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Proximal Humerus Fracture ORIF (Plate and Nail Fixation)

Overview

Locking plate fixation is an excellent device for managing displaced unstable proximal humeral fractures and expands the indications for ORIF in these patients [7]. It appears to provide a good option for the majority of patients with unstable proximal humeral fractures, yielding good functional outcomes [24]. In nonosteoporotic fractures, ORIF with locking plates leads to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. For elderly patients with a displaced 2-part fracture of the surgical neck, locking plates are a good treatment alternative, offering an acceptable complication rate and functional outcome, provided rigorous attention is paid to avoid screw penetration [11].

Intramedullary fixation represents an alternative treatment option with specific fixation and biologic advantages, including reported outcomes comparable with other techniques [18]. Fixation with locking plates or locking intramedullary nails produces similar clinical and radiologic results [6]. Nail versus plate fixation of three-part proximal humeral fractures yields similar 1-year outcomes, suggesting both techniques are useful for internal fixation [3]. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [5].

However, locking plate fixation in patients older than 60 years is associated with a 44% complication rate and a 34% failure rate [1]. Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [14]. There are no level 1 studies in the English language literature comparing ORIF with hemiarthroplasty for proximal humeral fractures [17].

Anatomy & Pathophysiology

Osseous and Implant Biomechanics

The biomechanical literature regarding proximal humerus fracture implants is diverse and heterogeneous [33]. In the context of reverse total shoulder arthroplasty (RTSA) for failed open reduction and internal fixation (ORIF), shoulder function, patient satisfaction, and pain levels can be reliably improved [8]. Greater tuberosity healing does not impact RTSA biomechanics during abduction or forward flexion, but it does affect biomechanics during external rotation [30]. When systematically repairing tuberosities around the implant in complex fractures treated by RTSA, shoulder rotational ability improves provided their consolidation is anatomic [39]. Higher primary stability of tuberosity fixation in reverse fracture arthroplasty is achieved with 135° humeral inclination compared with 155° humeral inclination, though clinical relevance requires verification [43]. A tensioning device increases the biomechanical stability of tuberosity fixation technique with cerclage sutures in RTSA for fracture, though clinical relevance requires verification [40].

For hemiarthroplasty in four-part proximal humeral fractures, with minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly when inferior tuberosity placement is used [32]. Varus and antecurvatum proximal humerus deformities as small as 15 degrees are associated with statistically significant alterations in glenohumeral joint mechanics in proximal humeral fracture malunion [49]. Range of motion and strength thresholds can identify subjects with normal shoulder function in proximal humerus fractures [31].

Fixation Techniques and Stability

Modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-Part proximal humeral fractures provides adequate fracture stability and permits early shoulder motion [36]. Different suture anchor fixation techniques affect contact properties in humeral greater tuberosity fracture, with the SB construct having superior interface contact immediately after fixation and the DR construct offering better contact performance at all abduction angles with applied force [48]. A safe distance between humerus shaft fracture and distal locking screws in antegrade nailing has been identified biomechanically, though clinical confirmation is needed [34].

Clinical Outcomes and Decision Factors

Dominance of the affected shoulder has no influence on functional and quality of life outcomes compared with the nondominant shoulder and should not be used to make treatment decisions [44]. Robot navigation-assisted intramedullary nail treatment for humeral shaft fractures helps surgeons determine insertion point and proximal opening direction faster, shortens surgical time, reduces bleeding, avoids intraoperative fluoroscopy, and enables better shoulder functional outcomes [46]. Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique in the management of clavicle nonunion and malunion [45]. A minimally invasive approach combined with a novel anatomical locking plate provides a biomechanical basis for treating scapular body fractures [35].

Classification

HGLS: The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems [79].

Neer: The Neer fracture classification differentiates function in patients treated with locked plating for unstable proximal humeral fractures [82].

Clinical Presentation

Proximal humerus fractures present across a broad demographic spectrum, with the majority of cases managed non-operatively [20]. In pediatric populations, outcomes are generally favorable with infrequent complications [61]. For nonosteoporotic fractures, locking plate fixation yields favorable functional and radiologic outcomes at minimum 10-year follow-up [2]. Conversely, in patients aged >60 years, ORIF with locking plates is associated with a 44% complication rate and a 34% failure rate [1]. Operative treatment, particularly ORIF, serves as an independent risk factor for inpatient adverse events and mortality in older adults admitted with isolated proximal humerus fractures [12]. Despite these risks, surgical fixation maintains a generally low complication and mortality profile overall [55].

