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Proximal Humerus Fracture ORIF (Plate and Nail Fixation)

48 citationsUpdated Aug 2026

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

Overview

Proximal humerus fractures are frequently managed nonoperatively, which demonstrates successful outcomes and union rates greater than 90% [4]. When surgical intervention is required for displaced fractures, both intramedullary nailing and locking plate fixation effectively restore shoulder function [3, 5]. Modern proximal humeral nail designs and techniques provide stable fixation [1], while intramedullary fixation offers specific fixation and biologic advantages with reported outcomes comparable to other techniques [7].

Intramedullary nailing is superior to locking plate fixation in reducing total complications, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [2]. Conversely, fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation [9]. Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [6]. Augmentation of plate fixation mechanically increases construct stability, reduces complication rates, and improves patient outcomes [20].

Limited evidence suggests that both locking plates and intramedullary nails are valuable options for treating proximal humeral fractures [10]. No single fixation method is a panacea for proximal humeral fractures; implant and method selection should be based on individual patient and fracture pattern characteristics [23].

Anatomy & Pathophysiology

Internal fixation of the proximal humerus requires a thorough understanding of osseous and neurovascular anatomy [29]. Successful outcomes depend on respecting principles aimed at stable anatomic osteosynthesis of surrounding structures to restore normal shoulder function [38].

Osseous and Tuberosity Considerations

Technical challenges in hemiarthroplasty include obtaining proper humeral head height, retroversion, and optimal positioning and fixation of the tuberosities, which substantially affect patient outcomes [49].

Classification

Neer: Proximal humerus fractures are described according to anatomic level, mechanism of injury, and physeal anatomy [35]. This system divides fractures into four parts based on the involvement of the articular surface, greater tuberosity, lesser tuberosity, and shaft [35]. Significant displacement is defined as greater than 1 cm of translation or angulation greater than 45° for any major fracture fragment [35].

AO/ASIF: The Association for the Study of Internal Fixation (AO/ASIF) classification system labels valgus impaction injuries as Type C (C2.1, C2.2) fractures of the proximal humerus [35]. Inconsistencies have been noted in the literature in defining the Type C valgus impacted subgroups of the AO/ASIF classification system [35]. Observer agreement for classifying proximal humeral fractures according to the AO-classification is low, with reported mean kappa values varying between 0.26 and 0.53 [31]. Mean kappa values for interobserver agreement decrease from 0.53 for AO Types to 0.2 for AO Groups, suggesting decreased agreement with increasing classification units [31]. Classification type and group seem to be of minor importance for clinical outcome in most studies [31]. Outcome after locking plate osteosynthesis in AO/OTA Type C fractures was comparable with outcome reported in displaced 4-part fractures [31].

Other Considerations: Fractures of the humeral head are the most common fracture type according to the ICD-10 classification system [34]. Intramedullary nail fixation is utilized maximally (~20%) in fractures of the surgical neck (S42.22) and is least likely used in humeral head fractures (S42.21) [34]. Reverse total shoulder arthroplasty (RSA) shows its highest utilization rate in humeral head fractures and fractures of the anatomical neck (S42.23) [34]. Fractures of the greater tuberosity (S42.24) are mainly managed by screw fixation (40.4%) [34].

Clinical Presentation

Proximal humerus fractures occur at an estimated annual rate of 6 per 10,000 persons in the United States [15]. These injuries vary in location and complexity, potentially involving any combination of the surgical and anatomic necks of the humerus, as well as the greater and lesser tuberosities [15].

Nonoperative Management: Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [8]. Multiple studies comparing nonoperative and operative treatment for displaced proximal humeral fractures in the geriatric population have demonstrated minimal differences in functional outcomes [15]. Consequently, over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment [17].

Operative Considerations: Plate fixation was associated with a higher risk of avascular necrosis (AVN) development than conservative treatment in patients with proximal humeral fractures [13]. Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humerus fractures [15].

Pediatric Population: Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent [14].

Literature Variability: Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging [19].

Investigations

Plain radiography: 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 [55].

