Proximal Humerus Fracture

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

Overview

Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [1]. Over the past decade, most older adults who sustain these fractures continue to receive nonoperative management [3], while most pediatric patients experience favorable results with infrequent complications [9]. Despite nonsurgical management demonstrating successful outcomes and union rates greater than 90% [17], treatment remains controversial. The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management in adult patients younger than 65 years [12].

Surgical selection is influenced by patient demographics, as both age and gender have an association with the definitive treatment received over the last decade [11]. However, most RCTs on surgical management do not include patient-specific variables within their inclusion and exclusion criteria [5]. For older patients with 3- or 4-part fractures, a new intramedullary support nail and plate system shows a 1-year advantage [6]. Reverse total shoulder arthroplasty (RTSA) is a current, reasonable, and safe option for those with higher Neer grades or older age [28], offering compelling evidence of effectiveness and functional durability in acute fractures [82]. Hemiarthroplasty also presents successful radiographic and functional results after a mean follow-up of 4.8 years for primary nonreconstructable humeral head fractures when using a specific fracture stem and adequate tuberosity management [30]. Future literature should utilize at least 3 outcomes measures and 1 general health score until optimal scores are determined [14].

Anatomy & Pathophysiology

Osseous Classification and Radiographic Assessment

The Neer classification defines a fracture "part" as displacement of greater than 1 cm or angulation of greater than 45 degrees [19, 20, 27], identifying four distinct components: the articular surface, greater tuberosity, lesser tuberosity, and humeral shaft [19, 20, 27]. A one-part fracture is nondisplaced or minimally displaced [19, 20], while a two-part fracture involves displacement of a tuberosity of more than 1 cm or displacement/angulation of the surgical neck with the head and shaft [19, 20]. Three-part fractures involve displacement of the greater or lesser tuberosities and the articular surface [19, 20], whereas four-part fractures involve displacement of the shaft, articular surface, and both tuberosities [19, 20]. A variant known as "head splitting" is characterized by a split through the articular surface [19, 20]. For the greater tuberosity specifically, a lower threshold of displacement greater than 5 mm has been considered for classification [27]. The AO classification system was defined in 1988 and identified 27 categories [27], with an updated 2018 version releasing 21 classifications [27] that organize fractures into three main groups: A (extra-articular unifocal), B (extra-articular bifocal), and C (intra-articular) [27]. All classification schemes exhibit poor interobserver reliability, representing at best slight to moderate agreement [27]. Standard radiographs include AP, true AP (Grashey), axillary lateral, and scapular-Y views [27], while internal and external rotation views can help distinguish subtle tuberosity fractures [27]. Plain radiographs underestimate the number of fragments in comminuted fractures by 60% compared to CT axial imaging [27].

Vascular and Neural Pathophysiology

Most proximal humerus fractures occur as the result of low-energy falls in the elderly population [14], with incidence increasing between 2008 and 2017 while surgical management decreased significantly in patients aged 65 years or older [18]. Nerve deficits, most commonly mixed brachial plexopathy, may be present in up to 70% of proximal humerus fractures, including those with low-energy mechanisms [27]. It was previously suggested that the anterior humeral circumflex artery was the predominant blood supply to the humeral head [27], but a 2011 investigation using gadolinium-enhanced MRI revealed that the posterior humeral circumflex artery is responsible for the majority (64%) of blood flow to the humeral head [27]. The posterior humeral circumflex artery anastomoses with the arcuate artery at the epiphyseal line [27]. Fracture patterns that disrupt the posteromedial neck were correlated with a higher risk of humeral head ischemia [27]. Higher rates of ischemia were observed with fracture extension into the metaphysis greater than 2 mm and less than 8 mm [27]. Diminished blood flow was noted in 78% of fractures with a disrupted medial hinge [27], whereas only 20% of perfused heads had a disrupted medial cortex [27]. Intraoperative blood flow does not predict osteonecrosis, as osteonecrosis had not developed in 8 of 10 initially avascular heads at 5-year follow-up [27]. Older case series suggest that osteonecrosis results in almost one-third of three-part or four-part fractures [27].

Kinematics and Deforming Forces

The supraspinatus, infraspinatus, and teres minor muscles attach to the greater tuberosity and exert abduction and external rotation forces [27], while the subscapularis attaches to the lesser tuberosity and exerts an adduction and internal rotation force [27]. The deltoid and pectoralis insert more distally on the shaft and provide deforming forces that displace the shaft component into flexion and internal rotation [27]. Positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures [63]. Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics [83]. With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly [53]. Inferior tuberosity displacement after prosthetic reconstruction of shoulder fractures may explain diminished functional results [42, 55].

