Shoulder Fractures

Proximal humeral fractures: management of minimally displaced injuries versus surgical selection for 3- and 4-part fractures (internal fixation vs arthroplasty).

Overview

Nonoperative management of proximal humeral fractures yields considerable variation in shoulder-specific and general health outcomes at one year, with a substantial proportion of patients reporting poor perceived functional results [1]. While clinical results at one year confirm the advantage of applying a new intramedullary support nail and plate system to three- or four-part fractures in older patients [7], most randomized controlled trials on surgical management fail to incorporate patient-specific variables into their inclusion and exclusion criteria beyond age [19]. In most studies, only one or two patients experiencing an alternative outcome or lost to follow-up would alter the conclusions for the dichotomous outcomes studied [8].

Reverse total shoulder arthroplasty (RSA) serves as an effective option for severe shoulder fracture management, offering predictable results for both salvage and first-line treatment [12]. Compelling evidence supports the effectiveness and functional durability of reverse total shoulder arthroplasty (rTSA) in treating acute proximal humerus fractures in older adults [24], with literature suggesting rTSA may yield more favorable clinical outcomes than hemiarthroplasty for complex fractures [87]. However, narrow indications are required for hemiarthroplasty to achieve successful radiographic and functional results after a mean follow-up of 4.8 years for primary nonreconstructable humeral head fractures [31].

Patients undergoing reverse total shoulder arthroplasty for proximal humerus fractures experience significantly worse perioperative outcomes, higher complication rates, longer hospital stays, and higher costs compared to patients with other indications [29]. Furthermore, while outcome and complication profiles are similar between acute fracture and degenerative condition indications [88], rTSA performed for acute three- and four-part fractures yields overall worse clinical outcomes and worse active range of motion compared to elective indications [89]. Both nonoperative and operative treatments may be successful for fractures complicating total shoulder arthroplasty [17].

Anatomy & Pathophysiology

Kinematics and Biomechanics

Biomechanical properties differ between the hip and shoulder joints, likely driving epidemiological variations between osteonecrosis of the humeral head and the femoral head [34]. The Latarjet procedure, with or without a coracoid bone block, alters normal joint kinematics by shifting the humeral head apex posteriorly during external rotation [45]. In hemiarthroplasty for four-part proximal humeral fractures, inferior tuberosity placement significantly displaces glenohumeral joint forces superiorly during minimal and moderate abduction [60]. Conversely, a modified construct for knotless rotator cuff repair demonstrates improved biomechanical properties by allowing external rotation during high-load testing [72]. For three-part humeral head fractures, a construct using blocked threaded wires is biomechanically valid, permitting only micromovements insufficient to cause humeral head rotation or translation [39, 40].

Osseous Stability and Reconstruction

Constructs for distal third clavicle fractures with coracoclavicular ligament disruption provide superior biomechanical stability and may reduce complications associated with subacromial hardware [46]. A minimally invasive approach combined with a novel anatomical locking plate offers a biomechanical basis for treating scapular body fractures [76]. In patients with os acromiale undergoing reverse total shoulder arthroplasty, inferior tilting is observed in approximately one-third of shoulders [82]. For proximal humerus resection due to bone tumors, a new endoprosthesis suspension method using polypropylene monofilament knitted mesh enables excellent stability for early exercise [84]. Preoperative planning likely suffices with 2D analysis, as 3D studies often reveal differences of only 1°-2° without proven clinical impact [85]. The biomechanical literature regarding proximal humerus fracture implants remains diverse and heterogeneous [65].

Soft Tissue and Functional Thresholds

Subscapularis repair via subscapularis peel, lesser tuberosity osteotomy, and subscapularis peel techniques was biomechanically equivalent in a cadaveric arthroplasty model [79]. Range of motion and strength thresholds can identify subjects with normal shoulder function following proximal humerus fractures [55].

Classification

General Principles: Classification systems guide treatment decisions for scapular fractures [11], proximal humerus fractures [14], and fractures of the clavicle, scapula, and glenoid [15]. Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions in proximal humerus fractures [14].

