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Shoulder Arthroplasty for Acute Proximal Humerus Fracture

155 citationsUpdated Sep 2026

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Overview¶

Proximal humeral fractures predominantly affect elderly patients who are often frail and face a greater-than-average risk of mortality for their age [4]. While the majority of these injuries are managed non-operatively [6], this approach yields good functional outcomes with union rates exceeding 90% [14, 32]. However, significant heterogeneity exists in the terminology used to describe complications following non-surgical management [12]. For complex fractures of the superior humerus, reverse shoulder arthroplasty (RTSA) is an accepted treatment modality, though it is restricted to elderly patients [1]. Success in arthroplasty for these fractures requires careful patient selection and skilled surgical technique to avoid poor results and complications [57].

Arthroplasty provides satisfactory long-term pain relief, although overall shoulder motion remains less predictable [2]. RTSA generally offers superior functional outcomes compared with conservative treatment [22] and hemiarthroplasty [9, 67], with primary hemiarthroplasty demonstrating satisfactory prosthetic survival at an average of 6.3 years [26]. In elderly patients undergoing RTSA, anatomic tuberosity healing improves both objective and subjective outcomes [3]. Conversely, RTSA performed for acute 3- and 4-part fractures yields worse clinical outcomes and active range of motion compared with elective indications [68]. Patients who undergo initial nonoperative management experience worse functional outcomes and higher complication rates than those treated with acute RTSA [7].

The increasing utilization of RTSA and decreasing short-term complication rates represent a substantial shift in management norms [71]. Despite these advances, treatment remains controversial [32, 21]. For patients aged 65 years or older with four-part fractures, no clear benefits have been observed with either hemiarthroplasty or nonoperative treatment [189]. Furthermore, the evidence base is fragile; in most studies, only one or two patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied [34]. The increased in-hospital risk for major adverse events and surgical complications may moderate enthusiasm for RTSA in patients 65 years and older [25]. Nevertheless, RTSA remains an effective treatment option for selected patients with acute proximal humerus fractures [201]. A greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for complex sequelae of proximal humerus fractures [30].

Anatomy & Pathophysiology¶

Bony Anatomy¶

The proximal humerus comprises four main parts: the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [72]. The articular head is spherical with a diameter of 37 to 57 mm [72] and an essentially spherical articular surface covering an arc of approximately 160 degrees [81]. The radius of curvature of the humeral head is approximately 25 mm, slightly larger in men than in women [81]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [72], with the superior margin normally positioned 8 to 10 mm superior to the top of the greater tuberosity [81]. Head height is approximately 5.6 cm above the superior border of the pectoralis major tendon [83].

Humeral version and inclination vary across measurements. Humeral version averages 29.8 degrees, with a range of 10 to 55 degrees [72]. The humeral head is retroverted an average of 30 degrees relative to the transepicondylar axis of the humerus [73, 83], or 19° of retroversion [74]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [72]. The neck-shaft angle measures an average of 135 degrees [73] or 41° of inclination [74]. Alternatively, the average neck-shaft angle is cited as 45 degrees (±5 degrees), with a range of 30 to 50 degrees [81]. The anatomic neck is located at the junction of the articular surface and the tuberosities [72], while the surgical neck represents an indistinct region below the tuberosities but above the humeral shaft [72].

The glenoid is a convex structure of shallow depth shaped like an inverted pear [72]. It averages 5° of retroversion in relation to the axis of the scapular body [74]. The glenoid articular surface and labrum combine to create a socket that is approximately 9 mm deep in the superoinferior direction and 5 mm deep in the anteroposterior direction [82]. Adding the glenoid labrum increases the glenoid surface to 75% of the humeral head vertically and 57% horizontally [82]. The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is called the lateral humeral offset [81].

The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons of the rotator cuff [72, 78]. The lesser tuberosity serves as the attachment site for the subscapularis tendon [72]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure that imparts stability to the shoulder girdle [72].

Vascular Supply¶

The proximal humerus receives its blood supply from the anterior and posterior humeral circumflex branches from the third division of the axillary artery [72]. The anterior humeral circumflex artery (AHCA) arises from the axillary artery at the inferior border of the subscapularis [72]. The AHCA provides vascular inflow to the humeral head by way of its terminal anterolateral branch known as the artery of Laing (also known as the arcuate artery) [72]. The ascending branch of the AHCA courses parallel to the lateral aspect of the long head biceps tendon and enters the humeral head at the interface of the bicipital groove and greater tuberosity [72]. The major blood supply to the humeral head is through this ascending branch, which penetrates the head at the bicipital groove and becomes the arcuate artery [73]. The terminal intraosseous portion of the artery enters at the proximal aspect of the intertubercular groove as the arcuate artery [74]. The anterolateral ascending branch of the anterior humeral circumflex artery provides the primary blood supply to the humeral head [74].

The posterior humeral circumflex artery travels with the axillary nerve, enters the quadrilateral space posteriorly, and anastomoses with a branch of the anterior circumflex to supply the posterior cuff [72]. Quantitative assessment has shown that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [78]. Additional extraosseous collateral branches can permit humeral head perfusion despite complete ligation of the arcuate artery [72]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [72].

Fractures of the anatomic neck have a poor prognosis because of complete disruption of the blood supply to the head [73]. Surgical neck fractures are common, and with these, the blood supply to the head is preserved [73]. A fracture involving the anatomic neck is prognostically worse than fractures involving other regions of the proximal humerus with respect to the potential disruption of the vascular supply to the humeral head and the subsequent development of avascular necrosis [72].

Soft Tissue & Joint Structures¶

The bicipital groove lies between the greater and lesser tuberosities and serves as a pathway for the long head of the biceps [72]. The distal aspect of the bicipital groove is internally rotated with respect to the proximal portion [72]. The rotator cuff, subacromial bursa, and subdeltoid bursa pass underneath the coracoacromial arch [72]. Displaced proximal humerus fractures can impede normal movement of the rotator cuff, subacromial bursa, and subdeltoid bursa, causing impingement and disruption of normal glenohumeral motion [72]. In proximal humerus fractures, the subdeltoid and subacromial bursae can become thickened and fibrotic, forming adhesions that can limit normal glenohumeral motion [72].

The rotator cuff consists of four muscles: the subscapularis, supraspinatus, infraspinatus, and teres minor [73]. The teres major is not a rotator cuff muscle [73]. The cuff muscles serve as depressors of the humeral head to allow the deltoid to efficiently abduct the humerus [73]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator of the humerus [73]. The deltoid and pectoralis major muscles, along with the rotator cuff, cause predictable displacement of fractures around the proximal humerus [73].

The glenohumeral joint depends on static and dynamic stabilizers for movement and stability, especially the rotator cuff [81]. The rotator cuff stabilizes the glenohumeral joint while allowing greater freedom of motion and fixes the fulcrum of the upper extremity against which the deltoid can contract [81]. The rotator cuff must act simultaneously and synergistically with the deltoid muscle for normal function [81]. The glenohumeral joint is composed of four articulations: the sternoclavicular, acromioclavicular, glenohumeral, and scapulothoracic [82]. The bony anatomy contributes little to stability and has been compared with a golf ball on a tee [82].