CT: Preoperative CT is extremely valuable for careful analysis of fracture type, fragment displacement, and bone quality in the surgical treatment of three and four-part proximal humeral fractures [57].

Treatment

Non-Operative

Non-operative treatment is advocated for the majority of non-displaced and minimally displaced isolated tuberosity fractures, which generally have good outcomes [44]. Displaced isolated tuberosity fractures may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors [44]. Significant heterogeneity exists in the terminology and definitions used to describe complications following non-surgical management of proximal humeral fractures [22].

Operative

Indications: Treatment for proximal humerus fractures remains controversial, with the choice of treatment depending on fracture type and severity, surgeon expertise, patient age, and patient health status [4, 18]. Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics, with a general evolution toward humeral head preservation using options ranging from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty [16]. No single fixation method is a panacea for proximal humeral fractures; the choice of implant and method should be selected according to individual patient and fracture pattern characteristics based on clearly defined indications and contraindications [23]. Surgical management of proximal humerus fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results [21].

Implant Selection: Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation [1]. Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques [7]. In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation (ORIF) [15]. The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of proximal humerus fractures [2]. Limited evidence suggests that locking plate and intramedullary nail are both valuable options for the treatment of proximal humeral fractures [10]. No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures [11]. The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method [3].

This article reviews current concepts in the plate and screw fixation of osteoporotic proximal humerus fractures, discussing surgical techniques and considerations specific to osteoporotic bone [12]. Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure that mechanically increases construct stability and reduces complication rates while improving patient outcomes [20]. Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone [27].

Arthroplasty Alternatives: In the geriatric population, reverse total shoulder arthroplasty has demonstrated improved functional outcomes, with a decreased rate of reoperation, compared with hemiarthroplasty [15]. Tuberosity repair has been shown to improve functional outcomes and range of motion after both hemiarthroplasty and reverse total shoulder arthroplasty and should be performed at the time of arthroplasty [15]. Comparative studies support the use of reverse shoulder arthroplasty in elderly patients with complex proximal humerus fractures because the functional outcomes and relief of pain are reliably improved [54]. This review discusses modern management controversies surrounding adult proximal humerus fractures, including surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty to assist surgeons in making evidence-based decisions [56].

Pain Management: Regional anaesthesia is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone [47].

Adjuncts: Several authors have demonstrated the negative effect of osteopenia on outcomes after ORIF of proximal humerus fractures; augmentative procedures, including cortical strut augmentation, are being investigated to address this issue, though their role is unclear at this time [15]. This review highlights various technical strategies to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates [42].

Complications

Avascular Necrosis (AVN): Intramedullary nailing is superior to locking plate fixation in reducing postoperative humeral head necrosis rates [2]. Plate fixation is associated with a higher risk of AVN development than conservative treatment [13]. Patients undergoing ORIF for proximal humerus fracture dislocations have relatively high AVN rates [6].

Reoperation and Implant Failure: Intramedullary nailing is superior to locking plate fixation in reducing total complication rates [2]. Fixation with proximal humerus locking plates is associated with a high rate of reoperation [9]. Patients undergoing ORIF for proximal humerus fracture dislocations have relatively high reoperation rates [6]. Augmentation of plate fixation reduces complication rates [20]. Proximal humerus fractures treated with a locking compression plate (LCP) augmented with a fibular allograft have decreased odds of a major complication compared with patients treated with an LCP alone [64]. Cement-augmented locked plate fixation may have lesser total complication rates and lesser implant failure rates than locked plate alone in elderly patients [27].

Operative Metrics and Healing: Intramedullary nailing is superior to locking plate fixation in reducing intraoperative blood loss [2], operative time [2], and postoperative fracture healing time [2].

Thromboembolism: Venous thromboembolism (VTE) is the most frequently reported complication after shoulder arthroplasty (SA) compared to open reduction and internal fixation (ORIF) [53]. Reverse shoulder arthroplasty (RSA) has the highest VTE rate among various procedures for proximal humerus fractures [53].