Sequelae and Functional Outcomes

The Boileau classification identifies four basic pathologic types of fracture sequelae: Type 1 (intracapsular/impacted with cephalic collapse or necrosis), Type 2 (intracapsular/impacted with locked dislocations), Type 3 (extracapsular/disimpacted with surgical neck nonunions), and Type 4 (extracapsular/disimpacted with severe tuberosity malunions) [64]. Positive results were obtained in Boileau Type 1 and Type 2 sequelae, in which osteotomy of the greater tuberosity was not required [78]. All patients in Boileau Type 3 and Type 4 sequelae, who underwent a greater tuberosity osteotomy, had fair or poor results with limited active elevation beyond 90 degrees [78]. Range of motion and strength thresholds can identify subjects with normal shoulder function [49], though shoulder flexion, extension, and abduction are only moderately correlated with patient-reported outcome measures (PROMs) [76]. Selective Glenohumeral External Rotation Deficit (SGERD) is a new shoulder evaluation symptom identified as a sequelae of post-ORIF deltoid adhesions [89].

Classification

HGLS: The HGLS classification system is a reliable method for describing proximal humerus fractures, demonstrating superior reliability compared to the Neer and AO systems [41].

Neer: The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice [45]. However, classifications based on the Neer system using CT scans and plain radiographs are not very reliable or reproducible due to the difficulty in determining which segments are fractured [44]. Interobserver agreement for classifying proximal humeral fractures using the Neer system remains at 50% [29]. Three-dimensionally printed models have been shown to improve interobserver agreement in the classification of proximal humeral fractures using the Neer system [70].

Mayo-FJD: The Mayo-FJD classification system allows for high intraobserver and interobserver agreement when utilizing both radiographs and computed tomography [61].

Four-segment: A new four-segment classification was developed to adequately describe displaced proximal humeral fractures based on the presence or absence of displacement of the articular surface, greater tuberosity, lesser tuberosity, and shaft [73].

Other Considerations: Proximal humerus fractures are osteoporotic injuries with an increasing incidence due to aging populations [7]. Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions regarding these fractures [7]. A new classification system emphasizing qualitative aspects of proximal humeral fractures demonstrated high reliability when based on a standardized imaging protocol including computed tomography scans [22]. Morphologic classification of proximal humerus fractures should be scrutinized as the sole basis for treatment algorithms and surgical success [68]. Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures overall [81]. Consensus on the management of proximal humerus fractures is limited to specific scenarios, while a lack of consensus persists in others [2]. Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [4]. Most randomized controlled trials investigating surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria, aside from age [5].

Clinical Presentation

Proximal humerus fractures are osteoporotic injuries with an increasing incidence driven by aging populations [7]. Fractures follow characteristic patterns [23], with nondisplaced variants being among the most common fractures associated with osteoporosis [47]. While most pediatric patients experience favorable results with infrequent complications [9], the vast majority of adult cases, particularly in older adults, are amenable to non-operative treatment with positive outcomes [1, 10, 15]. However, consensus on management remains limited to specific scenarios, persisting in others [2]. Both age and gender influence the definitive treatment received over the last decade [11], with treatment algorithms and outcomes for patients ≤60 years distinctly differing from the elderly population [26].

Clinical evaluation requires accurate imaging and classification to inform treatment decisions [7]. Computed tomography scans offer greater specificity than radiographs for assessing fracture sequelae [24]. Complications are varied, categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [8]. Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management [4]. Nondisplaced fractures can cause major functional disability and reduced subjective patient-perceived health [47].

Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [13]. As most unplanned hospital readmissions are associated with medical diagnoses, patient comorbidities must be considered before and during postoperative care [25]. In adult patients younger than 65 years, available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management [12]. Factors associated with poor results after surgical treatment include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension [52].

Future literature should utilize at least 3 outcome measures and 1 general health score until optimal scores are determined [14]. A wide range of outcome measures are currently used in studies, yet there is limited evidence regarding their psychometric properties in this specific population [51].

Investigations

Plain radiography: Standard views for proximal humeral fractures include AP, true AP (Grashey), axillary lateral, and scapular-Y views [27]. Internal and external rotation views assist in distinguishing subtle tuberosity fractures [27]. Patients typically present with a painful shoulder and ecchymosis along the pectoralis and biceps muscles [27]. Plain radiographs underestimate the number of fragments in comminuted proximal humeral fractures by 60% compared to CT axial imaging [27]. Convolutional neural networks proficiently rule out proximal humerus fractures on plain radiographs [94].

CT: Axillary or computed tomography scans are the best views for diagnosing posterior dislocation or fracture-dislocation [19]. Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae [24]. CT can provide more detail especially with comminuted fracture patterns, articular or glenoid involvement, and when considering surgical intervention [27]. The new classification system with emphasis on qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans [22]. The use of three-dimensional computed tomography imaging did not offer improved interobserver and intraobserver agreement compared with the use of two-dimensional computed tomography imaging with regard to classification and treatment of fractures of the proximal part of the humerus, except among reviewers with limited clinical experience [106]. 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 [110].