The glenoid is encircled by the labrum, composed of dense fibrocartilaginous tissue, which increases the depth of the socket by 50% around the humeral head [82]. The superior glenohumeral ligament is the primary restraint to inferior humeral subluxation in 0 degrees of abduction [82]. The middle glenohumeral ligament limits external rotation when the arm is in the lower and middle ranges of abduction but has little effect when the arm is in 90 degrees of abduction [82]. The inferior glenohumeral ligament is composed of an anterior band that is quite thick, a posterior band that is less thick and distinct, and a thinner intervening axillary pouch [82]. The anteroinferior glenohumeral ligament complex is the main stabilizer to anterior and posterior stresses when the shoulder is abducted 45 degrees or more [82].

The tendons of the infraspinatus and supraspinatus muscles join approximately 15 mm proximal to their insertion and cannot be readily separated by blunt dissection [82]. The infraspinatus and teres minor fuse near their musculotendinous junctions [82]. The supraspinatus and subscapularis tendons join as a sheath that surrounds the biceps tendon at the entrance of the bicipital groove [82]. The coracohumeral ligament is a thick band of fibrous tissue extending from the coracoid process along the surface of the capsule to the tuberosities between the supraspinatus and subscapularis tendons [82]. It originates from the base and lateral border of the coracoid process just below the origin of the coracoacromial ligament and inserts on the greater tuberosity [85].

The shoulder capsule is large and has twice the surface area of the humeral head [85]. The shoulder capsule typically accepts approximately 28 to 35 mL of fluid [85]. The capsule extends from the glenoid neck to the anatomic neck and the proximal shaft of the humerus [85]. The transverse humeral ligament consists of a few transverse fibers of capsule that extend between the greater and lesser tuberosities and help contain the long head of the biceps tendon in its groove [85]. On all sides of the shoulder capsule, except for the inferior portion, the capsule is reinforced and strengthened by the tendons of the rotator cuff muscles [85]. The rotator cuff tendons blend into the capsule over varying lengths and average approximately 2.5 cm [85].

Pathophysiology of Fracture Displacement¶

Following a fracture of the proximal humerus, displacement of each "part" occurs in a predictable manner based on the deforming forces created by the tendinous insertions of the pectoralis major, subscapularis, supraspinatus, and infraspinatus [72]. The subscapularis originates from the anterior scapula and inserts anteriorly onto the lesser tuberosity [78], causing medial displacement [72]. The greater tuberosity provides attachment superiorly and posteriorly for the supraspinatus, infraspinatus, and teres minor [78], which cause superior and posterior displacement [72]. The pectoralis major inserts on the humeral shaft and displaces it medially [72].

The deltoid forward flexes and abducts the shoulder and courses from the clavicle and acromion superiorly into a common tendinous insertion onto the lateral upper third of the humeral shaft [78]. The pectoralis major powers adduction and internal rotation due to its tendinous insertion anteriorly onto the lateral wall of the bicipital groove [78]. The pectoralis major forms the roof of the distal continuation of the bicipital tunnel, which is a closed space that extends proximally to the glenohumeral joint [78]. Proximal humerus fractures alter complex interactions of joint surface anatomy, joint volume, atmospheric pressure, and joint fluid cohesion, resulting in pain, decreased range of motion and stiffness, and disability [72].

The brachial plexus is prone to injury when the proximal humerus is injured in fractures or dislocations, or during traction [78]. The axillary nerve circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [78].

Biomechanical Alterations¶

Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics [131]. In the normal shoulder, the humeral head is maintained within one to two millimeters of the anatomic center of the humeral head with either passive or active range of motion in the plane of the scapula [99]. With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly [102].

Replacing the native head with a component of equal diameter reduced elevation 20%, rotation 40%, A/P translation 50%, and inferior translation 60% in the vented shoulder [117]. Kinematics of the arthroplasty are controlled primarily by soft-tissue releases and the selection of the prosthetic head-neck length [105, 106]. High variations in muscle moment arms were found for all 3 deltoid components, presenting an opportunity to dramatically change the deltoid moment arms through surgical placement of the reverse shoulder components and by varying the overall offset of the humerus [107].

Positioning the humeral tray with posterior offset offers a biomechanical advantage for patients needing reverse shoulder arthroplasty by decreasing superior impingement and increasing the internal rotational moment arm of the subscapularis, without creating inferior impingement [114]. 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 [97]. Even if teres minor external rotation moment arm is higher in reverse shoulder arthroplasty than in a normal shoulder, the decreased length could impair its force generation [98]. Scaption kinematics of reverse shoulder arthroplasty do not change after the sixth postoperative month [91]. 16 of the 34 modified placements had an overall beneficial impact on reverse shoulder biomechanics [92]. Elliptical and spherical heads show similar obligate glenohumeral translation during axial rotation in total shoulder arthroplasty [96].

Classification¶

Reliability and Reproducibility of Existing Systems¶

The Neer and AO classifications of proximal humeral fractures demonstrate limited intraobserver and interobserver reliability [53]. Specifically, the Neer system, whether applied to CT scans or plain radiographs, lacks reliability and reproducibility due to the difficulty in determining which segments are fractured [171]. The addition of two-dimensional (2-D) computed tomography (CT) scans did not improve the interobserver reproducibility of either the Neer or AO classification systems [53]. Interobserver agreement on the Neer classification was slight, indicated by a kappa measure of 0.069 to 0.14, across radiographs, 2-D CT scans, and 3-D CT scans [53]. In contrast, interobserver agreement on treatment preference was fair, indicated by a kappa measure of 0.28 to 0.33, across the same imaging modalities [53]. Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures overall [198]. This lack of a reliable classification confounds efforts to compare the outcomes of treatment methods among different clinical trials and reports [53].

Alternative and Revised Classification Systems¶

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 [154]. The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems [161]. The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice [168].

Epidemiology and Displacement Criteria¶

Approximately 51% of proximal humeral fractures are displaced when assessed according to the criteria of Neer's classification system [54]. Neer's classification system defines displacement as one or more parts of the fractured bone being displaced by more than one centimetre, or angulated more than 45 degrees [54]. The largest groups of displaced proximal humeral fractures are 2-part surgical neck fractures (28% of the whole population), followed by 3-part greater tuberosity and surgical neck fractures (9%) [54]. Four-part fractures without fracture dislocation account for around 2% of the total population of proximal humeral fractures [54].

Clinical Presentation¶

Epidemiology and Demographics¶

Proximal humeral fractures account for approximately 4 to 5% of all fractures [54]. The incidence increases rapidly with age, with a three-fold increase in low-energy trauma cases among people aged 60 and above observed over a 33-year period [54]. Women are affected over twice as often as men [54]. Nondisplaced proximal humeral fractures are among the most common fractures associated with osteoporosis [172]. Approximately 51% of these fractures are displaced according to Neer's classification criteria [54]. The largest groups of displaced fractures are two-part surgical neck fractures (28% of the whole population) and three-part greater tuberosity and surgical neck fractures (9%) [54].

Classification and Diagnosis¶

Fractures of the proximal humerus follow characteristic patterns [59]. Neer indicated that his classification was meant to be applied after operative exposure and believed that radiographs alone would be unreliable [53]. Interobserver agreement on the Neer classification was slight, indicated by a kappa measure of 0.069 to 0.14 [53]. The addition of two-dimensional (2-D) computed tomography (CT) scans did not improve the interobserver reproducibility of the Neer or AO classification systems [53]. Interobserver agreement on treatment was fair, indicated by a kappa measure of 0.28 to 0.33 [53]. 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 [64].

Mortality and Systemic Risk¶

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 [38]. Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [39].

