 10.1097/corr.0000000000002242

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

[39] Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLOS Medicine. 2019. DOI: 10.1371/journal.pmed.1002855

[40] Biomechanical Assessment Of Inferior Tuberosity Placement During Hemiarthroplasty For 4-Part Proximal Humerus Fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.027

[41] Readmissions, revisions, and mortality after treatment for proximal humeral fractures in three large states. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2812-9

[44] Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humerus fractures in elderly patients: results from a prior randomized clinical trial. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.032

[45] The Mayo-FJD Classification System For Proximal Humerus Fractures: Intra And Interobserver Agreement. Journal of Shoulder and Elbow Surgery. 2023. DOI: 10.1016/j.jse.2023.02.035

[46] Biomechanical investigation of arm position on deforming muscular forces in proximal humerus fractures. Clinics in Shoulder and Elbow. 2022. DOI: 10.5397/cise.2022.00885

[48] Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.01.025

[49] Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures. Acta Orthopaedica et Traumatologica Turcica. 2020. DOI: 10.1016/j.aott.2016.10.003

[50] The reliability of the Neer classification for proximal humerus fractures: a survey of orthopedic shoulder surgeons. JSES International. 2022. DOI: 10.1016/j.jseint.2022.02.006

[51] Standard compared with fracture-specific components in reverse shoulder arthroplasty for proximal humerus fractures. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b9.bjj-2024-1508.r2

[52] What Are the Long-term Outcomes of Locking Plates for Nonosteoporotic Three-part and Four-part Proximal Humeral Fractures With a Minimum 10-year Follow-up Period?. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002895

[54] Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: A prospective study. International Journal of Shoulder Surgery. 2013. DOI: 10.4103/0973-6042.118911

[56] 24. Proximal Humerus Fractures in the Adolescent Patient: Diagnosis, Management, and Complications. n.d..

[57] Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores. JSES International. 2024. DOI: 10.1016/j.jseint.2024.02.003

[58] Biology and Biomechanics in Osteosynthesis of Proximal Humerus Fractures. European Journal of Trauma and Emergency Surgery. 2007. DOI: 10.1007/s00068-007-7089-2

[59] Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database. JSES International. 2024. DOI: 10.1016/j.jseint.2024.02.005

[63] Proximal humeral fractures with minimal displacement treated conservatively. International Orthopaedics. 2004. DOI: 10.1007/s00264-004-0552-3

[64] Biomechanical study of two different fixation methods for the treatment of Neer III proximal humerus fractures. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-08216-0

[65] Open Reduction and Internal Fixation of Proximal Humerus Fractures. Orthopedic Clinics of North America. 2008. DOI: 10.1016/j.ocl.2008.06.003

[67] Reverse Total Shoulder Arthroplasty Patients with a Proximal Humerus Fracture Have Significantly Worse Perioperative Outcomes than Other Indications: An Analysis of 5644 Cases. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.05.005

[69] Proximal third humeral shaft fractures—A fracture entity not fully characterized by conventional AO classification. Injury. 2014. DOI: 10.1016/j.injury.2013.10.030

[72] Does primary treatment of proximal humerus fractures show favourable functional outcomes over secondary treatment with reverse shoulder arthroplasty?. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231190038

[74] Reverse shoulder arthroplasty for proximal humerus fractures: Is the glenoid implant problematic?. Orthopaedics & Traumatology: Surgery & Research. 2018. DOI: 10.1016/j.otsr.2018.06.008

[75] ICD-10 diagnosis codes in electronic health records do not adequately capture fracture complexity for proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2023.08.022

[76] Detection, classification, and characterization of proximal humerus fractures on plain radiographs. The Bone & Joint Journal. 2024. DOI: 10.1302/0301-620x.106b11.bjj-2024-0264.r1

[79] CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000002017

[83] Shoulder dislocation combined with proximal humerus fracture in children. Medicine. 2017. DOI: 10.1097/md.0000000000008977

[84] Delays beyond 5 days to surgery does not affect outcome following plate and screw fixation of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.019

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4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

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.

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

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