Proximal Humerus Fracture Info In-depth Evidence

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].
• 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 [2].
• Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade [4].
• Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [5].
• Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [6].
• Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [7].
• The results of low arthroplasty survival after treatment for proximal humerus fracture sequelae are pertinent when deciding on the treatment of proximal humerus fracture sequelae [9].
• Hemiarthroplasty and reverse prosthesis are indicated for complex proximal humerus fractures in patients no younger than 70 years of age [10].
• The literature reviews all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes [12].
• There are conflicting opinions on what outcome measure is best to assess function following the treatment of proximal humerus fractures [14].
• Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [18].
• Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [19].
• 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 [22].
• Most randomized controlled trials on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria besides age [24].
• Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [25].
• 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 [26].
• 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 [34].
• 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 [49].
• The selection of reverse total shoulder arthroplasty 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 [53].
• The development of an evidence-based clinical protocol for the treatment of proximal humerus fractures is long overdue, requiring a thoughtful, all-inclusive, randomized multicenter trial to determine the best treatment options [57].
• Less-invasive surgical procedure is a feasible treatment option in proximal humeral fractures with acceptable complications and considerable improvement during the first six months, but a lengthy recovery time is required [59].
• 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 [69].
• No single fixation method is considered the standard of care for the 15% to 20% of proximal humerus fractures that may benefit from surgery [73].
• 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 [150].

Anatomy & Pathophysiology

Bony Anatomy

• The proximal humerus comprises four main anatomic parts: the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [77].
• The articular surface of the humeral head is spherical with a diameter of 37 to 57 mm [77].
• The most superior portion of the articular surface of the humeral head averages 8 mm above the greater tuberosity [77].
• Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [77].
• The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [77].
• The anatomic neck is located at the junction of the articular surface and the tuberosities [77].
• The surgical neck represents the metadiaphyseal junction below the tuberosities but above the humeral shaft [77].
• The greater tuberosity is located in a posterior-superior position relative to the humeral shaft [77].
• The lesser tuberosity is located on the anterior aspect of the proximal humerus [77].
• The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps tendon [77].
• The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [77].
• The glenoid is a convex structure of shallow depth shaped like an inverted pear [77].
• The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [77].
• The humeral head averages 19° of retroversion and 41° of inclination (neck-shaft angle) [80].
• The humeral head is retroverted an average of 30 degrees [78].
• The neck-shaft angle measures an average of 135 degrees [78].
• The articular surface of the humeral head is essentially spherical, with an arc of approximately 160 degrees covered by articular cartilage [89].
• The radius of curvature of the humeral head is approximately 25 mm and is slightly larger in men than in women [89].
• The average neck-shaft angle is 45 degrees (±5 degrees), with a range of 30 to 50 degrees [89].
• The superior margin of the humeral head articular surface is normally superior to the top of the greater tuberosity by 8 to 10 mm [89].
• The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [89].
• Humeral articular malposition of more than 4 mm led to increased subacromial contact in biomechanical cadaver studies [89].
• An offset of 8 mm in any direction significantly decreased passive range of motion in biomechanical cadaver studies [89].
• Proximal humeral retroversion is highly variable, ranging from 0 to 55 degrees depending on the measurement method [89].
• The proximal humerus has three centers of ossification: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [80].
• The proximal humeral ossification centers fuse to the shaft at age 17 to 20 years [80].
• The proximal humeral physis closes by 14 to 17 years of age in girls and by 16 to 18 years in boys [84].
• Eighty percent of subsequent humeral growth comes from the proximal humeral physis, accounting for approximately 40% of the growth of the entire upper extremity [84].
• In infants and young children, humeral retroversion averages 65 degrees and gradually decreases, approaching adult values by 11 years of age [84].
• The periosteum is thicker and stronger in the posteromedial portion of the proximal humerus compared to the anterolateral portion, which is often quite thin [84].
• The posteromedial metaphysis, a portion of the physis, and the epiphysis are intracapsular [84].
• A large part of the proximal humeral physis is extracapsular, making it susceptible to traumatic injury [84].

Vascular Supply

• The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [77].
• The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [77].
• The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [77].
• The anterior humeral circumflex artery provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [77].
• The ascending branch of the anterior humeral circumflex artery courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [77].
• Injury to the arcuate artery may result in osteonecrosis of the humeral head [77].
• Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [77].
• The major blood supply to the humeral head is through the ascending branch of the anterior humeral circumflex artery, which penetrates the head at the bicipital groove and becomes the arcuate artery [78].
• Fractures of the anatomic neck have a poor prognosis because of complete disruption of the blood supply to the head [78].
• Surgical neck fractures are common, and with these, the blood supply to the head is preserved [78].
• The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [80].
• The terminal intraosseous portion of the anterior humeral circumflex artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [80].
• Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [84].
• A fracture involving the anatomic neck is prognostically worse than fractures involving other regions of the proximal humerus with respect to the potential disruption of the vascular supply to the humeral head and the subsequent development of avascular necrosis [77].