Functional Outcomes and Complications¶

Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year [60]. A substantial proportion of patients treated nonoperatively have poor perceived functional outcomes [60]. Nondisplaced proximal humeral fractures can be a major cause of functional disability and reduction in subjective patient-perceived health [172]. Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture [37]. Axillary artery injuries are rare but serious complications in proximal humeral fractures [173]. The vascular state should be evaluated periodically after a proximal humeral fracture because pulses may disappear and symptoms may appear after several days [173].

Treatment Considerations¶

The majority of proximal humerus fractures may be treated nonoperatively, though certain circumstances necessitate surgical intervention [19]. Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [29]. Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade [65]. Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population [33]. The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status [66]. Surgical treatment of proximal humerus fractures has unpredictable outcomes, with factors associated with poor results including being a woman, four-part fracture dislocation, and absence of metaphyseal head extension [162]. 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 [170].

Investigations¶

Plain radiography: The Neer trauma series is the recommended initial radiographic evaluation for proximal humerus fractures, consisting of an AP view, a lateral view in the scapular plane, and a Velpeau modified axillary view [88]. This combination allows evaluation of the shoulder joint in three separate perpendicular planes [88]. The AP view in the plane of the scapula is taken so that the x-ray beam passes through the glenohumeral joint, visualizing the superoinferior position of the humeral head relative to the glenoid, osteophytes, joint space narrowing, and medial displacement of the humerus relative to the lateral acromial line [44]. The true AP view in the scapular plane also visualizes the anterior greater tuberosity in profile and can reveal proximal humeral migration when the arm is held in neutral rotation with slight abduction [94]. An AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [94]. The axillary view, taken with the arm in the functional position of elevation in the plane of the scapula, is referred to as the “truth view” because it demonstrates glenohumeral relationships in functional elevation [44]. This view is critical for evaluating the glenoid articular surface and the relationship of the humeral head anteriorly and posteriorly [88], as well as for evaluating glenohumeral joint instability and determining humeral head position in the glenoid fossa [94]. It may detect occult, locked posterior shoulder dislocation in patients exhibiting a lack of passive external rotation [94]. The standardized axillary view enables measurement of posterior subluxation or “functional decentering” that is not evident in images taken with the arm at the side [44]. Posterior subluxation can be measured by the position of the center of the humeral head in relation to the plane of the scapula, the position of the center of the humeral head in relation to the glenoid face, or the point of contact of the humeral articular surface on the glenoid articular surface [44]. The point of contact reflects the degree of centering of the net humeral joint reaction force on the glenoid [44]. Malcentering of this force leads to posterior instability, posterior glenoid wear, and “rocking horse” loosening of prosthetic glenoid components [44]. The scapular Y view provides visualization of the coracoacromial arch and can reveal coracoacromial spurs associated with rotator cuff pathology [94]. It is a reliable alternative for evaluating glenohumeral subluxation and dislocation and can show scapular body abnormalities and acromial shape [94]. Normal acromiohumeral distance is 7 to 14 mm, and the width of the glenohumeral joint space should be symmetric superiorly and inferiorly [94]. The coracoclavicular distance is normally 1.1 to 1.3 cm [94]. Neer classified acromial morphology as type I (flat), type II (curved), and type III (hooked) [94]. Type III acromial morphology correlates with the presence of rotator cuff disease, although no direct causal relationship has been demonstrated [94]. The Neer classification of acromial morphology has shown relatively poor interobserver reliability [94]. Radiographic evaluation in patients with minimally displaced proximal humeral fractures is helpful in predicting functional outcome during conservative treatment, specifically angulation on the Y lateral view [241]. Anteroposterior abduction radiographies up to 90 degrees are superior to conventional radiographies for detecting radiolucent zones and loosening of the glenoid component [244]. Standardized plain films are almost always sufficient to garner the information needed for shoulder evaluation, and there is information that can be gathered from properly taken plain films that cannot be obtained from CT scans [44].

CT: CT imaging is frequently used to evaluate fractures of the shoulder, assess for bony lesions in recurrent instability cases, or for preoperative templating for shoulder arthritis [93]. On occasion, CT scanning may be necessary for detailing bony anatomy in proximal humerus fractures [88]. CT with three-dimensional reconstructions is the advanced imaging study of choice for determining the extent of glenoid bone loss in the setting of shoulder instability [94]. A morphovolumetric 3-dimensional approach using CT scans improves knowledge about pathomorphology of proximal humeral fractures [250]. There is relevant variability in displacement measurements between shoulder radiographs and CT scans in the coronal plane [220]. Nearly 30% of cases suggesting surgical treatment on radiographs are reclassified for conservative treatment based on CT findings [220]. Although CT scans may offer a few degrees of increased precision in the measurement of glenoid version, this precision does not necessarily improve the quality of the surgery or the clinical outcome [44]. Three-dimensional reconstructions can reveal fine details of the shoulder anatomy, but this additional information rarely changes the planning or conduct of the arthroplasty [44]. 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 [222]. The use of 3D-printed models as the sole determinant for recommending surgical intervention should be avoided at this time [222].

MRI: MRI is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [93]. T1-weighted MRI can reveal Hill-Sachs lesions and is often used with magnetic resonance arthrograms to provide a more detailed picture of the joint surfaces [93]. T2-weighted MRI provides better visualization of full thickness rotator cuff tears [93]. Evaluation of the integrity of the rotator cuff may be difficult in the acute setting, and ultrasound, MRI, arthrogram, or arthroscopy may be valuable in making this diagnosis [88]. Patients with persistent post-traumatic shoulder pain and limitation of function warrant MRI investigation to identify occult greater tuberosity fractures [206].

Ultrasonography: Ultrasonography is a low-cost alternative to MRI and arthrography for evaluating both skeletal and soft-tissue structures of the shoulder [93]. It can provide immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [93]. Ultrasonography can be used to measure the subacromial space and detect atrophy of rotator cuff muscles [93]. It can evaluate impingement in various positions and motions due to real-time imaging [93]. Ultrasonography is highly operator dependent and is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [93].

Arthrography: Arthrography involves injection of contrast agent in conjunction with either an MRI or CT scan, enhancing imaging of the joint to enable better identification of normal structures and pathology involving the joint surfaces [93]. MR arthrography is considered the benchmark for evaluation for labral tears and rarely is indicated for evaluation of rotator cuff pathology [93]. When MRI or MR arthrography is contraindicated, such as in patients with pacemakers or vascular clips, CT arthrography is indicated [93].

Other Considerations: The purpose of imaging of the shoulder is to help establish the diagnosis, determine the severity of the pathoanatomy, assist in surgical planning, and enable the surgeon to illustrate the condition of the shoulder to the patient [44]. The shoulder is a three-dimensional structure that cannot be represented by a single planar view [89]. Critical relationships, such as the degree of centering of the humeral head, change with the position of the arm [89]. Shoulder pathology may be found in a large number of different bones and soft tissues [89]. Overlying and superimposed structures as well as metallic implants may complicate imaging the structures of interest [89]. Proper radiographic technique is as important as proper surgical technique to achieve the desired outcome [44]. Surgeons need to develop a judicious approach to imaging that yields the information necessary to treat the patient while avoiding the tendency to "over-image" [89]. Unless a specific research protocol is in place, the temptation to “overimage” should be resisted, obtaining only the scans or reconstructions that are necessary for the care of the patient [44].

