Clinicians › Shoulder

Proximal Humerus Fracture

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

153 citationsUpdated Oct 2026

For patients: a plain-language version of this topic is available. See the patient guide.

Overview

Proximal humerus fractures in adults are predominantly managed non-operatively, a strategy associated with good outcomes in the majority of cases [1]. Most one-part fractures are amenable to this conservative approach, with positive outcomes reported in the vast majority of instances [11]. Nonsurgical management consistently demonstrates successful outcomes and union rates greater than 90% [12], supported by systematic reviews highlighting high rates of radiographic healing, good functional results, and a modest complication rate [13]. This remains the standard of care for most older adults [5] and most elderly patients, who generally achieve good functional outcomes without surgery [19].

Operative intervention remains controversial, as available literature does not demonstrate a clear clinical benefit of surgery over nonoperative management for adult patients younger than 65 years [24]. No single fixation method serves as a panacea; implant selection must be tailored to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [53]. While nail fixation is a very good technique when indications are well defined [44], prospective trials with longer-term follow-up are required to definitively assess the ideal construct for two-part fractures [27]. For specific subgroups, such as older patients with 3- or 4-part fractures, a new intramedullary support nail and plate system has confirmed advantages at 1-year follow-up [6]. Reverse total shoulder arthroplasty is a reasonable and safe option for higher Neer grades or older patients [59], though it carries significantly worse perioperative outcomes, including higher complication rates, longer hospital stays, and higher costs compared to other indications [203]. Hemiarthroplasty with a specific fracture stem and adequate tuberosity management yields successful radiographic and functional results after a mean follow-up of 4.8 years for primary nonreconstructable humeral head fractures [68].

Definitive treatment is influenced by age and gender [2], with distinct algorithms and outcomes for patients aged 60 years or younger compared to the elderly population [16]. Mortality at 1 year for fragility fractures is universally high regardless of risk factors [17]. Pediatric patients typically experience favorable results with infrequent complications [22]. Conversely, patients with pathologic humerus fractures have significantly higher complication rates after surgical treatment compared to those with native fractures, suggesting that guidelines for native fractures may not be generalizable to pathologic origins [70]. Current research methodology is limited by conflicting opinions on optimal outcome measures [20] and a lack of patient-specific variables in most randomized controlled trials [26]. It is recommended that future literature use at least three outcome measures and one general health score [3]. The development of an evidence-based clinical protocol is long overdue, requiring a thoughtful, all-inclusive, randomized multicenter trial to determine the best treatment options [69].

Anatomy & Pathophysiology

Bony Anatomy

The proximal humerus comprises four main parts: the humeral head, greater tuberosity (GT), lesser tuberosity (LT), and humeral shaft [76]. The articular head is spherical with a diameter of 37 to 57 mm [76] and an arc of approximately 160 degrees covered by articular cartilage [88]. The radius of curvature is approximately 25 mm, slightly larger in men than in women [88]. The most superior portion of the articular surface averages 8 mm above the greater tuberosity [76], with the superior margin normally positioned 8 to 10 mm superior to the top of the greater tuberosity [88]. Humeral version averages 29.8 degrees, ranging from 10 to 55 degrees [76], while retroversion averages 30 degrees [77] or 19 degrees depending on measurement method, with a highly variable range of 0 to 55 degrees [88]. The humeral head is inclined approximately 130 degrees with respect to the humeral shaft [76], and the neck-shaft angle measures an average of 135 degrees [77] or 45 degrees (±5 degrees) with a range of 30 to 50 degrees [88].

The anatomic neck is located at the junction of the articular surface and the tuberosities [76]. The surgical neck represents an indistinct metadiaphyseal junction below the tuberosities but above the humeral shaft [76]. The bicipital groove lies between the greater and lesser tuberosities, serving as a pathway for the long head of the biceps, with its distal aspect internally rotated relative to the proximal portion [76]. The glenoid is a convex, shallow structure shaped like an inverted pear [76], forming a socket approximately one-third the size of the humeral head [77]. The acromion, coracoacromial ligament, and coracoid process form the coracoacromial arch, a rigid bony-ligamentous structure imparting stability to the shoulder girdle [76]. The control volume is an important anatomic and functional area of the proximal humerus [71].

The distance from the lateral base of the coracoid process to the lateral margin of the greater tuberosity is defined as the lateral humeral offset [88]. A significant decrease in this offset reduces lever arms for the deltoid and supraspinatus muscles, weakening abduction and impairing function [88]. Conversely, a significant increase causes excessive soft tissue tension, resulting in loss of motion and likely accelerating polyethylene wear [88].

In pediatric anatomy, the proximal humerus has three centers of ossification: the humeral head (4 to 6 months), the greater tuberosity (1 to 3 years), and the lesser tuberosity (3 to 5 years) [79]. These centers fuse to the shaft at age 17 to 20 years [79]. The proximal humeral physis closes by 14 to 17 years in girls and 16 to 18 years in boys [83]. Eighty percent of subsequent humeral growth originates from this physis, accounting for approximately 40% of total upper extremity growth [83]. In infants and young children, humeral retroversion averages 65 degrees, gradually decreasing to adult values by 11 years of age [83]. The periosteum is thicker and stronger posteromedially than anterolaterally, where it is often quite thin [83]. The physis is irregularly shaped, with its apex located on the posteromedial portion of the proximal humerus [83].

Soft Tissue Anatomy

The greater tuberosity serves as the attachment site for the supraspinatus, infraspinatus, and teres minor tendons [76], while the lesser tuberosity serves as the attachment site for the subscapularis tendon [76]. The rotator cuff consists of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles [77]; the teres major is not a rotator cuff muscle [77]. These muscles act as depressors of the humeral head to allow efficient deltoid abduction [77]. The infraspinatus and teres minor are external rotators, while the subscapularis is an internal rotator [77].

Predictable fracture displacement occurs due to the deforming forces of the pectoralis major, subscapularis, supraspinatus, and infraspinatus [77]. The subscapularis inserts on the lesser tuberosity, causing medial displacement of fragments [76]. The supraspinatus and infraspinatus insert on the greater tuberosity, causing superior and posterior displacement [76]. The pectoralis major inserts on the humeral shaft, displacing it medially [76].

The subacromial bursa separates the rotator cuff tendons from the coracoacromial arch, allowing gliding [84]. The subscapular bursa lies between the subscapularis tendon and the scapular neck, communicating with the joint cavity between the superior and middle glenohumeral ligaments [80]. This bursa often houses loose bodies and is a region where synovitis may be most intense [80]. The rotator interval is defined medially by the coracoid base, superiorly by the supraspinatus tendon, and inferiorly by the subscapularis tendon [79]. It contains the coracohumeral ligament, superior glenohumeral ligament, and intra-articular portion of the long head of the biceps tendon [79].

The infraspinatus and supraspinatus tendons join approximately 15 mm proximal to insertion and cannot be readily separated by blunt dissection [89]. The supraspinatus and subscapularis tendons join as a sheath surrounding the biceps tendon at the bicipital groove entrance [89]. The roof of this sheath consists of a portion of the supraspinatus tendon, while a sheet of the subscapularis tendon forms the floor [89]. The coracohumeral ligament is a thick fibrous band extending from the coracoid process along the capsule to the tuberosities between the supraspinatus and subscapularis tendons [89]. It lies deep to the cuff insertion, blending with the capsule and supraspinatus tendon to form part of the biceps sheath roof [89].

The humeroscapular motion interface lies between the inner structures (proximal humerus, rotator cuff, coracohumeral ligament, biceps tendon sheath) and the superficial layer (acromion, deltoid, coracoacromial ligament, coracoid process, conjoined tendon) [82]. Smooth, unrestricted motion at this interface is vital to shoulder mobility [82]. Adhesions in this interface, such as scarring after proximal humerus fracture trauma, can limit shoulder mobility [82].

Vascular and Neurovascular Anatomy

The proximal humerus receives blood supply from the anterior and posterior humeral circumflex branches of the third division of the axillary artery [76]. The anterior humeral circumflex artery arises from the axillary artery at the inferior border of the subscapularis [76]. It provides vascular inflow to the humeral head via its terminal anterolateral branch, the artery of Laing (arcuate artery) [76]. The ascending branch courses parallel to the lateral aspect of the long head biceps tendon, entering the humeral head at the interface of the bicipital groove and greater tuberosity [76]. The anterolateral ascending branch provides the primary blood supply to the humeral head [79], with its terminal intraosseous portion entering at the proximal aspect of the intertubercular groove as the arcuate artery [79].

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 [76]. Quantitative assessment shows that 64% of the humeral head blood supply arises from the posterior humeral circumflex artery [83]. Injury to the arcuate artery may result in osteonecrosis of the humeral head [76], although additional extraosseous collateral branches can permit perfusion despite complete ligation of the arcuate artery [76].

