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Shoulder Arthroplasty for Acute Proximal Humerus Fracture PDF Evidence

Illustration of a person resting with the arm supported in a sling.
Treatment of a complex shoulder fracture with a replacement. Kieran Hirpara 4.0

What you're feeling

You likely have deep pain in the top of your shoulder where the bone broke. This pain often feels worse when you try to move your arm or lift anything heavy. You might notice the pain flares up at night, making it hard to fall asleep or stay asleep. Many patients find they cannot lie on the injured side at all. Even simple movements like reaching for a cup on a high shelf can trigger a sharp ache.

Daily tasks that used to be easy now feel difficult or impossible. You may struggle to reach behind your back to fasten a bra or tuck in your shirt. Washing your hair or combing your hair becomes a challenge because you cannot lift your arm high enough. If you try to carry groceries or push a door open, the pain in your shoulder will likely increase quickly. Your surgeon may tell you that while pain relief is often good, how well your shoulder moves again is less predictable.

The way your shoulder feels depends on how the bones heal. In older patients, if the bone fragments heal in the right position, you will likely feel better and move more easily. However, if the bones do not heal well, you might continue to feel weak or have limited motion. Some patients who do not have surgery find their shoulder function remains poor for a long time. You should expect that recovery takes time, and your surgeon will guide you through the process to help you get back to your normal life.

What's actually happening

Your shoulder is a ball-and-socket joint wrapped in a sleeve called the joint capsule. The bone ends are covered in smooth cartilage, which acts like a shock absorber so the bones glide easily. When you break the top of your arm bone, this smooth surface is often damaged. The broken pieces can shift out of place, changing how the joint moves. Even a small shift of 15 degrees can alter how your shoulder works.

The broken bone pieces are held together by strong ropes of tendon called tuberosities. These ropes attach to the shoulder muscles that lift and rotate your arm. If these ropes do not heal in the correct spot, your surgeon cannot restore normal movement. Your shoulder may still feel pain-free, but lifting your arm or turning it outward will be difficult. The broken bone fragments can also push upward against the socket, causing friction and pain.

For older patients, this injury is often severe. The bone is fragile, and the tissues are weak. Without surgery, the shoulder may not heal well, leading to more pain and less movement. A joint replacement can provide long-term pain relief. However, the ability to move your shoulder fully is less predictable than the pain relief you will get. The goal is to rebuild the joint so you can use your arm again, even if the movement is not perfect.

What we can do about it

Most people with a broken shoulder bone start with non-surgical care. You will rest the arm and use a sling for a short or long period, as both give similar results. Your physiotherapist will guide you through gentle movements to restore motion. While many elderly patients recover well this way, some experience poor function or pain after one year. If you have a bruise on the front of your shoulder, it may signal a hidden fracture that needs an MRI scan to find.

Your surgeon may prescribe pain medication and anti-inflammatories to help you sleep and move comfortably. For some, an injection of cortisone or hyaluronic acid can reduce swelling and pain for a few months. Platelet-rich plasma injections are also an option to support healing. If you have a hidden fracture that was missed, surgery to realign the bone can still work even if the injury happened over a year ago. These medical steps aim to manage pain while your body heals the broken bone, which usually joins back together successfully in more than 90% of cases treated without surgery.

Surgery is considered when non-surgical care fails or if the fracture is too complex to heal on its own. Your surgeon may recommend a shoulder replacement or a plate and nail system to stabilize the bone. This is often chosen for older patients with severe fractures to improve long-term function and reduce the risk of complications compared to waiting. The goal is to restore your shoulder to pre-injury levels so you can return to daily activities.

When to see someone

See your GP if you have persistent pain that does not improve with rest, or if you feel weakness and instability in your shoulder. Ask for a specialist review if your shoulder locks, gives way, or if symptoms interfere with your sleep or work. Contact your surgeon immediately if you notice a sudden worsening of symptoms. While most elderly patients can be treated without surgery, those with complex fractures may need joint replacement to avoid poor long-term results. Be aware that the risk of death is higher for one year after this injury compared to the general population, so report any new medical issues promptly.

Reviewed by Dr Kieran Hirpara · 2026-06-10 20:08:52.013898+00:00.

Want the clinical detail? Read the clinician version.

Talk to your treating clinician for advice specific to you.