Treatment¶

Non-Operative¶

The majority of proximal humerus fractures may be treated nonoperatively, although certain circumstances necessitate surgical intervention [19]. While nonsurgical management decreased during the study period [138], evidence suggests it should have a more prominent role in treatment [155]. Nonoperative treatment produces considerable variation in shoulder-specific and general health outcomes at 1 year, with a substantial proportion of patients reporting poor perceived functional outcomes [60]. Short and long periods of immobilization yield similar results for nonoperatively treated fractures, independent of the fracture pattern [149]. The current practice of performing surgery on the majority of displaced proximal 2-part fractures in older adults may not be beneficial [152].

Operative¶

Indications: Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus [163]. As the majority of unplanned hospital readmissions were associated with medical diagnoses, it is important to consider patient medical comorbidities before surgical treatment and during the postoperative care phase [17]. Reverse shoulder arthroplasty is advocated for complex proximal humerus fractures in elderly patients because it provides more consistent and predictable results compared with hemiarthroplasty or plate osteosynthesis [193]. The addition of reverse prosthetic arthroplasty has become an attractive option in the treatment of complex fractures, particularly in elderly patients in whom bone may not be ideal for internal fixation or in whom tuberosity bone quality or comminution might make healing uncertain when considering hemiarthroplasty [186]. Generally, primary implantation of traditional fracture prosthesis is indicated in most cases of humeral head fractures, but in carefully selected cases primary reverse shoulder arthroplasty may be superior and lead to better outcome [35].

Surgical Approach / Technique: The choice of approach for exposure of the proximal humerus region may influence the functional outcome [164]. This review highlights various technical strategies to maximize the success of surgical treatment, emphasizing innovations in technique and implant design to mitigate high complication rates [166]. For prosthetic hemiarthroplasty, surgical exposure is facilitated through a long deltopectoral approach [47]. Release of the upper half of the pectoralis major insertion and the coracoacromial ligament from its coracoid insertion will further augment exposure [47]. If the rotator cuff mechanism is deficient, preservation of the coracoacromial ligament or repair of the incised ligament is recommended [47]. Identification of the bicipital groove and the long head of the biceps is helpful in localizing the fractured greater and lesser tuberosities [47]. Four-part fractures generally occur at the greater tuberosity just lateral to the bicipital groove [47]. Reconstruction of the proximal humerus includes recreating soft tissue tension through soft-tissue balancing and appropriate implant positioning [47].

For reverse shoulder arthroplasty (RSA), the preferred surgical technique uses a deltopectoral approach with the patient in the beach-chair position [182]. A mechanical arm holder assists with positioning of the extremity throughout the entire case [182]. A skin incision is made from the coracoid process distally (approximately 10 cm) [182]. The cephalic vein is retracted laterally during the deltopectoral approach [182]. The axillary nerve is identified medially underneath the conjoined tendon [182]. The musculocutaneous nerve is identified posterior to the conjoined tendon before placement of a self-retaining retractor between the conjoined tendon and the deltoid [182]. A soft tissue biceps tenodesis is performed in all cases of RSA for fracture [182]. The deltopectoral approach allows adequate access to the fracture fragments for suture fixation and provides excellent glenoid exposure after fracture fragment mobilization [182]. However, exposure and reduction of the greater tuberosity can be challenging through this approach [182].

The anterosuperior approach uses a more limited superiorly based incision and a deltoid split [182]. One potential advantage of the anterosuperior approach is greater tuberosity access [182]. Disadvantages include the requirement for deltoid detachment and potential dehiscence, as well as limited extensibility [182]. The limited extensibility is especially relevant during humeral shaft exposure, particularly if there is shaft comminution [182]. In cases where arthroplasty is clearly indicated preoperatively, a modified lateral deltoid-splitting approach is used [183]. A 7-cm incision centered over the lateral acromion and in line with the raphe between the anterior and the middle third of the deltoid muscle is used for the lateral approach [183]. The fascia of the deltoid muscle is split over the acromion down to the bone [183]. The coracoacromial ligament is preserved during the lateral approach [183]. If staying above the distal border of the subacromial bursa, the axillary nerve is protected by the bursa, as it runs distally to the bursa [183]. The advantages of the lateral approach are better visualization and easier manipulation of the greater tuberosity and easier orientation of the prosthesis relative to the glenoid [183]. Potential disadvantages include the risk of iatrogenic damage to the axillary nerve and potential anterior deltoid dysfunction [183]. A deltopectoral approach is used in cases where there is doubt about the operative procedure (osteosynthesis or prosthesis) to be performed [183].

Implant Selection: Clinical results at 1-year follow-up confirmed the advantage of applying an intramedullary support nail and plate system to 3- or 4-part proximal humeral fractures in older patients [8]. Proximal humerus fractures in the elderly can be reliably fixed with a “hybrid” locked-plating technique [58]. In a series of 35 patients older than 75 years treated with a hybrid locked-plating technique, an acceptable reduction was achieved in 89% of the shoulders and maintained over time [58]. All fractures healed in this series [58]. Osteonecrosis was noted on radiographs in 11% of the shoulders [58]. Six weeks of immobilization did not lead to disabling stiffness [58]. At most recent followup, mean active elevation was 141 degrees, mean active internal rotation L1, and mean active external rotation 36 degrees [58]. The Humerus Block technique is a very good and predictable, minimally invasive, percutaneous operative technique for treatment of various types of proximal humeral fractures that results in very good pain relief, mobility, and pull force in the arm with a low incidence of avascular necrosis [70]. Although the less-invasive surgical procedure is a feasible treatment option with acceptable complications and considerable improvement during the first six months, a lengthy recovery time is required [151].

For hemiarthroplasty, prosthetic hemiarthroplasty for the treatment of displaced three and four-part fractures of the proximal humerus is a technically demanding procedure [47]. The long-term surgical result is dependent on the surgical technique and postoperative rehabilitation [47]. The goals of prosthetic reconstruction include replacement of the humeral-head articular fragment, stable and secure fixation of the prosthetic component, restoration of humeral length and humeral head version, stable and anatomic reduction of the greater and lesser tuberosities to ultimately achieve bone union, and functional and anatomic restoration of the rotator cuff mechanism [47]. 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 [179]. This method usually provides an acceptable shoulder function without pain for humeral head replacement for three or four part fractures of the proximal humerus in old patients [45].

For reverse shoulder arthroplasty, the current technique offers a reproducible way of performing a reverse shoulder replacement for acute proximal humerus fractures in the elderly population [11]. The preliminary clinical and radiographic results of the first 53 patients using the metaphyseal-centering technique are encouraging, with no complications related to humerus component fixation such as loosening, osteolysis, or intraoperative or postoperative periprosthetic humerus fractures [13]. Reverse shoulder prosthesis using a dedicated stem is a very viable solution to treat complex proximal humerus fractures with reliable restoration of elevation [192]. Satisfactory results can be expected with the trabecular metal shoulder prosthesis for the treatment of complex proximal humeral fractures [196].

Alignment / Balancing Strategy: Reconstruction of the proximal humerus includes recreating soft tissue tension through soft-tissue balancing and appropriate implant positioning [47]. By utilizing surgical techniques that focus on tuberosity reconstruction, excellent results can be seen with reverse shoulder replacement for fracture [157]. A no. 5 nonabsorbable manipulation suture is placed on the lesser and the greater tuberosities at the bone tendon junction [183]. Transosseous sutures can cause additional fragmentation of the tuberosities [183]. Manipulation of the tuberosities should be limited not to provoke any additional damage to the vascularity of the tuberosities [183].