The brachial plexus is prone to injury in proximal humerus fractures or dislocations due to close proximity [83]. The axillary nerve, a terminal branch of the posterior cord of the brachial plexus just proximal to the coracoid process [82], circles the humeral neck just inferior to the glenohumeral joint as it courses posteriorly [83]. It passes beneath the conjoined tendon anterior to the subscapularis, 3 to 5 mm medial to the musculotendinous junction, then adjacent to the inferior capsule before entering the quadrilateral space posteriorly [82]. Within the quadrangular space, the axillary nerve splits into anterior and posterior branches [82]. The anterior and middle deltoid muscles receive sole innervation from the anterior branch [82]. Posterior deltoid innervation varies: supply only from the anterior branch in 2.3% of cases, from the posterior branch in 8.5%, and from both branches in 89.1% [82]. The posterior branch supplies the teres minor muscle and terminates as the superior lateral brachial cutaneous nerve [82].

The close anatomical relationship between the proximal humerus, axillary artery, and brachial plexus predisposes these structures to combined injury patterns that can threaten limb viability [36]. Neurovascular injuries associated with proximal humerus fractures represent a rare yet clinically significant complication with potential for devastating functional outcomes [36].

Pathophysiology and Biomechanics

Stability and function of the glenohumeral joint are provided by interactions promoting a near global range of motion and purposeful function [76]. External loads are initially offset by joint surface anatomy, joint volume, atmospheric pressure, and joint fluid cohesion and adhesion [76]. Moderate and large loads are counterbalanced by the deltoid and rotator cuff, and by capsulolabral and bone structures, respectively [76]. The glenoid bone is generally harder and denser than the proximal humerus, acting as an 'anvil' on which the proximal humerus is impacted during injury [67]. The combination of blow direction, bone quality, and soft tissue pull produces various fracture patterns [67].

Proximal humerus fractures alter complex shoulder girdle interactions, resulting in pain, decreased range of motion, stiffness, and disability [76]. Displacement of fracture parts occurs predictably based on deforming forces from the pectoralis major, subscapularis, supraspinatus, and infraspinatus [76]. Fractures involving the anatomic neck are prognostically worse than other regions due to potential disruption of the vascular supply to the humeral head and subsequent avascular necrosis [76]. Anatomic neck fractures have a poor prognosis because of complete disruption of the blood supply to the head [77]. In contrast, surgical neck fractures are common, and the blood supply to the head is preserved [77].

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 [76]. In both displaced and nondisplaced fractures, the subdeltoid and subacromial bursae can become thickened and fibrotic, forming adhesions that limit normal glenohumeral motion [76]. Early range of motion exercises have been hypothesized to decrease the formation of such adhesions [76].

The biomechanical model distinguished between different mechanisms of injury and resulting fracture configurations [184]. Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics [195]. Marked varus deformity causes limitation of abduction and forward flexion of the shoulder [173]. Positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures [152]. With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly [138].

Biomechanical changes associated with inferior tuberosity positioning after hemiarthroplasty may explain diminished function in patients with proximal humerus fractures [141]. Anatomic reconstruction of the humeral prosthetic reconstruction for four-part proximal humerus fractures produced results indistinguishable from normal shoulder controls [181]. The impaired function after hemiarthroplasty in displaced four-fragment fracture of the proximal humerus seems to be caused by reduced glenohumeral mobility rather than muscle strength [146]. Rotator cuff tears are a detrimental factor and a major cause of painful shoulders in conservatively treated proximal humerus fractures [197].

Nerve lesions in proximal humeral fractures are caused by extreme movements of the arm beyond physiological limits, leading to traction injury [223]. Most nerve injuries, particularly involving the axillary nerve, demonstrate favorable outcomes with conservative management [36]. Vascular injuries associated with proximal humerus fractures demand urgent multidisciplinary intervention to restore perfusion and prevent irreversible ischemia [36].

Classification

Epidemiology and Context

Proximal humeral fractures account for approximately six per cent of all adult fractures [34]. The incidence rapidly increases with age [34], and women are affected between two and three times as often as men [34]. In adults, 87% of these fractures result from falls from standing height [34]. These injuries are osteoporotic in nature, with incidence rising due to aging populations [7]. In Finland, the incidence of osteoporotic-related proximal humerus fractures tripled between 1970 and 2002 to 105 per 100,000 people aged 60 or above [34]. A 2009 USA epidemiological study reported an overall incidence of 60 per 100,000 people [34], rising to 253 per 100,000 in those aged 65 or older [34]. Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions [7].

Neer Classification

Neer: The Neer classification divides the proximal humerus into four anatomical segments: the articular part, the greater tuberosity, the lesser tuberosity, and the humeral shaft [34]. A segment is considered a distinct 'part' if displaced by more than one centimetre or 45 degrees angulation from each other [34]. Fractures not meeting these displacement criteria are classified as 'minimally displaced' or one-part fractures [34]. Two-part, three-part, and four-part categories involve the displacement or angulation of some or all of these segments [34]. Developed to describe displaced fractures based on segmental involvement [172], Neer indicated the system was meant for application after operative exposure, believing radiographs alone were unreliable [23]. The classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice [122]. Fracture complexity according to the Neer classification is associated with clinical outcomes 10 years after nonoperative treatment [144]; less complex fractures show better range of motion and function compared with more complex ones at 10 years in nonoperatively treated patients [144]. The Neer classification is associated with 10-year clinical outcomes in nonoperatively treated fractures, whereas the AO classification is not [144]. However, the system has limited intraobserver and interobserver reliability [23], with considerable disagreement regarding classification [108]. Classifications based on CT scans and plain radiographs are not very reliable or reproducible due to difficulty in determining fractured segments [112]. Eleven observational studies consistently show a low level of observer agreement [189]. The belief that experts disagree less than nonexperts could not be supported [189], though training improves agreement among both groups [189]. Morphologic classification as the sole basis for treatment algorithms and surgical success should be scrutinized [160].

AO/OTA Classification

AO/OTA: The AO classification uses a 3-category division of A, B, and C [196]. Type A fractures are simple fractures [196], while Type B fractures involve the surgical neck [196]. The AO classification proved more comprehensive than the Neer system because it adequately describes the spectrum of proximal humeral fractures, including impacted valgus fractures not included in the Neer system [139]. However, the AO classification has limited intraobserver and interobserver reliability [23]. Classification of proximal humeral fractures with both the Neer and AO systems remains difficult [104]. The modified AO/OTA classification used in the Swedish Fracture Register had moderate reliability [163], with registered data showing only fair accuracy compared with a gold standard [163].

Reliability and Interobserver Agreement

The lack of a reliable classification confounds efforts to compare outcomes of treatment methods among different clinical trials and reports [23]. The addition of two-dimensional (2-D) computed tomography (CT) scans did not improve the interobserver reproducibility of the Neer or AO classification systems [23]. Agreement on the Neer classification was slight, indicated by a kappa measure (k = 0.069 to 0.14), across radiographs, 2-D CT scans, and three-dimensional (3-D) CT scans [23]. Agreement on treatment was fair (k = 0.28 to 0.33) across these imaging modalities [23]. Neither the Neer classification nor treatment selection exhibited strong performance for clinical or research use across imaging modalities [23]. Evaluation of classification systems using plain radiographs has yielded low interobserver reliability [109]. At present, there remains a 50% agreement between observers on how to classify proximal humeral fractures [63]. Simplifying classifications and training observers did not improve interobserver reliability for the diagnosis of proximal humeral fractures overall [192]. Three-dimensionally printed models improved interobserver agreement in the classification of proximal humeral fractures using the Neer system [167].

Alternative Classification Systems

HGLS: The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems [103]. Qualitative CT-based: A new classification system emphasizing qualitative aspects of proximal humeral fractures showed high reliability when based on a standardized imaging protocol including computed tomography scans [33]. Hertel vs. Neer: Data do not confirm superiority of either the Hertel or Neer classification system for the classification of comminuted proximal humeral fractures [145]. Mayo-FJD: The Mayo-FJD classification system for proximal humerus fractures seems to allow high intraobserver and interobserver agreement using both radiographs and computed tomography [149]. It is a robust tool for predicting clinical success in proximal humerus fractures initially treated nonsurgically [178]. MTM: The MTM-classification results in various differences in reliability depending on the short or extensive version of application [183]. The interobserver analysis of the short version resulted in moderate kappa values in the category 'main parts' and substantial kappa values for analyzing 'fracture displacement' [183]. The extensive version, including evaluation of the main or individual fracture type with inclusion of the specification, resulted in only fair agreement [183].

Other Considerations

Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others [10]. Future literature on proximal humerus fractures should use at least 3 outcome measures and 1 general health score until the optimal scores are determined [3]. Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [48]. Standardized definitions are needed to improve evidence synthesis for complications following non-surgical management of proximal humeral fractures [48]. Most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria besides age [26].

Clinical Presentation

Epidemiology and Demographics

Proximal humerus fractures are typically osteoporotic injuries occurring in women over 70, with prevalence increasing due to an aging population in poor general condition [39]. Nondisplaced proximal humeral fractures are among the most common fractures associated with osteoporosis [128]. These injuries are associated with an increased prevalence of previous fractures of the spine and extremities [25]. Furthermore, a fracture of the proximal humerus predicts an increased risk of future fractures [25].