Muscular Attachments and Deforming Forces

• The subscapularis inserts on the lesser tuberosity and causes medial displacement [77].
• The supraspinatus and infraspinatus insert on the greater tuberosity and cause superior and posterior displacement [77].
• The pectoralis major inserts on the humeral shaft and displaces it medially [77].
• The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons of the rotator cuff [77].
• The lesser tuberosity serves as the attachment site for the subscapularis tendon [77].
• Displacement of each proximal humerus fracture part occurs in a predictable manner based on the deforming forces created by the tendinous insertions of the pectoralis major, subscapularis, supraspinatus, and infraspinatus [77].
• The rotator cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [78].
• The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [78].
• The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [78].
• The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [84].
• The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [84].
• The deltoid forward flexes and abducts the shoulder and courses from the clavicle and acromion superiorly, coalescing into a common tendinous insertion onto the lateral upper third of the humeral shaft [84].
• The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [84].
• Positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures [130].

Neurovascular Anatomy

• The posterior humeral circumflex artery travels with the axillary nerve and enters the quadrilateral space posteriorly [77].
• The brachial plexus and axillary artery are anterior to the coracoid process of the scapula and humeral head [78].
• Nerves innervating muscles around the shoulder include the axillary, suprascapular, subscapular, and musculocutaneous nerves [78].
• An axillary nerve injury from proximal humeral fracture or fracture-dislocation would result in paralysis of the deltoid muscle and anesthesia over the “badge” region at the lateral proximal arm [78].
• The close anatomical relationship between the proximal humerus, axillary artery, and brachial plexus predisposes these structures to combined injury patterns that can threaten limb viability [28].
• The axillary nerve is a terminal branch coming off the posterior cord of the brachial plexus just proximal to the coracoid process [83].
• The axillary nerve passes beneath the conjoined tendon anterior to the subscapularis 3 to 5 mm medial to the musculotendinous junction and then adjacent to the inferior capsule before entering the quadrilateral space posteriorly [83].
• The axillary nerve splits into the anterior and posterior branches within the quadrangular space [83].
• The anterior and middle deltoid muscle receives sole innervation from the anterior branch of the axillary nerve [83].
• Posterior deltoid muscle innervation varies, with supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [83].
• The posterior branch of the axillary nerve branches to supply the teres minor muscle and then terminates as the superior lateral brachial cutaneous nerve [83].
• In the anterolateral deltoid splitting approach, the axillary nerve crosses approximately 5 cm inferior to the anterolateral acromial corner [83].
• In the posterior deltoid splitting approach, the axillary nerve is approximately 7 cm from the posterior acromial corner [83].
• The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [84].
• The brachial plexus is prone to injury when the proximal humerus is injured in fractures or dislocations, or during traction [84].