Other Considerations: Internal fixation of three-part and four-part proximal humerus fracture dislocations resulted in poor shoulder function and complications in a high number of patients, although fracture union was achieved in most patients [199]. Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for open reduction and internal fixation of unilateral displaced 3- or 4-part fractures at 12-month follow-up [61]. Although most patients could perform activities below the shoulder, only about one half could perform activities at or above the shoulder level after humeral head replacement for acute, four-part proximal humerus fractures [5]. This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty [15]. Pain relief is the most predictable outcome of hemiarthroplasty for severe proximal humeral fractures, with functional outcomes related to surgical technique and patient cooperation [180]. These findings suggest limited utility of hemiarthroplasty in the long term, supporting the need for careful patient selection and consideration of alternative surgical options such as reverse shoulder arthroplasty [181]. Technical considerations may play a key role in the poor and unpredictable results reported after shoulder replacement for four-part proximal humeral fractures [191]. 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 [20]. Reverse shoulder arthroplasty for the treatment of complex fractures of the proximal part of the humerus appears to have good results at short and intermediate-term follow-up [41]. Reverse shoulder arthroplasty provides satisfactory pain relief for proximal humerus fractures regardless of humeral fixation type [195]. Shoulder arthroplasty is an effective treatment for fracture sequelae with significant improvement in pain and function [187].

Complications and Outcomes¶

The most important risk factors for postoperative opioid dependence following proximal humeral fractures are preoperative dependence and fracture complexity [188]. Surgical fixation of periprosthetic humerus fractures is associated with lower mortality that becomes apparent in a delayed fashion and grows over time [24]. Most studies on periprosthetic postoperative humeral fractures after shoulder arthroplasty have reported occurrence rates between 0.5% and 3% [42]. A substantial number of periprosthetic humeral fractures can be successfully treated nonsurgically [42]. Excessively displaced fractures and those associated with a loose humeral implant are typically addressed surgically [42]. Internal fixation is likely to be successful provided the humeral implant is well fixed and adequate fracture stability can be achieved [42]. Revision procedures for the management of periprosthetic fractures with a loose humeral implant requires mastery of several reconstructive techniques, including implant revision, strut augmentation, supplemental internal fixation, modular segmental prostheses, and allograft prosthetic composites [42]. 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 [12]. Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [18].

Complications¶

Mortality and Systemic Risk: Elderly patients admitted for proximal humeral fractures are frail and face a greater-than-average risk of mortality for their age [4]. Combined fractures involving the femur or vertebrae carry significantly higher mortality and morbidity compared with isolated proximal humerus injuries [226]. Postoperative mortality following surgical fixation is 3.5%, approximately sixfold higher than the ninety-day mortality rate observed after other procedures [109]. Patients sustaining a combined hip and proximal humerus fracture experience higher 30-day and one-year mortality than those with a hip fracture alone [211].

In-Hospital and Early Adverse Events: In-hospital complications are more likely after reverse shoulder arthroplasty (RSA) than after locked plating [25]. The overall rate of complications following operative treatment is high [239]. Comorbidity indices mCCI and mFI-5 are strongly associated with adverse events but possess only moderate predictive ability for complications after surgical treatment [251]. Elevated risks of short-term complications after surgical fixation are associated with age sixty-five years or older, male sex, residence in the lowest two income quintiles, and preexisting comorbidities [109].

Infection (PJI): Acute deep infection after open reduction and internal fixation (ORIF) is a devastating complication characterized by high complication rates, poor functional outcomes, and a notably high nonunion rate [216]. In a series of 45 patients undergoing RSA, deep infection occurred in 3 cases [148]. Infection was the cause of reoperation in 1 patient within a systematic review of return to work after shoulder arthroplasty [50]. Infection is also listed among the most common reasons for reoperation after primary RSA, occurring at a rate under 1% [219].

Aseptic Loosening: Humeral loosening is rare in RSA, occurring in 0.7% of primary and 2.8% of revision cases [224]. The most common reasons for reoperation after primary RSA include humeral loosening, occurring at a rate under 1% [219]. In a study of fracture sequelae, humeral loosening was the most common complication, affecting 9 cases [112].

Instability: Anterior dislocation or shoulder instability was the second most common postoperative complication in shoulder arthroplasty studies, affecting 16 patients [50]. In a series of 45 patients undergoing RSA, dislocation occurred in 3 cases [148]. Instability was the second most common complication in a study of fracture sequelae, affecting 4 cases [112]. Dislocation is listed among the most common reasons for reoperation after primary RSA, occurring at a rate under 1% [219]. In a study comparing RSA for fracture versus elective indications, 0 cases of dislocation occurred in the fracture group compared with 22 cases in the elective group [125].

Periprosthetic Fracture: Periprosthetic fracture occurred in 3 patients in a systematic review of return to work after shoulder arthroplasty [50]. In a series of 45 patients undergoing RSA, periprosthetic humeral fracture occurred in 2 cases [148]. Intraoperative periprosthetic humerus fractures occurred in 36 shoulders (16%) during revision surgery to RSA [150]. Humeral component fracture is listed among the most common reasons for reoperation after primary RSA, occurring at a rate under 1% [219]. Special complications due to glenoid component insertion include anterior or posterior cortical bone effraction and fracture of the glenoid [141].

Nerve Palsy: Nerve injury following RSA is a known risk factor with wide-ranging incidences reported in a systematic review of 40,146 patients [143]. In humeral head replacement for osteonecrosis, nerve injury occurred in 6 (4.7%) shoulders [145].

Stiffness / Arthrofibrosis: Postoperative stiffness or pain was the most common postoperative complication in shoulder arthroplasty studies, affecting 47 patients [50]. In the surgical group of a randomized trial, posttraumatic stiffness was the second most common complication, affecting 6 patients [49]. In the nonsurgical group of the same trial, posttraumatic stiffness was one of the most common complications, affecting 5 patients [49].

Other Considerations: The rate of complications after operative treatment of proximal humeral fractures is high [239]. In a randomized trial, 30 patients (24%) in the surgical group experienced a complication related to shoulder fracture or its treatment compared to 23 patients (18%) in the nonsurgical group over the 2-year follow-up period [49]. Eleven participants (9%) in each group of this randomized trial required secondary surgery to the shoulder [49]. In the surgical group of a randomized trial, metalwork problems were the most common complication, affecting 10 patients [49]. In the nonsurgical group, symptomatic malunion and nonunion were the most common complications, affecting 5 patients each [49]. Surgery for complex proximal humeral fractures leads to overall good long-term outcomes with high overall complication and reoperation rates [245]. The prevalence of nonunion after proximal humeral fracture is higher than previously reported, with most patients having a very low risk but a smaller subgroup at much higher risk [218].

RSA had the highest probability for improving functional outcome and reduction in the total incidence of complications and requiring additional surgery among the five interventions for treating adults with displaced proximal humeral fracture [242]. In a registry-based study, no statistically significant difference existed in mortality rates between RSA patients and hemiarthroplasty patients at 6 months (3.3% vs. 2.4%) or at 1 year (3.8% vs. 3.4%) [130]. The incidence of postoperative adverse events was 7.1% (134 events) in the elective group versus 4.6% (5 events) in the fracture group for reverse total shoulder arthroplasty, with no significant difference [125]. A meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA [174].

Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty [142]. Revision shoulder arthroplasty remains challenging with a high rate of complications [214]. Complication and revision rates were highest in the revision group for RSA, at 47% and 26%, respectively [148]. The study highlights the previously underappreciated high incidence of humeral component malposition in cases requiring revision arthroplasty [236]. Overall, there was a moderate rate of complications but low rate of revision following intramedullary nailing of humerus fractures [237].