Other Considerations: Intramedullary nailing provides stable fixation with promising outcomes [1]. Fixation of proximal humerus fractures with locking plates is associated with a high rate of complications [9]. Augmentation of plate fixation mechanically increases construct stability [20] and improves patient outcomes [20]. There is significant heterogeneity in the terminology and definitions used to describe complications following non-surgical management [22]. Most studies of proximal humeral fractures are fragile, where only 1 or 2 patients experiencing an alternative outcome or lost to follow-up would change the conclusions for the dichotomous outcome studied [26]. Salvage reverse shoulder arthroplasty for failed primary fixation results in significantly better postoperative constant scores [24] and shoulder abduction [24] compared to salvage for failed hemiarthroplasty. Revision surgery for failed arthroplasty has a high likelihood of inferior outcomes compared with primary arthroplasty [60]. There are no significant differences in clinical outcomes or complication rates between standard components and fracture-specific components in RSA [50]. Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in RSA for complex fractures [61]. Open fractures have the highest complication rates following intramedullary nailing [62]. Four-part proximal humerus fractures have the highest complication rates following intramedullary nailing [62]. Fracture stems show promising overall clinical outcomes with low complication rates [63]. Cement-augmented locked plate fixation has no significant difference in revision rate compared to locked plate alone in elderly patients [27].

Recovery

Light activity (weeks): Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management [52]. Specific week ranges for light activity are not defined in the current evidence base.

Full activity (months): Specific month ranges for full activity are not defined in the current evidence base.

Complete recovery / outcome plateau (months): Specific month ranges for outcome plateau are not defined in the current evidence base.

Rehabilitation protocol: Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management [52]. In patients 65 years of age with 3- or 4-part proximal humerus fractures, early postoperative range of motion is associated with the most benefit in terms of range of motion, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing reverse total shoulder arthroplasty with a noncemented stem compared to reverse total shoulder arthroplasty with cemented stem and delayed rehabilitation [51].

Functional milestones: Patients undergoing open reduction and internal fixation for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [6]. Intramedullary nailing is superior to locking plate in reducing total complication, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate of proximal humerus fractures [2]. In the treatment of 2 and 3-part fractures involving the surgical neck, intramedullary nailing has demonstrated functional outcomes that are comparable with those of open reduction and internal fixation [15].

Other Considerations: Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90% [4]. Surgical management of proximal humerus fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results [21]. Plate fixation was associated with a higher risk of avascular necrosis development than conservative treatment in patients with proximal humerus fractures [13]. Several authors have demonstrated the negative effect of osteopenia on outcomes after open reduction and internal fixation of proximal humerus fractures [15]. Augmentative procedures, including cortical strut augmentation, are being investigated to address the negative effect of osteopenia on outcomes after open reduction and internal fixation of proximal humerus fractures, but their role in the treatment of these fractures is unclear at this time [15].