Joint Stability and Soft Tissue Structures

• Stability and function of the glenohumeral joint are provided by the interaction of the glenohumeral joint that promote a near global range of motion and purposeful function [77].
• External loads transferred to the shoulder girdle are initially offset by joint surface anatomy, joint volume, atmospheric pressure, and joint fluid cohesion and adhesion [77].
• Moderate and large loads are counterbalanced by the deltoid and rotator cuff and by the capsulolabral and bone structures, respectively [77].
• Proximal humerus fractures alter complex interactions of the shoulder girdle, resulting in pain, decreased range of motion and stiffness, and disability [77].
• Displaced proximal humerus fractures can impede normal movement of the rotator cuff, subacromial bursa, and subdeltoid bursa, causing impingement and disruption of normal glenohumeral motion [77].
• In displaced and nondisplaced proximal humerus fractures, the subdeltoid and subacromial bursae can become thickened and fibrotic, forming adhesions that can limit normal glenohumeral motion [77].
• The rotator cuff is a sheet of conjoined tendons closely applied over the shoulder capsule and inserting mainly into the greater tuberosity of the humerus, with the subscapularis inserted into the lesser tuberosity [85].
• The rotator cuff has an important function in stabilizing the head of the humerus by pulling it firmly into the glenoid whenever the deltoid lifts the arm forwards or sideways [85].
• The coracoacromial arch is formed by the acromion process posterosuperiorly, the coracoid process anteriorly, and the coracoacromial ligament joining them [85].
• The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch, allowing them to glide [85].
• The glenohumeral joint depends on static and dynamic stabilizers for movement and stability, especially the rotator cuff [89].
• The rotator cuff stabilizes the glenohumeral joint while allowing greater freedom of motion and fixes the fulcrum of the upper extremity against which the deltoid can contract and elevate the humerus [89].
• The rotator cuff must act simultaneously and synergistically with the deltoid muscle for normal function [89].
• The glenohumeral joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic joints [90].
• The bony anatomy of the shoulder contributes little to stability and has been compared with a golf ball on a tee [90].
• The glenoid labrum increases the depth of the socket by 50% around the humeral head and increases stability [90].
• The glenoid articular surface and the labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [90].
• Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [90].
• The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction and is the primary stabilizer to anterior and posterior stress in the same position [90].
• The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [90].
• The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch, creating a hammock-type sling [90].
• The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [90].
• The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [90].
• The infraspinatus and teres minor fuse near their musculotendinous junctions [90].
• The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [90].
• The roof of the biceps sheath consists of a portion of the supraspinatus tendon, and a sheet of the subscapularis tendon forms the floor [90].
• The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [90].
• The coracohumeral ligament is deep to the tendinous insertion of the cuff and blends with the capsule and supraspinatus tendon to form part of the roof of the biceps sheath [90].
• The subscapular bursa lies between the subscapularis tendon and the neck of the scapula and communicates with the joint cavity between the superior and middle glenohumeral ligaments [81].
• The subscapular bursa protects the tendon of the subscapularis at the point where it passes under the base of the coracoid process and over the neck of the scapula [81].
• The rotator interval is defined as the region between the superior border of the subscapularis and the anterior border of the supraspinatus [81].
• The rotator interval includes the region of the superior glenohumeral ligament and coracohumeral ligament, in addition to the middle glenohumeral ligament [81].
• The average area of the rotator interval is 20.96 mm [81].
• The humeroscapular motion interface lies between the inner structures of the proximal humerus, rotator cuff, coracohumeral ligament, and biceps tendon sheath and the superficial layer of the acromion, deltoid, coracoacromial ligament, coracoid process, and the conjoined tendon [83].
• Smooth, unrestricted motion at the humeroscapular motion interface is vital to

Classification

Reliability and Agreement

• Evaluation of classification systems for proximal humerus fractures using plain radiographs has yielded low interobserver reliability [41].
• The Neer classification for proximal humerus fractures has low agreement among 24 doctors, with only moderate agreement on displacement even between specialists [179].
• Training improves agreement among doctors using the Neer system for proximal humeral fractures [179].
• The Mayo-FJD classification system for proximal humerus fractures allows high intraobserver and interobserver agreement using both radiographs and computed tomography [126].
• Several observer studies have reported low agreement amongst doctors classifying proximal humeral fractures according to the AO-classification [166].
• Reported mean kappa values for interobserver agreement on the AO-classification have varied between 0.26 and 0.53 [166].
• Mean kappa values for the AO-classification decreased from 0.53 for AO Types to 0.2 for AO Groups, suggesting decreased agreement with an increasing number of classification units [166].
• Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized [56].

System Definitions and Criteria

• The Neer classification categorizes displaced proximal humerus fractures from two to four parts according to anatomic segments [162].
• In the Neer classification, displacement is defined as separation of a fragment >1 cm or angulation of a fragment greater than 45° [162].
• Fracture lines in nondisplaced segments are not included in the Neer classification [162].
• The AO classification is based on the vascular supply of the articular segments [162].
• The AO classification is divided into three categories (A, B, C) of increasing severity, with each category further split into numerical subgroupings [162].
• Neer defined significant displacement as greater than 1 cm of translation, or angulation greater than 45° for any of the major fracture fragments [176].
• The AO/ASIF group labeled valgus impaction injuries as Type C (C2.1, C2.2) fractures of the proximal humerus [176].
• Inconsistencies have been noted in the literature in defining the type C valgus impacted subgroups of the AO/ASIF classification system [176].

Clinical Utility and Outcomes

• Due to poor intra-observer reliability of classification systems and poor correlation with outcome, there has been less emphasis placed upon them in treatment algorithms [63].
• Classification type and group seem to be of minor importance for clinical outcome in most studies of locking plate osteosynthesis in AO/OTA Type C fractures [166].
• Fracture type remains the most critical independent predictor of shoulder function and patient satisfaction [60].
• The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [68].

