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Proximal Humerus Fractures

Original Editor - Shoko Otsuka
Top Contributors - Shoko Otsuka, Muhammad Arslan, Vidya Acharya, Ilona Malkauskaite, Alexandra Stead and Kim Jackson


Introduction

A proximal humerus fracture (PHF) is a common upper-limb injury, particularly among older adults, and is considered a major osteoporotic fracture.[1][2] PHFs include fractures involving the humeral head, anatomical neck, surgical neck, greater tuberosity, or lesser tuberosity, occurring either in isolation or in combination.[3]


Clinically Relevant Anatomy


The humerus is anatomically classified as a long bone of the upper limb, and the proximal humerus forms its upper end.[4]

Key features of the proximal humerus include:

Humeral head

The proximal articular surface of the humerus.[5] It articulates with the glenoid fossa of the scapula to form the glenohumeral joint.[6] Articular involvement in proximal humeral fractures may disrupt glenohumeral congruency and contribute to loss of shoulder movement and function.[7]

Greater tuberosity

A bony prominence located lateral to the humeral head.[8] It provides attachment for the supraspinatus, infraspinatus and teres minor tendons.[9] Fractures of the greater tuberosity (GT) may affect shoulder elevation and external rotation.[10]

Lesser tuberosity

A bony prominence located anteromedial to the proximal humerus.[11] It provides attachment for the subscapularis tendon.[12] A fracture of the lesser tuberosity may compromise shoulder stability and internal rotation by disrupting normal subscapularis function.[13]

Anatomical neck

A narrow region between the humeral head and the greater and lesser tuberosities.[14] Fractures of the anatomical neck may compromise the blood supply to the humeral head, increasing the risk of ischaemia and subsequent avascular necrosis.[15]

Surgical neck

Located immediately distal to the greater and lesser tuberosities, forming the transition between the proximal humerus and the shaft.[16] Fractures at the surgical neck may place the axillary nerve and posterior circumflex humeral artery at risk.[17]

Intertubercular groove

A groove between the greater and lesser tuberosities that contains the tendon of the long head of the biceps brachii.[18] Alterations in groove morphology may contribute to instability or pathology of the long head of the biceps tendon and anterior shoulder pain.[19]

Proximal humeral shaft

The upper portion of the humeral shaft, distal to the surgical neck.[20] It provides attachment sites for muscles involved in shoulder and upper-limb movement.[21] Fractures of the humeral shaft may injure the radial nerve and profunda brachii artery; radial nerve involvement can cause weakness of wrist, finger and thumb extension and sensory loss over the dorsum of the hand.[22][23]

Function

Proximal humerus serves as an attachment to 13-muscles which contribute to the movement of the hand and elbow, and therefore the function of the upper limb.[21]

Muscles:

The muscles of the shoulder which connect the scapula and/or clavicle to the humerus include:[24]


Epidemiology

PHFs are among the three most common non-vertebral osteoporotic fractures and occur predominantly in older adults.[25] They are more common in women, with women accounting for approximately 70–72% of cases in large population-based studies.[25][26] The incidence increases substantially with age, particularly after 60 years, and is strongly associated with osteoporosis and low-energy falls.[25][26]

Reported incidence varies between populations. A large Danish registry study of 137,436 PHFs reported an overall incidence of 138 per 100,000 person-years, increasing to 500 per 100,000 person-years among women aged ≥60 years.[25] A Spanish population-based study reported an overall incidence of 60.1 per 100,000 person-years, with higher rates among women (89.3 per 100,000) than men (28.2 per 100,000).[27] More recent German insurance data reported an overall incidence of 110 per 100,000 person-years, increasing to 351.1 per 100,000 among people aged ≥65 years.[26]

The incidence of PHFs is expected to remain an important healthcare concern as populations age and the prevalence of osteoporosis increases.[25][26]

Aetiology

The 2 most common mechanisms of PHF:[28]