Neer: The Neer classification system should continue to be used for communication regarding proximal humeral fractures [38]. The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice [43]. However, categorizing proximal humeral fractures is difficult, and reported treatment results may be inaccurate due to classification unreliability [38]. 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 [42]. In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of proximal humerus fractures in published manuscripts [54]. There remains a 50% agreement between observers on how to classify proximal humeral fractures [58]. Three-dimensionally printed models improved interobserver agreement in the classification of proximal humeral fractures using the Neer system [56].

HGLS: The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems [44].

AO/OTA: The AO/OTA scapula fracture classification system focusing on glenoid fossa involvement has proved to be sufficiently reliable and accurate when applied by experienced shoulder surgeons [61]. The 2013 newly introduced AO classification system allows reliable grading of glenoid fossa fractures with high inter- and intraobserver reliability in 84 patients using CT images [62].

Other Considerations: Most randomized controlled trials on surgical management of proximal humerus fractures lack consensus in inclusion criteria and do not include patient-specific variables beyond age [19]. A new classification system for proximal humeral fractures emphasizing qualitative aspects showed high reliability when based on a standardized imaging protocol including computed tomography scans [35].

Clinical Presentation

Proximal humeral fractures are increasingly common osteoporotic injuries driven by aging populations [14], with nondisplaced variants representing a frequent cause of functional disability and reduced patient-perceived health [47]. While most pediatric shoulder injuries, including clavicle, shoulder, and humerus trauma, are easily diagnosed and treated nonoperatively with rapid remodeling potential [10], scapular fractures often present diagnostic challenges due to frequent association with other injuries, leading to missed or delayed diagnoses [3]. Accurate clinical evaluation, imaging, and classification remain paramount for informed treatment decisions [14], with the initial step being a comprehensive clinical and radiographic examination to classify the fracture and select appropriate management [16].

Initial Assessment: The first step to successful management is the clinical and radiographic examination of the shoulder [16]. Imaging Modalities: Computed tomography scans demonstrate higher specificity than radiographs for assessing proximal humerus fracture sequelae [18]. Clinical Signs: In patients with traumatic shoulder injury and normal radiographs, the anterior bruise sign (ABS) serves as a highly sensitive and specific aid to identify occult greater tuberosity fractures [37]. Diagnostic Indications: Patients with persistent post-traumatic shoulder pain and functional limitation warrant MRI investigation to identify occult greater tuberosity fractures [6].

Management Outcomes: Nonoperative treatment of proximal humeral fractures yields considerable variation in shoulder-specific and general health outcomes at one year [1], with a substantial proportion of patients reporting poor perceived functional outcomes [1]. Conversely, undisplaced greater tuberosity fractures can be managed non-operatively with good results [6], and most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes in the vast majority of cases [21]. Complication Categories: Complications associated with proximal humerus fractures are varied, categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [4]. Terminology: There is significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [51].

Special Considerations: Fractures of the proximal humerus follow characteristic patterns [5], yet preferred management differs between shoulder and trauma surgeons for half of common presentations [36]. Pediatric clavicle, shoulder, and humerus trauma is common but often requires management strategies differing from adult protocols [48]. Regarding subacromial pain syndrome, clavicle fractures are not correlated to an increased occurrence of the condition, though the diagnosis is given 1–2 years earlier in patients with a previous clavicle fracture [22].

Investigations

Plain radiography: The initial step in managing proximal humeral fractures is a clinical and radiographic examination [16]. While scapular fractures are often associated with other injuries and prone to missed or delayed diagnosis due to difficulty in detection [3], post-injury radiographs do not alter management for extra-articular scapula body fractures managed nonsurgically [105]. For undisplaced greater tuberosity fractures, radiographs support non-operative management with good results [6]. However, radiographs may be unreliable for detecting acromial fractures following reverse total shoulder arthroplasty, often necessitating further imaging [28]. There is significant variability in displacement measurements between radiographs and CT scans in the coronal plane; nearly 30% of cases suggesting surgical treatment on radiographs are reclassified for conservative treatment based on CT findings [97]. Once clavicle fractures have healed, further radiographic imaging provides no notable information [98].