Acute Injury Patterns: Percutaneous treatment of selected fractures provides predictable union and good clinical results with low complication rates [5]. Patients with fracture dislocations undergoing ORIF achieve reasonable functional outcomes but face relatively high rates of avascular necrosis (AVN) and reoperation [14]. Poor prognostic factors for internal fixation of three- and four-part fracture-dislocations include female sex, four-part fracture dislocation morphology, and absence of metaphyseal head extension [64].

Complex and Delayed Presentations: In young, active patients with delayed presentation of complex fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head. This approach is indicated despite the risk of AVN, as conservative management yields poor functional outcomes [9].

Investigations

Plain radiography: Standard imaging is essential for pre-operative planning and post-operative assessment. The inherent nature of medial comminution in proximal humeral fractures may lead to inferior radiographic outcomes [76]. Intraoperative 3D imaging with a 160° orbital rotation yields sufficient image quality, enabling the reliable identification of intra-articular screws during plate osteosynthesis [92].

Other Considerations: Pre-operative evaluation must account for patient-specific factors influencing fixation stability and long-term outcomes. Locking plate fixation in patients older than 60 years is associated with a 44% complication rate and a 34% failure rate [1]. Conversely, ORIF of nonosteoporotic proximal humeral fractures with locking plates leads to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. In young, active patients with delayed presentation of complex proximal humeral fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head, despite the risk of avascular necrosis, as conservative management yields poor functional outcomes [9]. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [5].

Technical Factors: Specific technical failures significantly impact prognosis. Failure of the calcar screw to purchase both the proximal and distal fragments was associated with a significantly higher rate of failure of fixation in the surgical treatment of proximal humeral fractures using a locking plate [16]. Additionally, BMD changes appeared swiftly in the proximal humerus after treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis [91].

Treatment

Non-Operative

A majority of patients with proximal humeral fractures undergo non-operative treatment [20], and nonsurgical management demonstrates successful outcomes with union rates greater than 90% [60]. Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes [73]. Nonsurgical management of proximal humerus fractures decreased during the study period analyzed in one cost-minimization analysis [69]. There is no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus [59]. Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of fracture pattern [63].

Operative

Indications: Primary ORIF is supported for medically fit patients with severely displaced fractures or fracture-dislocations of the proximal humerus in centers with appropriate expertise [4]. The locking plate is an excellent device for managing displaced unstable proximal humeral fractures and expands the indications for ORIF in these cases [7]. Percutaneous treatment of selected proximal humeral fractures results in predictable union, good clinical results, and a low rate of complications [5]. Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated proximal humerus fracture [12].

Surgical Approach / Technique: The Humerus Block technique is a predictable, minimally invasive, percutaneous operative technique for various proximal humeral fractures, resulting in good pain relief, mobility, and pull force with a low incidence of avascular necrosis [78]. The use of a modified anterolateral approach and intra-osseous portal is safe and effective for minimally invasive reduction and plating of three-part proximal humeral fractures [53]. Combined medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation is effective in maintaining reduction and preventing varus collapse and implant failure in fractures with an unstable medial column [56].

Implant Selection: Locking plate fixation of proximal humerus fractures in patients older than 60 years is associated with a 44% complication rate and a 34% failure rate [1]. Locking plates are a good treatment alternative for elderly patients with displaced 2-part fractures of the surgical neck, offering acceptable complication rates and functional outcomes, provided screw penetration is avoided [11]. Failure of the calcar screw to purchase both the proximal and distal fragments is associated with a significantly higher rate of fixation failure when using locking plates [16]. Using the Locking Proximal Humerus Plate for all types of proximal humeral fractures is a reliable procedure with good results when careful planning and familiarity with the technique are applied [19]. Early results with locked plate fixation are encouraging, providing a potentially viable alternative to prosthetic replacement [23]. ORIF of nonosteoporotic proximal humeral fractures with locking plates leads to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2]. Nonsurgical treatment demonstrates better midterm outcomes compared to locking plate treatment for proximal humeral fractures [72]. Fixation of proximal humeral fractures with locking plates or locking intramedullary nails produces similar clinical and radiologic results [6]. The intramedullary nail is superior to the locking plate in reducing total complications, intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative humeral head necrosis rate [13]. Intramedullary fixation represents an alternative treatment option with specific fixation and biologic advantages and reported outcomes comparable to other techniques [18]. Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation [70]. Long PHILOS plate fixation provides reliable secure fixation for complex humeral fractures, including long segment periarticular fractures, segmental fractures involving the proximal humerus and shaft, periprosthetic fractures around well-fixed humeral resurfacing prostheses, and pathological fractures [71]. Dual plating is indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection [68].

