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Proximal Humerus Fracture ORIF (Plate and Nail Fixation)

Overview

Open reduction and internal fixation (ORIF) of proximal humerus fractures utilizes locking plates and intramedullary nails to address displaced unstable fractures, particularly in elderly populations. While locking plates demonstrate excellent utility in managing displaced unstable fractures and expanding ORIF indications [7], outcomes vary significantly by bone quality; in patients over 60 years, complication and failure rates reach 44% and 34% respectively [1]. Conversely, favorable functional and radiologic outcomes persist for nonosteoporotic fractures at minimum 10-year follow-up [2], and locking plates remain a viable alternative for displaced 2-part surgical neck fractures in the elderly with acceptable complication rates [11].

Comparative data indicate that locking plate fixation and locking intramedullary nails produce similar clinical and radiologic results [6], with nail versus plate fixation showing comparable 1-year outcomes for three-part fractures [3]. Percutaneous approaches for selected fractures yield predictable union and good clinical results with low complication rates [5], while intramedullary fixation offers specific biologic advantages with outcomes comparable to other techniques [18]. Despite these options, patients undergoing ORIF for fracture dislocations face relatively high rates of avascular necrosis and reoperation despite reasonable functional outcomes [14]. No level 1 studies currently compare ORIF with hemiarthroplasty for proximal humeral fractures [17].

Anatomy & Pathophysiology

Osseous and Articular Mechanics

Varus and antecurvatum proximal humerus deformities as small as 15 degrees are associated with statistically significant alterations in glenohumeral joint mechanics [49]. With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly during hemiarthroplasty for four-part proximal humeral fractures [32]. The biomechanical literature regarding proximal humerus fracture implants is diverse and heterogeneous [33]. Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion [30], whereas greater tuberosity healing affects reverse shoulder arthroplasty biomechanics during external rotation [30]. The SB construct has superior interface contact immediately after fixation for humeral greater tuberosity fractures [48], while the DR construct offers better contact performance at all abduction angles with applied force for humeral greater tuberosity fractures [48].

Surgical Fixation and Stability

A minimally invasive procedure using a modified minimally invasive reduction osteosynthesis system (MIROS) provides adequate fracture stability for Neer 2 and 3-part proximal humeral fractures [36]. The modified minimally invasive reduction osteosynthesis system (MIROS) permits early shoulder motion [36]. The modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-part proximal humeral fractures results in satisfactory functional and radiologic outcomes [36] and fewer complications [36]. Robot navigation-assisted intramedullary nail treatment for humeral shaft fractures helps surgeons determine the insertion point and proximal opening direction faster and more easily [46]. Robot navigation-assisted intramedullary nail treatment for humeral shaft fractures shortens surgical time [46], reduces bleeding [46], avoids more intraoperative fluoroscopy [46], and enables patients to achieve better shoulder functional outcomes [46].

Kinematics and Functional Outcomes

Shoulder function, patient satisfaction, and pain levels can be reliably improved following reverse total shoulder arthroplasty for failed open reduction and internal fixation of proximal humerus fractures [8]. Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant in reverse shoulder arthroplasty for complex shoulder fractures, provided their consolidation is anatomic [39]. Range of motion and strength thresholds can identify subjects with normal shoulder function in proximal humerus fractures [31]. Dominance of the affected shoulder has no influence on functional and quality of life outcomes compared with the nondominant shoulder in proximal humerus fractures [44], and dominance of the affected shoulder should not be used to make treatment decisions for proximal humerus fractures [44]. The authors recommend performing strength measurement at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane for the Constant score [42].

Imaging and Assessment

There is variability in the glenopolar angle with increased AP rotational offset of the shoulder radiograph [47]. Increased AP rotational offset of the shoulder radiograph reveals inaccuracies in the assessment of scapular radiographs even at an institution with an established protocol [47]. Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique in clavicle nonunion and malunion management [45].

Classification

AO/OTA: The AO/OTA classification system is utilized for describing proximal humeral fractures, with specific evidence supporting its application to OTA/AO type 11C1.1 and 11C3.1 fractures [83]. Fixation of these fracture types using locking plates or intramedullary nails yields similar satisfactory functional results and no significant difference in complication numbers [83]. Additionally, distal AO/OTA C-type distal humerus fractures in older adults can be treated reliably with good outcomes using ORIF with modern locking plates [10].

HGLS: The Humerus Glenoid Locking Screw (HGLS) classification is a reliable method for describing fractures of the proximal humerus compared with the Neer and AO systems [79].