Epidemiology and Demographics

• According to the AO-OTA classification, 49.2% of proximal humerus fractures were grouped into type A, 43.1% into type B, and 7.7% into type C [169].
• According to the Neer classification, 24.3% of proximal humeral fractures were non-displaced or minimally displaced, 32.3% were two-part displaced, 30.9% were three-part, 6.9% were four-part, and 5.6% were associated with a glenohumeral dislocation [169].
• There is no statistically significant association between gender and the AO-OTA classification or the Neer classification [169].
• The type of trauma did not show a statistically significant association with the AO-OTA classification or the Neer classification [169].
• The diagnosis of osteoporosis did not show a statistically significant association with the AO-OTA classification or the Neer classification [169].
• There is a statistically significant association between the AO-OTA and Neer classifications and age grouped by decades [169].
• There is a statistically significant association between the AO-OTA and Neer classifications and the type of treatment performed [169].

Coding and Data Limitations

• Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for proximal humerus fractures [157].

Clinical Presentation

• Neurovascular injuries associated with proximal humerus fractures represent a rare yet clinically significant complication with potential for devastating functional outcomes [28].
• The multifactorial etiology of neurovascular injuries in proximal humerus fractures encompasses direct trauma from displaced fracture fragments and indirect mechanisms [28].
• Diagnosis of neurovascular injuries in proximal humerus fractures relies on early recognition through meticulous clinical examination and advanced imaging modalities [28].
• Most nerve injuries associated with proximal humerus fractures, particularly involving the axillary nerve, demonstrate favorable outcomes with conservative management [28].
• Vascular injuries associated with proximal humerus fractures demand urgent multidisciplinary intervention to restore perfusion and prevent irreversible ischemia [28].
• No standardized management algorithm exists to universally optimize outcomes in complex cases of neurovascular injury associated with proximal humerus fractures [28].
• 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 [15].
• Surviving patients with a proximal humerus fracture frequently have persistent symptoms that can be predicted as early as after 1 year [16].
• Combined fractures with femoral or vertebral fractures are associated with significantly higher mortality and morbidity compared with isolated proximal humerus fractures [127].

Investigations

Plain Radiography

• At least two X-ray views should be obtained for shoulder imaging: an anteroposterior view in the plane of the glenoid and an axillary projection with the arm in abduction [94].
• The standard shoulder series includes a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [101].
• The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration when the arm is held in neutral rotation with slight abduction [101].
• The AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [101].
• The axillary view is necessary for evaluating glenohumeral joint instability and enables determination of the humeral head position in the glenoid fossa [101].
• The axillary view may detect occult, locked posterior shoulder dislocation in patients exhibiting a lack of passive external rotation [101].
• The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [101].
• The scapular Y view is a reliable alternative for evaluating glenohumeral subluxation and dislocation [101].
• The acromiohumeral distance is normally 7 to 14 mm [101].
• The width of the glenohumeral joint space should be symmetric superiorly and inferiorly [101].
• The coracoclavicular distance is normally 1.1 to 1.3 cm [101].
• Artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [68].
• Convolutional neural networks proficiently rule out proximal humerus fractures on plain radiographs [191].
• ChatGPT-5 is highly inaccurate at identifying proximal humerus fractures on shoulder x-rays, characterizing fracture patterns, and providing accurate interpretations [207].

Computed Tomography

• CT imaging is frequently used to evaluate fractures of the shoulder [100].
• CT is helpful for planning fracture surgery and shoulder joint replacement [94].
• Computed tomography scans were more specific than radiographs in the assessment of proximal humerus fracture sequelae [43].
• Zero-TE MRI presents a viable alternative to CT in the evaluation of proximal humerus fractures [163].
• 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 [203].
• The use of 3D-printed models as the sole determinant for recommending surgical intervention should be avoided at this time [203].

Magnetic Resonance Imaging

• MRI is useful to identify osteonecrosis of the humeral head or a bone tumour [94].
• MRI can identify labral tears and rotator cuff tears, although accuracy for these is enhanced by combining the scan with arthrography [94].
• MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [100].
• T1-weighted MRI can reveal Hill-Sachs lesions [100].
• T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [100].
• MR arthrography is considered the benchmark for evaluation of labral tears and is rarely indicated for evaluation of rotator cuff pathology [100].
• CT arthrography is indicated when MRI or MR arthrography is contraindicated, such as in the presence of a pacemaker or vascular clips [100].

Ultrasonography

• Ultrasonography is a simple and accurate test for identifying rotator cuff tears and calcific tendinitis [94].
• Ultrasonography can be useful in guiding injections or barbotage [94].
• Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [100].
• Ultrasonography can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [100].
• Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [100].
• Ultrasonography can evaluate impingement in various positions and motions due to real-time imaging capabilities [100].
• Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [100].
• Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures [214].