Adjuncts: Double plate fixation combined with autogenous iliac crest bone grafting results in successful salvage of humeral shaft nonunion after prior failed surgical interventions [15]. Immediate rigid fixation is necessary to achieve consistently good pain relief in metastatic disease of the humerus [74]. In the absence of conflicting goals or contraindications, internal stabilization of impending pathologic fractures before fracture completion is reasonable and appropriate [75].

Other Considerations: The most important risk factors for postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity [80].

Complications

Overall Complication and Failure Rates: Locking plate fixation of proximal humerus fractures in patients older than 60 years is associated with a 44% complication rate [1] and a 34% failure rate [1]. The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years [97]. Percutaneous treatment of selected proximal humeral fractures results in a low rate of complications [5]. Complications after non-surgical management of proximal humeral fractures exhibit significant heterogeneity in terminology and definitions [104].

Implant-Specific Comparisons: The intramedullary nail is superior to locking plate in reducing the total complication rate of proximal humerus fractures [13]. The intramedullary nail is superior to locking plate in reducing the postoperative humeral head necrosis rate of proximal humerus fractures [13]. In-hospital complications are more likely to occur after reverse shoulder arthroplasty than after locked plating for proximal humeral fractures [98]. 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 [98]. The risk of short-term complications is highest in patients undergoing shoulder arthroplasty for a fracture compared with nonfracture indications [101].

Infection and Wound Complications: Acute deep infection after ORIF of proximal humeral fractures is a devastating complication with high complication rates, poor functional outcomes, and a notably high nonunion rate [93]. Complications of shoulder arthrodesis are not uncommon, including nonunion, malunion, fracture, and infection [107].

Operative Risk and Mortality: Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus [12]. Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors [103].

Other Considerations: ORIF of proximal humerus fracture dislocations carries a high rate of reoperation [27].

Recovery

Light activity (weeks): Early mobilization is feasible with specific fixation techniques. Intramedullary stabilization with an angular and sliding stable antegrade locking nail allows for immediate postoperative mobilization [50]. The locked plate may also prove useful in enabling earlier pain-free rehabilitation [66]. Delays beyond 5 days to surgery do not affect outcome following plate and screw fixation of proximal humerus fractures [22].

Full activity (months): Patients with proximal humeral fractures treated with early range of motion exercises do well, largely returning to baseline functional status by 1 year [51]. Early active motion rehabilitation for postoperative treatment after locking plate fixation was not inferior to a restrictive treatment protocol after a follow-up period of 24 months [38]. Treatment with continuous passive motion (CPM) increases the range of motion after plate osteosynthesis in the first 6 weeks after surgery, but this effect is not sustained after 3 and 12 months [52].

Complete recovery / outcome plateau (months): Ten years after locked plating of displaced proximal humeral fractures, patients show good to excellent outcomes in the majority of cases with no relevant decline compared with the shoulder function 1 year after surgery [67]. Locking plate fixation of proximal humerus fractures in patients older than 60 years is associated with a 44% complication rate and a 34% failure rate [1]. ORIF of nonosteoporotic proximal humeral fractures with locking plates leads to favorable functional and radiologic outcomes at a minimum of 10 years of follow-up [2].

Rehabilitation protocol: External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized [62]. Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications [5]. Elective implant removal in symptomatic patients after internal fixation of proximal humerus fractures improves clinical outcome, with symptomatic patients showing statistically significant improvement of the Constant score after implant removal [21].

Functional milestones: Shoulder function, patient satisfaction, and pain levels can be reliably improved after reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus [8]. In young, active patients with delayed presentation of complex proximal humeral fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head, despite the risk of avascular necrosis, as conservative management yields poor functional outcomes [9]. The intramedullary nail 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 [13].