Neer: The Neer fracture classification differentiates function in patients undergoing locked plating of unstable proximal humeral fractures [82].

Other Considerations: Locking plate fixation of proximal humerus fractures in patients older than 60 years is associated with a 44% complication rate and a 34% failure rate [1]. Conversely, ORIF of nonosteoporotic proximal humeral fractures with locking plates leads to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. Fixation with locking plates or locking intramedullary nails produces similar clinical and radiologic results, with one-year outcomes for nail versus plate fixation of three-part fractures being similar [3, 6]. The locking plate is an excellent device for managing displaced unstable proximal humeral fractures and expands the indications for ORIF [7]. Primary ORIF is supported for medically fit patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus in centers with requisite expertise [4]. Using the Locking Proximal Humerus Plate for treatment of proximal humeral fractures of all types is reliable with good results when careful planning and familiarity with the operative technique are present [19]. Failure of the calcar screw to purchase both the proximal and distal fragments is associated with a significantly higher rate of fixation failure in the surgical treatment of proximal humeral fractures using a locking plate [16]. There are no level 1 studies in the English language literature comparing ORIF with hemiarthroplasty for proximal humeral fractures [17]. With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients, and improvement in function continues until 1 year postoperatively [82]. However, polytrauma patients perform worse clinically than other patients undergoing locked plating of unstable proximal humeral fractures [82].

Clinical Presentation

Patient Selection and Indications: Primary ORIF is supported for medically fit patients presenting with severely displaced fractures or fracture-dislocations of the proximal humerus in centers possessing the requisite expertise [4]. In young, active patients with delayed presentation of complex fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head despite avascular necrosis risks, as conservative management yields poor functional outcomes [9]. For elderly patients with displaced two-part surgical neck fractures, locking plates offer an acceptable complication rate and functional outcome [11]. Percutaneous treatment of selected fractures results in predictable union and good clinical results with low complication rates [5].

Outcomes and Complication Profiles: ORIF using locking plates in patients over 60 years resulted in a 44% complication and 34% failure rate [1]. Conversely, ORIF for nonosteoporotic fractures demonstrates favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. Patients undergoing ORIF for fracture-dislocations achieve reasonable functional outcomes but face relatively high rates of avascular necrosis and reoperation [14]. Operative treatment, particularly ORIF, is an independent risk factor for inpatient adverse events and mortality in older-aged patients with isolated proximal humerus fractures [12]. Surgical fixation generally maintains a low complication and mortality profile [55].

Implant Selection and Comparative Efficacy: Fixation with locking plates or locking intramedullary nails produces similar clinical and radiologic results [6]. The similar one-year outcomes for nail versus plate fixation in three-part fractures suggest both techniques are useful for internal fixation [3]. The locking plate is an excellent device for displaced unstable fractures, expanding ORIF indications [7]. Locking plate fixation provides a good option for the majority of unstable proximal humeral fractures with good functional outcomes [24]. Symptomatic patients after locked plate osteosynthesis show statistically significant improvement of the Constant score after implant removal [21].

Prognostic Factors and Timing: Timing of surgery does not impact outcomes for patients undergoing ORIF [22]. Factors associated with poor results after internal fixation of three-part and four-part fracture-dislocations include female sex, four-part fracture dislocation, and absence of metaphyseal head extension [64]. Most pediatric patients experience favorable results with infrequent complications [61]. A majority of patients with proximal humeral fractures undergo non-operative treatment [20].

Investigations

Plain radiography: Standard imaging is the primary modality for initial assessment, though the inherent nature of medial comminution may lead to inferior radiographic outcomes [76]. Intraoperative 3D imaging with a 160° orbital rotation yields sufficient image quality to enable the reliable identification of intra-articular screws during plate osteosynthesis of the proximal humerus [92].

Other Considerations: Pre-operative planning and prognostic factors are critical for decision-making. Locking plate fixation in patients older than 60 years is associated with a 44% complication rate and a 34% failure rate [1]. Conversely, ORIF of nonosteoporotic fractures with locking plates leads to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. Fixation with locking plates or locking intramedullary nails produces similar clinical and radiologic results [6], and one-year outcomes for nail versus plate fixation in three-part fractures are similar, suggesting both techniques may be useful [3]. Primary ORIF is supported for medically fit patients with severely displaced fractures or fracture-dislocations in centers with requisite expertise [4]. Percutaneous treatment of selected fractures results in predictable union and good clinical results with a low complication rate [5]. In young, active patients with delayed presentation of complex fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head despite the risk of avascular necrosis [9]. Technical failure is a specific concern; failure of the calcar screw to purchase both the proximal and distal fragments is associated with a significantly higher rate of fixation failure when using a locking plate [16]. Additionally, bone mineral density changes appear swiftly in the proximal humerus after treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis [91].