  • Low-energy trauma: typically a fall from standing height, particularly in older adults with osteoporosis.[29]
  • High-energy trauma: such as motor vehicle collisions and sports-related injuries, more commonly affecting younger.[30]

Associated injuries

Nerve injury

Neurological complications may include brachial plexus injury or traction injury to the axillary nerve, particularly in patients with fracture-dislocations.[31]

Vascular injury

Vascular complications are uncommon but may occur with fracture-dislocations.[32] Distal pulses and signs of ischaemia may remain normal; therefore, an expanding haematoma, pulsatile bleeding, unexplained hypotension, delayed anaemia, or associated nerve injury should raise suspicion of vascular injury.[33]

Clinical Presentation

Symptoms

Clinical presentation varies according to the fracture pattern and severity, but common symptoms include:[34][35][36]

  • Pain, particularly with shoulder movement
  • Swelling and tenderness around the shoulder
  • Reduced active and passive range of motion
  • Bruising or discolouration around the shoulder and upper arm
  • Weakness or difficulty using the affected upper limb
  • Functional limitation, such as difficulty dressing, reaching, or performing overhead activities

Classification

Several classification systems have been developed for PHFs, with the Neer and AO/OTA classifications among the most widely used.[37] Additional classification systems have been developed for specific fracture patterns, including GT fractures.[38]

The Neer Classification

The Neer classification system categorises proximal humerus fractures (PHFs) according to the number of displaced anatomical segments and it also includes distinct categories for fracture-dislocations and fractures involving the articular surface.[39] The four principal segments assessed are the greater tuberosity, lesser tuberosity, humeral head articular segment, and humeral shaft.[40] Under the traditional Neer criteria, a segment is considered displaced when it is separated by more than 1 cm or angulated by more than 45°.[41]

  • One-Part fractures:These fractures may contain multiple fracture lines; however, none of the resulting segments fulfils the displacement criteria. Classification as a one-part fracture therefore depends on the degree of displacement rather than the number of fracture lines.[42]
  • Two-Part fractures: A two-part fracture occurs when one anatomical segment is displaced relative to the remaining fragments. The fracture may involve the greater or lesser tuberosity or the humerus at the anatomical or surgical neck.[43]
  • Three-Part fractures: These fractures involve displacement of the surgical neck and one of the tuberosities. The other tuberosity remains attached to the humeral head segment, and displacement may produce rotational deformity.[41]
  • Four-Part fractures: In this pattern, the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft are separated into four displaced segments.[42] The articular segment may lose its normal relationship with the glenoid, and disruption of its blood supply increases the risk of avascular necrosis of the humeral head.[44]
  • Valgus-Impacted Four-Part Fractures: This variant is characterised by impaction of the humeral head in a valgus orientation. The articular surface is directed superiorly or superolaterally, and the fracture commonly exhibits comminution on the lateral side.[45]
  • Fracture Dislocations and Articular Surface Injuries: Neer also described fracture-dislocations and articular fractures as distinct injury patterns because of their specific clinical and treatment implications.[41] Fracture-dislocations may be associated with an increased risk of complications, including avascular necrosis. Articular surface injuries include head-splitting fractures, in which the articular segment is divided, and impression or impaction fractures, in which part of the articular surface is compressed or deformed.[42]

[46]

The AO/OTA Classification

The AO/OTA 2007 classification is based on the severity and articular/extraarticular and unifocal/bifocal pattern of the fracture, defining three main types (A, B, and C) which are as follows:[47]

  • Type A: extraarticular and unifocal
  • Type B: extraarticular and bifocal
  • Type C: articular

The 2018 revised AO/OTA classification categorises proximal humeral fractures according to fracture location, morphology, and articular involvement.[48] Proximal humeral fractures are designated as 11 and divided into three main groups: Type A, extra-articular unifocal fractures; Type B, extra-articular bifocal fractures; and Type C, articular fractures.[49] Each group is further subdivided according to the specific fracture pattern and degree of displacement.[50]