For an appointment with the CQ Hand + Upper Limb team, ask your GP about a referral or visit www.cqupperlimb.com.

Evidence & references

title: "Shoulder Arthroplasty for Acute Proximal Humerus Fracture" slug: proximal-humerus-arthroplasty region: shoulder audience: patient mesh_terms: ["Shoulder Fractures"] article_count: 733 model_used: qwen3.5-35b-a3b-q8 generated_at: '2026-05-18T14:19:37+00:00' key_articles: - title: "Shoulder hemiarthroplasty for acute fractures of the proximal humerus: A minimum five-year follow-up" ref_num: 1 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2007.06.025 year: 2008 - title: "How the greater tuberosity affects clinical outcomes after reverse shoulder arthroplasty for proximal humeral fractures" ref_num: 2 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2018.05.030 year: 2018 - title: "Technique and clinical results of a new intramedullary support nail and plate system for fixation of 3- or 4- part proximal humeral fractures in older adults" ref_num: 3 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-022-05998-z year: 2022 - title: "Mortality after inpatient stay for proximal humeral fractures" ref_num: 4 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2019.05.030 year: 2020 - title: "Minimum 2-year outcomes of reverse total shoulder arthroplasty for fracture: how does acute arthroplasty compare with salvage?" ref_num: 5 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2021.06.020 year: 2022 - title: "Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures" ref_num: 6 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2012.03.006 year: 2013 - title: "Fracture line morphology of complex proximal humeral fractures" ref_num: 7 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2017.05.014 year: 2017 - title: "Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty" ref_num: 8 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2012.03.011 year: 2013 - title: "Ten-year follow-up of stemmed hemiarthroplasty for acute proximal humeral fractures" ref_num: 9 evidence_tier: paper evidence_level: 3 doi: 10.1302/0301-620x.103b6.bjj-2020-1753.r1 year: 2021 - title: "Readmissions, revisions, and mortality after treatment for proximal humeral fractures in three large states" ref_num: 10 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-019-2812-9 year: 2019 - title: "Consensus statement on the treatment of proximal humerus fractures: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons" ref_num: 11 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2024.12.005 year: 2025 - title: "Complications after non-surgical management of proximal humeral fractures: a systematic review of terms and definitions" ref_num: 12 evidence_tier: paper evidence_level: 1 doi: 10.1186/s12891-019-2459-6 year: 2019 - title: "Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults" ref_num: 13 evidence_tier: paper evidence_level: 1 doi: 10.2106/jbjs.20.02018 year: 2021 - title: "Comparison of Hemiarthroplasty and Reverse Arthroplasty for Treatment of Proximal Humeral Fractures" ref_num: 14 evidence_tier: paper evidence_level: 2 doi: 10.2106/jbjs.l.01115 year: 2013 - title: "Morbidity and mortality of fragility proximal humerus fractures: a retrospective cohort study of patients presenting to a level one trauma center" ref_num: 15 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2022.03.006 year: 2022 - title: "Fragility of randomized controlled trials on treatment of proximal humeral fracture" ref_num: 16 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2022.01.141 year: 2022 - title: "Isolated avulsion fracture of the lesser tuberosity of the humerus in adolescents. A report of two cases." ref_num: 17 evidence_tier: paper evidence_level: 4 doi: 10.2106/00004623-199509000-00020 year: 1995 - title: "Hospital Readmissions After Surgical Treatment of Proximal Humerus Fractures: Is Arthroplasty Safer Than Open Reduction Internal Fixation?" ref_num: 19 evidence_tier: paper evidence_level: 3 doi: 10.1007/s11999-014-3613-y year: 2014 - title: "One Versus 3-Week Immobilization Period for Nonoperatively Treated Proximal Humeral Fractures" ref_num: 20 evidence_tier: paper evidence_level: 2 doi: 10.2106/jbjs.20.02137 year: 2021 - title: "In-hospital Complications Are More Likely to Occur After Reverse Shoulder Arthroplasty