MRI: Patients with persistent post-traumatic shoulder pain and functional limitation warrant MRI investigation to identify occult greater tuberosity fractures [6]. A non-contrast shoulder MRI obtained in the community setting after non-dislocating trauma demonstrates moderate sensitivity for most intra-articular pathologies when interpreted by musculoskeletal radiologists [90]. MRI findings of a glenoid rim fracture, equivalent to a bony Bankart lesion, serve as a prognostic factor for stability and good functional outcomes after primary shoulder dislocation [102]. High-resolution imaging is critical for early orthopaedic referral and expedient surgical intervention in skeletally immature wrestlers with pectoralis major avulsion to prevent diagnostic delay [106]. Additionally, average cortical bone thickness measurements obtained from shoulder MRI correlate with DXA and effectively differentiate patients with normal versus abnormal bone mineral density [95]. An MRI showing a giant geode in poorly controlled rheumatoid arthritis should alert clinicians to suspect shoulder involvement for early investigation [107].

CT: Computed tomography scans are more specific than radiographs for assessing proximal humerus fracture sequelae [18]. Increasingly sophisticated imaging and modeling lead to slight but significant improvements in diagnostic performance characteristics and interobserver agreement regarding fracture characteristics [100]. High-resolution CT should be considered for patients with Mason II radial head fractures to appropriately indicate treatment options [104].

Other Considerations: Preoperative MRI or diagnostic arthroscopy should be recommended to evaluate glenohumeral associated injuries in distal clavicle fractures [99]. Osteotomy and realignment of a displaced lesser tuberosity fracture can successfully enhance overall shoulder function even with a delayed diagnosis exceeding one year [9]. Most pediatric shoulder injuries are easily diagnosed and treated non-operatively, with fractures remodeling rapidly [10].

Treatment

Non-Operative

Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year [1], with a substantial proportion of patients reporting poor perceived functional outcomes [1]. Despite this variability, most one-part proximal humerus fractures are amenable to non-operative treatment with positive outcomes reported in the vast majority of cases [21]. Undisplaced greater tuberosity fractures can also be managed non-operatively with good results [6], and patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult greater tuberosity fractures [6]. Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [27]. In the geriatric population, multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures have demonstrated minimal differences in functional outcomes [59], and a randomized controlled 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 [53]. 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 [71]. Many proximal humerus fractures can be successfully treated nonsurgically, and indications for surgical intervention remain controversial [93]. A majority of patients with proximal humeral fractures underwent non-operative treatment [64], and over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [68], although nonsurgical management of proximal humerus fractures decreased during the study period [70]. Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery [67].

Operative

Indications: Surgical intervention is considered when nonoperative management is insufficient or specific fracture patterns preclude conservative success. Both nonoperative and operative treatment may be successful in the treatment of fractures complicating total shoulder arthroplasty [17]. Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [13]. There is a striking discrepancy between theoretical and actual recommendations for surgery in extra-articular scapular fractures at the studied centers, indicating a need for more research to determine if patients are being undertreated or if the guidelines are too stringent [91].

Surgical Approach / Technique: Modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-part proximal humeral fractures is a minimally invasive procedure that provides adequate fracture stability and permits early shoulder motion [2]. Posterior open wedge glenoid osteotomy provides reliable results in young patients with increased glenoid retroversion and posterior shoulder instability, but due to the risk of potentially severe complications, the procedure should be reserved for experienced shoulder surgeons only [30].