Classification and Diagnostic Reliability

• To enhance consistency in understanding complex proximal humerus fractures, imaging must be enhanced [213].
• The inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes [193].
• Radiographic parameters can be predictors of functional results in fractures of the proximal humerus treated with locking plates [196].

Treatment

Non-Operative Management

• In the vast majority of cases, proximal humerus fractures may be treated nonoperatively [3].
• A majority of patients with proximal humeral fractures underwent non-operative treatment [23].
• Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures [55].
• Approximately 80% of proximal humerus fractures are minimally displaced low energy injuries and are at low risk for future displacement, nonunion, or avascular necrosis, and have a high union rate with conservative management [63].
• Patients who have preexisting neurologic impairment on the side of injury resulting from a stroke or a traumatic spine injury, or who lead very inactive lifestyles, may not benefit from any acute intervention and can be managed nonoperatively [63].
• Patients who are medically unstable can be treated conservatively or treated in a delayed fashion once they are more physiologically stable [63].
• Nonsurgical management of proximal humerus fractures decreased during the study period [109].
• 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 [30].
• We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture [170].
• Nonoperative early functional treatment of proximal humerus and humeral shaft fractures results mainly in only minor humeral torsional side differences [183].
• Proximal humerus fractures in children have tremendous potential for remodeling, making non-operative management the treatment of choice for most fractures [136].
• Supervised rehabilitation is comparable to a single advice session after nonoperative treatment of displaced proximal humerus fracture [124].

Operative Management: Indications and General Principles

• Patients who have sustained an open fracture, vascular injuries, or those that have repairable neurologic injuries, are usually indicated for acute operative intervention [63].
• Operative fixation can provide stability if there is a need for any vascular or nerve repair procedures [63].
• Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [17].
• The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population [40].
• Delaying surgery for proximal humerus fracture is likely to increase inpatient morbidity, postoperative length of stay and non-routine discharge [161].

Operative Management: Internal Fixation (ORIF)

• 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 [13].
• Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results [27].
• Although the less-invasive surgical procedure is a feasible treatment option in proximal humeral fractures with acceptable complications and considerable improvement during the first six months, a lengthy recovery time is required [59].
• 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 [131].
• Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for this treatment [181].
• In this study PKW was superior to conservative treatment in individuals of all ages, especially in patients with 2-fragment fractures [128].
• The use of PHN in elderly patients was associated with poor functional results [128].
• There were no differences in the functional outcome between conservative treatment and surgery in the treatment of patients with displaced 3-4-fragment fractures [128].
• Osteosynthesis of the proximal humerus in osteoporotic bone typically produces inferior results to that in younger subjects with better bone stock [108].

Operative Management: Arthroplasty

• They are indicated for complex proximal humerus fractures in patients no younger than 70 years of age [10].
• It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [20].
• 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 [53].
• While the main potential advantage of the PCH—reduced glenoid erosion—will require further investigation with longer follow-up, this is the first study to demonstrate the safety and short-term outcomes of the PCH in treating proximal humerus fractures [58].
• RSA had significantly the highest Constant score and lower total incidence of complications than ORIF, HA and IN [115].
• RSA resulted in a lower incidence of additional surgery than ORIF and IN [115].
• The rank of treatments in terms high Constant score was: RSA, ORIF, IN, NOT and HA [115].
• The rank for reduction in total incidence of complications was: RSA, NOT, HA, IN and ORIF [115].
• For lowering the risk of additional surgery, the rank was: RSA, NOT, HA, IN and ORIF [115].
• 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 [132].
• RTSA is an effective treatment option for selected patients with acute proximal humerus fractures [133].
• RTSA has shown to provide reproducible functional outcomes and is a good treatment option for elderly patients with 3-part and 4-part proximal humerus fractures [134].

Rehabilitation and Outcomes Assessment

• Additionally, there are conflicting opinions on what outcome measure is best to assess function following the treatment of proximal humerus fractures [14].
• There is substantial variation in the literature regarding the optimal management for PHFs, with studies supporting nonoperative management, ORIF, and arthroplasty [125].
• Although there is some evidence that early intensive mobilization yields similar outcomes compared to later or conventional mobilization after operative treatment (both plate fixation and hemiarthroplasty) and conservative treatment, it has remained unclear how other aspects of rehabilitation impact outcomes such as sling usage and timing of physical therapy [125].