Than After Locked Plating for Proximal Humeral Fractures" ref_num: 21 evidence_tier: paper evidence_level: 3 doi: 10.1097/corr.0000000000001776 year: 2021 - title: "A new clinical sign to detect radiologically occult greater tuberosity fractures" ref_num: 22 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2023.07.044 year: 2024 - title: "Proximal Humeral Fracture Treatment in Adults" ref_num: 23 evidence_tier: paper evidence_level: 5 doi: 10.2106/jbjs.l.01293 year: 2014 - title: "Proximal Humeral Fractures: “Damned If You Operate, and Damned If You Don’t”" ref_num: 24 evidence_tier: paper evidence_level: 5 doi: 10.2106/jbjs.19.01109 year: 2019 - title: "Mortality after a proximal humeral fracture" ref_num: 25 evidence_tier: paper evidence_level: 3 doi: 10.1302/0301-620x.102b11.bjj-2020-0627.r1 year: 2020 - title: "Hemiarthroplasty versus reverse shoulder arthroplasty for treatment of proximal humeral fractures: a meta-analysis" ref_num: 26 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2015.08.030 year: 2016 - title: "Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database" ref_num: 27 evidence_tier: paper evidence_level: 3 doi: 10.1097/corr.0000000000002391 year: 2022 - title: "The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis" ref_num: 28 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2019.07.022 year: 2020 - title: "Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures" ref_num: 29 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2010.06.005 year: 2011 - title: "Neer Award 2006: Biomechanical assessment of inferior tuberosity placement during hemiarthroplasty for four-part proximal humeral fractures" ref_num: 30 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2007.06.017 year: 2008 - title: "Evaluation of the Constant score: which is the method to assess the objective strength?" ref_num: 35 evidence_tier: paper evidence_level: 3 doi: 10.1186/s12891-019-2795-6 year: 2019 - title: "Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder?" ref_num: 37 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2014.10.006 year: 2015 - title: "The assessment of scapular radiographs" ref_num: 38 evidence_tier: paper evidence_level: 4 doi: 10.1302/0301-620x.95b8.30631 year: 2013 - title: "Altered Glenohumeral Biomechanics in Proximal Humeral Fracture Malunion" ref_num: 40 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-20-00555 year: 2020 - title: "Effects of shoulder position on axillary nerve positions during the split lateral deltoid approach" ref_num: 43 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2008.12.001 year: 2009 - title: "A morphovolumetric study of head malposition in proximal humeral fractures based on 3-dimensional computed tomography scans: the control volume theory" ref_num: 44 evidence_tier: paper evidence_level: 5 doi: 10.1016/j.jse.2017.12.004 year: 2018 - title: "Cost-Minimization Analysis and Treatment Trends of Surgical and Nonsurgical Treatment of Proximal Humerus Fractures" ref_num: 46 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jhsa.2020.03.022 year: 2020 - title: "Reverse shoulder arthroplasty or nothing for patients with displaced proximal humeral fractures: a randomized controlled trial" ref_num: 47 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2024.02.023 year: 2024 - title: "Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial" ref_num: 48 evidence_tier: paper evidence_level: 1 doi: 10.1371/journal.pmed.1002855 year: 2019 - title: "Classification of proximal humeral fractures based on a pathomorphologic analysis" ref_num: 49 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2015.08.006 year: 2016 - title: "Evaluation and Management of Pediatric Proximal Humerus Fractures" ref_num: 50 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-14-00033 year: 2015 - title: "Contemporary Management of Proximal Humeral Fractures" ref_num: 51 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-24-01073 year: 2025 - title: "Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment" ref_num: 52 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2011.01.025 year: 2011 - title: "Osteoporosis does not affect bone mineral density change in the proximal humerus or the functional outcome after open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up" ref_num: 