Implant Selection: Reverse total shoulder arthroplasty (RSA) is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment [12]. RSA offers compelling evidence of effectiveness and functional durability in treating acute proximal humerus fractures in older adults [24]. Reverse total shoulder arthroplasty is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [26]. MIROS fixation for Neer 2 and 3-part proximal humeral fractures results in satisfactory functional and radiologic outcomes with fewer complications [2]. 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 [31]. A randomized controlled trial was designed to determine which surgical treatment option (hemiarthroplasty versus angle-stable locking compression plate osteosynthesis) provides the fastest recovery of functional capacity and better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications for three- and four-part fractures of the proximal humerus in the elderly [50]. A randomized controlled trial was designed to provide level-1 evidence on the effectiveness of primary hemiarthroplasty versus conservative treatment for comminuted fractures of the proximal humerus in the elderly [63].

Other Considerations: Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications [29]. Outcomes for patients with scapular fractures after reverse shoulder arthroplasty are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture [52]. Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture [28]. Both nonoperative and operative treatment groups had very good restoration of shoulder function and patient satisfaction at 24 months for type III and V acromioclavicular joint dislocation, and operative treatment did not lead to better outcomes compared with nonoperative treatment [49].

Complications

Infection (PJI): Infection occurs in slightly more than 1% of primary shoulder arthroplasty cases [96].

Aseptic loosening: Revision surgery occurs in approximately 1% of patients per year after the initial 2 years following primary shoulder arthroplasty, indicating that complications of shoulder arthroplasty accrue over time [96].

Instability: Posterior open wedge glenoid osteotomy provides reliable results in young patients with increased glenoid retroversion and posterior shoulder instability [30]. Due to the risk of potentially severe complications, this procedure should be reserved for experienced shoulder surgeons only [30]. Patients with seizure-related shoulder injuries report only moderate clinical results at midterm follow-up, with poor outcomes and a high percentage of unsatisfying results especially after posterior proximal humerus fracture-dislocations [23].

Periprosthetic fracture: 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 [4]. 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 [7].

Thromboembolism: Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [25]. Proximal humeral fractures confer a more than two-fold increase in mortality at 1 year (9.8%) [83], and mortality continues to increase to 28.2% at 5 years [83]. 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 [73].

Stiffness / Arthrofibrosis: Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year [1]. A substantial proportion of patients treated nonoperatively for proximal humeral fractures have poor perceived functional outcomes [1]. 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 [8].

Nerve palsy: Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus [86].

Other Considerations: Scapular fractures are often associated with other injuries and can be difficult to diagnose, leading to missed or delayed diagnoses [3]. Historically, more than 90% of scapula fractures are non- or minimally displaced [33]. Good clinical outcomes can be expected with non-operative treatment for scapula fractures, although recent literature documents that non-operative treatment does not always result in positive outcomes [33]. Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced fracture of the lesser tuberosity was successful and enhanced the overall function of the shoulder in two adolescent patients [9]. Clavicle fractures were not correlated to an increased occurrence of later diagnosis of subacromial pain syndrome (SAPS), though the diagnosis was given 1-2 years earlier for people with a previous clavicle fracture [22]. At mid-term, hook plate fixation of acute displaced lateral clavicle fractures yields excellent results with no long-term complications addressed to the use of the plate [78]. The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after trauma when midshaft clavicle fractures were treated conservatively [94]. More proximal humeral fractures were seen during winter months in earlier decades but not in recent decades [32]. This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty [20].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or driving; however, short and long periods of immobilization yield similar results for nonoperatively treated fractures, independent of the fracture pattern [27].

Full activity (months): 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 [7]. Double-plating yields good clinical mid- to long-term results in complex and highly unstable fractures [81]. Ten years after locked plating, patients show good to excellent outcomes in the majority of cases [75]. Reverse total shoulder replacement is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [26]. Long-term treatment with reverse shoulder arthroplasty for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment [69].

Complete recovery / outcome plateau (months): Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year [1]. A substantial proportion of patients have poor perceived functional outcomes following nonoperative treatment [1]. The difference in functional outcomes between reverse shoulder arthroplasty and nonoperative treatment is attributed to the deterioration of functional outcomes of the nonoperative treatment over time [69]. There is no relevant decline in shoulder function 10 years after locked plating compared with the shoulder function 1 year after surgery [75]. Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up [23]. Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [25]. Osteotomy and realignment of a displaced fracture of the lesser tuberosity was successful and enhanced the overall function of the shoulder in adolescents despite a delayed diagnosis of more than one year [9].