Other Considerations: The Neer classification defines a "part" as displacement of greater than 1 cm or angulation of greater than 45 degrees [19], defining the four parts as the articular surface, greater tuberosity, lesser tuberosity, and shaft [19]. One-part fractures are nondisplaced or minimally displaced, often of the humeral neck [19]. Two-part fractures involve displacement of a tuberosity of more than 1 cm or displacement/angulation of the surgical neck with the head/shaft [19]. Three-part fractures involve displacement of the greater or lesser tuberosities and the articular surface [19]. Four-part fractures involve displacement of the shaft, articular surface, and both tuberosities [19]. "Head splitting" is a variant with a split through the articular surface that usually requires replacement [19]. For the greater tuberosity in the Neer classification, a lower threshold of displacement greater than 5 mm has been considered [27]. The AO classification was defined in 1988 and identified 27 categories [27], with an updated 2018 version releasing 21 classifications [27]. The 2018 AO/OTA classification has improved interobserver reliability to k = 0.67 [27]. All classification schemes for proximal humeral fractures exhibit poor interobserver reliability, representing slight to moderate agreement at best [27], with a 50% agreement between observers on how to classify proximal humeral fractures at present [29]. Radiologic reevaluation is only necessary in patients with comminution and may be redundant for 77% of patients with one-part proximal humeral fractures [18]. Fractures of the proximal humerus follow characteristic patterns [23]. A simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures [112].

Treatment

Non-Operative

Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [1]. Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [3], and a majority of patients with proximal humeral fractures underwent non-operative treatment [15]. Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90% [17]. Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [62]. Proximal humerus fractures in children have tremendous potential for remodeling, making non-operative management the treatment of choice for most fractures [66]. Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [4].

Operative

Indications: 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 [26]. 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 [12]. Current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial [16]. Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade [11]. No single fixation method is considered the standard of care for the 15% to 20% of proximal humerus fractures that may benefit from surgery [58].

Surgical Approach / Technique: The medial approach is feasible and opens a new perspective in the optimal management of complex fractures of the proximal humerus [56]. The choice of approach for exposure of the proximal humerus region may influence the functional outcome [65]. Various technical strategies exist to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates [54]. A less-invasive surgical procedure for proximal humeral fractures is a feasible treatment option with acceptable complications and considerable improvement during the first six months, though a lengthy recovery time is required [59]. The Humerus Block technique is a very good and predictable, minimally invasive, percutaneous operative technique for treatment of various types of proximal humeral fractures that results in very good pain relief, mobility, and pull force in the arm with a low incidence of avascular necrosis [93].

Implant Selection: Clinical results at 1-year follow-up confirmed the advantage of applying a new intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [6]. Early results with locked plate fixation for the treatment of proximal humerus fractures have been encouraging, providing a potentially viable alternative to prosthetic replacement [91]. Internal fixation of proximal humerus fractures with locking plates in patients over the age of 60 resulted in a 44% complication rate, including a 34% failure rate defined as reoperation or radiographic failure [39]. Symptomatic patients after locked plate osteosynthesis for proximal humerus fractures showed statistically significant improvement of the Constant score after implant removal [97]. All-suture fixation of proximal humeral fractures presents an attractive alternative to conventional techniques, whilst avoiding complications relating to metalwork implantation [92]. Medial support with an intramedullary fibular graft in an angular stable fixation of the proximal humerus increases overall stiffness of the bone-implant construct and reduces migration of the humeral head fragment [101]. Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures [37]. Reverse shoulder prosthesis using a dedicated stem is a very viable solution to treat complex proximal humerus fractures with reliable restoration of elevation [100]. The selection of reverse total shoulder arthroplasty (RTSA) over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients [28]. 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 [30]. Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years [38].

Other Considerations: Consensus on managing proximal humerus fractures is limited to specific scenarios, whereas a lack of consensus still exists in others [2]. Besides age, most randomized controlled trials on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria [5]. 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 [8]. Surgical fixation of proximal humeral fractures has a low complication and mortality profile [96]. Nonsurgical management of proximal humerus fractures decreased during the study period [46].

Complications

Mortality and Systemic Morbidity: Mortality following proximal humeral fractures is universally high, with a more than two-fold increase at one year (9.8%) rising to 28.2% at five years [117]. The adjusted one-year mortality rate is 13.05%, significantly higher than other upper extremity fractures though lower than hip fractures [122]. Patients face a significantly higher risk of mortality up to one year compared with the general population [33], and this risk remains high regardless of specific risk factors [13]. Combined fractures involving the femur or vertebrae are associated with significantly higher mortality and morbidity than isolated proximal humerus fractures [114]. Most unplanned hospital readmissions after surgical treatment are associated with medical diagnoses rather than surgical complications [25].