Complications

General and Mortality

• The adjusted one-year mortality rate following a proximal humerus fracture was 13.05%, which is significantly higher than other upper extremity fractures but lower than hip fractures [66].
• There is a 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 [16].
• Proximal humerus fractures are now typically osteoporotic fractures in women over 70, with prevalence increasing due to an aging population in poor general condition [44].

Non-Operative Complications

• The prevalence of nonunion after proximal humeral fracture is higher than previously reported, with most patients having a very low risk but a smaller subgroup at much higher risk [75].

Operative Complications: Internal Fixation

• Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation [146].
• Predictive models constructed using machine learning techniques demonstrated 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 [64].
• After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms [46].
• The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures [48].
• Percutaneous proximal humerus fixation offers less complications compared to other methods [152].

Operative Complications: Arthroplasty

• Hemiarthroplasty for the treatment of complex proximal humerus fractures yields variable long-term clinical outcomes and high rates of failure, with the majority due to greater tuberosity malunion or nonunion [61].
• Hemiarthroplasty outcomes for acute proximal humerus fractures and fracture sequelae did not differ significantly, supporting the use of hemiarthroplasty in both settings with modest clinical outcomes [145].
• Low arthroplasty survival after treatment for proximal humerus fracture sequelae is pertinent when deciding on the treatment of these cases [9].
• Long-term treatment with reverse shoulder arthroplasty 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 [54].
• 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 [20].
• While the main potential advantage of the pyrolytic carbon head—reduced glenoid erosion—will require further investigation with longer follow-up, this is the first study to demonstrate the safety and short-term outcomes of the pyrolytic carbon head in treating proximal humerus fractures [58].

Specific Complications and Sequelae

• Selective Glenohumeral External Rotation Deficit (SGERD) is a new shoulder evaluation symptom identified as a sequela of post-ORIF deltoid adhesions after treatment of the proximal humerus fracture [70].

Recovery

Non-Operative Management

Operative Management

• Functional outcomes of proximal humerus fractures treated with reverse shoulder arthroplasty improve with surgical experience, and outcomes become less variable after approximately 20 procedures [65].
• Double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures [138].
• Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures [206].
• Early operative intervention does not appear to decrease the rate of development of avascular necrosis after proximal humeral fracture [209].

Long-Term Outcomes and Follow-Up

• 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 [16].
• Patients in the proximal humerus fracture (PHF) cohort were less likely to report persistent shoulder pain at all evaluated time points compared to the osteoarthritis (OA) cohort, suggesting that symptom relief following treatment of traumatic pathology may differ fundamentally from that of chronic degenerative disease [201].

Complications and Sequelae

• Post-traumatic osteonecrosis of the proximal humerus is a challenging problem commonly seen following multi-fragmentary fractures, affecting long-term functional recovery [142].
• If patients do not follow the usual course of improvement after a proximal humerus fracture from a superior traction mechanism, consideration should be given to associated superior labral tears that may require surgical intervention [208].
• These results are pertinent when deciding on the treatment of proximal humerus fracture sequelae [9].

Mortality and Demographics

• The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months [210].