Rehabilitation protocol: Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type [101]. Complications associated with proximal humerus fractures can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [4].

Functional milestones: 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 [8]. This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty [20].

Key Evidence

• [L1] Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. (10.2106/jbjs.20.02018)
• [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)
• [L4] Fractures of the proximal humerus follow characteristic patterns. (10.1016/j.jse.2017.05.014)
• [L4] Undisplaced greater tuberosity fractures can be managed non-operatively with good results, but patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult fractures. (10.1186/s12891-018-2225-1)
• [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)
• [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)
• [L4] Despite a delayed diagnosis of more than one year, osteotomy and realignment of the displaced fracture of the lesser tuberosity was successful and enhanced the overall function of the shoulder in these two patients. (10.2106/00004623-199509000-00020)
• [L3] RSA is an effective option in severe shoulder fracture management with predictable results for salvage as well as first-line treatment. (10.1186/s12891-020-03903-0)
• [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)
• [L5] The first step to a successful management of PHF is the clinical and radiographic examination of the shoulder, which enables the physician to classify the fracture and choose the appropriate treatment option. (10.1016/j.jht.2017.05.005)
• [L4] Both nonoperative and operative treatment may be successful in the treatment of fractures complicating total shoulder arthroplasty. (10.1016/j.jse.2007.05.007)
• [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. (10.1177/17585732221150785)
• [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] This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty. (10.1302/0301-620x.103b6.bjj-2020-1753.r1)
• [L4] Clavicle fractures were not correlated to an increased occurrence of later diagnosis of SAPS, although the diagnosis was given 1-2 years earlier for people with a previous fracture. (10.1016/j.xrrt.2024.01.008)
• [L3] Patients with seizure-related shoulder injuries reported only moderate clinical results at their midterm follow-up. (10.1016/j.jse.2023.09.023)
• [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)
• [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. (10.1016/j.jse.2022.03.006)
• [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] 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)
• [L3] Radiographs may be unreliable for detecting acromial fractures after reverse total shoulder arthroplasty, and CT scans are often needed to identify the fracture. (10.2106/jbjs.k.01516)
• [Abstract] Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications. (10.1016/j.jse.2015.05.005)
• [L4] However, due to the risk of potentially severe complications, the procedure should be reserved for experienced shoulder surgeons only. (10.1007/s00167-018-5223-9)
• [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)
• [L4] More fractures were seen during winter months in earlier but not recent decades. (10.1186/s12891-024-07602-y)
• [L3] Despite anatomical similarities, different biomechanical properties between the hip and shoulder joints likely cause epidemiological differences between ONHH and ONFH. (10.1186/s12891-023-07022-4)
• [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] The preferred management differed between shoulder and trauma surgeons for half of the common PHF presentations, highlighting the need for future research. (10.1016/j.jse.2021.11.016)
• [L2] In patients presenting with a traumatic shoulder injury with normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify patients with an occult greater tuberosity fracture. (10.1016/j.jse.2023.07.044)
• [L5] The Neer classification system should continue to be used for communication, but clinicians must recognize that categorizing proximal humeral fractures is difficult and that reported treatment results may be inaccurate due to classification unreliability. (10.2106/00004623-199405000-00002)
• [L5] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jseint.2021.06.007)
• [Abstract] The studied construct is biomechanically valid; it only allows micromovements that are not able to cause humeral head rotation and translation. (10.1016/j.jse.2022.01.037)
• [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)
• [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] Both procedures alter normal joint kinematics by shifting the humeral head apex posteriorly in external rotation. (10.1007/s00167-015-3885-0)