Clinical Evaluation and Imaging

Accurate clinical evaluation, imaging, and classification are paramount for informed treatment decisions in proximal humerus fractures [7]. The axillary view is painful, labor-intensive, costly, and does not appear to provide additional diagnostic value [55]. Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae [38]. Diagnosis of neurovascular injuries associated with proximal humerus fractures relies on early recognition through meticulous clinical examination and advanced imaging modalities [36].

Classification Reliability

Treatment protocols and scientific experiments rely on accurate and reliable fracture characterization prior to surgery [23]. However, the Neer and AO classifications of proximal humeral fractures have limited intraobserver and interobserver reliability [23]. Some investigators have reported that 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 [23]. There was slight agreement on the Neer classification, as indicated by the kappa measure (k = 0.069 to 0.14), and fair agreement on treatment (k = 0.28 to 0.33) across radiographs, 2-D CT scans, and three-dimensional (3-D) CT scans [23]. Neither the Neer classification nor treatment selection exhibited strong performance for clinical or research use based on interobserver agreement studies [23]. Surgeons agree more on treatment recommendations than on classification of proximal humeral fractures [41].

Fracture Morphology and Patterns

Fractures of the proximal humerus follow characteristic patterns [8]. Complications associated with proximal humerus fractures are varied and can be categorized as occurring at the time of initial injury, during operative management, or as delayed sequelae [21]. The multifactorial etiology of neurovascular injuries encompasses direct trauma from displaced fracture fragments and indirect mechanisms [36].

Prognosis and Outcomes

In the vast majority of cases, proximal humerus fractures may be treated nonoperatively [14]. A majority of patients with proximal humeral fractures underwent non-operative treatment [56]. Nonsurgical management of proximal humerus fractures that would traditionally necessitate surgical treatment can be a viable option in certain patients whose circumstances preclude surgical treatment [4]. There is a substantial mortality in patients with a proximal humerus fracture [9]. Surviving patients with proximal humerus fractures frequently have persistent symptoms that can be predicted as early as after 1 year [9]. Nondisplaced proximal humeral fractures can be a major cause of functional disability and reduction in subjective patient-perceived health [128]. Fractures of the proximal humerus, even with the most expert treatment, can result in pain, stiffness, and loss of function [121]. In the young, active patient, a failure to diagnose and treat proximal humerus injuries promptly can result in significant morbidity and a high socioeconomic cost [121].

Decision-Making Factors

The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status [140]. Orthopaedic management of proximal humerus fractures requires proper evaluation, radiological views, patient age, and activity levels [35]. A simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures [58]. 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 [120]. 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 [135].

Investigations

Clinical Evaluation and Epidemiology: The incidence of proximal humerus fractures increases sharply in the elderly [95]. These injuries carry substantial mortality [9]. Among surviving patients, persistent symptoms are frequent and can be predicted as early as one year post-injury [9].

Plain Radiography: Standardized plain films are almost always sufficient for shoulder evaluation, provided proper radiographic technique is employed, which is as critical to outcome as surgical technique [31]. The recommended series is the Neer trauma series, comprising an AP view, a lateral view in the scapular plane, and a Velpeau modified axillary view [95]. This combination allows evaluation of the shoulder joint in three separate perpendicular planes [95]. The axillary view is essential for evaluating the glenoid articular surface and the anterior-posterior relationship of the humeral head [95]. At least two views are required: an anteroposterior view in the plane of the glenoid and an axillary projection with the arm in abduction [93]. The standard shoulder series should also include a true AP view in the scapular plane, an AP view, an axillary view, and a scapular Y view [101]. The true AP view in the scapular plane visualizes the anterior greater tuberosity in profile [101]. The AP view with the arm in internal rotation visualizes the posterior aspect of the greater tuberosity and the lesser tuberosity in profile [101]. The axillary view determines humeral head position within the glenoid fossa and may detect occult, locked posterior shoulder dislocation in patients lacking passive external rotation [101]. The scapular Y view visualizes the coracoacromial arch, reveals coracoacromial spurs, and serves as a reliable alternative for evaluating glenohumeral subluxation and dislocation [101]. Normal acromiohumeral distance is 7 to 14 mm, the glenohumeral joint space width should be symmetric superiorly and inferiorly, and the coracoclavicular distance is normally 1.1 to 1.3 cm [101]. Initially, AP and lateral plain radiographs are usually obtained for acute shoulder trauma, including fractures or dislocations, and are often the only required studies [100]. The shoulder is a three-dimensional structure that cannot be represented by a single planar view, and critical relationships such as humeral head centering change with arm position [96]. Overlying structures and metallic implants may complicate imaging [96]. Surgeons must adopt a judicious approach to imaging to avoid "over-imaging," obtaining only necessary scans or reconstructions [31, 96]. One-week control X-rays are not necessary for conservatively treated proximal humeral fractures [229]. Non-operative treatment seldom results in displacement warranting operative intervention, rendering routine postoperative radiographs of little utility in follow-up [52].

Computed Tomography (CT): CT is helpful for planning fracture surgery and shoulder joint replacement [93]. On occasion, CT scanning is necessary for detailing bony anatomy in proximal humerus fractures [95]. CT imaging is frequently used to evaluate shoulder fractures [100]. However, CT may offer only a few degrees of increased precision in measuring glenoid version, which does not improve surgical quality or clinical outcome [31]. Information gathered from properly taken plain films cannot always be obtained from CT scans [31]. The addition of two-dimensional (2-D) CT scans did not improve the interobserver reproducibility of the Neer or AO classification systems [23]. Three-dimensional (3-D) CT imaging did not offer improved interobserver and intraobserver agreement compared with 2-D CT regarding classification and treatment, except among reviewers with limited clinical experience [244]. Conversely, 3-D CT images were more reliable than plain radiographs in assessing prognostic factors of reduction loss in fractures treated with locking plates [235]. The routine use of 3D-printed models may not be beneficial for classifying fracture patterns beyond current imaging modalities, and their use as the sole determinant for recommending surgical intervention should be avoided [246].

Magnetic Resonance Imaging (MRI): MRI is useful for identifying osteonecrosis of the humeral head or bone tumours [93]. It is the modality of choice for evaluating the rotator cuff, biceps, and subacromial/subdeltoid bursa [100]. T1-weighted MRI can reveal Hill-Sachs lesions, while T2-weighted MRI provides better visualization of full-thickness rotator cuff tears [100]. Traditional MRI utilizes high contrast and spatial resolution for soft tissue evaluation [98]. MR accuracy in identifying labral and rotator cuff tears ranges from 70% to 100% [98]. Multi-planar imaging allows detailed evaluation of the glenoid, labrum, joint capsule, and rotator cuff in different planes [98]. Magnetic resonance arthrography (MRA) involves MRI after intra-articular injection of a contrast agent such as diluted gadolinium or saline [98]. MRA increases both sensitivity and specificity for detecting capsulolabral–ligamentous complex injuries compared to traditional MRI [98]. In a meta-analysis of 6 studies including 4,667 shoulders, MRA had greater diagnostic test accuracy for glenoid labral lesions than MRI (MRA sensitivity 88% and specificity 93% vs. MRI sensitivity 76% and specificity 87%) [98]. Abduction and external rotation (ABER) of the arm is an alternative position to increase sensitivity and specificity for detecting anteroinferior labroligamentous injury [98]. However, limited range of motion or pain may prohibit the ABER maneuver [98]. Full routine MRI or MRA examination had similar accuracy as the ABER sequence for evaluating the anteroinferior labral–ligamentous complex [98]. The sensitivity of MRA with the ABER position for detecting anteroinferior labral lesions was significantly higher than MRA in the neutral position [98]. MRA with the ABER position was more effective in identifying Perthes lesions than MRA in the neutral position [98]. MRAs can demonstrate a patulous capsule on coronal, sagittal, and axial imaging in patients with multidirectional instability [98]. MRAs are helpful in evaluating rotator interval lesions and other findings that may affect surgical planning [98]. The diagnosis of multidirectional instability is clinical, and the need for expensive or invasive imaging should be weighed against the information gained [98]. A high index of suspicion and MRI arthrogram investigation are necessary for non-operatively treated proximal humerus fractures if symptoms persist, to address biceps tendon pathology operatively if indicated [211]. ZTE MRI presents a viable alternative to CT in the evaluation of proximal humerus fractures [210].

Ultrasonography: Ultrasonography is a simple, accurate, and low-cost alternative to MRI and arthrography for evaluating skeletal and soft-tissue structures of the shoulder [93, 100]. It is useful for identifying rotator cuff tears and calcific tendinitis [93]. Ultrasound provides immediate, real-time visualization of the rotator cuff, biceps tendon, and calcific deposits [100]. It can be used to measure the subacromial space, detect atrophy of rotator cuff muscles, and evaluate impingement in various positions and motions [100]. Ultrasound can also guide injections or barbotage of calcific deposits [93]. The most commonly performed joint examination using ultrasonography is the shoulder examination [91]. However, ultrasonography is highly operator dependent, and accuracy depends on the skill of the scanner and awareness of pitfalls [91, 100]. It is not as useful for evaluating labral tears or rotator cuff tears that are very small or larger than 3 cm [100].