Treatment

Non-Operative

Nonsurgical management remains a primary option, with union rates exceeding 90% and successful outcomes demonstrated in the majority of patients [60, 73]. A majority of patients with proximal humeral fractures undergo non-operative treatment, and nonsurgical management rates have decreased during recent study periods [20, 69]. Treatment duration does not significantly impact outcomes, as short and long periods of immobilization yield similar results for nonoperatively treated fractures independent of the fracture pattern [63]. However, a 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 [59]. Consequently, nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures [72].

Operative

Indications: Primary ORIF is supported for medically fit patients presenting with severely displaced fractures or fracture-dislocations of the proximal humerus in centers possessing the requisite expertise [4]. The locking plate is an excellent device for displaced, unstable proximal humeral fractures, expanding the indications for ORIF [7]. For elderly patients with a displaced 2-part fracture of the surgical neck, locking plates appear to be a good alternative provided rigorous attention is paid to avoid screw penetration [11]. In cases of complex distal humeral fractures not amenable to stable fixation in elderly patients, total elbow arthroplasty (TEA) is a preferred alternative to ORIF [58]. Immediate rigid fixation is necessary to achieve consistently good pain relief in metastatic disease of the humerus, with surgical options including intramedullary nails, plates, or prosthetic arthroplasty [65]. Internal stabilization of impending pathologic fractures before completion is reasonable in the absence of conflicting goals or contraindications [75].

Surgical Approach / Technique: The modified anterolateral approach combined with an intra-osseous portal is safe and effective for minimally invasive reduction and plating of three-part proximal humeral fractures [53]. An anterior approach allows supine positioning and yields union and complication rates comparable to a posterior approach with plate fixation for humeral shaft fractures [54]. The Humerus Block technique is a predictable, minimally invasive, percutaneous operative method that results in excellent pain relief, mobility, and pull force with a low incidence of avascular necrosis [78]. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low complication rate [5]. For unstable medial column fractures, the combined application of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation is effective in maintaining reduction and preventing varus collapse [56].

Implant Selection: Fixation with locking plates or locking intramedullary nails produces similar clinical and radiologic results [6]. However, the intramedullary nail is superior to the locking plate regarding total complication rates, intraoperative blood loss, operative time, postoperative fracture healing time, and the rate of humeral head necrosis [13]. Using the Locking Proximal Humerus Plate for all fracture types is a reliable procedure with good results obtained through careful planning and familiarity with the technique [19]. Modern proximal humeral nail designs demonstrate promising outcomes and can provide stable fixation [70]. The long PHILOS plate fixation provides reliable secure fixation for complex fractures, including long segment periarticular, segmental, periprosthetic, and pathological fractures [71]. Double plate fixation combined with autogenous iliac crest bone grafting results in successful salvage of humeral shaft nonunion after prior failed interventions [15]. Dual plating is indicated for old ununited fractures where intramedullary nailing is difficult but is contraindicated in severely comminuted fractures requiring extensive dissection [68].

Alignment / Balancing Strategy: Failure of the calcar screw to purchase both the proximal and distal fragments was associated with a significantly higher rate of fixation failure in the surgical treatment of proximal humeral fractures using a locking plate [16].

Pain Management: The most important risk factors for postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity [80].

Setting of Care: Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus [12].

Revision: Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques [18]. ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. Early results with locked plate fixation have been encouraging, providing a potentially viable alternative to prosthetic replacement [23]. ORIF of proximal humerus fractures with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate [1]. The similar 1-year outcomes for nail versus plate fixation of three-part proximal humeral fractures suggest that both techniques may be useful for internal fixation of these fractures [3].

Complications

Infection (PJI): Acute deep infection following ORIF of proximal humeral fractures is a devastating complication characterized by high complication rates, poor functional outcomes, and a notably high nonunion rate [93].

Implant Failure and Revision: ORIF of proximal humerus fractures with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate [1]. While fixation in elderly patients using locked plates with or without cement augmentation shows no significant difference in revision rates, implant failure and total complication rates may be lower with cement-augmented locked plates compared to locked plates alone [96]. ORIF of proximal humerus fracture dislocations carries a high rate of reoperation [27].