In a study of 184 patients with proximal humeral hemiarthroplasty, nine patients (13%) in the conventional stem group either died or were lost to follow-up at minimum 24 months postoperatively [110]. In the same study, five patients (4%) in the fracture-specific stem group either died or were lost to follow-up at mandatory minimum 24-month review [110]. Postoperative complications in humeral head replacement for osteonecrosis included rotator cuff stretching or tearing in 23 (18.1%) shoulders, instability in 7 (5.5%) shoulders, nerve injury in 6 (4.7%) shoulders, and humeral fracture in 2 (1.6%) shoulders [145]. Progressive arthritis requiring revision occurred in 7 patients in shoulder arthroplasty studies [50]. A clear standardised set of shoulder arthroplasty complication definitions is lacking [234].

Recovery¶

Functional Outcomes and Range of Motion: Arthroplasty for acute proximal humerus fractures provides satisfactory long-term pain relief, although overall shoulder motion results remain less predictable [2]. Primary hemiarthroplasty effectively relieves pain, but functional outcomes are less predictable [248]. In elderly patients with inadequate bone stock requiring early recovery of autonomy in daily activities, reverse shoulder arthroplasty effectively treats complex proximal humerus fractures [177]. This procedure offers predictable pain relief and functional restoration independent of rotator cuff function, though it carries substantial risks of complications [210]. Patients with acute proximal humeral fractures undergoing reverse shoulder arthroplasty appear to achieve superior 5-year functional outcomes compared with those undergoing hemiarthroplasty [9]. In elderly patients who have undergone reverse shoulder arthroplasty for acute proximal humeral fractures, anatomic tuberosity healing improves objective and subjective outcomes [3]. Although most patients treated with humeral head replacement for acute four-part proximal humerus fractures could perform activities below the shoulder, only about one half could perform activities at or above the shoulder level [5]. Patients who undergo initial periods of nonoperative management have worse functional outcomes and higher complication rates than those who undergo acute reverse total shoulder arthroplasty for proximal humeral fractures [7].

Non-Operative Recovery and Rehabilitation: Patients with proximal humeral fractures treated with early range of motion exercises do well, largely returning to baseline functional status by 1 year [113]. Patients with minimally displaced (<3 mm) or non-displaced fractures of the proximal humerus can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol, although full recovery might take an average of 8 months [134]. Immediate physiotherapy after a minimally displaced proximal humeral fracture results in faster recovery, with maximal functional benefit being achieved at 1 year [140]. Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months [153]. 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 [207]. Shoulder function was restored to preinjury levels for most patients treated with open reduction and internal fixation, and osteoporosis may not be regarded as a contraindication for this treatment [61]. Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy within a month [208]. The Shoulder Function Index (SFInX) is a feasible outcome measure which clinicians can use to reliably measure and detect clinically important changes in the construct of 'shoulder function' in people recovering from a proximal humeral fracture [184].

Complications and Adverse Events: In the surgical group for displaced proximal humerus fractures, the most common complications were metalwork problems in 10 patients and posttraumatic stiffness in 6 patients [49]. In the nonsurgical group for displaced proximal humerus fractures, the most common complications were symptomatic malunion, nonunion, and posttraumatic stiffness, with 5 patients for each complication [49]. Eleven participants (9%) in each group (surgical and nonsurgical) required secondary surgery to the shoulder over the 2-year follow-up period [49]. The most common postoperative complications reported in shoulder arthroplasty studies were postoperative stiffness/pain (n = 47), anterior dislocation or shoulder instability (n = 16), and progressive arthritis requiring revision (n = 7) [50]. The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with reverse shoulder arthroplasty for proximal humeral fractures in patients 65 years and older [25].

Mortality and Patient Factors: Trauma surgeons have a more aggressive approach to rehabilitation following operative proximal humerus fracture repair compared to shoulder surgeons regarding time to weightbearing status and passive range of motion [156].