Other Considerations: Classification and Diagnostic Reliability: There was slight agreement on the Neer classification (k = 0.069 to 0.14) and fair agreement on treatment (k = 0.28 to 0.33) across radiographs, 2-D CT scans, and 3-D CT scans [23]. Neither the Neer classification nor treatment agreement exhibited strong performance for clinical or research use [23]. Artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs [224]. Convolutional neural networks (CNNs) proficiently rule out proximal humerus fractures on plain radiographs [225].

Bone Quality Assessment: DEXA examination of the central skeleton may not reflect the bone quality of the proximal humerus or the severity of the fracture [227]. The proximal humeral average CT value could serve as an objective alternative to DXA for assessing bone quality in elderly patients with proximal humeral fractures [240]. The medial cortex ratio is significantly associated with loss of surgical fixation and may prove useful for clinical decision making [241].

Prognostic and Stability Assessment: Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries [221]. The inherent nature of medial comminution may lead to inferior radiographic outcomes [231]. A radiographic parameter can serve as a predictor of functional results in proximal humerus fractures treated with locking plates [237].

Treatment

Non-Operative Management

The majority of proximal humerus fractures are treated nonoperatively with good functional results [186], and nonsurgical management demonstrates successful outcomes and union rates greater than 90% [12]. Systematic review literature confirms high rates of radiographic healing, good functional outcomes, and a modest complication rate [13]. In a systematic review of 12 studies, the mean rate of radiographic union for non-operative management was 98% (range 93–100%) [105]. The estimated median time to definitive union was 14 weeks, with a 7% risk of delayed or nonunion [105]. A 13% complication rate was reported across studies, with varus malunion being the most common at 7% [105]. Proximal humerus avascular necrosis was found to be uncommon at 2% [105]. The eventual operation rate for non-operatively managed patients was 5.6% in the largest included trial [105].

Indications for nonsurgical treatment include minimal displacement, impacted displaced fractures, medical comorbidities, osteoporosis, low functional demand, and low outcome expectations [115]. Nonsurgical intervention is successful most of the time [115]. However, nonsurgical treatment is not simply “benign neglect” and requires frequent follow-up examination and imaging [115]. Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern [64]. Nonoperative management with a period of immobilization and progressive physiotherapy is a simple, noninvasive, and readily available treatment option [105]. Impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed of 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week [188].

Despite these benefits, nonoperative treatment produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes [151]. Nonsurgical management of proximal humerus fractures decreased during the study period [127]. Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures [157]. Displaced proximal humeral fractures can be treated satisfactorily by non-operative methods [182].

Operative Management

Indications: Treatment for proximal humerus fractures remains controversial, with no good evidence existing whether surgery is clearly superior to nonoperative treatment [190]. There is no evidence of a difference in functional outcome at 1-year follow-up between surgical treatment and conservative treatment of displaced proximal humeral fractures in elderly patients [62]. A trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures [137]. In a randomized controlled trial, surgical treatment proved no better results than conservative treatment for patients with displaced proximal humeral fracture at 2-year follow-up [155]. There is moderate/low certainty of evidence that surgical treatment of moderately displaced proximal humerus fractures in elderly patients has not been proven to be superior to less costly non-surgical treatment options [150]. Indications for surgical treatment include young, high-demand patients, elderly patients with high expectations, cooperative patients, displaced unstable nonimpacted fractures, fracture-dislocations, and adequate bone quality [115].

Surgical Approach / Technique: The rate of complications following operative treatment of proximal humerus fractures is high [61]. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [60]. Minimally invasive plate osteosynthesis (MIPO) is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent [159]. The effectiveness of the NCB (non-bridging construct) is similar to other published methods of treatment for fractures of the proximal humerus and potentially provides a less invasive option [153]. Treatment of 3- and 4-part proximal humeral fractures with an expandable intramedullary cage produced good clinical outcomes and a 100% union rate [158]. Closed reduction and percutaneous pinning has limited indications based on simple fracture pattern, patient compliance, and surgeon experience, and is primarily reserved for the pediatric population [115]. Contraindications for closed reduction and percutaneous pinning include dislocations, metaphyseal comminution/diaphyseal extension, severe osteoporosis (relative), or head-split fracture [115].

Implant Selection: The short-term efficacy of one-stage reverse shoulder arthroplasty to treat complex proximal humeral fractures in the elderly is satisfactory [28]. Reverse shoulder arthroplasty is indicated for complex proximal humerus fractures in patients no younger than 70 years of age [47]. Reverse total shoulder replacement and internal fixation is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [49]. A meta-analysis demonstrates no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in reverse shoulder arthroplasty for proximal humerus fractures [161]. The early, published results to date are encouraging in the treatment of three-part proximal humerus fractures [29].

Other Considerations: It is recommended that future literature on proximal humerus fractures use at least 3 outcome measures and 1 general health score until the optimal scores are determined [3]. The currently available evidence cannot be used to derive any standardized, evidence-based treatment scheme for proximal humeral fractures [136]. Besides age, most randomized controlled trials on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria [26]. The incidence of proximal humeral fractures rapidly increases with age, and women are affected between two and three times as often as men [34]. An epidemiological study reported an incidence of 60 proximal humeral fractures per 100,000 people overall, with a four-fold increased incidence of 253 per 100,000 in those aged 65 or older [34]. The introduction of fixed angle osteosynthesis has led to an extension of the indications for osteosynthesis [136]. Initial randomized trials showed conservative treatment to be superior to osteosynthesis for elderly patients, but these trials were carried out on small, heterogeneous groups of patients with short follow-up intervals and did not include all treatment options [136]. It would be incorrect to conclude that every elderly person with a proximal humeral fracture should be treated conservatively, but trials show that not every fracture needs to be operated on [136]. In elderly patients, including those with three- and four-fragment fractures, Neer threshold values for displacements should be respected if possible [136].

Complications

General and Systemic

Proximal humeral fractures are associated with significant systemic morbidity and mortality. Patients experience a more than two-fold increase in mortality at 1 year (9.8%), which continues to increase to 28.2% at 5 years [65]. Compared with the general population, these patients have a significantly higher risk of mortality up to one year after injury [66]. Substantial mortality persists, and surviving patients frequently report persistent symptoms that can be predicted as early as after 1 year [9]. Registry data indicate that at 5 years, 40.6% of patients had died following inpatient stay for proximal humeral fractures [212]. Additionally, a fracture of the proximal humerus is associated with an increased prevalence of previous fractures of the spine and extremities and predicts an increased risk of future fractures [25].

Operative Complications

Surgery for complex proximal humeral fractures leads to overall good long-term outcomes, but with high overall complication and reoperation rates [57]. In-hospital complications are more likely to occur after reverse shoulder arthroplasty than after locked plating [169]. The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with reverse total shoulder arthroplasty for proximal humeral fractures in patients 65 years and older [169]. After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures [70]. Predictive models using machine learning techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged length of stay and serious adverse complications occurring within 30 days of surgical intervention [191].

Non-Operative Complications

The systematic review of the literature on the nonoperative treatment of proximal humerus fractures demonstrates a modest complication rate [13].

Other Considerations

Low arthroplasty survival is observed after treatment for proximal humerus fracture sequelae, based on 3,245 shoulder replacements from the Nordic Arthroplasty Register Association [15].

Recovery

Mortality and Systemic Outcomes: Patients sustaining a proximal humeral fracture face a significantly higher risk of mortality up to one year after the injury compared with the general population [66].

Nonoperative Management Outcomes: Long-term treatment with reverse shoulder arthroplasty for displaced 3- or 4-part proximal humerus fractures provides better functional outcomes compared to nonoperative treatment [147]. This difference is attributed to the deterioration of functional outcomes of the nonoperative treatment over time [147].

Operative Management Outcomes: The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures [50]. ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [162]. Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results [75]. Reverse total shoulder replacement is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome [49]. The functionality and quality of life of patients with complex proximal humerus fractures treated with reverse total shoulder arthroplasty decreased significantly compared to the 2-year evaluation, although this change was not clinically relevant [168].

Prognostic Factors and Assessment: 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 [238]. Low arthroplasty survival results are pertinent when deciding on the treatment of proximal humerus fracture sequelae [15].

Other Considerations: After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms [45]. Patients in the proximal humerus fracture cohort were less likely to report persistent shoulder pain at all evaluated time points compared to the osteoarthritis cohort, suggesting that symptom relief following treatment of traumatic pathology may differ fundamentally from that of chronic degenerative disease [242].