Assessment and Resources

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] 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. [2] (10.1016/j.xrrt.2023.01.002)
• [L4] In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. [3] (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. [4] (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. [5] (10.1016/j.jseint.2021.08.006)
• [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [6] (10.1016/j.jse.2022.03.006)
• [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [7] (10.2106/jbjs.l.01293)
• [L3] These results are pertinent when deciding on the treatment of proximal humerus fracture sequelae. [9] (10.1080/17453674.2020.1793548)
• [L4] They are indicated for complex proximal humerus fractures in patients no younger than 70 years of age. [10] (10.1016/j.otsr.2008.09.002)
• [L4] This article reviews the most up-to-date literature regarding all phases of proximal humerus fracture osteosynthesis, including diagnosis, imaging, anatomic considerations, surgical indications, fixation, and surgical outcomes. [12] (10.1007/s12178-012-9150-y)
• [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. [13] (10.1097/corr.0000000000002242)
• [L4] Additionally, there are conflicting opinions on what outcome measure is best to assess function following the treatment of proximal humerus fractures. [14] (10.1007/s00264-017-3569-0)
• [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. [16] (10.1080/17453670510041295)
• [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. [17] (10.1016/j.jse.2024.12.005)
• [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [19] (10.5435/jaaos-d-14-00033)
• [L3] It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. [20] (10.1186/s12891-023-06669-3)
• [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. [22] (10.1016/j.xrrt.2021.04.014)
• [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. [23] (10.1186/s12891-019-2812-9)
• [L2] Besides age, most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria. [24] (10.1016/j.xrrt.2025.07.023)
• [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. [25] (10.1016/j.jse.2006.09.006)
• [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. [26] (10.1016/j.injury.2013.08.024)
• [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. [27] (10.1016/j.injury.2015.05.017)
• [L5] [28] (10.1016/j.xrrt.2026.100825)
• [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. [30] (10.1371/journal.pmed.1002855)
• [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. [34] (10.1016/j.ocl.2008.06.003)
• [L1] The results of this trial will provide Level 1 evidence to guide decision-making in the treatment of proximal humerus fractures in the elderly population. [40] (10.1186/s12891-018-2223-3)
• [L5] Evaluation of the classification systems for fractures of the proximal humerus with plain radiographs has yielded low interobserver reliability. [41] (10.1016/j.ocl.2008.05.002)
• [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. [43] (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. [44] (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. [46] (10.1007/s00590-021-03099-6)
• [L4] The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. [48] (10.1007/s00590-010-0655-z)
• [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. [49] (10.1016/j.injury.2010.10.016)
• [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. [53] (10.1097/corr.0000000000002430)
• [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. [54] (10.1016/j.jse.2024.09.032)
• [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. [55] (10.1016/j.jse.2011.01.025)
• [L2] Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized. [56] (10.1016/j.jseint.2022.02.006)
• [L5] The development of an evidence-based clinical protocol for the treatment of proximal humerus fractures is long overdue, requiring a thoughtful, all-inclusive, randomized multicenter trial to determine the best treatment options. [57] (10.1016/j.injury.2014.05.017)
• [L2] While the main potential advantage of the PCH—reduced glenoid erosion—will require further investigation with longer follow-up, this is the first study to demonstrate the safety and short-term outcomes of the PCH in treating proximal humerus fractures. [58] (10.1016/j.jse.2025.07.032)
• [L3] Although the less-invasive surgical procedure is a feasible treatment option in proximal humeral fractures with acceptable complications and considerable improvement during the first six months, a lengthy recovery time is required. [59] (10.1186/s12891-015-0618-y)
• [L4] Fracture type remains the most critical independent predictor of shoulder function and patient satisfaction. [60] (10.1016/j.jseint.2026.101743)
• [L5] Hemiarthroplasty for the treatment of complex proximal humerus fractures yields variable long-term clinical outcomes and high rates of failure, with the majority due to greater tuberosity malunion or nonunion. [61] (10.1016/j.xrrt.2025.100616)
• [L4] [63] (10.1007/s12178-012-9130-2)
• [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. [64] (10.1016/j.jseint.2024.02.005)
• [L4] Functional outcomes of proximal humerus fractures treated with reverse shoulder arthroplasty improve with surgical experience, and outcomes become less variable after approximately 20 procedures. [65] (10.1016/j.jseint.2021.07.008)
• [L3] The adjusted one-year mortality rate following a proximal humerus fracture was 13.05%, which is significantly higher than other upper extremity fractures but lower than hip fractures. [66] (10.1016/j.jse.2015.11.031)
• [L4] The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs. [68] (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. [69] (10.1016/j.jse.2020.10.024)
• [L4] These observations allow the identification of a new shoulder evaluation symptom: Selective Glenohumeral External Rotation Deficit (SGERD). [70] (10.1186/s12891-020-03634-2)
• [L3] The prevalence of nonunion after proximal humeral fracture is higher than previously reported, with most patients having a very low risk but a smaller subgroup at much higher risk. [75] (10.2106/jbjs.20.01139)
• [L4] [108] (10.1016/j.injury.2005.05.030)
• [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. [109] (10.1016/j.jhsa.2020.03.022)
• [L1] [115] (10.1371/journal.pone.0166801)
• [L1] [124] (10.1016/j.jse.2025.11.013)
• [L4] [125] (10.1177/17585732231182374)
• [L4] The Mayo-FJD classification system for proximal humerus fractures seems to allow high intraobserver and interobserver agreement using both radiographs and computed tomography. [126] (10.1016/j.jse.2023.02.035)