Surgical Complications and Infection: The rate of complications following operative treatment is high [118, 121]. Internal fixation with locking plates in patients over 60 resulted in a 44% complication rate, including a 34% failure rate defined as reoperation or radiographic failure [39]. Acute deep infection after ORIF is a devastating complication characterized by high complication rates, poor functional outcomes, and a notably high nonunion rate [120]. The rate of pulmonary embolism after operative treatment is not low [107]. Increased in-hospital risk for major adverse events and surgical complications may moderate enthusiasm for RTSA in patients 65 years and older [108].

Implant-Specific and Revision Outcomes: Revision surgery for failed arthroplasty is complex with a high likelihood of inferior outcomes compared with primary arthroplasty [102]. Primary shoulder hemiarthroplasty is associated with satisfactory prosthetic survival at an average of 6.3 years [38]. In elderly patients undergoing reverse shoulder arthroplasty, anatomic tuberosity healing improves objective and subjective outcomes [40]. There are no significant differences in clinical outcomes or complication rates between standard and fracture-specific components in reverse shoulder arthroplasty [87]. Revision rates and mortality are similar between cemented and cementless humeral stems [116], as are revision rates and patient-reported outcomes [123]. Fixation using locked plates with cement augmentation shows no significant difference in revision rate compared to locked plates alone, though implant failure and total complication rates may be lower with cement augmentation [124]. Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex fractures [37]. Complication and revision rates for IM nails designed to capture tuberosities are similar to those for locked proximal humerus plate systems [125].

Nonunion and Predictive Factors: The prevalence of nonunion is higher than previously reported, with most patients at very low risk but a smaller subgroup at much higher risk [126]. Terminology and definitions for complications following non-surgical management exhibit significant heterogeneity [4]. Complications can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [8]. Comorbidity indices mCCI and mFI-5 are strongly associated with adverse events but have moderate ability to predict complications following surgical treatment [127]. Predictive models using ML techniques demonstrated favorable discrimination in forecasting prolonged LOS and serious adverse complications within 30 days of surgical intervention [128]. Most pediatric patients have favorable results with infrequent complications [9].

Other Considerations: Complications associated with proximal humerus fractures can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [8].

Recovery

Light activity (weeks): Patients treated with early range of motion exercises largely return to baseline functional status by 1 year, with recovery enhanced by overcoming fears of movement or reinjury within one week after injury and greater self-efficacy within one month [43, 105]. Social independence is a key predictor, as people recovering from proximal humerus fractures experience less incapability in proportion to their social independence [72].

Full activity (months): Most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [1]. Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90% [17]. Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [119], and over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [3]. Conversely, clinical results at 1-year follow-up confirmed the advantage of applying intramedullary support nail and plate systems to 3- or 4-part proximal humeral fractures in older patients [6]. MultiLoc nails are well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications [113], and are a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [71]. In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [40]. Reverse shoulder arthroplasty offers predictable pain relief and functional restoration independent of rotator cuff function but carries substantial risks of complications [115]. Functional outcomes of proximal humerus fractures treated with reverse shoulder arthroplasty improve with surgical experience, and outcomes become less variable after approximately 20 procedures [103]. The current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial [16]. Proximal humeral fractures of adolescents heal well and rarely result in impairments whether treated operatively or nonoperatively [34].

Complete recovery / outcome plateau (months): Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management [60]. Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months [50]. The functionality and quality of life of patients with complex proximal humerus fractures treated with rTSA decreased significantly compared to the 2-year evaluation, although this change was not clinically relevant [98].

Rehabilitation protocol: Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management [60]. Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months [50]. Differences in rehabilitation after proximal humerus fracture treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies [48].

Functional milestones: The SFInX is a feasible outcome measure which clinicians can use to reliably measure and detect clinically important changes in the construct of 'shoulder function' in people recovering from a proximal humeral fracture [104]. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures [99].

Other Considerations: Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [13]. 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 [33]. 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 [90]. 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 [32]. Future literature on proximal humerus fractures should use at least 3 outcomes measures and 1 general health score until the optimal scores are determined [14].