• [L5] These constructs offer superior biomechanical stability in our model and potentially reduce complications associated with subacromial hardware. (10.1016/j.xrrt.2025.100645)
• [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)
• [L1] Both the nonoperative and operative treatment groups had very good restoration of shoulder function and patient satisfaction at 24 months, and operative treatment did not lead to better outcomes compared with nonoperative treatment. (10.1016/j.jse.2021.12.003)
• [L1] This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity and better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications. (10.1186/1471-2474-13-16)
• [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] Although nonsurgical and surgical treatment improves clinical outcomes from the patient's preoperative state, outcomes for patients with fractures are generally inferior to those of a control group undergoing reverse shoulder arthroplasty without fracture. (10.5435/jaaos-d-20-01205)
• [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)
• [L2] In more than one-third of cases, specialized shoulder surgeons disagree with article authors when interpreting the Neer classification of de-identified images of proximal humerus fractures in published manuscripts. (10.1016/j.jseint.2022.02.006)
• [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. (10.1016/j.jse.2010.06.005)
• [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)
• [L5] At present, there remains a 50% agreement between observers on how to classify proximal humeral fractures. (10.1111/sae.12013)
• [L5] Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes. (10.2106/jbjs.20.00665)
• [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. (10.1016/j.jse.2007.06.017)
• [L2] This new system for scapular glenoid fractures has proved to be sufficiently reliable and accurate when applied by experienced shoulder surgeons. (10.1016/j.jse.2012.08.003)
• [L4] The 2013 newly introduced AO classification system allows reliable grading of glenoid fossa fractures with high inter- and intraobserver reliability in 84 patients using CT images. (10.1186/s12891-018-2016-8)
• [L1] This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly. (10.1186/1471-2474-11-97)
• [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
• [L4] The biomechanical literature was found to be both diverse and heterogeneous. (10.1186/s12891-015-0627-x)
• [L4] Nonoperative management of distal humerus fractures in the elderly seems to be associated with acceptable functional outcomes and low rates of delayed surgery. (10.1016/j.xrrt.2021.10.001)
• [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] Long-term treatment with RSA for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time. (10.1016/j.jse.2024.09.032)
• [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
• [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)
• [L5] The modified construct shows improved biomechanical properties when allowing for external rotation during high-load testing. (10.1016/j.arthro.2010.11.006)
• [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)
• [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)
• [L5] The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures. (10.1186/s13018-024-04905-7)
• [L4] At mid term the results are excellent and no long term complications can be addressed to the use of the plate. (10.1186/1749-799x-7-2)
• [L5] In this cadaveric model, subscapularis repair via ST, SP, and LTO techniques was biomechanically equivalent. (10.1186/s13018-019-1372-x)
• [Abstract] Double-plating of proximal humeral fractures yields good clinical mid- to long-term results in complex and highly unstable fractures. (10.1016/j.jse.2022.01.036)
• [L4] Inferior tilting is observed in approximately one-third of the shoulders after RTSA and does not seem to change the overall outcome of the procedure. (10.1016/j.jse.2017.02.012)
• [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] Excellent stability of our new method enables exercise of the surgical shoulder at an early stage, leading to improved range of shoulder joint motion. (10.1016/j.jse.2014.10.011)
• [L5] The author argues that 2D analysis likely suffices for preoperative planning of shoulder anatomy and that 3D studies often show differences of only 1°-2° without proven clinical impact. (10.1016/j.jse.2018.01.011)
• [L3] Injuries to the upper extremities seem to have limited effect on long-term outcome in patients with polytrauma, as long as no injury was caused to the brachial plexus. (10.1302/0301-620x.99b2.37999)
• [L1] The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication. (10.1016/j.jse.2015.08.030)