Diagnostic Procedures

Radiological assessment is essential for confirming the diagnosis, defining fracture morphology and displacement, and guiding the management of PHFs.[37] The following imaging modalities may be used in the assessment of PHFs:[51]

Plain X-rays

Plain radiographic imaging is the primary baseline investigation for diagnosis, classification, and management planning of PHFs.[51] X-rays should include:[36]

  • True anteroposterior view
  • Trans-scapular Y view
  • Axillary lateral view when tolerated

Doppler Ultrasound

Doppler ultrasound may be used to assess arterial flow when vascular injury is suspected.[52] Musculoskeletal ultrasound may also help identify associated rotator cuff tears.[53][54]

Computerised tomography

Computerised tomography (CT) may be used to provide detailed three-dimensional assessment of proximal humeral anatomy, including the distribution of bone stock and bone quality, which may assist in preoperative assessment and planning of fracture fixation.[55]

CT angiography

CT angiography can be used for accurate diagnosis and guiding management of co-existing arterial injury.[56]

Magnetic resonance arthrography

Magnetic resonance arthrography may be used as an additional imaging tool for assessing periarticular soft-tissue injuries, particularly in patients with persistent symptoms following a proximal humeral fracture.[57][51]

Angiography

Angiography is an additional imaging tool for the assessment of vascular injuries.[56]

Differential Diagnosis

The differential diagnosis of proximal humerus fracture should consider other traumatic injuries and conditions that may present with acute shoulder pain, swelling, and restricted range of motion.[36] These include clavicular and scapular fractures, glenohumeral dislocation, acromioclavicular joint injuries, proximal humeral or humeral shaft fractures, and soft-tissue injuries such as rotator cuff tears.[58][59] Cervical spine pathology and associated brachial plexus or peripheral nerve injuries should also be considered during the assessment of patients with proximal humerus fractures, particularly when neurological symptoms are present or the mechanism of injury suggests additional trauma.[36][60]

Following suspected PHF, clinical evaluation should begin with a thorough assessment of the neurological and vascular status of the affected extremity.[34] The entire limb should be examined for additional fractures or associated injuries, particularly following high-energy trauma.[61] Neurological complications may include axillary nerve and, less commonly, brachial plexus or suprascapular nerve injuries, while vascular complications may include axillary artery injury.[62] High-energy mechanisms may also be associated with thoracic injuries, including pneumothorax or haemothorax.[63] Associated rotator cuff injury should also be considered, particularly in patients with persistent weakness or functional limitation.[64]

Outcome Measures

Management / Interventions

PHF can be treated conservatively with the anticipation that the fracture will heal, and the patient will regain function in that shoulder.[2] The treatment is usually a sling and early range-of-motion exercises, however, sometimes can be open reduction with internal fixation (ORIF) or prosthetic joint replacement. Choosing conservative treatment or surgical fracture management depends on the type and severity of the fracture, concomitant soft-tissue injuries, and other individual factors such as age, comorbidities, activity level, quality of bone, and motivation of the patient.[3]

Conservative Medical Management

The vast majority of nondisplaced proximal humerus fractures can be successfully managed conservatively, with non-operative treatment generally associated with fewer complications and no consistent evidence of superior functional or clinical outcomes following surgical intervention.[66][67][68]

Patients receiving a conservative treatment are generally immobilised 4 to 6 weeks in a simple sling, with the glenohumeral joint in the resting position, in internal rotation, and 0° of adduction.[3]

Rehabilitation After Initial Conservative Treatment

Rehabilitation following a proximal humerus fracture should be individualised according to fracture severity and pattern, patient characteristics, and clinical progress; the following protocol provides a structured approach to rehabilitation with the aim of restoring ROM, normal strength, and function:[3]

Timeframe Interventions & Goals Precautions & Progression Notes
Within 1 week post-PHF • Early passive mobilisation of the shoulder in forward elevation, abduction, and external rotation (to patient tolerance).