Key Evidence

• [L4] Non-operative management is associated with good outcomes in the majority of proximal humerus fractures in adults. [1] (10.5312/wjo.v5.i5.685)
• [L3] Both age and gender have an association with the definitive treatment patients received for proximal humerus fractures over the last decade. [2] (10.1016/j.jseint.2021.11.007)
• [L4] We recommend that future literature on proximal humerus fractures use at least 3 outcomes measures and 1 general health score until the optimal scores are determined. [3] (10.1016/j.jse.2020.04.006)
• [L4] This finding suggests that nonsurgical management of proximal humerus fractures that would traditionally necessitate surgical treatment can be a viable option in certain patients whose circumstances preclude surgical treatment. [4] (10.1097/bte.0000000000000174)
• [L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. [5] (10.1016/j.jseint.2021.08.006)
• [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. [6] (10.1186/s12891-022-05998-z)
• [L4] Fractures of the proximal humerus follow characteristic patterns. [8] (10.1016/j.jse.2017.05.014)
• [L3] Our results suggest that there is a substantial mortality in patients with a proximal humerus fracture, as we have previously reported, and that surviving patients frequently have persistent symptoms that can be predicted as early as after 1 year. [9] (10.1080/17453670510041295)
• [L5] Consensus when managing proximal humerus fractures is limited to specific scenarios, whereas lack of consensus still exists in others. [10] (10.1016/j.jse.2024.12.005)
• [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. [12] (10.5435/jaaos-d-24-01073)
• [L4] The systematic review of the literature on the nonoperative treatment of proximal humerus fractures demonstrates high rates of radiographic healing, good functional outcomes, and a modest complication rate. [13] (10.1097/bot.0b013e3182008df8)
• [L4] In the vast majority of cases, proximal humerus fractures may be treated nonoperatively. [14] (10.1155/2012/861598)
• [L3] These results are pertinent when deciding on the treatment of proximal humerus fracture sequelae. [15] (10.1080/17453674.2020.1793548)
• [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. [16] (10.1016/j.xrrt.2023.01.002)
• [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. [17] (10.1016/j.jse.2022.03.006)
• [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [19] (10.2106/jbjs.l.01293)
• [L4] Additionally, there are conflicting opinions on what outcome measure is best to assess function following the treatment of proximal humerus fractures. [20] (10.1007/s00264-017-3569-0)
• [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [22] (10.5435/jaaos-d-14-00033)
• [L3] [23] (10.2106/jbjs.l.00586)
• [L1] The available literature does not demonstrate a clear clinical benefit of operative treatment over nonoperative management of proximal humeral fractures in adult patients younger than 65 years. [24] (10.1016/j.xrrt.2021.04.014)
• [L3] A fracture of the proximal humerus is associated both with increased prevalence of previous fractures of the spine and extremities and also predicting an increased risk of future fractures. [25] (10.1016/j.bone.2004.01.009)
• [L2] Besides age, most RCTs on surgical management of proximal humerus fractures do not include patient-specific variables within their inclusion and exclusion criteria. [26] (10.1016/j.xrrt.2025.07.023)
• [L3] However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures. [27] (10.1016/j.injury.2013.08.024)
• [L4] The short-term efficacy of one-stage reverse shoulder arthroplasty to treat complex proximal humeral fractures in the elderly is satisfactory. [28] (10.1111/os.12777)
• [L5] The early, published results to date are encouraging in the treatment of three-part proximal humerus fractures. [29] (10.1097/00132589-200206000-00007)
• [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. [33] (10.1016/j.jse.2015.08.006)
• [L1] [34] (10.1002/14651858.cd000434.pub4)
• [L1] Orthopaedic management of proximal humerus fractures requires proper evaluation, radiological views, patient age, and activity levels. [35] (10.1016/j.injury.2026.113686)
• [L5] [36] (10.1016/j.xrrt.2026.100825)
• [L2] Computed tomography scan was more specific than radiographs in the assessment of proximal humerus fracture sequelae. [38] (10.1177/17585732221150785)
• [L2] Proximal humerus fractures are now typically osteoporotic fractures in women over 70, with prevalence increasing due to an aging population in poor general condition. [39] (10.1016/j.otsr.2012.05.013)
• [Paper] The majority of proximal humerus fractures may be treated nonoperatively; however, there are certain circumstances that necessitate surgical intervention. [40] (10.1097/bte.0000000000000095)
• [L4] [41] (10.1186/1471-2474-13-114)
• [Paper] Nail fixation for proximal humerus fractures is a very good technique if the indication is well defined. [44] (10.1097/bte.0b013e31817303af)
• [L3] After one-year, long-term follow-up of fixed proximal humerus fractures may be unnecessary for those without symptoms. [45] (10.1007/s00590-021-03099-6)
• [L4] They are indicated for complex proximal humerus fractures in patients no younger than 70 years of age. [47] (10.1016/j.otsr.2008.09.002)
• [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. [48] (10.1186/s12891-019-2459-6)
• [L3] It is a promising treatment for geriatrics with three- and four-part proximal humerus fractures aiming for a better long-term functional outcome. [49] (10.1186/s12891-023-06669-3)
• [L4] The locking plate provides satisfactory functional outcomes after a mid-term follow-up in patients with displaced proximal humerus fractures. [50] (10.1007/s00590-010-0655-z)
• [Paper] Non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention, and there is little utility to the routine use of postoperative radiographs in follow-up of these patients. [52] (10.1016/j.otsr.2016.09.022)
• [L4] No single fixation method is a panacea for proximal humeral fractures; choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications. [53] (10.1016/j.injury.2010.10.016)
• [L3] The axillary view for proximal humerus fractures is painful, labor-intensive, costly, and does not appear to provide additional diagnostic value. [55] (10.1007/s11420-015-9445-9)
• [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. [56] (10.1186/s12891-019-2812-9)
• [L5] Surgery for complex proximal humeral fractures leads to overall good long-term outcomes with high overall complication and reoperation rates. [57] (10.2106/jbjs.19.01109)
• [L3] Our data suggest that a simple fragility evaluation can help inform surgical decision-making and counseling in patients older than 50 years with proximal humerus fractures. [58] (10.1016/j.jseint.2020.10.017)
• [L5] The selection of RTSA over other surgical options is a current, reasonable, and safe option to treat proximal humerus fractures, particularly in those with higher Neer grades and/or in older patients. [59] (10.1097/corr.0000000000002430)
• [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. [60] (10.1016/j.jse.2006.09.006)
• [L3] The rate of complications following operative treatment of proximal humerus fractures is high. [61] (10.1016/j.jse.2007.02.109)
• [L1] There is no evidence of a difference in functional outcome at 1-year follow-up between surgical treatment and conservative treatment of displaced proximal humeral fractures in elderly patients. [62] (10.1097/bot.0b013e31821c2e15)
• [L5] At present, there remains a 50% agreement between observers on how to classify proximal humeral fractures. [63] (10.1111/sae.12013)
• [L2] Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern. [64] (10.2106/jbjs.20.02137)
• [L3] Proximal humeral fractures confer a more than two-fold increase in mortality at 1 year (9.8%), which continues to increase to 28.2% mortality at 5 years. [65] (10.1177/1758573214525761)
• [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. [66] (10.1302/0301-620x.102b11.bjj-2020-0627.r1)
• [L5] [67] (10.1007/978-3-319-08951-5_2)
• [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. [68] (10.1016/j.jse.2023.02.118)
• [L5] The development of an evidence-based clinical protocol for the treatment of proximal humerus fractures is long overdue, requiring a thoughtful, all-inclusive, randomized multicenter trial to determine the best treatment options. [69] (10.1016/j.injury.2014.05.017)
• [L3] After surgical treatment, patients with pathologic humerus fractures had significantly higher complication rates compared with native humerus fractures, suggesting that guidelines and treatment algorithms for native humerus fractures may not be generalizable for those of pathologic origin. [70] (10.1016/j.jse.2020.10.024)
• [L5] The control volume is an important anatomic and functional area of the proximal humerus. [71] (10.1016/j.jse.2017.12.004)
• [L4] Minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock yields good midterm clinical and radiological results. [75] (10.1016/j.injury.2015.05.017)
• [L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. [103] (10.1016/j.jse.2012.09.018)
• [L4] The classification of proximal humeral fractures with both the Neer and AO systems remains difficult. [104] (10.1111/ans.13451)
• [L1] [105] (10.1186/s12891-018-2223-3)
• [L4] The studies included in this review show that there is considerable disagreement with regard to the classification of proximal humeral fractures using the Neer system. [108] (10.1007/s00590-008-0325-6)
• [L5] Evaluation of the classification systems for fractures of the proximal humerus with plain radiographs has yielded low interobserver reliability. [109] (10.1016/j.ocl.2008.05.002)
• [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. [112] (10.2106/00004623-199609000-00012)
• [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. [120] (10.1007/s11999-014-3613-y)
• [L4] [121] (10.1016/j.jse.2007.12.012)
• [L4] The revised Neer classification covers 98% of all proximal humeral fractures and is appropriate for clinical practice. [122] (10.1016/j.jse.2009.01.018)
• [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. [127] (10.1016/j.jhsa.2020.03.022)
• [L4] Nondisplaced proximal humeral fractures are among the most common fractures associated with osteoporosis, and they can be a major cause of functional disability and reduction in subjective patient-perceived health. [128] (10.1016/j.jse.2010.09.008)
• [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. [135] (10.1097/corr.0000000000002242)
• [L4] [136] (10.3238/arztebl.2013.0591)
• [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. [137] (10.1371/journal.pmed.1002855)
• [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. [138] (10.1016/j.jse.2007.06.017)