Key Evidence

• [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. (10.1016/j.jse.2024.12.005)
• [L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. (10.1016/j.jseint.2021.08.006)
• [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. (10.1186/s12891-019-2459-6)
• [L2] Besides age, most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria. (10.1016/j.xrrt.2025.07.023)
• [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. (10.1186/s12891-022-05998-z)
• [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. (10.5435/jaaos-d-14-00033)
• [L4] In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. (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. (10.1016/j.jseint.2021.11.007)
• [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. (10.1016/j.xrrt.2021.04.014)
• [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. (10.1016/j.jse.2022.03.006)
• [L4] We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined. (10.1016/j.jse.2020.04.006)
• [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
• [L1] These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial. (10.1371/journal.pmed.1002855)
• [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. (10.5435/jaaos-d-24-01073)
• [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. (10.1016/j.jse.2015.08.006)
• [L4] Fractures of the proximal humerus follow characteristic patterns. (10.1016/j.jse.2017.05.014)
• [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. (10.1177/17585732221150785)
• [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. (10.1007/s11999-014-3613-y)
• [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. (10.1016/j.xrrt.2023.01.002)
• [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. (10.1097/corr.0000000000002430)
• [L5] At present, there remains a 50% agreement between observers on how to classify proximal humeral fractures. (10.1111/sae.12013)
• [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. (10.1016/j.jse.2023.02.118)
• [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. (10.1016/j.jse.2022.01.141)
• [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. (10.1302/0301-620x.102b11.bjj-2020-0627.r1)
• [L3] Proximal humeral fractures of adolescents heal well and rarely result in impairments whether treated operatively or nonoperatively. (10.2106/jbjs.22.01131)
• [L5] The control volume is an important anatomic and functional area of the proximal humerus. (10.1016/j.jse.2017.12.004)
• [L4] The study describes a novel simulation system used to quantify the bone-determined ROM in proximal humeral fractures and may be a useful adjunct in the diagnostic armamentarium for proximal humeral fractures. (10.1177/1758573217713693)
• [L4] Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures. (10.1016/j.xrrt.2025.100625)
• [L2] Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years. (10.2106/jbjs.l.01115)
• [L3] Internal fixation of proximal humerus fractures with locking plates in patients over the age of 60 resulted in a 44% complication rate, including a 34% failure rate defined as reoperation or radiographic failure. (10.1016/j.jse.2018.11.028)
• [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. (10.1016/j.jse.2018.05.030)
• [L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. (10.1016/j.jse.2012.09.018)
• [L5] These biomechanical observations may explain diminished functional results observed in patients treated with inferior tuberosity displacement after prosthetic reconstruction of shoulder fractures. (10.1016/j.jse.2007.02.110)
• [L3] Patients with proximal humeral fractures treated with early range of motion exercises do well, largely returning to baseline functional status by 1 year. (10.1016/j.jse.2007.07.016)
• [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. (10.2106/00004623-199609000-00012)
• [L4] The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice. (10.1016/j.jse.2009.01.018)
• [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
• [L4] Nondisplaced proximal humeral fractures are among the most common fractures associated with osteoporosis, and they can be a major cause of functional disability and reduction in subjective patient-perceived health. (10.1016/j.jse.2010.09.008)
• [L4] Differences in rehabilitation after proximal humerus fracture treatment should be further evaluated to determine the role it may play in the outcomes of treatment studies. (10.1016/j.jse.2021.12.045)
• [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. (10.1016/j.jse.2010.06.005)
• [L2] Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months. (10.1016/j.jse.2025.01.042)
• [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. (10.1016/j.jse.2010.10.028)
• [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. (10.1097/corr.0000000000002242)
• [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. (10.1016/j.jse.2007.06.017)
• [L5] This review highlights various technical strategies to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates. (10.5435/jaaos-d-22-01211)
• [Abstract] These biomechanical changes may explain diminished function in patients with inferior tuberosity positioning after hemiarthroplasty for proximal humerus fractures. (10.1016/j.jse.2007.02.027)
• [L5] The medial approach is feasible and opens a new perspective in the optimal management of complex fractures of the proximal humerus. (10.1186/s13018-021-02897-2)
• [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. (10.1186/s12891-015-0618-y)
• [L4] Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management. (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. (10.1016/j.jse.2023.02.035)
• [L2] Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern. (10.2106/jbjs.20.02137)
• [L5] These findings suggest that positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures. (10.5397/cise.2022.00885)
• [L3] The choice of approach for exposure of the proximal humerus region may influence the functional outcome. (10.1016/j.jse.2007.03.029)
• [L2] Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized. (10.1016/j.jseint.2022.02.006)
• [L5] Three-dimensionally printed models improved interobserver agreement in the classification of proximal humeral fractures using the Neer system. (10.1016/j.jseint.2020.10.019)
• [L3] It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. (10.1186/s12891-023-06669-3)
• [L2] People recovering from proximal humerus fractures experience less incapability in proportion to their social independence, emphasizing the important associations of social factors to musculoskeletal health and the utility of accounting for social factors in care strategies. (10.1016/j.jseint.2023.05.013)
• [L4] A new four-segment classification based on the presence or absence of displacement of the articular surface, greater tuberosity, lesser tuberosity, and shaft was developed to adequately describe displaced proximal humeral fractures. (10.2106/00004623-197052060-00001)
• [L3] Holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. (10.1016/j.jseint.2024.02.003)
• [L3] Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures overall. (10.5435/jaaos-d-16-00223)