• Pain control strategies.

• Active mobilisation of distal and adjacent joints (neck, elbow, wrist, and hand).

• Patient education to prevent complications related to immobilisation.

• Limit external rotation to 30°–40° for the first 3 weeks to restrict rotational stress on the fracture site.
3 to 5 weeks • Active-assisted mobilisation of the shoulder joint. • Monitor patient tolerance and tissue response closely.
4 weeks • Submaximal isometric exercises in flexion, abduction, and internal rotation. • Ensure contractions remain submaximal and pain-free.
4 to 6 weeks • Active mobilisations of the shoulder.

• Progress positioning: Start in supine, then gradually advance to sitting.

• Initiate only when sling is no longer needed and adequate fracture consolidation is verified.
8 to 12 weeks • Progressive strengthening exercises focusing on:

- Rotator cuff muscles

- Scapulothoracic musculature

• Ensure proper scapular kinematics during resistance loading.
8 to 16 weeks • Gradual return to work. • Timeline depends on specific occupational physical demands.
> 12 weeks • Functional exercises tailored to daily living tasks.

• Return to leisure or sports activities.

• Guided by patient tolerance, physical capacity, and individual goals.

Surgical Fracture Management

Recent evidence suggests that surgical treatment does not consistently provide superior functional outcomes compared with non-operative management for displaced proximal humerus fractures in older adults, including complex fracture patterns. However, outcomes may vary according to fracture type and surgical procedure.[67][69][70]  However, surgical treatments are recommended for active patients with displaced PHF on initial x-rays or CT imaging or following secondary displacement in the first 3 weeks of follow-up.[3]

Types of Surgeries

Following are types of surgeries considered for PHF:[68]

  • Closed reduction and percutaneous stabilisation using pins or wires maybe considered for selected displaced two-part fractures, three-part fractures, and valgus-impacted four-part fractures, particularly when good bone quality, minimal comminution, and a stable closed reduction can be achieved and maintained.[71][37]
  • External fixation maybe considered as a minimally invasive option for selected three- and four-part proximal humerus fractures, particularly in elderly patients when closed reduction and external fixation can provide adequate stability.[72]
  • Open reduction and plating for example, buttress plates, angle blade plates and proximal humeral locking plates.[73][74] Open reduction and internal fixation with locking plates (ORIF-LP) maybe considered for displaced proximal humerus fractures when satisfactory reduction and stable fixation can be achieved, particularly in physiologically young patients and in selected complex fracture patterns.[75]
  • Open reduction and fixation using a tension-band principle which maybe used as a fixation or augmentation method in selected proximal humerus fractures, particularly for tuberosity fragments, and may also be used in combination with other fixation constructs to improve fracture stability.[76]
  • Intramedullary nailing either antegrade or retrograde insertion; nowadays, intramedullary nails are 'locked' into place, generally using screws.[77]
  • Hemiarthroplasty (replacement of the humeral head)
  • Total shoulder replacement (replacement of the entire joint, both the 'ball' (humeral head) and 'socket' (glenoid)). This includes reverse polarity arthroplasty, where the joint polarity is reversed such that the ball is on glenoid side and the socket on the humeral side.[78][79]

Rehabilitation Post-Surgical Treatment

Rehabilitation following PHF surgery should be tailored to the fracture pattern, fixation stability, bone quality and associated soft-tissue injuries.[80] Restrictions may differ when additional procedures have been performed, such as shoulder dislocation repair or rotator cuff repair.[64] The rehabilitation plan should therefore be agreed with the treating surgeon and adjusted according to tissue healing and the patient's clinical progress.[3]

After Open Reduction Internal Fixation (ORIF)

This protocol is criteria-based as well as time-based (depending on tissue healing).[1][81] Treatment selection should be individualised according to the patient’s functional needs, bone quality, and fracture characteristics, with clinical decision-making guided by an evidence-based treatment algorithm.[82] The following phases provide a general framework rather than a universal protocol; individual restrictions may vary according to the procedure performed and any postoperative complications.