53 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2022.07.008 year: 2023 - title: "Reverse Shoulder Arthroplasty to Treat Proximal Humerus Fracture Sequelae: A Review" ref_num: 54 evidence_tier: paper evidence_level: 5 doi: 10.5435/jaaos-d-23-00740 year: 2024 - title: "Path analysis of factors for functional outcome at one year in 463 proximal humeral fractures" ref_num: 55 evidence_tier: paper evidence_level: 2 doi: 10.1016/j.jse.2011.06.009 year: 2011 - title: "A comprehensive classification of proximal humeral fractures: HGLS system" ref_num: 56 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2012.09.018 year: 2013 - title: "CORR Insights®: What Factors Are Associated With Poor Shoulder Function and Serious Complications After Internal Fixation of Three-part and Four-part Proximal Humerus Fracture-dislocations?" ref_num: 57 evidence_tier: paper evidence_level: 5 doi: 10.1097/corr.0000000000002242 year: 2022 - title: "Four-segment classification of proximal humeral fractures revisited: A multicenter study on 509 cases" ref_num: 58 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2009.01.018 year: 2009 - title: "Outcome measures in the management of proximal humeral fractures: a systematic review of their use and psychometric properties" ref_num: 59 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2010.10.028 year: 2011 - title: "Evaluation of the Neer System of Classification of Proximal Humeral Fractures with Computerized Tomographic Scans and Plain Radiographs*" ref_num: 60 evidence_tier: paper evidence_level: 4 doi: 10.2106/00004623-199609000-00012 year: 1996 - title: "Outcomes after percutaneous reduction and fixation of proximal humeral fractures" ref_num: 62 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2006.09.006 year: 2007 - title: "Long-term outcomes of reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humerus fractures in elderly patients: results from a prior randomized clinical trial" ref_num: 63 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2024.09.032 year: 2025 - title: "Is there still a place for anatomic hemiarthroplasty in patients with high functional demands in primary, nonreconstructable proximal humeral fractures? A clinical and radiographic assessment" ref_num: 65 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2023.02.118 year: 2023 - title: "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" ref_num: 66 evidence_tier: paper evidence_level: 1 doi: 10.1016/j.jse.2021.07.014 year: 2022 - title: "Hemiarthroplasty for Humeral Four-part Fractures for Patients 65 Years and Older: A Randomized Controlled Trial" ref_num: 67 evidence_tier: paper evidence_level: 1 doi: 10.1007/s11999-012-2531-0 year: 2012 - title: "The effect of medial calcar support on proximal humeral fractures treated with locking plates" ref_num: 71 evidence_tier: paper evidence_level: 3 doi: 10.1186/s13018-022-03337-5 year: 2022 - title: "Missed fractures of the greater tuberosity" ref_num: 72 evidence_tier: paper evidence_level: 4 doi: 10.1186/s12891-018-2225-1 year: 2018 - title: "Coronal displacement in proximal humeral fractures: correlation between shoulder radiographic and computed tomography scan measurements" ref_num: 73 evidence_tier: paper evidence_level: 3 doi: 10.1016/j.jse.2016.05.016 year: 2017 - title: "CORR Insights®: 3D-printed Handheld Models Do Not Improve Recognition of Specific Characteristics and Patterns of Three-part and Four-part Proximal Humerus Fractures" ref_num: 74 evidence_tier: paper evidence_level: 5 doi: 10.1097/corr.0000000000002017 year: 2021 - title: "Detection, classification, and characterization of proximal humerus fractures on plain radiographs" ref_num: 76 evidence_tier: paper evidence_level: 3 doi: 10.1302/0301-620x.106b11.bjj-2024-0264.r1 year: 2024 - title: "Missed posterior dislocation of the shoulder after intramedullary fixation of humeral fractures: A report of three cases" ref_num: 79 evidence_tier: paper evidence_level: 4 doi: 10.1016/j.jse.2008.10.020 year: 2009 - title: "Does time to surgery affect patient-reported outcome in proximal humeral fractures? A subanalysis of the PROFHER randomized clinical trial" ref_num: 80 evidence_tier: paper evidence_level: 1 doi: 10.1302/0301-620x.102b1.bjj-2020-0546.r1 year: 2020 synthesis_version: "v2" verifier_status: skipped