Other Considerations: Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates [14]. ORIF of proximal humerus fracture dislocations carries a high rate of reoperation [27]. Double plate fixation combined with autogenous iliac crest bone grafting results in successful salvage of humeral shaft nonunion after prior failed surgical interventions [15].

Key Evidence

  • [L4] ORIF of proximal humerus fractures with locking plates in patients aged >60 years resulted in a 44% complication and 34% failure rate. (10.1016/j.jse.2019.11.026)
  • [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. (10.1097/corr.0000000000002895)
  • [L2] The similar 1-year outcomes for nail versus plate fixation of three-part proximal humeral fractures suggest that both techniques may be useful for internal fixation of these fractures. (10.1007/s11999-011-2056-y)
  • [L4] Our results support the use of primary ORIF in medically fit patients with a severely displaced fracture or a fracture-dislocation of the proximal part of the humerus in centers where the expertise to carry out such treatment exists. (10.2106/jbjs.19.00595)
  • [L4] Percutaneous treatment of selected proximal humeral fractures results in predictable union and good clinical results with a low rate of complications. (10.1016/j.jse.2006.09.006)
  • [L1] Fixation of proximal humeral fractures with locking plates or locking intramedullary nails produces similar clinical and radiologic results. (10.1016/j.jse.2016.02.003)
  • [L2] The locking plate is an excellent device in the management of displaced unstable proximal humeral fractures and is expanding the indications for ORIF in these fractures. (10.1016/j.jse.2009.08.008)
  • [L4] Shoulder function, patient satisfaction, and pain levels can be reliably improved. (10.1016/j.jse.2016.05.020)
  • [L4] In young, active patients with delayed presentation of complex proximal humeral fractures, ORIF with osteotomy and bone grafting is recommended to preserve the humeral head, despite the risk of avascular necrosis, as conservative management yields poor functional outcomes. (10.1016/j.jse.2007.12.012)
  • [L4] Locking plates appear to be a good treatment alternative in elderly patients with a displaced 2-part fracture of the surgical neck of the proximal humerus with an acceptable complication rate and an acceptable functional outcome; however, rigorous attention has to be paid to avoid screw penetration. (10.1016/j.jse.2009.11.046)
  • [L3] Operative treatment, particularly open reduction and internal fixation, is an independent risk factor for inpatient adverse events and mortality in older-aged patients admitted with an isolated fracture of the proximal humerus and should perhaps be offered more judiciously. (10.1016/j.jse.2013.09.006)
  • [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. (10.1186/s13018-019-1345-0)
  • [L4] Patients undergoing ORIF for proximal humerus fracture dislocations have reasonable functional outcomes but relatively high avascular necrosis and reoperation rates. (10.1016/j.jse.2022.04.018)
  • [L4] Double plate fixation combined with autogenous iliac crest bone grafting results in successful salvage of humeral shaft nonunion after prior failed surgical interventions. (10.1186/s12891-020-03743-y)
  • [L3] Failure of the calcar screw to purchase both the proximal and distal fragments was associated with a significantly higher rate of failure of fixation in the surgical treatment of proximal humeral fractures using a locking plate. (10.1302/0301-620x.107b9.bjj-2024-1649.r1)
  • [L5] There are no level 1 studies in the English language literature comparing ORIF with hemiarthroplasty for proximal humeral fractures. (10.1016/j.jhsa.2010.07.019)
  • [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. (10.5435/jaaos-d-18-00360)
  • [L2] Using the Locking Proximal Humerus Plate for treatment of proximal humeral fractures of all types is a reliable procedure, with good results being obtained with careful planning and familiarity with the special features of the operative technique. (10.1097/01.blo.0000137554.91189.a9)
  • [L3] A majority of patients with proximal humeral fractures underwent non-operative treatment. (10.1186/s12891-019-2812-9)
  • [L4] Symptomatic patients after locked plate osteosynthesis for proximal humerus fractures showed statistically significant improvement of the Constant score after implant removal. (10.1186/s12891-016-0977-z)
  • [L3] Timing of surgery did not impact outcomes of patients who underwent ORIF for proximal humerus fractures. (10.1016/j.jse.2025.02.019)
  • [L4] Early results with locked plate fixation for the treatment of proximal humerus fractures have been encouraging, providing a potentially viable alternative to prosthetic replacement. (10.5435/00124635-200805000-00008)