The following are the phases of rehabilitation:[83]

Rehabilitation phase Goals Precautions Interventions Criteria for progression
Phase I: Early postoperative phase (weeks 1–4) • Control pain and swelling.

• Protect the fixation and support fracture healing. • Begin restoring passive shoulder mobility. • Maintain movement in the elbow, wrist and hand.

• Limit shoulder abduction to 90° and external rotation to 40° or less, unless otherwise prescribed.

• Avoid lifting more than 1 lb (approximately 0.45 kg). • Avoid painful movements. • Do not drive until shoulder control and mobility are adequate, sling use has been discontinued and sedating analgesics are no longer being taken, subject to medical and legal advice.

• Use a sling for approximately 3 weeks or as directed by the surgeon.

• Apply ice or other appropriate measures to manage pain and swelling. • Introduce gentle passive shoulder movements and pendulum exercises when permitted. • Perform active movements of the elbow, wrist and hand. • Practise hand gripping, scapular retraction and gentle scapular mobility exercises.

• Pain is adequately controlled.

• Full active elbow movement is achieved. • Shoulder passive range of motion (PROM) reaches approximately 140° flexion, 40° external rotation and 90° abduction, provided these targets are permitted by the surgical protocol. • Progress towards sling withdrawal when clinically appropriate.

Phase II: Progressive mobility (weeks 4–8) • Improve shoulder PROM towards full available range.

• Introduce active-assisted range of motion (AAROM) and, when permitted, active range of motion (AROM), commonly from week 6. • Begin gentle elbow strengthening. • Introduce low-intensity shoulder isometric exercises. • Reduce compensatory movement patterns and support the return to everyday activities.

• Avoid lifting more than 2 lb (approximately 0.9 kg) before week 6.

• Delay active shoulder movement until the prescribed postoperative milestone. • Avoid forceful stretching or overpressure at the end of range. • Do not begin resisted shoulder strengthening until authorised.

• Continue suitable exercises from Phase I.

• Use supported AAROM exercises, including table slides, wall slides, pulley exercises and gradual elevation in a supported position. • Progress to supine shoulder flexion, side-lying external rotation with the arm supported, side-lying abduction up to 90°, side-lying flexion and low punches as tolerated. • Introduce gentle shoulder isometrics in flexion, extension, internal rotation and external rotation. • Add biceps curls, triceps extensions and supported prone rows when permitted.

• Shoulder PROM is restored to the expected range for the procedure.

• Full active elbow movement is maintained. • Pain remains controlled. • Shoulder isometrics and elbow strengthening are tolerated without adverse symptoms.

Phase III: Active movement and initial strengthening (weeks 8–12) • Restore full shoulder AROM with appropriate movement control.

• Introduce progressive shoulder strengthening. • Improve elbow and wrist strength. • Maintain symptom control during exercise.

• Avoid lifting more than 10 lb (approximately 4.5 kg), unless restrictions are revised by the surgeon.

• Do not force painful stretches. • Avoid excessive weight-bearing through the operated arm.

• Continue appropriate mobility exercises from earlier phases.

• Progress to standing shoulder flexion and abduction using a dowel where needed. • Practise controlled shoulder elevation, proprioceptive neuromuscular facilitation (PNF) diagonals and prone I, Y and T exercises. • Introduce gentle doorway, pectoral, biceps and cross-body stretches when appropriate. • Progress to rows, straight-arm pull-downs, resisted external and internal rotation with the arm by the side, resisted low punches and supine shoulder protraction.

• Shoulder AROM is functionally complete, with appropriate movement mechanics.

• Strengthening can be performed without pain or significant compensatory movements.