Overview

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

Anatomy & Pathophysiology

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

Classification

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

Clinical Presentation

  • Patients undergoing arthroplasty for acute proximal humerus fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • In elderly patients undergoing reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [2].
  • Clinical results at 1-year follow-up confirm the advantage of applying a new intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [3].
  • Elderly patients requiring admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age [4].
  • Patients undergoing initial nonoperative management have worse functional outcomes and higher complication rates than those undergoing acute reverse total shoulder arthroplasty for proximal humeral fractures [5].
  • Fractures of the proximal humerus follow characteristic patterns [7].
  • A majority of patients with proximal humeral fractures undergo non-operative treatment [10].
  • Consensus on managing proximal humerus fractures is limited to specific scenarios, while a lack of consensus exists in others [11].
  • There is significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [12].
  • Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, with a substantial proportion of patients having poor perceived functional outcomes [13].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [15].
  • The majority of unplanned hospital readmissions after surgical treatment of proximal humerus fractures are associated with medical diagnoses [19].
  • In patients presenting with a traumatic shoulder injury and normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify occult greater tuberosity fractures [22].
  • Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [23].
  • Patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury compared with the general population [25].
  • Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [50].
  • Reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae when joint-preserving options are not optimal, provided there is careful management of the tuberosities and understanding of associated pearls and pitfalls [54].
  • Prevention of local complications, particularly those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture [55].
  • Factors associated with poor results after internal fixation of three-part and four-part proximal humerus fracture-dislocations include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension [57].
  • A wide range of outcome measures are used in proximal humeral fracture studies, but there is limited evidence regarding their psychometric properties in this specific population [59].

Investigations

  • Elderly patients requiring admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age [4].
  • A majority of patients with proximal humeral fractures undergo non-operative treatment [10].
  • Fractures of the proximal humerus follow characteristic patterns [7].
  • Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced lesser tuberosity fracture can be successful and enhance overall shoulder function [17].
  • Undisplaced greater tuberosity fractures can be managed non-operatively with good results [72].
  • Patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult greater tuberosity fractures [72].
  • In patients presenting with a traumatic shoulder injury with normal radiographs, the anterior bruise sign (ABS) is a highly sensitive and specific clinical aid to identify patients with an occult greater tuberosity fracture [22].
  • There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane [73].
  • Nearly 30% of cases suggesting surgical treatment on radiographs are reclassified for conservative treatment based on CT findings [73].
  • The inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes [71].
  • Routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities [74].
  • The routine use of 3D-printed models should be avoided as the sole determinant for recommending surgical intervention at this time [74].
  • Convolutional neural networks (CNNs) proficiently rule out proximal humerus fractures on plain radiographs [76].
  • Missed posterior dislocation of the shoulder after intramedullary fixation of proximal humeral fractures is an extremely rare injury that can be missed due to inadequate initial and postoperative x-ray images and incorrect interpretation [79].
  • Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [11].

Treatment

  • Patients undergoing shoulder hemiarthroplasty for acute proximal humerus fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • In elderly patients undergoing reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [2].
  • Clinical results at 1-year follow-up confirm the advantage of applying a new intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [3].
  • Elderly patients requiring admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age [4].
  • Patients undergoing initial nonoperative management have worse functional outcomes and higher complication rates than those undergoing acute reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures [5].
  • Patients with acute proximal humeral fractures who undergo reverse shoulder arthroplasty appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty [6].
  • Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant in complex shoulder fractures treated by reverse shoulder arthroplasty, provided their consolidation is anatomic [8].
  • A majority of patients with proximal humeral fractures underwent non-operative treatment [10].
  • Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [12].
  • Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, with a substantial proportion of patients having poor perceived functional outcomes [13].
  • Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years [14].
  • Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [20].
  • Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [23].
  • Available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication [26].
  • Nonsurgical management of proximal humerus fractures decreased during the study period [46].
  • Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture [47].
  • There is no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus [48].
  • Nonsurgical management of proximal humerus fractures demonstrates successful outcomes and union rates greater than 90% [51].
  • Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures compared to locking plate fixation [52].
  • Osteoporosis may not be regarded as a contraindication for open reduction and internal fixation of unilateral displaced 3- or 4-part fractures, as shoulder function was restored to preinjury levels for most patients at 12-month follow-up [53].
  • Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [62].
  • With narrow indications, use of a specific fracture stem and adequate tuberosity management, successful radiographic and functional results are presented after a mean follow-up of 4.8 years after hemiarthroplasty for primary nonreconstructable humeral head fractures [65].