Key Evidence

  • [L5] Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation. [1] (10.1016/j.jse.2015.11.016)
  • [L1] The intramedullary nail is superior to locking plate in reducing the total complication, intraoperative blood loss, operative time, postoperative fracture healing time and postoperative humeral head necrosis rate of PHF. [2] (10.1186/s13018-019-1345-0)
  • [L5] The available evidence suggests that both intramedullary nails and locking plates can effectively restore shoulder function in the treatment of displaced proximal humeral fractures, with unclear superiority of either method. [3] (10.1016/j.xrrt.2024.01.001)
  • [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. [4] (10.5435/jaaos-d-24-01073)
  • [L1] Intramedullary nailing and plating demonstrate equivalent clinical outcomes for the surgical management of displaced proximal humerus fractures in adults. [5] (10.1016/j.jse.2026.02.016)
  • [L4] Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. [6] (10.1016/j.jse.2022.04.018)
  • [L4] Intramedullary fixation represents an alternative treatment option for proximal humeral fractures with specific fixation and biologic advantages, including reported outcomes comparable with other techniques. [7] (10.5435/jaaos-d-18-00360)
  • [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. [8] (10.2106/jbjs.l.01293)
  • [L4] Fixation of proximal humerus fractures with proximal humerus locking plates is associated with a high rate of complications and reoperation. [9] (10.1016/j.injury.2010.11.058)
  • [L1] Limited evidence suggests that locking plate and intramedullary nail are both valuable options for the treatment of proximal humeral fractures. [10] (10.1186/s13018-015-0242-4)
  • [L1] No superior treatment was suggested between locking plates and intramedullary nails for displaced proximal humeral fractures. [11] (10.1007/s00264-017-3683-z)
  • [L5] This article reviews current concepts in the plate and screw fixation of osteoporotic proximal humerus fractures, discussing surgical techniques and considerations specific to osteoporotic bone. [12] (10.1016/j.injury.2007.08.013)
  • [L1] Plate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures. [13] (10.1186/1749-799x-9-31)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. [14] (10.5435/jaaos-d-14-00033)
  • [L5] [15] (10.2106/jbjs.20.00665)
  • [L5] Treatment of displaced proximal humerus fractures must be individualized based on patient and fracture characteristics, with a general evolution toward humeral head preservation using options ranging from nonsurgical immobilization to various surgical techniques including locking plate fixation and hemiarthroplasty. [16] (10.5435/00124635-200701000-00003)
  • [L4] Over the past decade, most older adults who sustain proximal humerus fractures continue to receive nonoperative treatment. [17] (10.1016/j.jseint.2021.08.006)
  • [L4] The choice of treatment for proximal humeral fractures depends on the fracture type and severity, surgeon expertise, patient age, and patient health status. [18] (10.5435/jaaos-d-15-00240)
  • [L4] Considerable variability exists in the use of outcome measures across the proximal humerus fracture literature, making treatment comparison challenging. [19] (10.1016/j.jse.2020.04.006)
  • [L1] Augmentation of plate fixation for proximal humeral fractures seems to be a reliable and safe procedure that mechanically increases construct stability and reduces complication rates while improving patient outcomes. [20] (10.1007/s00402-019-03162-2)
  • [L5] The paper concludes that surgical management of proximal humeral fractures in younger patients is challenging due to high expectations and the lack of a single device providing reproducible results. [21] (10.1016/j.jse.2010.12.006)
  • [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. [22] (10.1186/s12891-019-2459-6)
  • [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. [23] (10.1016/j.injury.2010.10.016)
  • [L2] The failed fixation group performed significantly better than the failed HA group in postoperative constant and shoulder abduction. [24] (10.1177/17585732221099200)
  • [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. [26] (10.1016/j.jse.2022.01.141)
  • [L1] Fixation of proximal humeral fractures in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. [27] (10.1186/s12891-024-07502-1)
  • [L5] Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy, with biomechanical studies showing that locked plating provides stable fixation. [29] (10.5435/jaaos-d-20-00558)
  • [L2] [31] (10.1016/j.injury.2011.08.025)
  • [L4] [34] (10.1007/s00402-019-03252-1)
  • [L5] [35] (10.1097/01.blo.0000194675.64387.33)
  • [L5] Results in hemiarthroplasty are primarily dependent on respecting the rules of the art, which aim at stable anatomic osteosynthesis of the surrounding structures so as to restore normal shoulder function. [38] (10.1016/j.otsr.2010.07.001)
  • [L5] This review highlights various technical strategies to maximize the success of surgical treatment for proximal humerus fractures, emphasizing innovations in technique and implant design to mitigate high complication rates. [42] (10.5435/jaaos-d-22-01211)
  • [L4] Non-operative treatment is advocated for the majority of non-displaced and minimally displaced fractures with generally good outcomes, while displaced fractures may require arthroscopically assisted fixation or open/percutaneous reduction and internal fixation depending on fracture type and patient factors. [44] (10.1016/j.injury.2007.09.022)
  • [L1] This systematic review suggests that RA is a good option for postoperative analgesia in patients undergoing surgical repair of a proximal humerus fracture and is associated with fewer adverse events, a shorter recovery time, and a better functional outcome than those achieved by general anaesthesia alone. [47] (10.1007/s00402-019-03253-0)
  • [L5] Technical challenges, including obtaining proper humeral head height, retroversion, and optimal positioning and fixation of the tuberosities, have a substantial effect on patient outcomes. [49] (10.5435/jaaos-20-01-017)
  • [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. [50] (10.1302/0301-620x.107b9.bjj-2024-1508.r2)
  • [L1] Patients 65 years of age with 3- or 4-part proximal humerus fractures achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM compared to rTSA with cemented stem and delayed rehabilitation. [51] (10.1016/j.jse.2024.03.040)
  • [L4] Published rehabilitation protocols for proximal humerus fractures vary considerably regardless of management. [52] (10.1177/17585732231182374)
  • [L4] Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate. [53] (10.1016/j.xrrt.2023.06.003)
  • [L4] Comparative studies support the use of reverse shoulder arthroplasty in elderly patients with complex proximal humerus fractures because the functional outcomes and relief of pain are reliably improved. [54] (10.5435/jaaos-d-13-00190)
  • [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. [55] (10.1530/eor-2026-0043)
  • [L5] This review discusses modern management controversies surrounding adult proximal humerus fractures, including surgical indications, the role of intramedullary nailing and supplemental fixation, as well as timing and techniques for reverse total shoulder arthroplasty to assist surgeons in making evidence-based decisions. [56] (10.1016/j.jhsa.2025.07.009)
  • [L4] All available ORIF techniques require careful analysis of fracture type, fragment displacement, and bone quality, making preoperative CT extremely valuable. [57] (10.1016/j.otsr.2012.12.006)
  • [L5] Revision surgery for failed arthroplasty of proximal humerus fracture is complex with a high likelihood of inferior outcomes compared with primary arthroplasty. [60] (10.5435/jaaos-d-17-00051)
  • [L4] Locked humeral stems provide reliable diaphyseal fixation with a low incidence of screw-related complications in reverse total shoulder arthroplasty for complex proximal humerus fractures. [61] (10.1016/j.xrrt.2025.100625)
  • [L4] Open fractures and 4-part proximal humerus fractures had the highest complication rates. [62] (10.1016/j.jse.2024.07.049)
  • [L1] Fracture stems showed promising overall clinical outcomes with low complication rates in treating proximal humeral fractures. [63] (10.1016/j.jse.2020.09.044)
  • [L1] The pooled WMD and prediction interval suggest that 95% of patients with proximal humerus fractures treated with an LCP augmented with a fibular allograft will have improved radiographic outcomes, improved ASES clinical outcome scores, and decreased odds of a major complication when compared with patients treated with an LCP alone. [64] (10.1016/j.jse.2021.11.004)