Phase IV: Advanced strengthening and functional recovery (week 12 onwards) • Increase shoulder strength and endurance.

• Progress towards compound and functional movements. • Address any remaining mobility limitations. • Prepare for work, recreational activities or sport, where appropriate.

• Increase resistance gradually according to symptoms, movement quality and tissue healing.

• Avoid progressing load when pain, loss of control or compensatory movements develop.

• Continue suitable exercises from the preceding phases.

• Progress rhythmic stabilisation, scaption raises and resisted shoulder diagonals. • Introduce resisted internal and external rotation at 90° abduction when appropriate. • Progress closed-chain activities, including wall press-ups, countertop press-ups, modified press-ups and high-plank variations. • Add quadruped stability exercises and shoulder plyometrics when indicated. • Introduce graded return-to-sport activities for suitable patients.

• Operated-arm strength reaches at least 80% of the opposite arm when measured by dynamometry, if this is an appropriate goal.

• Progressive strengthening is completed without pain. • Patient-reported function indicates minimal or no remaining disability. • Functional goals are achieved before unrestricted activity resumes.

List of common surgical complications

Complications following PHF surgery differ according to whether the fracture is treated with internal fixation or shoulder arthroplasty.[84] Most common surgical complications in surgical management of PHFs are:[3]

Open reduction and internal fixation (ORIF) Shoulder replacement (arthroplasty)
Avascular necrosis of the humeral head Joint instability or dislocation
Screw cut-out or penetration of the articular surface Incorrect implant positioning
Non-union Implant loosening
Malunion Infection, including Cutibacterium acnes infection (formerly Propionibacterium acnes)
Persistent dislocation Biceps tendon pathology
Infection Axillary nerve palsy
Capsulitis and shoulder stiffness Brachial plexus palsy
Rotator cuff tear Rotator cuff failure following hemiarthroplasty
Biceps tendon pathology Glenoid notching following reverse shoulder arthroplasty
Axillary nerve palsy Periprosthetic fracture
Brachial plexus palsy Heterotopic ossification
Heterotopic ossification

[85]

[86]

Summary

Proximal humerus fractures are common upper-limb injuries, particularly among older adults, and are frequently associated with osteoporosis and low-energy falls.[27][61] Clinical presentation typically includes shoulder pain, swelling, bruising, tenderness, and restricted range of motion.[3] Assessment should include neurological and vascular examination to identify associated injuries.[34] Diagnosis is primarily based on plain radiographs, with computed tomography (CT) used when detailed assessment of fracture morphology is required.[87][34] The Neer and AO/OTA classification systems help describe fracture patterns and guide treatment planning.[37] Management may be conservative or surgical, depending on fracture displacement, complexity, bone quality, patient characteristics, functional demands, and associated injuries.[64] Conservative treatment generally involves sling immobilisation and progressive rehabilitation, while surgical options include fracture fixation and shoulder arthroplasty for selected patients.[61] Rehabilitation should be individualised according to fracture stability, healing, and treatment approach, progressing from protected mobilisation to active movement, strengthening, and functional activities.[88] Early identification of complications, appropriate treatment selection, and a structured rehabilitation programme are essential to optimise shoulder function and recovery.[89]

[90]

[91]