  • [L4] Locking plate fixation appears to provide a good option for the majority of patients with unstable proximal humeral fractures, with good functional outcomes. (10.1016/j.jse.2006.06.006)
  • [L4] ORIF of proximal humerus fracture dislocations carries a high rate of reoperation. (10.1016/j.jse.2021.01.025)
  • [L5] Greater tuberosity healing does not seem to impact reverse shoulder arthroplasty biomechanics during abduction or forward flexion; however, it does affect biomechanics during external rotation. (10.1016/j.jse.2019.07.022)
  • [L3] Range of motion and strength thresholds can identify subjects with normal shoulder function. (10.1016/j.jse.2010.06.005)
  • [L5] With minimal and moderate amounts of glenohumeral abduction, glenohumeral joint forces are significantly displaced superiorly. (10.1016/j.jse.2007.06.017)
  • [L4] The biomechanical literature was found to be both diverse and heterogeneous. (10.1186/s12891-015-0627-x)
  • [L5] These biomechanical results, although very promising, should be confirmed with clinical studies. (10.1186/s12891-025-08711-y)
  • [L5] The study provided a biomechanical basis to guide the clinical treatment of scapular body fractures. (10.1186/s13018-024-04905-7)
  • [L3] It is a minimally invasive procedure that provides adequate fracture stability and permits early shoulder motion, with satisfactory functional and radiologic outcomes and fewer complications. (10.1186/s12891-025-08600-4)
  • [L2] Early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months. (10.1016/j.jse.2025.01.042)
  • [L3] Shoulder rotational ability is improved by systematically repairing the tuberosities around the implant, provided their consolidation is anatomic. (10.1016/j.jse.2012.03.011)
  • [L5] However, transferability of these promising biomechanical results and their clinical relevance have to be verified with clinical studies. (10.1016/j.jse.2020.08.015)
  • [L5] However, transferability and clinical relevance of these biomechanical results have to be verified with clinical studies. (10.1016/j.jse.2020.09.009)
  • [L3] Dominance of the affected shoulder has no influence and should not be used to make treatment decisions. (10.1016/j.jse.2014.10.006)
  • [L5] Reliable bony union and improved shoulder function can be expected with thoughtful surgical planning, appropriate implant choice, and meticulous surgical technique. (10.1016/j.jse.2013.01.022)
  • [L3] It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes. (10.1186/s12891-024-07848-6)
  • [L5] Findings suggest that despite the SB construct having superior interface contact immediately after fixation, the DR construct offered better contact performance at all abduction angles with applied force. (10.1186/s12891-019-2412-8)
  • [L5] Varus and antecurvatum proximal humerus deformities as small as 15 degrees were associated with statistically significant alterations in glenohumeral joint mechanics. (10.5435/jaaos-d-20-00555)
  • [L4] Intramedullary stabilization of proximal humeral fractures with an angular and sliding stable antegrade locking nail represents a minimally invasive procedure that provides a high degree of primary stability even in osteoporotic bone and allows for immediate postoperative mobilization. (10.2106/00004623-200300004-00019)
  • [L3] Patients with proximal humeral fractures treated with early range of motion exercises do well, largely returning to baseline functional status by 1 year. (10.1016/j.jse.2007.07.016)
  • [L1] The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery, but this effect is not sustained after 3 and 12 months. (10.1186/s13018-024-04804-x)
  • [L3] The use of the modified anterolateral approach and intra-osseous portal is safe and effective for minimally invasive reduction and plating treatment for three-part proximal humeral fractures. (10.1186/s13018-017-0701-1)
  • [L4] Surgical fixation of proximal humeral fractures has a low complication and mortality profile. (10.2106/jbjs.m.01039)
  • [L4] The combined application of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation is effective in maintaining operative reduction and preventing varus collapse and implant failure in proximal humerus fractures with an unstable medial column. (10.1186/s13018-020-02094-7)
  • [L1] This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. (10.1371/journal.pmed.1002855)
  • [L5] Treatment for proximal humerus fractures remains controversial, with nonsurgical management demonstrating successful outcomes and union rates greater than 90%. (10.5435/jaaos-d-24-01073)
  • [L5] Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent. (10.5435/jaaos-d-14-00033)
  • [L3] External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized. (10.1186/s12891-023-07037-x)
  • [L2] Short and long periods of immobilization yield similar results for nonoperatively treated proximal humeral fractures, independent of the fracture pattern. (10.2106/jbjs.20.02137)