• [Letter] Our study offers compelling evidence of the effectiveness and functional durability of rTSA in treating acute proximal humerus fractures in older adults, with findings interpreted as confirmation of the procedure's sustained efficacy rather than an indication of functional failure. (10.1016/j.jse.2025.05.045)
• [L5] Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics. (10.5435/jaaos-d-20-00555)
• [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. (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
• [L4] These observations allow the identification of a new shoulder evaluation symptom: Selective Glenohumeral External Rotation Deficit (SGERD). (10.1186/s12891-020-03634-2)
• [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. (10.1016/j.jse.2019.05.030)
• [L4] Early results with locked plate fixation for the treatment of proximal humerus fractures have been encouraging, providing a potentially viable alternative to prosthetic replacement. (10.5435/00124635-200805000-00008)
• [L4] Our results suggest that all-suture fixation of proximal humeral fractures presents an attractive alternative to conventional techniques, whilst avoiding complications relating to metalwork implantation. (10.1177/17585732231184208)
• [L4] The Humerus Block technique is a very good and predictable, minimally invasive, percutaneous operative technique for treatment of various types of proximal humeral fractures that results in very good pain relief, mobility, and pull force in the arm with a low incidence of avascular necrosis. (10.1016/j.jse.2011.07.029)
• [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. (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. (10.1186/s13018-022-03337-5)
• [L4] Surgical fixation of proximal humeral fractures has a low complication and mortality profile. (10.2106/jbjs.m.01039)
• [L4] Symptomatic patients after locked plate osteosynthesis for proximal humerus fractures showed statistically significant improvement of the Constant score after implant removal. (10.1186/s12891-016-0977-z)
• [L4] The functionality and quality of life of patients with complex proximal humerus fractures treated with rTSA decreased significantly compared to the 2-year evaluation, although this change was not clinically relevant. (10.1016/j.jse.2024.05.045)
• [L2] Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures. (10.1097/blo.0b013e31803bb400)
• [L4] Reverse shoulder prosthesis using a dedicated stem is a very viable solution to treat complex proximal humerus fractures with reliable restoration of elevation. (10.1186/s13018-015-0261-1)
• [L5] Medial support with an intramedullary fibular graft in an angular stable fixation of the proximal humerus in vitro increases overall stiffness of the bone-implant construct and reduces migration of the humeral head fragment. (10.1016/j.jse.2010.10.040)
• [L5] Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty. (10.5435/jaaos-d-17-00051)
• [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. (10.1016/j.jseint.2021.07.008)
• [L3] The SFInX is a feasible outcome measure which clinicians can use to reliably measure and detect clinically important changes in the construct of 'shoulder function', the ability to perform activities in which the shoulder is involved, in people recovering from a proximal humeral fracture. (10.1186/s12891-016-1138-0)
• [L3] Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy within a month. (10.1302/0301-620x.101b6.bjj-2018-0857.r1)
• [L3] The use of three-dimensional computed tomography imaging did not offer improved interobserver and intraobserver agreement compared with the use of two-dimensional computed tomography imaging with regard to classification and treatment of fractures of the proximal part of the humerus, except among reviewers with limited clinical experience. (10.2106/jbjs.m.00199)
• [L3] The rate of pulmonary embolism after operative treatment of proximal humeral fractures is not low. (10.1016/j.jse.2006.12.004)
• [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. (10.1097/corr.0000000000001776)
• [L4] The study demonstrated satisfactory functional and radiologic outcomes, suggesting that RSA is a good management option for elderly patients with proximal humeral fractures. (10.1016/j.jse.2015.09.007)
• [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. (10.1097/corr.0000000000002017)
• [L3] Proximal humeral fracture classifications may be helpful conceptually, but they have poor interobserver reliability even when 3-D rather than 2-D CT is utilized. (10.2106/jbjs.l.00586)
• [L3] Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures. (10.1016/j.jseint.2020.10.017)
• [L4] MultiLoc nails are well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. (10.1186/s12891-024-07656-y)
• [L3] Combined fractures with femoral or vertebral fractures are associated with significantly higher mortality and morbidity compared with isolated proximal humerus fractures. (10.1016/j.jse.2025.04.013)
• [L1] The authors critically reviewed existing Level I and Level II studies to determine the role of RTSA for treating proximal humerus fractures in patients older than 65 years, noting that while RTSA offers predictable pain relief and functional restoration independent of rotator cuff function, it carries substantial risks of complications. (10.1097/corr.0000000000001910)
• [L3] Revision rates and mortality are similar between cemented and cementless humeral stems used for rTSA for proximal humerus fractures. (10.1016/j.jseint.2024.09.023)
• [L3] Proximal humeral fractures confer a more than two-fold increase in mortality at 1 year (9.8%), which continues to increase to 28.2% mortality at 5 years. (10.1177/1758573214525761)
• [L3] The rate of complications following operative treatment of proximal humerus fractures is high. (10.1016/j.jse.2007.02.109)
• [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. (10.2106/jbjs.l.01293)
• [L4] Acute deep infection after ORIF of proximal humeral fractures is a devastating complication with high complication rates, poor functional outcomes, and a notably high nonunion rate. (10.1016/j.jse.2006.09.021)
• [L4] The rate of complications after operative treatment of proximal humeral fractures is high. (10.1016/j.jse.2006.05.008)
• [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. (10.1016/j.jse.2015.11.031)
• [L3] Revision rates and patient-reported outcomes are similar between cemented and uncemented humeral stems. (10.1016/j.jseint.2025.10.009)
• [L1] Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. (10.1186/s12891-024-07502-1)
• [L3] Complication and revision rates in this cohort are similar to rates reported in cohorts where locked proximal humerus plate systems were utilized. (10.1016/j.jse.2020.01.049)
• [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. (10.2106/jbjs.20.01139)
• [L4] The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures. (10.1016/j.jse.2020.06.014)
• [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. (10.1016/j.jseint.2024.02.005)