See Also

References

[1] Intramedullary nailing of the proximal humerus: evolution, technique, and results. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2015.11.016

[2] Effect of intramedullary nail and locking plate in the treatment of proximal humerus fracture: an update systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1345-0

[3] Intramedullary versus locking plate fixation for proximal humerus fractures: indications and technical considerations. JSES Reviews, Reports, and Techniques. 2024. DOI: 10.1016/j.xrrt.2024.01.001

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

[5] Effectiveness of intramedullary nailing vs. locked plating (open reduction and internal fixation) in adult displaced proximal humerus fractures: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2026. DOI: 10.1016/j.jse.2026.02.016

[6] Fracture dislocations of the proximal humerus treated with open reduction and internal fixation: a systematic review. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2022.04.018

[7] Intramedullary Fixation for Proximal Humeral Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-18-00360

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

[9] A systematic review of locking plate fixation of proximal humerus fractures. Injury. 2011. DOI: 10.1016/j.injury.2010.11.058

[10] Meta-analysis of locking plate versus intramedullary nail for treatment of proximal humeral fractures. Journal of Orthopaedic Surgery and Research. 2015. DOI: 10.1186/s13018-015-0242-4

[11] Locking plates versus intramedullary nails in the management of displaced proximal humeral fractures: a systematic review and meta-analysis. International Orthopaedics. 2017. DOI: 10.1007/s00264-017-3683-z

[12] Current concepts in plate and screw fixation of osteoporotic proximal humerus fractures. Injury. 2007. DOI: 10.1016/j.injury.2007.08.013

[13] Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/1749-799x-9-31

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

[15] Current Controversies in the Treatment of Geriatric Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.20.00665

[16] Innovations in the Management of Displaced Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200701000-00003