Nerve Palsy and Head Necrosis: The intramedullary nail is superior to the locking plate in reducing the rate of postoperative humeral head necrosis [13].

Wound Complications and General Morbidity: Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus [12]. The risk of short-term complications is highest in patients undergoing surgery for a fracture compared with nonfracture indications [101]. Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [103].

Other Considerations: ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. The similar 1-year outcomes for nail versus plate fixation of three-part proximal humeral fractures suggest that both techniques may be useful for internal fixation of these fractures [3]. The intramedullary nail is superior to the locking plate in reducing total complication, intraoperative blood loss, operative time, and postoperative fracture healing time [13]. The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years [97]. 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 [98]. Complications are not uncommon in shoulder arthrodesis, including nonunion, malunion, fracture, and infection [107].

Recovery

Light activity (weeks): Patients may resume desk work, driving, and light activities of daily living (ADLs) following early active motion rehabilitation protocols, which are not inferior to restrictive treatment after 24 months [38]. Early mobilization is facilitated by intramedullary nails providing high primary stability even in osteoporotic bone [50], and external fixation in paediatric cases allows for immediate limb mobilization [62]. The locked plate may also support earlier pain-free rehabilitation [66].

Full activity (months): Patients treated with early range of motion exercises largely return to baseline functional status by 1 year [51]. Continuous passive motion (CPM) increases range of motion in the first 6 weeks after plate osteosynthesis, though this effect is not sustained at 3 or 12 months [52].

Complete recovery / outcome plateau (months): Functional outcomes, including shoulder function, patient satisfaction, and pain levels, stabilize with no relevant decline compared to 1-year results at 10 years post-locked plating [67]. Similarly, favorable functional and radiologic outcomes are maintained at a minimum of 10 years for nonosteoporotic fractures treated with locking plates [2].

Rehabilitation protocol: Early active motion rehabilitation is supported as a viable alternative to restrictive protocols following locking plate fixation [38]. Intramedullary stabilization with an angular and sliding stable antegrade locking nail allows for immediate postoperative mobilization [50]. Timing of surgery does not impact outcomes, even with delays beyond 5 days [22].

Functional milestones: Symptomatic patients after locked plate osteosynthesis show statistically significant improvement in the Constant score following implant removal [21]. In young, active patients with delayed complex fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head despite avascular necrosis risks, as conservative management yields poor functional outcomes [9]. Shoulder function, satisfaction, and pain levels reliably improve following reverse total shoulder arthroplasty for failed ORIF [8].

Other Considerations: ORIF with locking plates in patients aged >60 years results in a 44% complication and 34% failure rate [1]. Conversely, primary ORIF is supported for medically fit patients with severely displaced fractures or fracture-dislocations in centers with appropriate expertise [4]. Percutaneous treatment of selected fractures yields predictable union and good clinical results with low complication rates [5]. The intramedullary nail is superior to locking plates regarding total complications, intraoperative blood loss, operative time, postoperative healing time, and humeral head necrosis rates [13]. Patients with proximal humerus fracture dislocations undergoing ORIF have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [14]. ORIF of fracture dislocations specifically carries a high rate of reoperation [27]. Double plate fixation with autogenous iliac crest bone grafting successfully salvages humeral shaft nonunion after prior failed interventions [15].

