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Education · shoulder

Shoulder Arthroplasty for Acute Proximal Humerus Fracture Info Evidence Consent

Reviewed by Dr Kieran Hirpara, Specialist Orthopaedic Surgeon Last reviewed

Why this operation has been suggested

Dr Kieran Hirpara, an upper-limb surgeon at Mater Private Hospital Rockhampton, starts with the least invasive options that suit your condition. Patients are generally referred to our clinic by their GP; if a physiotherapist has suggested you see us, you will still need a referral from your GP in order to be eligible for the Medicare rebate. A clinic assessment establishes the diagnosis. For acute injuries, surgery may be recommended straight away.

We suggest this procedure when non-operative care has not given enough improvement or when the fracture pattern makes healing unlikely. The operation replaces the damaged upper arm bone to provide long-term pain relief. While motion results vary, this approach offers superior functional outcomes compared with conservative treatment for complex fractures. It aims to restore stability and allow you to manage daily activities with less discomfort.

Before the operation

Please fast for seven hours before your surgery. We ask for this extra hour so your procedure can start earlier if the schedule allows. Arrange a ride home and wear comfortable clothing. Bring a list of all your current medications. Your surgeon will tell you which medicines to stop. You will have an X-ray to plan the operation. An MRI or ultrasound may be used if needed. Most patients do not need blood tests or an anaesthetist review. If you have other medical conditions, you may need them. We will guide you on what is required for your specific case.

On the day

You present to the hospital's surgical admissions unit, where you are checked in and prepared for theatre. You meet the anaesthetist, who explains your pain management plan. This operation is done under general anaesthetic combined with a regional nerve block. You will be fully asleep for the operation, and the block — an injection that numbs the nerves supplying the arm before you wake up — provides pain relief for the first 12 to 24 hours after surgery. The anaesthetist will meet you before the operation and talk you through both parts.

You are then taken into the operating theatre, where the operation is performed. You wake up in the recovery area, where nurses monitor you while the anaesthetic wears off. Once you are stable you either go to the ward or go home, depending on the procedure and your recovery.

What the operation involves

Your surgeon will make a single cut over the area being operated on to access the shoulder. Through this opening, your surgeon removes the damaged head of your upper arm bone. This is the rounded top part that normally fits into the shoulder socket. Your surgeon then replaces it with a metal implant designed to mimic the shape and function of your natural bone.

If you are having a reverse shoulder replacement, your surgeon may also adjust the shoulder socket to work with this new design. For complex fractures, your surgeon carefully repairs the tuberosities. These are the bony bumps on the shoulder where your muscles and tendons attach. Your surgeon reattaches these pieces to the implant. This step is important because healing them in the correct position helps your shoulder rotate and move better later on.

Once the new parts are in place and the bone pieces are secured, your surgeon closes the cut. A fine self-adhesive mesh is laid over the closed wound first, holding the skin edges together. A liquid skin adhesive is then painted over the mesh, where it sets to seal the whole thing. This mesh and adhesive form one closure. It stays on for roughly one to two weeks and then lifts and peels away by itself. There is nothing to be taken out.

After the operation

You will wake up in the recovery ward with your arm supported in a simple sling for comfort. We manage your pain with standard medication, and you must have someone stay with you for the first 24 hours. Your wound is covered with a dressing that stays in place. Most patients stay one night in hospital after this operation, though some are able to go home the same day. You must not drive while wearing the sling. Our policy is that you cannot drive for at least six weeks after any shoulder operation, regardless of which arm was operated on. You may drive once your surgeon clears you, typically at the six-week review. See our guide on Driving after upper-limb surgery.

Recovery

You will have a single cut over the shoulder area. Your arm rests in a simple sling for comfort. You can take it off for exercises and washing. We do not use special braces or pillows. The sling keeps your shoulder still while the tissues heal.

Pain and swelling are normal at first. Your surgeon will guide you on pain relief. Swelling eases as movement returns. You will start gentle physio exercises soon. Your physiotherapist guides your rehabilitation. You will learn to move your shoulder safely. Rotational ability improves as the muscles heal around the implant.

Daily life changes while you recover. You will need help with tasks like dressing or cooking. Sleep may be difficult at first. Try propping yourself up with pillows. Do not drive while in a sling. Your surgeon’s policy is to wait at least six weeks before driving, regardless of which arm was operated on. You can drive once your surgeon clears you, typically at the six-week review. See our guide on Driving after upper-limb surgery for details.

Recovery varies between individuals. Your timeline may differ; your surgeon and physio will guide you. Most patients find that shoulder function improves steadily. You will return to normal activities as your strength returns.

What can go wrong

Most patients do well, but problems can occasionally happen. Your surgeon and the team monitor you closely to spot any issue early.

