Fratura do Húmero Proximal Folheto

O que você está sentindo

Você provavelmente sentirá uma dor aguda na parte superior do braço, perto da articulação do ombro. Essa dor frequentemente irradia para baixo pelo braço ou para cima em direção ao pescoço. A lesão é uma fratura na parte superior do osso do braço, que pode ocorrer se você cair ou se os seus ossos estiverem enfraquecidos pelo afinamento relacionado à idade.

A dor geralmente piora quando você tenta mover o braço. Tarefas simples, como levantar uma xícara, alcançar uma prateleira ou guardar a camisa dentro da calça, podem tornar-se difíceis ou impossíveis. Você pode ter dificuldade em alcançar as costas para fechar um sutiã ou abotoar uma camisa. Até mesmo movimentos leves podem desencadear uma exacerbação do desconforto.

Muitas pessoas notam que a dor é mais intensa à noite. Deitar-se do lado lesionado é frequentemente doloroso demais, por isso você pode ter dificuldade em encontrar uma posição confortável para dormir. Acordar com o ombro rígido e dolorido é comum. Manter o braço em uma tipóia pode ajudar a reduzir a dor ao manter o osso fraturado imóvel. No entanto, manter o braço imóvel por longos períodos também pode fazer com que a articulação fique rígida e tensa.

Embora a dor seja intensa, é importante saber que a maioria dessas fraturas cicatriza bem sem cirurgia. Seu cirurgião orientará sobre como proteger o braço enquanto ele cicatriza. Na grande maioria dos casos, o tratamento não cirúrgico leva a uma cicatrização bem-sucedida e taxas de consolidação superiores a 90%. Isso significa que o osso se une corretamente para a maioria dos pacientes.

Se você é um adulto mais velho, o seu plano de tratamento considerará a sua saúde geral e a força óssea. Para adultos mais jovens com menos de 65 anos, a cirurgia nem sempre é melhor do que o repouso e o suporte. Seu cirurgião analisará as imagens para ver exatamente onde está a fratura e decidirá o melhor caminho a seguir.

Para alguns pacientes mais velhos com fraturas mais complexas, pode-se discutir a substituição da articulação. Essa opção oferece resultados duradouros para o tratamento de fraturas agudas em adultos mais velhos. É uma escolha segura e razoável quando o dano ósseo é grave.

A maioria das crianças com esse tipo de fratura cicatriza rapidamente, com poucas complicações. Se você está cuidando de uma criança, o prognóstico é geralmente muito positivo.

Esteja ciente de que essa lesão pode impactar significativamente a sua vida diária. Pode causar incapacidade temporária e reduzir o seu senso de bem-estar. No entanto, com cuidados adequados e paciência, a maioria das pessoas recupera o uso do braço. Siga as orientações do seu cirurgião sobre movimento e repouso para apoiar a sua recuperação.

O que está realmente acontecendo

A extremidade superior do úmero é um volume de controle complexo para o movimento do ombro. Quando você cai, essa área pode se fragmentar. As partes mais críticas são os tubérculos, que são saliências ósseas onde os tendões do manguito rotador se inserem. Pense nesses tendões como cordas fortes que levantam e rotacionam seu braço. Se esses tubérculos se deslocarem, as cordas perdem sua âncora. Isso altera a forma como a força é transmitida através da articulação do ombro. Mesmo pequenos desvios na posição podem alterar significativamente a maneira como a articulação se move e suporta carga.

Seu cirurgião avalia a estabilidade dessas conexões. A cápsula articular é a capa ao redor do ombro, e a cartilagem é o revestimento liso nas extremidades ósseas. Quando os fragmentos ósseos se deslocam, eles podem esfregar uns contra os outros ou exercer pressão desigual sobre a cartilagem. Isso causa dor e limita sua amplitude de movimento. Em alguns casos, o suprimento sanguíneo para a cabeça óssea fica comprometido. Isso pode levar à rigidez ou fraqueza se os fragmentos não se curarem no alinhamento correto.

Entendemos que as opções de tratamento dependem da sua idade e do padrão específico da fratura. Para muitas fraturas em um único fragmento, nas quais o osso está fraturado, mas ainda alinhado, o tratamento não operatório funciona bem. A maioria dos adultos mais velhos com essas fraturas estáveis continua a receber tratamento não cirúrgico com resultados positivos. O manejo não cirúrgico demonstra resultados bem-sucedidos e taxas de consolidação superiores a 90%. Isso significa que o osso se cura adequadamente sem cirurgia na grande maioria dos casos.

No entanto, se os fragmentos ósseos estiverem deslocados ou instáveis, seu cirurgião pode recomendar cirurgia. O objetivo é restaurar a anatomia para que seus tendões possam puxar efetivamente novamente. Utilizamos placas bloqueadas ou hastes para manter os fragmentos unidos enquanto se curam. Isso fornece fixação estável para o úmero proximal. Em casos graves, nos quais o osso está muito danificado para ser reparado, podemos considerar a substituição articular. Essa opção oferece evidências convincentes de eficácia e durabilidade funcional no tratamento de fraturas agudas do úmero proximal em adultos mais velhos.