Complications

  • Patients undergoing arthroplasty for acute proximal humeral fractures may achieve satisfactory long-term pain relief, but overall shoulder motion results are less predictable [1].
  • In elderly patients undergoing reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [2].
  • Clinical results at 1-year follow-up confirm the advantage of applying a new intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [3].
  • Elderly patients requiring admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age [4].
  • Patients undergoing initial nonoperative management have worse functional outcomes and higher complication rates than those undergoing acute reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures [5].
  • Patients with acute proximal humeral fractures who undergo reverse shoulder arthroplasty (RSA) appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty [6].
  • Fractures of the proximal humerus follow characteristic patterns [7].
  • Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years [14].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [15].
  • The majority of unplanned hospital readmissions after surgical treatment of proximal humerus fractures are associated with medical diagnoses [19].
  • In-hospital complications are more likely to occur after reverse shoulder arthroplasty than after locked plating for proximal humeral fractures [21].
  • Surgery for complex proximal humeral fractures leads to overall good long-term outcomes but is associated with high overall complication and reoperation rates [24].
  • Patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury compared with the general population [25].
  • Short-term complication rates for fixation and arthroplasty alike have decreased compared with recent historic norms [27].

Recovery

  • Patients undergoing arthroplasty for acute proximal humerus fractures may achieve satisfactory long-term pain relief, though overall shoulder motion results are less predictable [1].
  • In elderly patients undergoing reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [2].
  • Clinical results at 1-year follow-up confirm the advantage of applying a new intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [3].
  • Elderly patients requiring admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age [4].
  • Patients who undergo initial nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute reverse total shoulder arthroplasty (rTSA) for proximal humeral fractures [5].
  • Patients with acute proximal humeral fractures who undergo reverse shoulder arthroplasty appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty [6].
  • Fractures of the proximal humerus follow characteristic patterns [7].
  • This study represents the largest long-term follow-up of acute proximal humeral fractures treated with hemiarthroplasty [9].
  • Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, with a substantial proportion of patients having poor perceived functional outcomes [13].
  • Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years [14].
  • Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [15].
  • In most studies of proximal humeral fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied [16].
  • Despite a delayed diagnosis of more than one year, osteotomy and realignment of a displaced lesser tuberosity fracture was successful and enhanced overall shoulder function in two adolescent patients [17].
  • Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [20].
  • Surgery for complex proximal humeral fractures leads to overall good long-term outcomes despite high overall complication and reoperation rates [24].
  • The increasing utilization of reverse total shoulder arthroplasty (RTSA) and decreasing short-term complication rates for fixation and arthroplasty represent a substantial change compared with recent historic norms in the management of proximal humerus fractures [27].
  • Long-term treatment with reverse shoulder arthroplasty (RSA) for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment, a difference attributed to the deterioration of functional outcomes of the nonoperative treatment over time [63].
  • Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type [80].