See Also

• Fractures
• Patient Demographics
• Total shoulder arthroplasty
• Shoulder Fractures
• Internal Fixation
• Reverse Shoulder Arthroplasty
• Rotator Cuff
• Shoulder Arthroplasty

References

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

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

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

[4] Complications after non-surgical management of proximal humeral fractures: a systematic review of terms and definitions. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2459-6

[5] 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

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

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

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

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

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

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

[12] 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

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

[14] Outcome measures reported for the management of proximal humeral fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.04.006

[15] 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

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

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

[18] Orthopaedic Knowledge Update Trauma. Proximal Humerus Fracture > Annotated References.

[19] Miller S Review Of Orthopaedics. PROXIMAL HUMERUS FRACTURES (FIG. 11.3).

[20] Miller S Review Of Orthopaedics. SECTION 16 PATELLAR TRACKING IN TOTAL KNEE ARTHROPLASTY > PROXIMAL HUMERUS FRACTURES (FIG. 11.3).

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

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

[24] 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

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

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

[27] Orthopaedic Knowledge Update Trauma. Proximal Humerus Fracture > Presentation, Anatomy, and Classification.

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

[29] Decision-Making in Proximal Humeral Fractures. Shoulder & Elbow. 2013. DOI: 10.1111/sae.12013

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

[31] Orthopaedic Knowledge Update Trauma. Proximal Humerus Fracture > Surgical Treatment > Arthroplasty for Fracture.

[32] Fragility of randomized controlled trials on treatment of proximal humeral fracture. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.01.141

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

[34] Outcomes at a Mean of 13 Years After Proximal Humeral Fracture During Adolescence. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.01131

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

[36] Simulation of bone-determined range of motion in proximal humeral fractures. Shoulder & Elbow. 2017. DOI: 10.1177/1758573217713693

[37] Use of locking humeral stems in reverse total shoulder arthroplasty for complex proximal humerus fractures: a scoping review. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100625

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

[39] Locking-plate fixation of proximal humerus fractures in patients over 60 continues to be associated with a high complication rate. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2018.11.028

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

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

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

[43] Functional outcome following one-part proximal humeral fractures: A prospective study. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.07.016

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

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

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

[47] Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.09.008

[48] Understanding postoperative rehabilitation preferences in operatively managed proximal humerus fractures: do trauma and shoulder surgeons differ?. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.12.045

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

[50] Postoperative treatment of proximal humerus fractures with an early active motion protocol: a prospective randomized controlled trail. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.042

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

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

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

[54] Technical Tips for Reduction and Stable Fixation of Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-01211

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

[56] Anatomical study for the treatment of proximal humeral fracture through the medial approach. Journal of Orthopaedic Surgery and Research. 2022. DOI: 10.1186/s13018-021-02897-2

[58] 3. Open Reduction, Internal Fixation of Proximal Humerus Fractures: Indications, Techniques, Outcomes, and Complications. n.d..

[59] Mid-term results of a less-invasive locking plate fixation method for proximal humeral fractures: a prospective observational study. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0618-y

[60] Rehabilitation protocols in proximal humerus fracture management: A systematic review. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231182374

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

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

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

[64] Classifications And Scores Of The Shoulder. 11.4 Surgical classification of sequelae of proximal humerus fracture according to Boileau et al. [15]*.