O que podemos fazer a respeito

A forma como abordamos o seu cuidado reflete como o Dr. Kieran Hirpara, cirurgião de membro superior no Mater Private Hospital Rockhampton, gerencia essas lesões em nossa clínica. A maioria das fraturas da parte proximal do úmero em um fragmento cicatriza bem sem cirurgia. Na grande maioria dos casos, o tratamento não operatório leva a resultados positivos. As taxas de consolidação para o manejo não cirúrgico são superiores a 90%. Sua jornada frequentemente começa com o autocuidado e a fisioterapia. Podemos usar uma atadura para apoiar seu braço. Períodos curtos ou longos de imobilização produzem resultados semelhantes, por isso adaptamos a duração ao seu conforto e ao padrão da fratura. A fisioterapia visa restaurar o movimento e a força à medida que o osso cicatriza. A maioria dos adultos mais velhos com essas fraturas continua a receber esse tipo de cuidado com bons resultados funcionais.

O manejo médico concentra-se em mantê-lo confortável enquanto o osso consolida. Utilizamos analgésicos e anti-inflamatórios para controlar o desconforto. Se o inchaço ou a rigidez persistirem, podemos discutir injeções. Injeções de cortisona reduzem a inflamação e a dor por um período limitado. Injeções de ácido hialurônico lubrificam a articulação para melhorar o movimento. Injeções de plasma rico em plaquetas (PRP) utilizam seus próprios componentes sanguíneos para apoiar a cicatrização. Essas opções ajudam a gerenciar os sintomas quando o tratamento conservador por si só não é suficiente. Para problemas degenerativos ou de longa data, geralmente tentamos primeiro essas etapas não operatórias. Consideramos a cirurgia apenas quando elas não proporcionaram melhora suficiente.

A cirurgia é considerada quando o tratamento conservador atingiu seu limite ou quando a fratura é complexa. Para fraturas deslocadas em dois fragmentos em pacientes com 60 anos ou mais, não há diferença significativa nos resultados clínicos aos 2 anos entre a cirurgia e o tratamento não operatório. No entanto, para fraturas em três ou quatro fragmentos em pacientes mais velhos, a cirurgia pode oferecer melhores resultados funcionais a longo prazo. A artroplastia total reversa do ombro (substituição da articulação) é uma opção razoável e segura para adultos mais velhos com fraturas graves. Ela fornece resultados funcionais eficazes e duradouros. O tratamento percutâneo de fraturas selecionadas também resulta em consolidação previsível com uma baixa taxa de complicações. A taxa de complicações após o tratamento operatório é alta, por isso reservamos a cirurgia para cenários específicos. Para problemas estruturais ou agudos, a cirurgia pode ser recomendada imediatamente. Apresentamos essas opções como uma decisão compartilhada, com base na sua idade, na qualidade óssea e no padrão da fratura.

O que esperar

Sua perspectiva depende em grande parte da sua idade e da gravidade da fratura. Para a maioria dos adultos mais velhos, essas fraturas cicatrizam bem sem cirurgia. O manejo não cirúrgico leva à cicatrização bem-sucedida em mais de 90% dos casos. É provável que você use uma atadura por um curto período, como uma semana, ou por um período mais longo, como três semanas. Ambas as opções produzem resultados semelhantes. A maioria dos pacientes recupera boa função com essa abordagem.

Se você tiver menos de 65 anos, seu cirurgião pode discutir a cirurgia. No entanto, as evidências não mostram um benefício claro da operação em relação aos cuidados não cirúrgicos para adultos abaixo dessa idade. Para fraturas complexas em pacientes mais velhos, a cirurgia geralmente proporciona melhor função a longo prazo do que deixá-la sem tratamento. Procedimentos como a artroplastia reversa do ombro ou a fixação interna com placas e hastes ajudam a estabilizar o osso. Esses métodos visam restaurar o movimento e reduzir a dor ao longo do tempo.

A recuperação é um processo gradual. Você pode notar que seu ombro fica rígido ou fraco por vários meses. Com a cirurgia, você pode experimentar alguns contratempos, pois as taxas de complicações e de reintervenção são mais altas para fraturas complexas. Apesar disso, muitos pacientes alcançam bons resultados a longo prazo. Seu cirurgião orientará sua reabilitação para garantir que você recupere a força com segurança.

É importante compreender o panorama geral da saúde. Fraturas por fragilidade em adultos mais velhos carregam um risco maior de eventos graves de saúde. O risco de mortalidade dentro de um ano após a lesão é de 9,8%. Esse risco aumenta para 28,2% aos cinco anos. Esse aumento é mais do que o dobro do da população em geral. Seu cirurgião monitorará de perto sua saúde geral durante a recuperação para gerenciar esses riscos.

A maioria das crianças se recupera completamente, com poucas complicações. Para adultos, a paciência é fundamental. Embora algum desconforto possa persistir, a maioria dos pacientes retorna às atividades diárias. Seu cirurgião adaptará seu plano de cuidados ao seu padrão de fratura específico e ao seu estado de saúde. Acompanhamentos regulares garantem que seu osso esteja cicatrizando corretamente e ajudam a abordar quaisquer preocupações precocemente.

Quando procurar ajuda médica

Consulte o seu médico de família se tiver dor persistente que não melhora com o repouso. Solicite uma avaliação especializada se notar fraqueza ou instabilidade no ombro. Procure atendimento urgente se o ombro travar ou ceder. Contacte o seu médico se os sintomas interferirem no seu sono ou no trabalho. O agravamento súbito da dor também é motivo para procurar ajuda. A maioria das fraturas de um único fragmento cicatriza bem sem cirurgia. No entanto, uma avaliação precisa é fundamental. O seu cirurgião utilizará exames de imagem para verificar a presença de complicações. A avaliação precoce ajuda a prevenir incapacidades a longo prazo. Não ignore os sinais de que a sua recuperação não está a progredir conforme o esperado.

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