Key Evidence

  • [L3] Patients undergoing arthroplasty as treatment of an acute fracture of the proximal humerus may achieve satisfactory long-term pain relief; however, the result for overall shoulder motion is less predictable. (10.1016/j.jse.2007.06.025)
  • [L3] In elderly patients who have undergone a reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes. (10.1016/j.jse.2018.05.030)
  • [L3] Clinical results at 1-year follow-up confirmed the advantage of applying it to 3- or 4-part proximal humeral fractures in older patients. (10.1186/s12891-022-05998-z)
  • [L3] Elderly patients who require admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age. (10.1016/j.jse.2019.05.030)
  • [L3] Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute rTSA for proximal humeral fractures. (10.1016/j.jse.2021.06.020)
  • [L3] Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty. (10.1016/j.jse.2012.03.006)
  • [L4] Fractures of the proximal humerus follow characteristic patterns. (10.1016/j.jse.2017.05.014)
  • [L3] Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic. (10.1016/j.jse.2012.03.011)
  • [L3] This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty. (10.1302/0301-620x.103b6.bjj-2020-1753.r1)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
  • [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. (10.1016/j.jse.2024.12.005)
  • [L1] This systematic review highlights significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures, calling for standardized definitions to improve evidence synthesis. (10.1186/s12891-019-2459-6)
  • [L1] Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. (10.2106/jbjs.20.02018)
  • [L2] Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years. (10.2106/jbjs.l.01115)
  • [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. (10.1016/j.jse.2022.03.006)
  • [L2] In most studies of proximal humeral fractures, only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied. (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] As the majority of unplanned hospital readmissions were associated with medical diagnoses, it is important to consider patient medical comorbidities before surgical treatment of proximal humerus fractures and during the postoperative care phase. (10.1007/s11999-014-3613-y)
  • [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] 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] 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] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. (10.2106/jbjs.l.01293)
  • [L5] Surgery for complex proximal humeral fractures leads to overall good long-term outcomes with high overall complication and reoperation rates. (10.2106/jbjs.19.01109)
  • [L3] Compared with the general population, patients sustaining a proximal humeral fracture have a significantly higher risk of mortality up to one year after the injury. (10.1302/0301-620x.102b11.bjj-2020-0627.r1)
  • [L1] The available literature suggests that reverse shoulder arthroplasty performed to address complex proximal humeral fractures might result in more favorable clinical outcomes than hemiarthroplasty performed for the same indication. (10.1016/j.jse.2015.08.030)
  • [L3] The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. (10.1097/corr.0000000000002391)
  • [L5] Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. (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)
  • [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)
  • [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] 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)
  • [L5] Vertical abduction has the greatest effect on axillary nerve position, while horizontal glenohumeral forward flexion and humeral rotation have little effect. (10.1016/j.jse.2008.12.001)
  • [L5] The control volume is an important anatomic and functional area of the proximal humerus. (10.1016/j.jse.2017.12.004)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
  • [L1] Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. (10.1016/j.jse.2024.02.023)
  • [L1] This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. (10.1371/journal.pmed.1002855)
  • [L3] The new classification system with emphasis on the qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans. (10.1016/j.jse.2015.08.006)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. (10.5435/jaaos-d-14-00033)
  • [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. (10.5435/jaaos-d-24-01073)
  • [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. (10.1016/j.jse.2011.01.025)
  • [L1] Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for this treatment. (10.1016/j.jse.2022.07.008)
  • [L5] Reverse shoulder arthroplasty is a powerful tool for managing proximal humerus fracture sequelae when joint-preserving options are not optimal, provided there is careful management of the tuberosities and understanding of associated pearls and pitfalls. (10.5435/jaaos-d-23-00740)
  • [L2] Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture. (10.1016/j.jse.2011.06.009)
  • [L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. (10.1016/j.jse.2012.09.018)
  • [L5] Surgical treatment of proximal humerus fractures remains far from straightforward, with unpredictable outcomes where factors associated with poor results include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension. (10.1097/corr.0000000000002242)
  • [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)
  • [L1] The review identified a wide range of outcome measures used in proximal humeral fracture studies, but found limited evidence regarding their psychometric properties in this specific population. (10.1016/j.jse.2010.10.028)
  • [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] 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] 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] 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)
  • [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)
  • [L1] We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment. (10.1007/s11999-012-2531-0)
  • [L3] This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes. (10.1186/s13018-022-03337-5)
  • [L4] Undisplaced greater tuberosity fractures can be managed non-operatively with good results, but patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult fractures. (10.1186/s12891-018-2225-1)
  • [L3] There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane, with nearly 30% of cases suggesting surgical treatment on radiographs being reclassified for conservative treatment based on CT findings. (10.1016/j.jse.2016.05.016)
  • [L5] The routine use of 3D-printed models may not be beneficial for classifying proximal humeral fracture patterns beyond the information gained from currently available imaging modalities, and their use as the sole determinant for recommending surgical intervention should be avoided at this time. (10.1097/corr.0000000000002017)
  • [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
  • [L4] Missed posterior dislocation of the shoulder after intramedullary fixation of proximal humeral fractures is an extremely rare injury that can be missed due to inadequate initial and postoperative x-ray images and incorrect interpretation. (10.1016/j.jse.2008.10.020)
  • [L1] Timing of surgery did not affect Oxford Shoulder Score at any stage of follow-up, irrespective of age or fracture type. (10.1302/0301-620x.102b1.bjj-2020-0546.r1)

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Using Creative Commons Public Licenses

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Considerations for licensors: Our public licenses are intended for use by those authorized to give the public permission to use material in ways otherwise restricted by copyright and certain other rights. Our licenses are irrevocable. Licensors should read and understand the terms and conditions of the license they choose before applying it. Licensors should also secure all rights necessary before applying our licenses so that the public can reuse the material as expected. Licensors should clearly mark any material not subject to the license. This includes other CC- licensed material, or material used under an exception or limitation to copyright. More considerations for licensors: wiki.creativecommons.org/Considerations_for_licensors