• [L4] The AO classification proved to be more comprehensive than the Neer classification because it adequately describes the spectrum of proximal humeral fractures, including impacted valgus fractures which are not included in the Neer system. [139] (10.1080/000164701753542023)
• [L4] The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status. [140] (10.5435/jaaos-d-15-00240)
• [Abstract] These biomechanical changes may explain diminished function in patients with inferior tuberosity positioning after hemiarthroplasty for proximal humerus fractures. [141] (10.1016/j.jse.2007.02.027)
• [L3] Fracture complexity according to the Neer classification was associated with clinical outcomes 10 years after a nonoperatively treated proximal humeral fracture, with a less complex proximal humeral fracture showing better range of motion and function compared with a more complex proximal humeral fracture. [144] (10.1016/j.jse.2026.03.017)
• [L4] Data of this study do not confirm superiority of either classification system for the classification of comminuted proximal humeral fractures. [145] (10.1016/j.jos.2016.05.011)
• [L4] The impaired function seems to be caused by reduced glenohumeral mobility rather than muscle strength. [146] (10.1080/000164702317281396)
• [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. [147] (10.1016/j.jse.2024.09.032)
• [L4] The Mayo-FJD classification system for proximal humerus fractures seems to allow high intraobserver and interobserver agreement using both radiographs and computed tomography. [149] (10.1016/j.jse.2023.02.035)
• [L1] There is moderate/low certainty of evidence that surgical treatment of moderately displaced proximal humerus fractures in elderly patients has not been proven to be superior to less costly non-surgical treatment options. [150] (10.1371/journal.pone.0207815)
• [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. [151] (10.2106/jbjs.20.02018)
• [L5] These findings suggest that positioning the arm in abduction and internal rotation may help mitigate deforming muscular forces in proximal humerus fractures. [152] (10.5397/cise.2022.00885)
• [L4] The effectiveness of the NCB is similar to other published methods of treatment for fractures of the proximal humerus and potentially provides a less invasive option for this problem. [153] (10.1097/bot.0b013e3181ccafb3)
• [L1] In this randomized controlled trial, surgical treatment proved no better results than conservative treatment for patients with displaced proximal humeral fracture at 2-year follow-up. [155] (10.1007/s00590-013-1403-y)
• [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. [157] (10.1016/j.jse.2011.01.025)
• [L4] Treatment of 3- and 4-part proximal humeral fractures with an expandable intramedullary cage produced good clinical outcomes and a 100% union rate. [158] (10.1016/j.jse.2019.05.002)
• [L4] MIPO is a safe and effective option for the treatment of proximal humerus fractures, with good functional recovery and fewer complications, which are typically technique dependent. [159] (10.1016/j.aott.2016.10.003)
• [L2] Morphologic classification of proximal humerus fractures as the sole basis for treatment algorithms and surgical success should be scrutinized. [160] (10.1016/j.jseint.2022.02.006)
• [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. [161] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
• [L3] ORIF of nonosteoporotic proximal humeral fractures with locking plates led to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up. [162] (10.1097/corr.0000000000002895)
• [L4] The modified AO/OTA classification for proximal humerus fractures used in the SFR had moderate reliability but registered data only fair accuracy compared with a gold standard. [163] (10.1016/j.injury.2025.112558)
• [L5] Three-dimensionally printed models improved interobserver agreement in the classification of proximal humeral fractures using the Neer system. [167] (10.1016/j.jseint.2020.10.019)
• [L4] The functionality and quality of life of patients with complex proximal humerus fractures treated with rTSA decreased significantly compared to the 2-year evaluation, although this change was not clinically relevant. [168] (10.1016/j.jse.2024.05.045)
• [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. [169] (10.1097/corr.0000000000001776)
• [L4] A new four-segment classification based on the presence or absence of displacement of the articular surface, greater tuberosity, lesser tuberosity, and shaft was developed to adequately describe displaced proximal humeral fractures. [172] (10.2106/00004623-197052060-00001)
• [L4] Marked varus deformity causes limitation of abduction and forward flexion of shoulder. [173] (10.1016/s1058-2746(96)80458-7)
• [L4] The Mayo-FJD classification is a robust tool for predicting clinical success in proximal humerus fractures initially treated nonsurgically. [178] (10.1016/j.jseint.2026.101743)
• [L5] In contrast, anatomic reconstruction produced results indistinguishable from normal shoulder controls. [181] (10.1067/mse.2001.113962)
• [L4] It is concluded that displaced proximal humeral fractures can be treated satisfactorily by non-operative methods. [182] (10.1016/0020-1383(92)90124-b)
• [L4] [183] (10.1186/1471-2474-9-21)
• [L5] The novel biomechanical model distinguished between different mechanisms of injury and resulting fracture configurations. [184] (10.1177/1758573218768535)
• [L4] The majority of proximal humerus fractures are treated nonoperatively with good functional results. [186] (10.1097/bot.0b013e318133479c)
• [L1] This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week. [188] (10.1007/s12306-017-0483-y)
• [L2] [189] (10.1016/j.jclinepi.2007.04.014)
• [L4] Evidence-based recommendations to guide treatment of proximal humerus fractures are lacking, and no good evidence exists whether surgery is clearly superior to nonoperative treatment. [190] (10.1016/j.ocl.2008.06.003)
• [L3] Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. [191] (10.1016/j.jseint.2024.02.005)
• [L3] Simplifying classifications and training observers did not improve the interobserver reliability for the diagnosis of proximal humeral fractures overall. [192] (10.5435/jaaos-d-16-00223)
• [L5] Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics. [195] (10.5435/jaaos-d-20-00555)
• [L5] [196] (10.1016/j.jht.2017.05.005)
• [Paper] Rotator cuff tears are a detrimental factor and a major cause of painful shoulders. [197] (10.1007/s00264-004-0552-3)
• [Abstract] Patients with a proximal humerus fracture undergoing reverse total shoulder arthroplasty have significantly worse perioperative outcomes, including higher rates of complications, longer hospital stays, and higher costs, compared to patients with other indications. [203] (10.1016/j.jse.2015.05.005)
• [L4] ZTE MRI presents a viable alternative to CT in the evaluation of proximal humerus fractures (PHF). [210] (10.1016/j.jseint.2024.08.111)
• [L5] The authors emphasize that a high index of suspicion and MRI arthrogram investigation are necessary for non-operatively treated proximal humerus fractures if symptoms persist, to address biceps tendon pathology operatively if indicated. [211] (10.1136/bcr-2019-232124)
• [L3] [212] (10.1016/j.jse.2019.05.030)
• [L5] Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries. [221] (10.1530/eor-2026-0043)
• [L2] [223] (10.1067/mse.2001.118002)
• [L4] The use of artificial intelligence can accurately detect and classify proximal humerus fractures on plain shoulder AP radiographs. [224] (10.1080/17453674.2018.1453714)
• [L3] CNNs proficiently rule out proximal humerus fractures on plain radiographs. [225] (10.1302/0301-620x.106b11.bjj-2024-0264.r1)
• [Paper] DEXA examination of the central skeleton may not reflect the bone quality of the proximal humerus and severity of proximal humeral fracture. [227] (10.1016/j.injury.2016.10.028)
• [L1] According to the results of this study, one-week control X-Ray is not necessary in proximal humeral fractures conservatively treated. [229] (10.1016/j.jseint.2024.08.092)
• [L3] This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes. [231] (10.1186/s13018-022-03337-5)
• [L4] The present study demonstrated that 3-D CT images were more reliable than plain radiographs in the assessment of the prognostic factors of reduction loss of fractures of the proximal part of the humerus with the treatment of locking plates. [235] (10.1111/os.12332)
• [L4] This radiographic parameter can be one of the predictors of functional results in fractures of the proximal humerus treated with locking plates. [237] (10.1590/1413-785220192703142049)
• [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. [238] (10.1016/j.jse.2022.01.141)
• [L4] The authors concluded that the proximal humeral average CT value could be used as an objective alternative method for DXA in the assessment of bone quality for these patients. [240] (10.1111/os.13145)
• [L3] Medial cortex ratio is significantly associated with loss of surgical fixation and may prove to be a useful adjunct for clinical decision making in patients with proximal humeral fractures. [241] (10.1016/j.injury.2015.12.029)
• [L3] Patients in the proximal humerus fracture (PHF) cohort were less likely to report persistent shoulder pain at all evaluated time points compared to the osteoarthritis (OA) cohort, suggesting that symptom relief following treatment of traumatic pathology may differ fundamentally from that of chronic degenerative disease. [242] (10.1016/j.jsea.2026.100012)
• [L3] The use of three-dimensional computed tomography imaging did not offer improved interobserver and intraobserver agreement compared with the use of two-dimensional computed tomography imaging with regard to classification and treatment of fractures of the proximal part of the humerus, except among reviewers with limited clinical experience. [244] (10.2106/jbjs.m.00199)
• [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. [246] (10.1097/corr.0000000000002017)

See Also

• Fractures
• Total shoulder arthroplasty
• Rotator Cuff
• Internal Fixation
• Calcific Tendinitis
• Reverse Shoulder Arthroplasty
• Shoulder Arthroplasty

References

[1] Management of proximal humerus fractures in adults. World Journal of Orthopedics. 2014. DOI: 10.5312/wjo.v5.i5.685

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

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

[4] Clinical Results of Conservative Treatment of Severe Proximal Humerus Fractures Requiring Surgical Treatment in Old Patients. Techniques in Shoulder & Elbow Surgery. 2019. DOI: 10.1097/bte.0000000000000174

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

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

[7] 1. Clinical Evaluation, Imaging, and Classification of Proximal Humerus Fractures. 2011.