• [L3] Outcome and complication profiles are similar between patients undergoing RTSA for acute fracture and those indicated for the treatment of degenerative conditions of the shoulder. (10.1016/j.jse.2020.03.053)
• [L1] RTSA performed for acute 3- and 4-part proximal humeral fractures yields overall worse clinical outcomes and active ROM compared with RTSA performed for elective indications. (10.1016/j.jse.2021.07.014)
• [L4] A non-contrast shoulder MRI obtained in the community setting after non-dislocating shoulder trauma has a moderate sensitivity for most intraarticular pathologies when interpreted by musculoskeletal radiologists. (10.1007/s00167-014-3102-6)
• [L4] There is a striking discrepancy between theoretical and actual recommendations for surgery in extra-articular scapular fractures at the studied centers, indicating a need for more research to determine if patients are being undertreated or if the guidelines are too stringent. (10.1177/1758573215578587)
• [L4] The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. (10.1186/s13018-023-04450-9)
• [L3] Average cortical bone thickness measurements obtained from shoulder MRI are correlated with DXA and appear effective in differentiating patients with normal and abnormal BMD, potentially guiding further diagnostic assessments. (10.1177/17585732241279090)
• [L5] Complications of shoulder arthroplasty accrue over time, with infection occurring in slightly more than 1% of primary cases and revision surgery occurring in approximately 1% of patients per year after the initial 2 years. (10.1016/j.jse.2018.01.025)
• [L3] There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane, with nearly 30% of cases suggesting surgical treatment on radiographs being reclassified for conservative treatment based on CT findings. (10.1016/j.jse.2016.05.016)
• [L3] Once clavicle fractures are healed, further radiographic imaging does not provide any notable information. (10.5435/jaaos-d-17-00598)
• [L1] Preoperative MRI or diagnostic arthroscopy to evaluate glenohumeral associated injuries to distal clavicle fractures should be recommended. (10.1186/s13018-022-02919-7)
• [L1] Increasingly sophisticated imaging and modeling leads to slight but significant improvements in diagnostic performance characteristics and interobserver agreement on fracture characteristics. (10.1016/j.jse.2012.01.009)
• [L1] Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type. (10.1302/0301-620x.102b1.bjj-2020-0546.r1)
• [L3] MRI findings of a glenoid rim fracture, equal to a bony Bankart lesion, were found to be a prognostic factor for stability and a good functional outcome. (10.1007/s00167-009-0998-3)
• [L3] High-resolution CT should be considered for patients with Mason II radial head fractures to appropriately indicate treatment options. (10.1016/j.jseint.2021.04.012)
• [L4] Postinjury radiographs did not change management in any cases of extra-articular scapula body fractures managed nonsurgically. (10.5435/jaaos-d-19-00553)
• [L4] Early orthopaedic referral and early MRI may help prevent delay in diagnosis and allow expedient surgical intervention in appropriate candidates. (10.1177/0363546509351559)
• [Case_report] An impressive MRI image showing a giant geode in poorly controlled RA should alert rheumatologists to raise suspicion of shoulder involvement for early investigation and treatment. (10.1186/s12891-023-06695-1)

See Also

• Fractures
• Total shoulder arthroplasty
• Shoulder Arthroplasty
• Latarjet Procedure
• Rotator cuff repair
• Os Acromiale
• Proximal Humerus Fracture
• Clavicle Fracture
• Shoulder Instability
• Reverse Shoulder Arthroplasty

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[87] Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.08.030

[88] Does reverse total shoulder arthroplasty for proximal humeral fracture portend poorer outcomes than for elective indications?. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.03.053

[89] Clinical outcomes of reverse total shoulder arthroplasty for elective indications versus acute 3- and 4-part proximal humeral fractures: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.07.014

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[91] Extra-articular scapular fractures: comparison of theoretical and actual treatment. Shoulder & Elbow. 2015. DOI: 10.1177/1758573215578587

[93] Chapter 24 Proximal Humerus Fracture. 2021.

[94] Long-term conservative treatment outcomes for midshaft clavicle fractures: a 10-to-30-year follow-up. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04450-9

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[104] Radiographic evaluation of partial articular radial head fractures: assessment of reliability. JSES International. 2021. DOI: 10.1016/j.jseint.2021.04.012

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