Shoulder movement may not return to normal. You might notice that your shoulder feels stiff or does not move as freely as expected. This is a known risk with this surgery. Your surgeon will discuss your specific goals for motion during your pre-operative visits.

You may experience ongoing pain or discomfort. While many patients find their pain improves significantly, some continue to feel ache or soreness in the shoulder area. If your pain does not ease with prescribed medication, or if it suddenly worsens, contact our clinic. We need to check if there is an underlying cause for the discomfort.

Infection is a potential risk with any surgery involving an implant. You might notice increased redness, warmth, or swelling around the incision site. You may also see drainage from the wound or develop a fever. If you notice any of these signs, call our clinic immediately. We may need to examine you to rule out an infection.

Medical issues unrelated to the shoulder can occur after surgery. These are often due to general health factors rather than the shoulder procedure itself. If you feel unwell, experience chest pain, shortness of breath, or other systemic symptoms, seek urgent medical attention. Do not assume these symptoms are related to your shoulder surgery.

Reoperation may be necessary if complications arise. This could involve fixing a problem with the implant or addressing a non-healing bone. If you feel a clicking, grinding, or instability in your shoulder, or if you lose range of motion suddenly, contact our clinic. We will assess whether further intervention is needed.

The complications table on this page lists typical rates if you want the specifics.

When to call us

Call us if you have a fever, increasing wound redness or discharge, or sudden severe pain. Go to emergency if you notice calf swelling or shortness of breath. Contact us immediately if you lose sensation or cannot move your limb. These symptoms need urgent assessment to ensure your recovery stays on track.

Where to read more

This page is about the operation itself. The condition it treats — including what the evidence shows about when surgery helps and when it does not — is covered in more detail on the Proximal Humerus Fracture page.

Where to read more

This page is about the operation itself. The condition it treats — including what the evidence shows about when surgery helps and when it does not — is covered in more detail on the Proximal Humerus Fracture page.

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.

Evidence & references

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

Overview

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

Anatomy & Pathophysiology

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

Classification

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

Clinical Presentation

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

Investigations

  • Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced lesser tuberosity fracture can be successful and enhance overall shoulder function [17].
  • Undisplaced greater tuberosity fractures can be managed non-operatively with good results [72].
  • Patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult greater tuberosity fractures [72].
  • In patients presenting with a traumatic shoulder injury with normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify patients with an occult greater tuberosity fracture [22].
  • There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane [73].
  • Nearly 30% of cases suggesting surgical treatment on radiographs are reclassified for conservative treatment based on CT findings [73].
  • The inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes [71].
  • Routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities [74].
  • The routine use of 3D-printed models should be avoided as the sole determinant for recommending surgical intervention at this time [74].
  • Convolutional neural networks (CNNs) proficiently rule out proximal humerus fractures on plain radiographs [76].
  • Missed posterior dislocation of the shoulder after intramedullary fixation of proximal humeral fractures is an extremely rare injury that can be missed due to inadequate initial and postoperative x-ray images and incorrect interpretation [79].

Treatment

  • Patients undergoing shoulder hemiarthroplasty for acute proximal humerus fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • Patients undergoing initial nonoperative management have worse functional outcomes and higher complication rates than those undergoing acute reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures [5].
  • Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant in complex shoulder fractures treated by reverse shoulder arthroplasty, provided their consolidation is anatomic [8].
  • A majority of patients with proximal humeral fractures underwent non-operative treatment [10].
  • Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [12].
  • Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years [14].
  • Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [20].
  • Nonsurgical management of proximal humerus fractures decreased during the study period [46].
  • Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [47].
  • There is no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus [48].
  • Nonsurgical management of proximal humerus fractures demonstrates successful outcomes and union rates greater than 90% [51].
  • Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures compared to locking plate fixation [52].
  • Osteoporosis may not be regarded as a contraindication for open reduction and internal fixation of unilateral displaced 3- or 4-part fractures, as shoulder function was restored to preinjury levels for most patients at 12-month follow-up [53].
  • Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [62].
  • With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8 years after hemiarthroplasty for primary nonreconstructable humeral head fractures [65].

Complications

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

Recovery

  • This study represents the largest long-term follow-up of acute proximal humeral fractures treated with hemiarthroplasty [9].
  • Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced lesser tuberosity fracture was successful and enhanced overall shoulder function in two adolescent patients [17].
  • Surgery for complex proximal humeral fractures leads to overall good long-term outcomes despite high overall complication and reoperation rates [24].
  • The increasing utilization of reverse total shoulder arthroplasty (RTSA) and decreasing short-term complication rates for fixation and arthroplasty represent a substantial change compared with recent historic norms in the management of proximal humerus fractures [27].
  • Long-term treatment with reverse shoulder arthroplasty (RSA) for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time [63].
  • Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type [80].

Key Evidence

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

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