Key Evidence

  • [L4] ORIF of proximal humerus fractures with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. (10.1016/j.jse.2019.11.026)
  • [L3] ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. (10.1097/corr.0000000000002895)
  • [L2] The similar 1-year outcomes for nail versus plate fixation of three-part proximal humeral fractures suggest that both techniques may be useful for internal fixation of these fractures. (10.1007/s11999-011-2056-y)
  • [L4] Our results support the use of primary ORIF in medically fit patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus in centers where the expertise to carry out such treatment exists. (10.2106/jbjs.19.00595)
  • [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. (10.1016/j.jse.2006.09.006)
  • [L1] Fixation of proximal humeral fractures with locking plates or locking intramedullary nails produces similar clinical and radiologic results. (10.1016/j.jse.2016.02.003)
  • [L2] The locking plate is an excellent device in the management of displaced unstable proximal humeral fractures and is expanding the indications for ORIF in these fractures. (10.1016/j.jse.2009.08.008)
  • [L4] Shoulder function, patient satisfaction, and pain levels can be reliably improved. (10.1016/j.jse.2016.05.020)
  • [L4] In young, active patients with delayed presentation of complex proximal humeral fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head, despite the risk of avascular necrosis, as conservative management yields poor functional outcomes. (10.1016/j.jse.2007.12.012)
  • [L3] Distal AO/OTA C-type distal humerus fractures in older adults can be treated reliably and with good outcomes with ORIF using modern locking plates. (10.1186/s12891-022-05431-5)
  • [L4] Locking plates appear to be a good treatment alternative in elderly patients with a displaced 2-part fracture of the surgical neck of the proximal humerus with an acceptable complication rate and an acceptable functional outcome; however, rigorous attention has to be paid to avoid screw penetration. (10.1016/j.jse.2009.11.046)
  • [L3] Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously. (10.1016/j.jse.2013.09.006)
  • [L1] The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. (10.1186/s13018-019-1345-0)
  • [L4] Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. (10.1016/j.jse.2022.04.018)
  • [L4] Double plate fixation combined with autogenous iliac crest bone grafting results in successful salvage of humeral shaft nonunion after prior failed surgical interventions. (10.1186/s12891-020-03743-y)
  • [L3] Failure of the calcar screw to purchase both the proximal and distal fragments was associated with a significantly higher rate of failure of fixation in the surgical treatment of proximal humeral fractures using a locking plate. (10.1302/0301-620x.107b9.bjj-2024-1649.r1)
  • [L5] There are no level 1 studies in the English language literature comparing ORIF with hemiarthroplasty for proximal humeral fractures. (10.1016/j.jhsa.2010.07.019)
  • [L4] Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques. (10.5435/jaaos-d-18-00360)
  • [L2] Using the Locking Proximal Humerus Plate for treatment of proximal humeral fractures of all types is a reliable procedure, with good results being obtained with careful planning and familiarity with the special features of the operative technique. (10.1097/01.blo.0000137554.91189.a9)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
  • [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)
  • [L3] Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures. (10.1016/j.jse.2025.02.019)
  • [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] Locking plate fixation appears to provide a good option for the majority of patients with unstable proximal humeral fractures, with good functional outcomes. (10.1016/j.jse.2006.06.006)
  • [L4] ORIF of proximal humerus fracture dislocations carries a high rate of reoperation. (10.1016/j.jse.2021.01.025)
  • [L5] Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. (10.1016/j.jse.2019.07.022)
  • [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. (10.1016/j.jse.2010.06.005)
  • [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. (10.1016/j.jse.2007.06.017)
  • [L4] The biomechanical literature was found to be both diverse and heterogeneous. (10.1186/s12891-015-0627-x)
  • [L3] It is a minimally invasive procedure that provides adequate fracture stability and permits early shoulder motion, with satisfactory functional and radiologic outcomes and fewer complications. (10.1186/s12891-025-08600-4)
  • [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)
  • [L3] Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic. (10.1016/j.jse.2012.03.011)
  • [L3] The authors recommend performing the measurement at the insertion of the deltoid muscle in a 90° abduction position in the scapula plane. (10.1186/s12891-019-2795-6)
  • [L3] Dominance of the affected shoulder has no influence and should not be used to make treatment decisions. (10.1016/j.jse.2014.10.006)
  • [L5] Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique. (10.1016/j.jse.2013.01.022)
  • [L3] It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes. (10.1186/s12891-024-07848-6)
  • [L4] The study demonstrates variability in the glenopolar angle with increased AP rotational offset of the shoulder radiograph, revealing inaccuracies even at an institution with an established protocol. (10.1302/0301-620x.95b8.30631)
  • [L5] Findings suggest that despite the SB construct having superior interface contact immediately after fixation, the DR construct offered better contact performance at all abduction angles with applied force. (10.1186/s12891-019-2412-8)
  • [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)
  • [L4] Intramedullary stabilization of proximal humeral fractures with an angular and sliding stable antegrade locking nail represents a minimally invasive procedure that provides a high degree of primary stability even in osteoporotic bone and allows for immediate postoperative mobilization. (10.2106/00004623-200300004-00019)
  • [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)
  • [L1] The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery, but this effect is not sustained after 3 and 12 months. (10.1186/s13018-024-04804-x)
  • [L3] The use of the modified anterolateral approach and intra-osseous portal is safe and effective for minimally invasive reduction and plating treatment for three-part proximal humeral fractures. (10.1186/s13018-017-0701-1)