  • [L5] Surgical treatment of proximal humerus fractures remains far from straightforward, with unpredictable outcomes where factors associated with poor results include being a woman, four-part fracture dislocation, and absence of metaphyseal head extension. (10.1097/corr.0000000000002242)
  • [L5] The locked plate may prove useful in earlier pain-free rehabilitation of proximal humeral fractures. (10.1016/j.jse.2006.03.013)
  • [L4] Ten years after locked plating of displaced proximal humeral fractures, patients show good to excellent outcomes in the majority of cases with no relevant decline compared with the shoulder function 1 year after surgery. (10.1016/j.jse.2013.11.009)
  • [L4] Dual plating is still indicated for certain cases, particularly old ununited fractures where intramedullary nailing is difficult, but is contraindicated in severely comminuted fractures requiring extensive dissection. (10.2106/00004623-196345020-00026)
  • [L4] Nonsurgical management of proximal humerus fractures decreased during the study period. (10.1016/j.jhsa.2020.03.022)
  • [L5] Modern proximal humeral nail designs and techniques have demonstrated promising outcomes and can provide stable fixation. (10.1016/j.jse.2015.11.016)
  • [L4] The long PHILOS plate fixation provides reliable secure fixation for the treatment of complex humeral fractures, especially long segment periarticular fractures, segmental fractures involving proximal humerus and shaft, periprosthetic fractures around well-fixed humeral resurfacing prosthesis and pathological fractures. (10.1111/j.1758-5740.2010.00085.x)
  • [L3] Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures. (10.1016/j.jse.2011.01.025)
  • [L5] Most proximal humeral fractures in elderly patients can be treated nonoperatively with good functional outcomes. (10.2106/jbjs.l.01293)
  • [L4] Immediate rigid fixation is necessary to achieve consistently good pain relief. (10.5435/00124635-200307000-00008)
  • [L4] In the absence of conflicting goals or contraindications, internal stabilization of impending pathologic fractures before the completion of the fracture seems to be reasonable and appropriate. (10.1097/01.blo.0000093849.72468.82)
  • [L3] This implies that the inherent nature of medial comminution of proximal humeral fracture may lead to inferior radiographic outcomes. (10.1186/s13018-022-03337-5)
  • [L4] The Humerus Block technique is a very good and predictable, minimally invasive, percutaneous operative technique for treatment of various types of proximal humeral fractures that results in very good pain relief, mobility, and pull force in the arm with a low incidence of avascular necrosis. (10.1016/j.jse.2011.07.029)
  • [L3] The HGLS classification is a reliable method of describing fractures of the proximal humerus compared with the Neer and AO systems. (10.1016/j.jse.2012.09.018)
  • [L3] The most important risk factors for postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. (10.1186/s13018-019-1233-7)
  • [L4] With locked plating of unstable proximal humeral fractures, older patients function as well as younger patients; improvement continues until 1 year postoperatively, the Neer fracture classification differentiates function, and polytrauma patients perform worse clinically. (10.1007/s11999-011-1935-6)
  • [L1] BMD changes appeared swiftly in the proximal humerus after treatment of displaced 3- or 4-part fractures with ORIF, particularly affecting the proximal diaphysis. (10.1016/j.jse.2022.07.008)
  • [L5] Intraoperative 3D imaging with a 160° orbital rotation yields sufficient image quality, enabling the reliable identification of intra-articular screws during plate osteosynthesis of the proximal humerus. (10.1186/s13018-026-06800-9)
  • [L4] Acute deep infection after ORIF of proximal humeral fractures is a devastating complication with high complication rates, poor functional outcomes, and a notably high nonunion rate. (10.1016/j.jse.2006.09.021)
  • [L4] The overall complication rate of locking plate osteosynthesis for proximal humeral fractures has been decreasing considerably within the last years. (10.1016/j.jse.2016.02.015)
  • [L3] The increased in-hospital risk for major adverse events and surgical complications may moderate the enthusiasm associated with RTSA for proximal humeral fractures in patients 65 years and older. (10.1097/corr.0000000000001776)
  • [L2] The findings indicate that the risk of short-term complications is highest in patients undergoing surgery for a fracture compared with nonfracture indications. (10.1016/j.jse.2010.11.005)
  • [L3] Mortality at 1 year for fragility proximal humerus fractures is universally high regardless of risk factors. (10.1016/j.jse.2022.03.006)
  • [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. (10.1186/s12891-019-2459-6)
  • [L5] Complications are not uncommon, including nonunion, malunion, fracture, and infection. (10.5435/jaaos-d-21-00667)