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

[9] Long-term outcome of a proximal humerus fracture predicted after 1 year. Acta Orthopaedica. 2005. DOI: 10.1080/17453670510041295

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

[11] 2. Non-operative Management of Proximal Humerus Fractures: Indications, Protocols, and Outcomes. 2011.

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

[13] Nonoperative Treatment of Proximal Humerus Fractures: A Systematic Review. Journal of Orthopaedic Trauma. 2008. DOI: 10.1097/bot.0b013e3182008df8

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

[15] Low arthroplasty survival after treatment for proximal humerus fracture sequelae: 3,245 shoulder replacements from the Nordic Arthroplasty Register Association. Acta Orthopaedica. 2020. DOI: 10.1080/17453674.2020.1793548

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

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

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

[20] Orthopaedic surgeons’ opinions surrounding the management of proximal humerus fractures: an international survey. International Orthopaedics. 2017. DOI: 10.1007/s00264-017-3569-0

[21] 6. Complications of Proximal Humerus Fractures: Evaluation and Management. 2011.

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

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

[24] Analyzing outcomes after proximal humerus fractures in patients <65 years: a systematic review and meta-analysis. JSES Reviews, Reports, and Techniques. 2021. DOI: 10.1016/j.xrrt.2021.04.014

[25] Increased fragility in patients with fracture of the proximal humerus: a case control study. Bone. 2004. DOI: 10.1016/j.bone.2004.01.009

[26] Randomized controlled trials investigating proximal humerus fractures lack consensus in inclusion criteria. JSES Reviews, Reports, and Techniques. 2025. DOI: 10.1016/j.xrrt.2025.07.023

[27] A comprehensive update on current fixation options for two-part proximal humerus fractures. Injury. 2014. DOI: 10.1016/j.injury.2013.08.024

[28] Treatment of Complex Proximal Humeral Fractures in the Elderly with Reverse Shoulder Arthroplasty. Orthopaedic Surgery. 2020. DOI: 10.1111/os.12777

[29] Operative Fixation of Three-Part Proximal Humerus Fractures. Techniques in Shoulder and Elbow Surgery. 2002. DOI: 10.1097/00132589-200206000-00007

[31] Rockwood And Matsen S The Shoulder. Arthroscopic Management of Prearthritic and Arthritic Conditions of the Shoulder and the Postarthroplasty Shoulder > Radiographic Evaluation.

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

[34] Interventions for treating proximal humeral fractures in adults. Cochrane Database of Systematic Reviews. 2015. DOI: 10.1002/14651858.cd000434.pub4

[35] Locked plate fixation versus non-operative management for three and four-part proximal humeral fractures in elderly; a randomized controlled trial. Injury. 2026. DOI: 10.1016/j.injury.2026.113686

[36] Neurovascular Injuries Associated with Proximal Humerus Fractures: A Review of the Current Literature. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2026.100825

[38] Computed tomography improves the diagnostic accuracy but not the interobserver reliability of the Boileau classification of proximal humerus fracture sequelae. Shoulder & Elbow. 2023. DOI: 10.1177/17585732221150785

[39] Epidemiology of proximal humerus fractures managed in a trauma center. Orthopaedics & Traumatology: Surgery & Research. 2012. DOI: 10.1016/j.otsr.2012.05.013

[40] Shoulder Fracture Special Preface. Techniques in Shoulder & Elbow Surgery. 2016. DOI: 10.1097/bte.0000000000000095

[41] Surgeons agree more on treatment recommendations than on classification of proximal humeral fractures. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-114

[44] Nail Fixation of Proximal Humerus Fractures. Techniques in Shoulder & Elbow Surgery. 2008. DOI: 10.1097/bte.0b013e31817303af

[45] No change in outcome ten years following locking plate repair of displaced proximal humerus fractures. European Journal of Orthopaedic Surgery & Traumatology. 2021. DOI: 10.1007/s00590-021-03099-6

[47] Three or four parts complex proximal humerus fractures: Hemiarthroplasty versus reverse prosthesis: A comparative study of 40 cases. Orthopaedics & Traumatology: Surgery & Research. 2009. DOI: 10.1016/j.otsr.2008.09.002

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

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

[50] Results of 131 consecutive operated patients with a displaced proximal humerus fracture: an analysis with more than two years follow-up. European Journal of Orthopaedic Surgery & Traumatology. 2010. DOI: 10.1007/s00590-010-0655-z

[52] Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures. Orthopaedics & Traumatology: Surgery & Research. 2017. DOI: 10.1016/j.otsr.2016.09.022

[53] New trends in fixation of proximal humeral fractures: A review. Injury. 2011. DOI: 10.1016/j.injury.2010.10.016

[55] The Axillary View Typically Does Not Contribute to Decision Making in Care for Proximal Humeral Fractures. HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery. 2015. DOI: 10.1007/s11420-015-9445-9

[56] Readmissions, revisions, and mortality after treatment for proximal humeral fractures in three large states. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2812-9

[57] Proximal Humeral Fractures: “Damned If You Operate, and Damned If You Don’t”. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.01109

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

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

[60] Outcomes after percutaneous reduction and fixation of proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.09.006

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

[62] Surgical Treatment With an Angular Stable Plate for Complex Displaced Proximal Humeral Fractures in Elderly Patients: A Randomized Controlled Trial. Journal of Orthopaedic Trauma. 2012. DOI: 10.1097/bot.0b013e31821c2e15

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

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

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

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

[67] Nonoperative Treatment of Proximal Humerus Fractures. Proximal Humerus Fractures. 2014. DOI: 10.1007/978-3-319-08951-5_2

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

[69] Proximal humerus fractures: Is there more than one way to skin a cat?. Injury. 2014. DOI: 10.1016/j.injury.2014.05.017

[70] Morbidity and mortality of surgically treated pathologic humerus fractures compared to native humerus fractures. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.10.024

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

[75] Midterm outcome and complications after minimally invasive treatment of displaced proximal humeral fractures in patients younger than 70 years using the Humerusblock. Injury. 2015. DOI: 10.1016/j.injury.2015.05.017

[76] Rockwood And Matsen S The Shoulder. Shoulder and Elbow Specialty Clinic Workers’ Survey > ANATOMY.

[77] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > SHOULDER AND ARM INJURIES.

[79] Aaos Comprehensive Orthopaedic Review 3. Anatomy of the Shoulder, Arm, and Elbow > I. Shoulder.

[80] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > Bursae.

[82] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > EDITOR COMMENTARY.

[83] Rockwood And Matsen S The Shoulder. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children > FRACTURES OF THE PROXIMAL HUMERUS.

[84] Apley And Solomon S Concise System Of Orthopaedics And Trauma. DISORDERS OF THE ROTATOR CUFF.

[88] Campbell S Operative Orthopaedics 4 Volume Set. RECONSTRUCTIVE PROCEDURES OF THE SHOULDER AND ELBOW IN ADULTS > ANATOMY AND BIOMECHANICS.

[89] Campbell S Operative Orthopaedics 4 Volume Set. ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH BONE-PATELLAR TENDON-BONE GRAFT > SHOULDER INJURIES > ANATOMY AND BIOMECHANICS.

[91] Orthopaedic Knowledge Update Sports Medicine 6. Diagnostic Ultrasonography and Ultrasonography-­Guided Procedures > Annotated References.

[93] Apley And Solomon S Concise System Of Orthopaedics And Trauma. INVESTIGATION.

[95] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 2Musculoskeletal Trauma Surgery > FRACTURES AND DISLOCATIONS AROUND THE SHOULDER.

[96] Rockwood And Matsen S The Shoulder. Developmental Anatomy of the Shoulder and Anatomy of the Glenohumeral Joint > SENIOR EDITOR COMMENTARY.