  • [L3] An anterior approach allows supine positioning of the patient and yields union and complication rates comparable to those of a posterior approach with plate fixation for the treatment of humeral shaft fractures. (10.1186/s12891-019-2888-2)
  • [L4] Surgical fixation of proximal humeral fractures has a low complication and mortality profile. (10.2106/jbjs.m.01039)
  • [L4] The combined application of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation is effective in maintaining operative reduction and preventing varus collapse and implant failure in proximal humerus fractures with an unstable medial column. (10.1186/s13018-020-02094-7)
  • [L1] TEA is a preferred alternative for ORIF in elderly patients with complex distal humeral fractures that are not amenable to stable fixation. (10.1016/j.jse.2008.06.005)
  • [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. (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)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. (10.5435/jaaos-d-14-00033)
  • [L3] External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized. (10.1186/s12891-023-07037-x)
  • [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] 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] Most patients with humeral metastases can be treated effectively with external beam irradiation, while surgical options include intramedullary nails, plates, or prosthetic arthroplasty to achieve rigid fixation and immediate function. (10.1097/01.blo.0000093052.96273.a7)
  • [L5] The locked plate may prove useful in earlier pain-free rehabilitation of proximal humeral fractures. (10.1016/j.jse.2006.03.013)
  • [L4] Ten years after locked plating of displaced proximal humeral fractures, patients show good to excellent outcomes in the majority of cases with no relevant decline compared with the shoulder function 1 year after surgery. (10.1016/j.jse.2013.11.009)
  • [L4] Dual plating is still indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection. (10.2106/00004623-196345020-00026)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
  • [L5] Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation. (10.1016/j.jse.2015.11.016)
  • [L4] The long PHILOS plate fixation provides reliable secure fixation for the treatment of complex humeral fractures, especially long segment periarticular fractures, segmental fractures involving proximal humerus and shaft, periprosthetic fractures around well-fixed humeral resurfacing prosthesis and pathological fractures. (10.1111/j.1758-5740.2010.00085.x)
  • [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. (10.1016/j.jse.2011.01.025)
  • [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. (10.2106/jbjs.l.01293)
  • [L4] Immediate rigid fixation is necessary to achieve consistently good pain relief. (10.5435/00124635-200307000-00008)
  • [L4] In the absence of conflicting goals or contraindications, internal stabilization of impending pathologic fractures before the completion of the fracture seems to be reasonable and appropriate. (10.1097/01.blo.0000093849.72468.82)
  • [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] 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] 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)
  • [L3] The most important risk factors for postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. (10.1186/s13018-019-1233-7)
  • [L4] With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1 year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. (10.1007/s11999-011-1935-6)
  • [L3] Similar satisfactory functional results can be achieved with locking plates and intramedullary nailing for OTA/AO type 11C1.1 and 11C3.1 proximal humerus fractures, with no significant difference in the number of complications between these two techniques. (10.1186/s12891-023-06567-8)
  • [L1] BMD changes appeared swiftly in the proximal humerus after treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis. (10.1016/j.jse.2022.07.008)
  • [L5] Intraoperative 3D imaging with a 160° orbital rotation yields sufficient image quality, enabling the reliable identification of intra-articular screws during plate osteosynthesis of the proximal humerus. (10.1186/s13018-026-06800-9)
  • [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)
  • [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)
  • [L4] The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. (10.1016/j.jse.2016.02.015)
  • [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)
  • [L2] The findings indicate that the risk of short-term complications is highest in patients undergoing surgery for a fracture compared with nonfracture indications. (10.1016/j.jse.2010.11.005)
  • [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. (10.1016/j.jse.2022.03.006)
  • [L5] Complications are not uncommon, including nonunion, malunion, fracture, and infection. (10.5435/jaaos-d-21-00667)

See Also

References

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[3] Similar Outcomes for Nail versus Plate Fixation of Three-part Proximal Humeral Fractures. Clinical Orthopaedics & Related Research. 2012. DOI: 10.1007/s11999-011-2056-y

[4] Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00595

[5] 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

[6] Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.02.003

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[8] Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.05.020

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[39] Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.03.011

[42] Evaluation of the Constant score: which is the method to assess the objective strength?. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2795-6

[44] Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder?. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.10.006

[45] Management of clavicle nonunion and malunion. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.022

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[47] The assessment of scapular radiographs. The Bone & Joint Journal. 2013. DOI: 10.1302/0301-620x.95b8.30631

[48] Different suture anchor fixation techniques affect contact properties in humeral greater tuberosity fracture: a biomechanical study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2412-8

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

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a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

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

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