• [L3] Combined fractures with femoral or vertebral fractures are associated with significantly higher mortality and morbidity compared with isolated proximal humerus fractures. [127] (10.1016/j.jse.2025.04.013)
• [L3] [128] (10.1016/j.injury.2015.05.049)
• [L5] These findings suggest that positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures. [130] (10.5397/cise.2022.00885)
• [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. [131] (10.1016/j.aott.2016.10.003)
• [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. [132] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
• [Abstract] RTSA is an effective treatment option for selected patients with acute proximal humerus fractures. [133] (10.1016/j.jse.2014.06.021)
• [L4] RTSA has shown to provide reproducible functional outcomes and is a good treatment option for elderly patients with 3-part and 4-part proximal humerus fractures. [134] (10.1097/bot.0000000000000607)
• [Abstract] Double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures. [138] (10.1016/j.jse.2022.01.036)
• [L4] Post-traumatic osteonecrosis of the proximal humerus is a challenging problem commonly seen following multi-fragmentary fractures, affecting long-term functional recovery. [142] (10.1016/j.injury.2015.06.026)
• [L3] Hemiarthroplasty outcomes for acute proximal humerus fractures and fracture sequelae did not differ significantly, supporting the use of hemiarthroplasty in both settings with modest clinical outcomes. [145] (10.1016/j.jseint.2022.10.009)
• [L4] Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. [146] (10.1016/j.injury.2010.11.058)
• [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. [150] (10.1016/j.jse.2015.05.005)
• [L4] This study explains positive experience with percutaneous proximal humerus fixation, suggesting it offers less complications compared to other methods, and encourages continuing the technique with longer term follow-up. [152] (10.1016/j.jse.2021.03.017)
• [L3] Current diagnosis coding practices do not adequately capture the fracture complexity needed to conduct subgroup analysis for proximal humerus fractures. [157] (10.1016/j.jse.2023.08.022)
• [Abstract] Delaying surgery for proximal humerus fracture is likely to increase inpatient morbidity, postoperative length of stay and non-routine discharge. [161] (10.1016/j.jse.2014.11.011)
• [L5] [162] (10.21037/aoj-20-42)
• [L4] ZTE MRI presents a viable alternative to CT in the evaluation of proximal humerus fractures (PHF). [163] (10.1016/j.jseint.2024.08.111)
• [L2] [166] (10.1016/j.injury.2011.08.025)
• [L4] [169] (10.1186/s13018-021-02551-x)
• [L1] We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture. [170] (10.1016/j.jse.2018.03.009)
• [L5] [176] (10.1097/01.blo.0000194675.64387.33)
• [L4] [179] (10.1186/1749-799x-6-38)
• [L1] Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for this treatment. [181] (10.1016/j.jse.2022.07.008)
• [L3] Nonoperative early functional treatment of proximal humerus and humeral shaft fractures results mainly in only minor humeral torsional side differences. [183] (10.1186/s13018-023-03671-2)
• [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. [191] (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
• [L3] This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes. [193] (10.1186/s13018-022-03337-5)
• [L4] This radiographic parameter can be one of the predictors of functional results in fractures of the proximal humerus treated with locking plates. [196] (10.1590/1413-785220192703142049)
• [L3] Patients in the proximal humerus fracture (PHF) cohort were less likely to report persistent shoulder pain at all evaluated time points compared to the osteoarthritis (OA) cohort, suggesting that symptom relief following treatment of traumatic pathology may differ fundamentally from that of chronic degenerative disease. [201] (10.1016/j.jsea.2026.100012)
• [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. [203] (10.1097/corr.0000000000002017)
• [L3] Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures. [206] (10.1016/j.jse.2025.02.019)
• [L4] This study demonstrates that ChatGPT-5 is highly inaccurate at identifying proximal humerus fractures on shoulder x-rays, characterizing fracture patterns, and providing accurate interpretations. [207] (10.1016/j.jseint.2025.101426)
• [L4] If patients do not follow the usual course of improvement after a proximal humerus fracture from a superior traction mechanism, consideration should be given to associated superior labral tears that may require surgical intervention. [208] (10.1016/j.arthro.2006.08.010)
• [L4] Early operative intervention does not appear to decrease the rate of development of avascular necrosis after proximal humeral fracture. [209] (10.1007/s12306-016-0425-0)
• [L4] The incidence of proximal humerus fractures increases with age, and we observe a seasonal variation strongly favoring winter months. [210] (10.1007/s11657-015-0209-4)
• [L4] To enhance consistency in understanding these fractures, imaging of complex fractures must be enhanced. [213] (10.1016/j.jse.2005.02.014)
• [L4] Ultrasonography can accurately depict radial nerve lesions with coexistent plate fixation of humeral shaft fractures. [214] (10.1016/j.injury.2020.11.042)

References

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[10] 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

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[15] 6. Complications of Proximal Humerus Fractures: Evaluation and Management. 2011.

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

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[22] 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

[23] 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

[24] 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

[25] 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

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

[27] 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

[28] Neurovascular Injuries Associated with Proximal Humerus Fractures: A Review of the Current Literature. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100825

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

[43] 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

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

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[48] 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

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

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