[98] Rockwood And Green S Fractures In Adults. 29: Principles of Nonunion and Bone Defect Treatment > Magnetic Resonance Imaging and Arthrography.

[100] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Shoulder Anatomy and Biomechanics, Clinical Evaluation, Imaging > Clinical Evaluation > Imaging.

[101] Aaos Comprehensive Orthopaedic Review 3. Imaging of the Shoulder and Elbow > I. Shoulder.

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

[104] Interobserver agreement of Neer and AO classifications for proximal humeral fractures. ANZ Journal of Surgery. 2016. DOI: 10.1111/ans.13451

[105] Open reduction internal fixation vs non-operative management in proximal humerus fractures: a prospective, randomized controlled trial protocol. BMC Musculoskeletal Disorders. 2018. DOI: 10.1186/s12891-018-2223-3

[108] Reliability of the Neer classification system in proximal humeral fractures: a systematic review of the literature. European Journal of Orthopaedic Surgery & Traumatology. 2008. DOI: 10.1007/s00590-008-0325-6

[109] Classification and Imaging of Proximal Humerus Fractures. Orthopedic Clinics of North America. 2008. DOI: 10.1016/j.ocl.2008.05.002

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

[115] Chapter 90 Proximal Humeral Fractures. 2019.

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

[121] Four-part valgus impacted proximal humeral fracture presenting three months after injury in a young patient: Open reduction and internal fixation with triple osteotomy and bone graft augmentation. Journal of Shoulder and Elbow Surgery. 2009. DOI: 10.1016/j.jse.2007.12.012

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

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

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

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

[136] The Treatment of Proximal Humeral Fracture in Adults. Deutsches Ärzteblatt international. 2013. DOI: 10.3238/arztebl.2013.0591

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

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

[139] The epidemiology of proximal humeral fractures. Acta Orthopaedica Scandinavica. 2023. DOI: 10.1080/000164701753542023

[140] Management of Acute Proximal Humeral Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2017. DOI: 10.5435/jaaos-d-15-00240

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

[144] The Neer classification, but not the AO classification, is associated with 10-year clinical outcomes in nonoperatively treated proximal humeral fractures: a cohort study in Malmö, Sweden. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.03.017

[145] The reliability and reproducibility of the Hertel classification for comminuted proximal humeral fractures compared with the Neer classification. Journal of Orthopaedic Science. 2016. DOI: 10.1016/j.jos.2016.05.011

[146] Strength and motion after hemiarthroplasty in displaced four-fragment fracture of the proximal humerus: 27 patients followed for 1-6 years. Acta Orthopaedica Scandinavica. 2002. DOI: 10.1080/000164702317281396

[147] 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. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.09.032

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

[150] Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice. PLOS ONE. 2018. DOI: 10.1371/journal.pone.0207815

[151] Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.02018

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

[153] Clinical Results for Minimally Invasive Locked Plating of Proximal Humerus Fractures. Journal of Orthopaedic Trauma. 2010. DOI: 10.1097/bot.0b013e3181ccafb3

[155] Displaced proximal humeral fractures: operative versus non-operative treatment—a 2-year extension of a randomized controlled trial. European Journal of Orthopaedic Surgery & Traumatology. 2014. DOI: 10.1007/s00590-013-1403-y

[157] Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2011.01.025

[158] Three- and 4-part proximal humeral fracture fixation with an intramedullary cage: 1-year clinical and radiographic outcomes. Journal of Shoulder and Elbow Surgery. 2019. DOI: 10.1016/j.jse.2019.05.002

[159] Minimally invasive plate osteosynthesis with PHILOS plate for proximal humerus fractures. Acta Orthopaedica et Traumatologica Turcica. 2020. DOI: 10.1016/j.aott.2016.10.003

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

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

[162] What Are the Long-term Outcomes of Locking Plates for Nonosteoporotic Three-part and Four-part Proximal Humeral Fractures With a Minimum 10-year Follow-up Period?. Clinical Orthopaedics & Related Research. 2023. DOI: 10.1097/corr.0000000000002895

[163] Only fair accuracy of the radiographic classification of adult proximal humeral fractures in the Swedish Fracture Register: a cohort analysis. Injury. 2025. DOI: 10.1016/j.injury.2025.112558

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

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

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

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

[173] Osteotomy of the proximal humerus for traumatic varus deformity. Journal of Shoulder and Elbow Surgery. 1996. DOI: 10.1016/s1058-2746(96)80458-7

[178] Prognostic value of the Mayo-Fundación Jiménez Díaz classification for nonsurgical proximal humerus fractures: a morphological approach to predicting functional outcomes. JSES International. 2026. DOI: 10.1016/j.jseint.2026.101743

[181] Biomechanical effects of malposition of tuberosity fragments on the humeral prosthetic reconstruction for four-part proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2001. DOI: 10.1067/mse.2001.113962

[182] Displaced proximal humeral fractures: results of conservative treatment. Injury. 1992. DOI: 10.1016/0020-1383(92)90124-b

[183] Inter- and intraobserver reliability of the MTM-classification for proximal humeral fractures: A prospective study. BMC Musculoskeletal Disorders. 2008. DOI: 10.1186/1471-2474-9-21

[184] The biomechanics of proximal humeral fractures: Injury mechanism and cortical morphology. Shoulder & Elbow. 2018. DOI: 10.1177/1758573218768535

[186] Treatment of Proximal Humerus Fractures. Journal of Orthopaedic Trauma. 2007. DOI: 10.1097/bot.0b013e318133479c

[188] Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial. MUSCULOSKELETAL SURGERY. 2017. DOI: 10.1007/s12306-017-0483-y

[189] Training improves agreement among doctors using the Neer system for proximal humeral fractures in a systematic review. Journal of Clinical Epidemiology. 2008. DOI: 10.1016/j.jclinepi.2007.04.014

[190] Open Reduction and Internal Fixation of Proximal Humerus Fractures. Orthopedic Clinics of North America. 2008. DOI: 10.1016/j.ocl.2008.06.003

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

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

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

[196] Acute proximal humeral fractures in adults. Journal of Hand Therapy. 2017. DOI: 10.1016/j.jht.2017.05.005

[197] Proximal humeral fractures with minimal displacement treated conservatively. International Orthopaedics. 2004. DOI: 10.1007/s00264-004-0552-3

[203] Reverse Total Shoulder Arthroplasty Patients with a Proximal Humerus Fracture Have Significantly Worse Perioperative Outcomes than Other Indications: An Analysis of 5644 Cases. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2015.05.005

[210] "Preliminary Study Of Integrating ZTE MRI In Proximal Humerus Fractures: Bridging The Gap Between CT And MRI". JSES International. 2024. DOI: 10.1016/j.jseint.2024.08.111

[211] Atypical biceps-related complication of proximal humerus fracture leading to internal shoulder impingement due to tendon stump dislocation. BMJ Case Reports. 2019. DOI: 10.1136/bcr-2019-232124

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

[221] Imaging-based assessment of fracture stability does not reliably predict outcomes in patients with two-part proximal humeral fractures and may lead to unnecessary surgeries. EFORT Open Reviews. 2026. DOI: 10.1530/eor-2026-0043

[223] Nerve lesions in proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2001. DOI: 10.1067/mse.2001.118002

[224] Automated detection and classification of the proximal humerus fracture by using deep learning algorithm. Acta Orthopaedica. 2018. DOI: 10.1080/17453674.2018.1453714

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

[227] Is central skeleton bone quality a predictor of the severity of proximal humeral fractures?. Injury. 2016. DOI: 10.1016/j.injury.2016.10.028

[229] Is It Necessary To Do A One-Week X-Ray Control In Acute Proximal Humeral Fractures Conservatively Treated? Prospective Randomized Multicentric Study. JSES International. 2024. DOI: 10.1016/j.jseint.2024.08.092

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

[235] Postoperative Evaluation of Reduction Loss in Proximal Humeral Fractures: A Comparison of Plain Radiographs and Computed Tomography. Orthopaedic Surgery. 2017. DOI: 10.1111/os.12332

[237] PROXIMAL HUMERUS FRACTURE WITH LOCKING PLATE: FUNCTIONAL AND RADIOGRAPHIC RESULTS. Acta Ortopédica Brasileira. 2019. DOI: 10.1590/1413-785220192703142049

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

[240] Correlation of CT Values and Bone Mineral Density in Elderly Chinese Patients with Proximal Humeral Fractures. Orthopaedic Surgery. 2021. DOI: 10.1111/os.13145

[241] Simple radiographic assessment of bone quality is associated with loss of surgical fixation in patients with proximal humeral fractures. Injury. 2016. DOI: 10.1016/j.injury.2015.12.029

[242] Complication rates following total shoulder arthroplasty for osteoarthritis versus proximal humerus fracture: a propensity-matched cohort comparison of 9,190 patients. Journal of Shoulder and Elbow Arthroplasty. 2026. DOI: 10.1016/j.jsea.2026.100012

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

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