See Also

References

[1] Locking plate fixation of proximal humerus fractures in patients older than 60 years continues to be associated with a high complication rate. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.11.026

[2] 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

[3] Similar Outcomes for Nail versus Plate Fixation of Three-part Proximal Humeral Fractures. Clinical Orthopaedics & Related Research. 2012. DOI: 10.1007/s11999-011-2056-y

[4] Complications and Long-Term Outcomes of Open Reduction and Plate Fixation of Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00595

[5] 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

[6] Locking intramedullary nails compared with locking plates for two- and three-part proximal humeral surgical neck fractures: a randomized controlled trial. Journal of Shoulder and Elbow Surgery. 2016. DOI: 10.1016/j.jse.2016.02.003

[7] The results of ORIF of displaced unstable proximal humeral fractures using a locking plate. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.08.008

[8] Reverse total shoulder arthroplasty for failed open reduction and internal fixation of fractures of the proximal humerus. Journal of Shoulder and Elbow Surgery. 2017. DOI: 10.1016/j.jse.2016.05.020

[9] 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

[11] Quality of life and functional outcome after a 2-part proximal humeral fracture: A prospective cohort study on 50 patients treated with a locking plate. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2009.11.046

[12] Treatment choice affects inpatient adverse events and mortality in older aged inpatients with an isolated fracture of the proximal humerus. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.09.006

[13] 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

[14] 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

[15] Double plating with autogenous bone grafting as a salvage procedure for recalcitrant humeral shaft nonunion. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-03743-y

[16] Purchase of both proximal and distal fragments by the calcar screw is critical when using a locking plate in the treatment of proximal humeral fractures. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b9.bjj-2024-1649.r1

[17] Three- and Four-Part Proximal Humerus Fractures: Open Reduction and Internal Fixation Versus Arthroplasty. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.07.019

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

[19] A New Locking Plate for Unstable Fractures of the Proximal Humerus. Clinical Orthopaedics & Related Research. 2005. DOI: 10.1097/01.blo.0000137554.91189.a9

[20] 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

[21] Elective implant removal in symptomatic patients after internal fixation of proximal humerus fractures improves clinical outcome. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-0977-z

[22] Delays beyond 5 days to surgery does not affect outcome following plate and screw fixation of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.02.019

[23] Fixed-angle Locked Plating of Two-, Three-, and Four-part Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2008. DOI: 10.5435/00124635-200805000-00008

[24] Locking plate fixation for proximal humeral fractures: Initial results with a new implant. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.06.006

[27] Outcomes of open reduction and internal fixation of proximal humerus fracture dislocations. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2021.01.025

[30] The role of greater tuberosity healing in reverse shoulder arthroplasty: a finite element analysis. Journal of Shoulder and Elbow Surgery. 2020. DOI: 10.1016/j.jse.2019.07.022

[31] Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures. Journal of Shoulder and Elbow Surgery. 2011. DOI: 10.1016/j.jse.2010.06.005

[32] 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

[33] A scoping review of biomechanical testing for proximal humerus fracture implants. BMC Musculoskeletal Disorders. 2015. DOI: 10.1186/s12891-015-0627-x

[34] Mechanical study of the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08711-y

[35] Finite element analysis of the treatment of a minimally invasive approach combined with a novel anatomical locking plate for scapular body fractures. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04905-7

[36] Assessment of fracture stability following modified minimally invasive reduction osteosynthesis system (MIROS) fixation for Neer 2 and 3-Part proximal humeral fractures. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08600-4