Key Evidence¶

[L3] Management of complex fractures of the superior extremity of the humerus by reverse shoulder arthroplasty is an accepted approach, but such treatment is restricted to elderly patients. [1] (10.1016/j.jse.2012.03.011)
[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. [2] (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. [3] (10.1016/j.jse.2018.05.030)
[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. [4] (10.1016/j.jse.2019.05.030)
[L4] Although most patients could perform activities below the shoulder, only about one half could perform activities at or above the shoulder level. [5] (10.1016/s1058-2746(09)80084-0)
[L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. [6] (10.1186/s12891-019-2812-9)
[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. [7] (10.1016/j.jse.2021.06.020)
[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. [8] (10.1186/s12891-022-05998-z)
[L3] Patients with acute proximal humeral fractures who undergo RSA appear to achieve superior 5-year functional outcomes compared with patients who undergo hemiarthroplasty. [9] (10.1016/j.jse.2012.03.006)
[L5] The current technique offers a reproducible way of performing a reverse shoulder replacement for acute proximal humerus fractures in the elderly population. [11] (10.1097/bte.0b013e3181a598ae)
[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. [12] (10.1186/s12891-019-2459-6)
[L4] The preliminary clinical and radiographic results of the first 53 patients are encouraging, with no complications related to humerus component fixation such as loosening, osteolysis, or intraoperative or postoperative periprosthetic humerus fractures. [13] (10.1097/bte.0000000000000133)
[L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [14] (10.2106/jbjs.l.01293)
[L3] This is the largest long-term follow-up study of acute proximal humeral fractures treated with hemiarthroplasty. [15] (10.1302/0301-620x.103b6.bjj-2020-1753.r1)
[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. [17] (10.1007/s11999-014-3613-y)
[L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. [18] (10.1016/j.jse.2024.12.005)
[Paper] The majority of proximal humerus fractures may be treated nonoperatively; however, there are certain circumstances that necessitate surgical intervention. [19] (10.1097/bte.0000000000000095)
[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. [20] (10.5435/jaaos-d-23-00740)
[L5] This review discusses modern management controversies surrounding adult proximal humerus fractures, including surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty to assist surgeons in making evidence-based decisions. [21] (10.1016/j.jhsa.2025.07.009)
[L1] Treatment with reverse shoulder arthroplasty provides superior functional outcomes compared with conservative treatment for patients presenting with an acute proximal humeral fracture. [22] (10.1016/j.jse.2024.02.023)
[L3] Surgical fixation of periprosthetic humerus fractures is associated with lower mortality that becomes apparent in a delayed fashion and grows over time. [24] (10.1016/j.jseint.2026.101688)
[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. [25] (10.1097/corr.0000000000001776)
[L2] Primary shoulder hemiarthroplasty for proximal humeral fracture is associated with satisfactory prosthetic survival at an average of 6.3 years. [26] (10.2106/jbjs.l.01115)
[L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. [29] (10.1016/j.jseint.2021.08.006)
[L4] A greater tuberosity osteotomy is the most likely reason for poor and unpredictable results after shoulder replacement arthroplasty for the treatment of the complex sequelae of proximal humerus fractures. [30] (10.1067/mse.2001.115985)
[L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. [32] (10.5435/jaaos-d-24-01073)
[L4] Treatment algorithms and outcomes following proximal humerus fractures in patients less than or equal to 60 years of age are distinctly different from that of a more elderly population. [33] (10.1016/j.xrrt.2023.01.002)
[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. [34] (10.1016/j.jse.2022.01.141)
[Case_report] Generally, primary implantation of traditional fracture prosthesis is indicated in most cases of humeral head fractures, but in carefully selected cases primary reverse shoulder arthroplasty may be superior and lead to better outcome. [35] (10.1007/s00402-007-0519-0)
[L2] Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture. [37] (10.1016/j.jse.2011.06.009)
[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. [38] (10.1302/0301-620x.102b11.bjj-2020-0627.r1)
[L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [39] (10.1016/j.jse.2022.03.006)
[L2] Reverse shoulder arthroplasty for the treatment of complex fractures of the proximal part of the humerus appears to have good results at short and intermediate-term follow-up. [41] (10.2106/jbjs.rvw.m.00140)
[L4] [42] (10.5435/jaaos-d-21-01001)
[L4] This method usually provides an acceptable shoulder function without pain. [45] (10.1016/s1058-2746(96)80113-3)
[L5] [47] (10.5435/00124635-200011000-00005)
[L1] [49] (10.1001/jama.2015.1629)
[L1] [50] (10.1016/j.jse.2018.12.011)
[L3] [53] (10.2106/jbjs.l.00586)
[L2] [54] (10.1186/1471-2474-10-140)
[L4] Success in arthroplasty for fractures of the proximal humerus requires careful selection of patients suitable for this treatment and skilled surgical technique in order to avoid poor results and complications. [57] (10.1016/s1058-2746(96)80114-5)
[L4] [58] (10.1007/s11999-011-1894-y)
[L4] Fractures of the proximal humerus follow characteristic patterns. [59] (10.1016/j.jse.2017.05.014)
[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. [60] (10.2106/jbjs.20.02018)
[L1] Shoulder function was restored to preinjury levels for most patients, and osteoporosis may not be regarded as a contraindication for this treatment. [61] (10.1016/j.jse.2022.07.008)
[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. [64] (10.1016/j.jse.2023.07.044)
[L3] Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade. [65] (10.1016/j.jseint.2021.11.007)
[L4] The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status. [66] (10.5435/jaaos-d-15-00240)
[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. [67] (10.1016/j.jse.2015.08.030)
[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. [68] (10.1016/j.jse.2021.07.014)
[L4] The Humerus Block technique is a very good and predictable, minimally invasive, percutaneous operative technique for treatment of various types of proximal humeral fractures that results in very good pain relief, mobility, and pull force in the arm with a low incidence of avascular necrosis. [70] (10.1016/j.jse.2011.07.029)
[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. [71] (10.1097/corr.0000000000002391)
[L4] Scaption kinematics of reverse shoulder arthroplasty do not change after the sixth postoperative month. [91] (10.1016/j.clinbiomech.2018.07.005)
[L5] We found that 16 of the 34 modified placements had an overall beneficial impact on reverse shoulder biomechanics. [92] (10.1002/jor.25238)
[L5] A gained understanding of the consequences of implant head shape in TSA may guide future surgical implant choice for better recreation of native shoulder kinematics and potentially improved patient outcomes. [96] (10.1186/s12891-023-06273-5)
[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. [97] (10.1016/j.jse.2019.07.022)
[L5] Even if TM external rotation moment arm is higher in RTSA than in a normal shoulder, the decreased length could impair its force generation. [98] (10.1016/j.jse.2014.08.019)
[L5] In the normal shoulder, the humeral head is maintained within one to two millimeters of the anatomic center of the humeral head with either passive or active range of motion in the plane of the scapula. [99] (10.1016/s1058-2746(96)80116-9)
[L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. [102] (10.1016/j.jse.2007.06.017)
[L5] Kinematics of the arthroplasty are controlled primarily by soft-tissue releases and the selection of the prosthetic head-neck length. [105] (10.1016/s1058-2746(96)80396-x)
[L5] Kinematics of the arthroplasty are controlled primarily by soft-tissue releases and the selection of the prosthetic head-neck length. [106] (10.1016/1058-2746(93)90075-r)
[L5] High variations in muscle moment arms were found for all 3 deltoid components, presenting an opportunity to dramatically change the deltoid moment arms through surgical placement of the reverse shoulder components and by varying the overall offset of the humerus. [107] (10.1016/j.jse.2015.10.028)
[L4] [109] (10.2106/jbjs.m.01039)
[L4] [110] (10.1007/s11999-011-1919-6)
[L4] [112] (10.1016/j.jse.2020.03.010)
[L3] Patients with proximal humeral fractures treated with early range of motion exercises do well, largely returning to baseline functional status by 1 year. [113] (10.1016/j.jse.2007.07.016)
[L5] Positioning the humeral tray with posterior offset offers a biomechanical advantage for patients needing RTSA by decreasing superior impingement and increasing the internal rotational moment arm of the subscapularis, without creating inferior impingement. [114] (10.1016/j.jse.2014.09.022)
[L5] Replacing the native head with a component of equal diameter reduced elevation 20%, rotation 40%, A/P translation 50%, and inferior translation 60% in the vented shoulder. [117] (10.1016/s1058-2746(98)90006-4)
[L3] [125] (10.1016/j.jse.2020.03.053)
[L3] [130] (10.1016/j.jse.2017.02.005)
[L5] Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics. [131] (10.5435/jaaos-d-20-00555)
[L4] Patients with minimally displaced (<3 mm) or non-displaced fractures of the proximal humerus can be reassured that a favorable outcome is anticipated with a staged rehabilitation protocol, although full recovery might take an average of 8 months. [134] (10.1016/j.jse.2013.01.033)
[L4] Nonsurgical management of proximal humerus fractures decreased during the study period. [138] (10.1016/j.jhsa.2020.03.022)
[L1] Immediate physiotherapy after a minimally displaced proximal humeral fracture results in faster recovery, with maximal functional benefit being achieved at 1 year. [140] (10.1016/j.jse.2006.06.003)
[L4] [141] (10.1097/00132589-200306000-00005)
[L5] Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty. [142] (10.5435/jaaos-d-17-00051)
[L4] [143] (10.1016/j.jse.2022.10.022)