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

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

[19] 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

[20] Augmentation of plate osteosynthesis for proximal humeral fractures: a systematic review of current biomechanical and clinical studies. Archives of Orthopaedic and Trauma Surgery. 2019. DOI: 10.1007/s00402-019-03162-2

[21] Proximal humeral fractures in younger patients: fixation techniques and arthroplasty. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.12.006

[22] 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

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

[24] Outcomes after salvage reverse shoulder arthroplasty for failed primary fixation or hemiarthroplasty for proximal humerus fractures: A systematic review. Shoulder & Elbow. 2022. DOI: 10.1177/17585732221099200

[26] 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

[27] Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07502-1

[29] Principles of Locking Plate Fixation of Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2021. DOI: 10.5435/jaaos-d-20-00558

[31] Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: A systematic review. Injury. 2012. DOI: 10.1016/j.injury.2011.08.025

[34] Trends in surgical management of proximal humeral fractures in adults: a nationwide study of records in Germany from 2007 to 2016. Archives of Orthopaedic and Trauma Surgery. 2019. DOI: 10.1007/s00402-019-03252-1

[35] Evaluation and Management of Valgus Impacted Four-part Proximal Humerus Fractures. Clinical Orthopaedics & Related Research. 2006. DOI: 10.1097/01.blo.0000194675.64387.33

[38] Shoulder arthroplasty for acute proximal humerus fracture. Orthopaedics & Traumatology: Surgery & Research. 2010. DOI: 10.1016/j.otsr.2010.07.001

[42] Technical Tips for Reduction and Stable Fixation of Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-01211

[44] Isolated tuberosity fractures of the proximal humerus: Current concepts. Injury. 2008. DOI: 10.1016/j.injury.2007.09.022

[47] Regional anaesthesia for surgical repair of proximal humerus fractures: a systematic review and critical appraisal. Archives of Orthopaedic and Trauma Surgery. 2019. DOI: 10.1007/s00402-019-03253-0

[49] Hemiarthroplasty for Three- and Four-part Proximal Humerus Fractures. American Academy of Orthopaedic Surgeon. 2012. DOI: 10.5435/jaaos-20-01-017

[50] 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

[51] Optimal combination of arthroplasty type, fixation method, and postoperative rehabilitation protocol for complex proximal humerus fractures in the elderly: a network meta-analysis. Journal of Shoulder and Elbow Surgery. 2024. DOI: 10.1016/j.jse.2024.03.040

[52] Rehabilitation protocols in proximal humerus fracture management: A systematic review. Shoulder & Elbow. 2023. DOI: 10.1177/17585732231182374

[53] Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review. JSES Reviews, Reports, and Techniques. 2023. DOI: 10.1016/j.xrrt.2023.06.003

[54] Reverse Shoulder Arthroplasty for the Management of Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2015. DOI: 10.5435/jaaos-d-13-00190

[55] 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

[56] Controversies in the Management of Proximal Humerus Fractures. The Journal of Hand Surgery. 2026. DOI: 10.1016/j.jhsa.2025.07.009

[57] Surgical treatment of three and four-part proximal humeral fractures. Orthopaedics & Traumatology: Surgery & Research. 2013. DOI: 10.1016/j.otsr.2012.12.006

[60] Management of the Failed Arthroplasty for Proximal Humerus Fracture. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00051

[61] Use of locking humeral stems in reverse total shoulder arthroplasty for complex proximal humerus fractures: a scoping review. JSES Reviews, Reports, and Techniques. 2026. DOI: 10.1016/j.xrrt.2025.100625

[62] Complications following intramedullary nailing of proximal humerus and humeral shaft fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2024.07.049

[63] Improved functional outcome and tuberosity healing in patients treated with fracture stems than nonfracture stems during shoulder arthroplasty for proximal humeral fracture: a meta-analysis and systematic review. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.044

[64] Improved outcomes for proximal humerus fracture open reduction internal fixation augmented with a fibular allograft in elderly patients: a systematic review and meta-analysis. Journal of Shoulder and Elbow Surgery. 2022. DOI: 10.1016/j.jse.2021.11.004

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