[38] Postoperative treatment of proximal humerus fractures with an early active motion protocol: a prospective randomized controlled trail. Journal of Shoulder and Elbow Surgery. 2025. DOI: 10.1016/j.jse.2025.01.042

[39] Improvement in shoulder rotation in complex shoulder fractures treated by reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2012.03.011

[40] Tensioning device increases biomechanical stability of tuberosity fixation technique with cerclage sutures in reverse shoulder arthroplasty for fracture. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.08.015

[43] Higher primary stability of tuberosity fixation in reverse fracture arthroplasty with 135° than with 155° humeral inclination. Journal of Shoulder and Elbow Surgery. 2021. DOI: 10.1016/j.jse.2020.09.009

[44] Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder?. Journal of Shoulder and Elbow Surgery. 2015. DOI: 10.1016/j.jse.2014.10.006

[45] Management of clavicle nonunion and malunion. Journal of Shoulder and Elbow Surgery. 2013. DOI: 10.1016/j.jse.2013.01.022

[46] A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07848-6

[48] Different suture anchor fixation techniques affect contact properties in humeral greater tuberosity fracture: a biomechanical study. BMC Musculoskeletal Disorders. 2019. DOI: 10.1186/s12891-019-2412-8

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

[50] STABILIZATION OF PROXIMAL HUMERAL FRACTURES WITH AN ANGULAR AND SLIDING STABLE ANTEGRADE LOCKING NAIL (TARGON PH). The Journal of Bone and Joint Surgery-American Volume. 2003. DOI: 10.2106/00004623-200300004-00019

[51] Functional outcome following one-part proximal humeral fractures: A prospective study. Journal of Shoulder and Elbow Surgery. 2008. DOI: 10.1016/j.jse.2007.07.016

[52] Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures – results of a prospective, randomized trial. Journal of Orthopaedic Surgery and Research. 2024. DOI: 10.1186/s13018-024-04804-x

[53] Modified minimally invasive approach and intra-osseous portal for three-part proximal humeral fractures: a comparative study. Journal of Orthopaedic Surgery and Research. 2018. DOI: 10.1186/s13018-017-0701-1

[55] Factors Predicting Complication and Reoperation Rates Following Surgical Fixation of Proximal Humeral Fractures. Journal of Bone and Joint Surgery. 2014. DOI: 10.2106/jbjs.m.01039

[56] A novel surgical approach and technique and short-term clinical efficacy for the treatment of proximal humerus fractures with the combined use of medial anatomical locking plate fixation and minimally invasive lateral locking plate fixation. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-020-02094-7

[59] 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

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

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

[62] Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-07037-x

[63] 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

[64] 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

[66] Biomechanical evaluation of locked plating in proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2007. DOI: 10.1016/j.jse.2006.03.013

[67] Long-term functional outcomes (median 10 years) after locked plating for displaced fractures of the proximal humerus. Journal of Shoulder and Elbow Surgery. 2014. DOI: 10.1016/j.jse.2013.11.009

[68] DUAL SLOTTED PLATES IN FIXATION OF FRACTURES OF THE FEMORAL SHAFT. The Journal of Bone & Joint Surgery. 1963. DOI: 10.2106/00004623-196345020-00026

[69] 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

[70] 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

[71] Long Philos Plate Fixation for Complex Humeral Fractures. Shoulder & Elbow. 2010. DOI: 10.1111/j.1758-5740.2010.00085.x

[72] 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

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

[74] Metastatic Bone Disease of the Humerus. Journal of the American Academy of Orthopaedic Surgeons. 2003. DOI: 10.5435/00124635-200307000-00008

[75] Metastatic Disease of the Femur: Surgical Treatment. Clinical Orthopaedics and Related Research. 2003. DOI: 10.1097/01.blo.0000093849.72468.82

[76] 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

[78] Functional and radiographic medium-term outcome evaluation of the Humerus Block, a minimally invasive operative technique for proximal humeral fractures. Journal of Shoulder and Elbow Surgery. 2012. DOI: 10.1016/j.jse.2011.07.029

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

[80] Can patient and fracture factors predict opioid dependence following upper extremity fractures?: a retrospective review. Journal of Orthopaedic Surgery and Research. 2019. DOI: 10.1186/s13018-019-1233-7

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