[L4] [145] (10.1016/s1058-2746(00)90052-1)
[Paper] [148] (10.1097/01.bte.0000169730.36840.4b)
[L2] Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern. [149] (10.2106/jbjs.20.02137)
[L3] [150] (10.1007/s11999-015-4448-x)
[L3] Although the less-invasive surgical procedure is a feasible treatment option in proximal humeral fractures with acceptable complications and considerable improvement during the first six months, a lengthy recovery time is required. [151] (10.1186/s12891-015-0618-y)
[L1] These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial. [152] (10.1371/journal.pmed.1002855)
[L2] Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months. [153] (10.1016/j.jse.2025.01.042)
[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. [154] (10.1016/j.jse.2015.08.006)
[L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. [155] (10.1016/j.jse.2011.01.025)
[L4] Trauma surgeons have a more aggressive approach to rehabilitation following operative proximal humerus fracture repair compared to shoulder surgeons regarding time to weightbearing status and passive range of motion. [156] (10.1016/j.jse.2021.12.045)
[Paper] By utilizing surgical techniques that focus on tuberosity reconstruction, excellent results can be seen with reverse shoulder replacement for fracture. [157] (10.1097/bte.0000000000000102)
[L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. [161] (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. [162] (10.1097/corr.0000000000002242)
[L3] Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously. [163] (10.1016/j.jse.2013.09.006)
[L3] The choice of approach for exposure of the proximal humerus region may influence the functional outcome. [164] (10.1016/j.jse.2007.03.029)
[L5] This review highlights various technical strategies to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates. [166] (10.5435/jaaos-d-22-01211)
[L4] The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice. [168] (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. [170] (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. [171] (10.2106/00004623-199609000-00012)
[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. [172] (10.1016/j.jse.2010.09.008)
[Case_report] Axillary artery injuries are rare but serious complications in proximal humeral fractures, and the vascular state should be evaluated periodically after a fracture because pulses may disappear and symptoms may appear after several days. [173] (10.1016/j.jse.2006.04.009)
[L1] This meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA, suggesting comparable performance in the treatment of proximal humerus fractures. [174] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
[L4] In elderly with inadequate bone stock and needing early recovery of autonomy in daily activities, RTSA effectively treats complex proximal humerus fractures. [177] (10.1016/j.injury.2020.07.056)
[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. [179] (10.1016/j.jse.2023.02.118)
[L4] Pain relief is the most predictable outcome of hemiarthroplasty for severe proximal humeral fractures, with functional outcomes related to surgical technique and patient cooperation. [180] (10.1067/mse.2002.126615)
[L5] These findings suggest limited utility of hemiarthroplasty in the long term, supporting the need for careful patient selection and consideration of alternative surgical options such as reverse shoulder arthroplasty. [181] (10.1016/j.xrrt.2025.100616)
[L5] [182] (10.1016/j.jse.2013.10.003)
[L4] [183] (10.1097/bte.0b013e3181a61de8)
[L3] The SFInX is a feasible outcome measure which clinicians can use to reliably measure and detect clinically important changes in the construct of 'shoulder function', the ability to perform activities in which the shoulder is involved, in people recovering from a proximal humeral fracture. [184] (10.1186/s12891-016-1138-0)
[Paper] [186] (10.1097/bte.0000000000000062)
[L3] Shoulder arthroplasty is an effective treatment for fracture sequelae with significant improvement in pain and function. [187] (10.1007/s00402-014-2074-9)
[L3] The most important risk factors for postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. [188] (10.1186/s13018-019-1233-7)
[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. [189] (10.1007/s11999-012-2531-0)
[L5] Technical considerations may play a key role in the poor and unpredictable results reported after shoulder replacement for four-part proximal humeral fractures. [191] (10.1097/00132589-200001020-00004)
[L4] Reverse shoulder prosthesis using a dedicated stem is a very viable solution to treat complex proximal humerus fractures with reliable restoration of elevation. [192] (10.1186/s13018-015-0261-1)
[L5] Reverse shoulder arthroplasty is advocated for complex proximal humerus fractures in elderly patients because it provides more consistent and predictable results compared with hemiarthroplasty or plate osteosynthesis. [193] (10.5435/jaaos-d-24-00890)
[L3] Reverse shoulder arthroplasty provides satisfactory pain relief for proximal humerus fractures regardless of humeral fixation type. [195] (10.1016/j.jse.2017.06.027)
[L4] Satisfactory results can be expected with the trabecular metal shoulder prosthesis for the treatment of complex proximal humeral fractures. [196] (10.1007/s00264-013-2061-8)
[L3] Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures overall. [198] (10.5435/jaaos-d-16-00223)
[L3] Internal fixation of three-part and four-part proximal humerus fracture dislocations resulted in poor shoulder function and complications in a high number of patients, although fracture union was achieved in most patients. [199] (10.1097/corr.0000000000002190)
[Abstract] RTSA is an effective treatment option for selected patients with acute proximal humerus fractures. [201] (10.1016/j.jse.2014.06.021)
[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. [206] (10.1186/s12891-018-2225-1)
[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. [207] (10.1016/j.jse.2013.11.009)
[L3] Recovery from a proximal humeral fracture appears to be enhanced by overcoming fears of movement or reinjury within a week after injury and greater self-efficacy within a month. [208] (10.1302/0301-620x.101b6.bjj-2018-0857.r1)
[L1] The authors critically reviewed existing Level I and Level II studies to determine the role of RTSA for treating proximal humerus fractures in patients older than 65 years, noting that while RTSA offers predictable pain relief and functional restoration independent of rotator cuff function, it carries substantial risks of complications. [210] (10.1097/corr.0000000000001910)
[Paper] A third concludes that 30-day and one-year mortality is higher for patients who have sustained a combined hip and proximal humerus fracture compared to those with a hip fracture alone. [211] (10.1177/1758573218791110)
[L4] Nevertheless, revision shoulder arthroplasty remains challenging with a high rate of complications. [214] (10.1016/j.jse.2013.07.041)
[L4] Acute deep infection after ORIF of proximal humeral fractures is a devastating complication with high complication rates, poor functional outcomes, and a notably high nonunion rate. [216] (10.1016/j.jse.2006.09.021)
[L3] The prevalence of nonunion after proximal humeral fracture is higher than previously reported, with most patients having a very low risk but a smaller subgroup at much higher risk. [218] (10.2106/jbjs.20.01139)
[L4] The most common reasons for reoperation were humeral component fracture for 1 particular implant, humeral loosening, dislocation, infection, and glenoid failure, each occurring at a rate under 1%. [219] (10.1016/j.jse.2019.01.026)
[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. [220] (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. [222] (10.1097/corr.0000000000002017)
[L4] Humeral loosening is rare in RSA, occurring in 0.7% of primary and 2.8% of revision cases. [224] (10.1016/j.jse.2023.02.006)
[L3] Combined fractures with femoral or vertebral fractures are associated with significantly higher mortality and morbidity compared with isolated proximal humerus fractures. [226] (10.1016/j.jse.2025.04.013)
[L1] A clear standardised set of shoulder arthroplasty complication definitions is lacking. [234] (10.1007/s00402-017-2635-9)
[L4] The study highlights the previously underappreciated high incidence of humeral component malposition in cases requiring revision arthroplasty. [236] (10.1016/j.jse.2024.11.015)
[L4] Overall, there was a moderate rate of complications but low rate of revision following IMN of humerus fractures. [237] (10.1016/j.jse.2024.07.049)
[L4] The rate of complications after operative treatment of proximal humeral fractures is high. [239] (10.1016/j.jse.2006.05.008)
[L2] Radiographic evaluation of the shoulder in patients with minimally displaced proximal humeral fractures is helpful in predicting functional outcome during conservative treatment, specifically angulation on the Y lateral view. [241] (10.1016/j.jse.2009.07.066)
[L1] Reverse shoulder arthroplasty (RSA) had the highest probability for improving functional outcome and reduction in the total incidence of complications and requiring additional surgery among the five interventions for treating adults with displaced proximal humeral fracture. [242] (10.1371/journal.pone.0166801)
[L4] Anteroposterior abduction radiographies up to 90 degrees are superior to conventional radiographies for detecting both radiolucent zones (78 per cent) and loosening of the glenoid component (15.5 per cent). [244] (10.1016/s1058-2746(96)80401-0)
[L5] Surgery for complex proximal humeral fractures leads to overall good long-term outcomes with high overall complication and reoperation rates. [245] (10.2106/jbjs.19.01109)
[L5] Primary hemiarthroplasty for proximal humerus fractures effectively relieves pain, although functional outcome is less predictable. [248] (10.1097/00132589-200412000-00001)
[L5] A morphovolumetric 3-dimensional approach improves knowledge about pathomorphology of proximal humeral fractures. [250] (10.1016/j.jse.2017.12.004)
[L4] The comorbidity indices mCCI and mFI-5 are both strongly associated with adverse events but have moderate ability to predict complications following surgical treatment of proximal humerus fractures. [251] (10.1016/j.jse.2020.06.014)

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