Considerations for the public: By using one of our public licenses, a licensor grants the public permission to use the licensed material under specified terms and conditions. If the licensor's permission is not necessary for any reason--for example, because of any applicable exception or limitation to copyright--then that use is not regulated by the license. Our licenses grant only permissions under copyright and certain other rights that a licensor has authority to grant. Use of the licensed material may still be restricted for other reasons, including because others have copyright or other rights in the material. A licensor may make special requests, such as asking that all changes be marked or described. Although not required by our licenses, you are encouraged to respect those requests where reasonable. More considerations for the public: wiki.creativecommons.org/Considerations_for_licensees

Creative Commons Attribution-NonCommercial 4.0 International Public License

By exercising the Licensed Rights (defined below), You accept and agree to be bound by the terms and conditions of this Creative Commons Attribution-NonCommercial 4.0 International Public License ("Public License"). To the extent this Public License may be interpreted as a contract, You are granted the Licensed Rights in consideration of Your acceptance of these terms and conditions, and the Licensor grants You such rights in consideration of benefits the Licensor receives from making the Licensed Material available under these terms and conditions.

Section 1 -- Definitions.

a. Adapted Material means material subject to Copyright and Similar Rights that is derived from or based upon the Licensed Material and in which the Licensed Material is translated, altered, arranged, transformed, or otherwise modified in a manner requiring permission under the Copyright and Similar Rights held by the Licensor. For purposes of this Public License, where the Licensed Material is a musical work, performance, or sound recording, Adapted Material is always produced where the Licensed Material is synched in timed relation with a moving image.

b. Adapter's License means the license You apply to Your Copyright and Similar Rights in Your contributions to Adapted Material in accordance with the terms and conditions of this Public License.

c. Copyright and Similar Rights means copyright and/or similar rights closely related to copyright including, without limitation, performance, broadcast, sound recording, and Sui Generis Database Rights, without regard to how the rights are labeled or categorized. For purposes of this Public License, the rights specified in Section 2(b)(1)-(2) are not Copyright and Similar Rights.

d. Effective Technological Measures means those measures that, in the absence of proper authority, may not be circumvented under laws fulfilling obligations under Article 11 of the WIPO Copyright Treaty adopted on December 20, 1996, and/or similar international agreements.

e. Exceptions and Limitations means fair use, fair dealing, and/or any other exception or limitation to Copyright and Similar Rights that applies to Your use of the Licensed Material.

f. Licensed Material means the artistic or literary work, database, or other material to which the Licensor applied this Public License.

g. Licensed Rights means the rights granted to You subject to the terms and conditions of this Public License, which are limited to all Copyright and Similar Rights that apply to Your use of the Licensed Material and that the Licensor has authority to license.

h. Licensor means the individual(s) or entity(ies) granting rights under this Public License.

i. NonCommercial means not primarily intended for or directed towards commercial advantage or monetary compensation. For purposes of this Public License, the exchange of the Licensed Material for other material subject to Copyright and Similar Rights by digital file-sharing or similar means is NonCommercial provided there is no payment of monetary compensation in connection with the exchange.

j. Share means to provide material to the public by any means or process that requires permission under the Licensed Rights, such as reproduction, public display, public performance, distribution, dissemination, communication, or importation, and to make material available to the public including in ways that members of the public may access the material from a place and at a time individually chosen by them.

k. Sui Generis Database Rights means rights other than copyright resulting from Directive 96/9/EC of the European Parliament and of the Council of 11 March 1996 on the legal protection of databases, as amended and/or succeeded, as well as other essentially equivalent rights anywhere in the world.

l. You means the individual or entity exercising the Licensed Rights under this Public License. Your has a corresponding meaning.

Section 2 -- Scope.

a. License grant.

1. Subject to the terms and conditions of this Public License, the Licensor hereby grants You a worldwide, royalty-free, non-sublicensable, non-exclusive, irrevocable license to exercise the Licensed Rights in the Licensed Material to:

a. reproduce and Share the Licensed Material, in whole or in part, for NonCommercial purposes only; and

b. produce, reproduce, and Share Adapted Material for NonCommercial purposes only.

2. Exceptions and Limitations. For the avoidance of doubt, where Exceptions and Limitations apply to Your use, this Public License does not apply, and You do not need to comply with its terms and conditions.

3. Term. The term of this Public License is specified in Section 6(a).

4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

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.

Creative Commons may be contacted at creativecommons.org.