[65] The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.03.029

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

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

[70] Interobserver and intraobserver agreement of three-dimensionally printed models for the classification of proximal humeral fractures. JSES International. 2021. DOI: 10.1016/j.jseint.2020.10.019

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

[72] Social determinants of outcomes in nonoperatively treated proximal humerus fractures. JSES International. 2023. DOI: 10.1016/j.jseint.2023.05.013

[73] Displaced Proximal Humeral Fractures. The Journal of Bone & Joint Surgery. 1970. DOI: 10.2106/00004623-197052060-00001

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

[78] Rockwood And Matsen S The Shoulder. Shoulder and Elbow Specialty Clinic Workers’ Survey > COMPLICATIONS ASSOCIATED WITH TREATMENT OF PROXIMAL HUMERUS FRACTURES.

[81] The Effect of Two Factors on Interobserver Reliability for Proximal Humeral Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-16-00223

[82] Response to Qin et al regarding: “Effectiveness over time of the reverse shoulder prosthesis for acute proximal humeral fracture”. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.05.045

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

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

[89] Selective Glenohumeral external rotation deficit – sequelae of post-ORIF deltoid adhesions after treatment of the proximal humerus fracture. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03634-2

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

[91] Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200805000-00008

[92] Clinical outcomes of a novel ‘all-suture’ fixation for valgus-impacted proximal humeral fractures. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231184208

[93] Functional and radiographic medium-term outcome evaluation of the Humerus Block, a minimally invasive operative technique for proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.07.029

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

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

[96] Factors Predicting Complication and Reoperation Rates Following Surgical Fixation of Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01039

[97] Elective implant removal in symptomatic patients after internal fixation of proximal humerus fractures improves clinical outcome. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0977-z

[98] Effectiveness over time of the reverse shoulder prosthesis for acute proximal humeral fracture. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.05.045

[99] Defining the Relationship Between Rotator Cuff Injury and Proximal Humerus Fractures. Clinical Orthopaedics & Related Research. 2007. DOI: 10.1097/blo.0b013e31803bb400

[100] Reverse shoulder arthroplasty for proximal humerus fracture using a dedicated stem: radiological outcomes at a minimum 2 years of follow-up—case series. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0261-1

[101] Medial support by fibula bone graft in angular stable plate fixation of proximal humeral fractures: an in vitro study with synthetic bone. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.10.040

[102] Management of the Failed Arthroplasty for Proximal Humerus Fracture. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00051

[103] Surgical learning curve in reverse shoulder arthroplasty for proximal humerus fractures. JSES International. 2021. DOI: 10.1016/j.jseint.2021.07.008

[104] The Shoulder Function Index (SFInX): evaluation of its measurement properties in people recovering from a proximal humeral fracture. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1138-0

[105] Factors associated with the magnitude of limitations during recovery from a fracture of the proximal humerus. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b6.bjj-2018-0857.r1

[106] The Impact of Three-Dimensional CT Imaging on Intraobserver and Interobserver Reliability of Proximal Humeral Fracture Classifications and Treatment Recommendations. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.00199

[107] Pulmonary embolism after operative treatment of proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.12.004

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

[109] Functional and radiologic outcomes of uncemented reverse shoulder arthroplasty in proximal humeral fractures: cementing the humeral component is not necessary. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.09.007

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

[111] Interobserver Reliability of Classification and Characterization of Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2013. DOI: 10.2106/jbjs.l.00586

[112] Use of a 5-item modified Fragility Index for risk stratification in patients undergoing surgical management of proximal humerus fractures. JSES International. 2021. DOI: 10.1016/j.jseint.2020.10.017

[113] Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07656-y

[114] Combined proximal humerus fractures are associated with greater mortality and morbidity compared with isolated fractures: a retrospective cohort study. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2025.04.013

[115] CORR® Synthesis: What Is the Role of Reverse Shoulder Arthroplasty for the Treatment of Proximal Humerus Fractures in Patients Older Than 65 Years?. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001910

[116] Cemented vs. cementless stems for reverse shoulder arthroplasty for proximal humerus fractures: a registry analysis with patient-reported outcomes from a level 1 trauma centre. JSES International. 2025. DOI: 10.1016/j.jseint.2024.09.023

[117] Risk factors and predictors of mortality for proximal humeral fractures. Shoulder & Elbow. 2014. DOI: 10.1177/1758573214525761

[118] Early Complications Of Operatively Treated Proximal Humerus Fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2007.02.109

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

[120] Acute deep infection after surgical fixation of proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.021

[121] Early complications of operatively treated proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.05.008

[122] Mortality after proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.031

[123] Do uncemented humeral components perform better than cemented humeral components in reverse total shoulder arthroplasty for acute proximal humerus fracture? A New Zealand Joint Registry study. JSES International. 2026. DOI: 10.1016/j.jseint.2025.10.009

[124] Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07502-1

[125] Three and Four-Part Proximal Humerus Fracture Fixation Using an IM Nail Designed to Capture the Tuberosities. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2020.01.049

[126] Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.01139

[127] Efficacy of the modified Frailty Index and the modified Charlson Comorbidity Index in predicting complications in patients undergoing operative management of proximal humerus fracture. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.06.014

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