References

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  36. ↑ 36.0 36.1 36.2 36.3 Khmelnitskaya E, Lamont LE, Taylor SA, Lorich DG, Dines DM, Dines JS. Evaluation and management of proximal humerus fractures. Advances in orthopedics. 2012;2012(1):861598.
  37. ↑ 37.0 37.1 37.2 37.3 Baker HP, Gutbrod J, Cahill M, Shi L. Optimal treatment of proximal humeral fractures in the elderly: risks and management challenges. Orthopedic research and reviews. 2023 Dec 31:129-37.
  38. ↑ Foruria AM, Martinez-Catalan N, Pardos B, Larson D, Barlow J, Sanchez-Sotelo J. Classification of proximal humerus fractures according to pattern recognition is associated with high intraobserver and interobserver agreement. JSES international. 2022 Jul 1;6(4):563-8.
  39. ↑ Baker HP, Gutbrod J, Strelzow JA, Maassen NH, Shi L. Management of proximal humerus fractures in adults-A scoping review. J Clin Med. 2022;11(20):6140.
  40. ↑ Ismayl G, Ogbechie C, Goundry S, Budworth L, Ejiofor I, Sheikh H, et al. Classification and measurement of displacement of isolated greater tuberosity fractures: intra and interobserver reliability. Shoulder Elbow. 2025;17(1):50-56.
  41. ↑ 41.0 41.1 41.2 Carofino BC, Leopold SS. Classifications in brief: the Neer classification for proximal humerus fractures, Clin Orthop Relat Res. 2013;471(1):39-43. doi:10.1007/s11999-012-2454-9
  42. ↑ 42.0 42.1 42.2 Kalacun D, Komadina R, Brilej D. Proximal humerus fractures in the elderly work up, classifications and fracture biomechanics. Eur J Trauma Emerg Surg. 2025;51(1):300.
  43. ↑ Marmor MT, Agel J, Dumpe J, Kellam JF, Marecek GS, Meinberg E, Nguyen MP, Sims S, Soles GL, Karam MD. Comparison of the Neer classification to the 2018 update of the Orthopedic Trauma Association/AO fracture classification for classifying proximal humerus fractures. OTA International. 2022 Jun 16;5(3):e200.
  44. ↑ Resch H, Povacz P, Fröhlich R, Wambacher M. Percutaneous fixation of three-and four-part fractures of the proximal humerus. The Journal of Bone & Joint Surgery British Volume. 1997 Mar 1;79(2):295-300.
  45. ↑ Martinez-Catalan N. Conservative treatment of proximal humerus fractures: when, how, and what to expect. Current reviews in musculoskeletal medicine. 2023 Feb;16(2):75-84.
  46. ↑ nabil ebraheim. Proximal Humerus Fractures classification - Everything You Need To Know - Dr. Nabil Ebraheim. Available from: https://www.youtube.com/watch?v=IXCD_BcbgOw&t=5s [last accessed 6/11/2022]
  47. ↑ Marongiu G, Leinardi L, Congia S, Frigau L, Mola F, Capone A. Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems. Journal of Orthopaedics and Traumatology. 2020 Dec;21(1):1-9.
  48. ↑ Marongiu G, Leinardi L, Congia S, Frigau L, Mola F, Capone A. Reliability and reproducibility of the new AO/OTA 2018 classification system for proximal humeral fractures: a comparison of three different classification systems. Journal of orthopaedics and traumatology. 2020 Dec;21(1):4.
  49. ↑ Diaz LE, DADA NETO FR, Lofrano L, Garcia JV, Santana MV, Dobashi ET. Intra-and inter-observer agreement of proximal humeral fractures classifications in adults. Acta Ortopédica Brasileira. 2022 Dec 16;30(6):e257229.
  50. ↑ Pai S, Kotekar MF, Pawaskar SM, Kumar MA. Proximal humerus fractures in the elderly. Indian Journal of Orthopaedics. 2025 Mar;59(3):346-57.
  51. ↑ 51.0 51.1 51.2 Vachtsevanos L, Hayden L, Desai AS, Dramis A. Management of proximal humerus fractures in adults. World journal of Orthopedics. 2014 Nov 11;5(5):685.
  52. ↑ Faur CI, Nitu R, Abu-Awwad SA, Tudoran C, Abu-Awwad A. The Arterial Axis Lesions in Proximal Humeral Fractures—Case Report and Literature Review. Journal of Personalized Medicine. 2023 Dec 14;13(12):1712.
  53. ↑ Gallo RA, Altman DT, Altman GT. Assessment of rotator cuff tendons after proximal humerus fractures: is preoperative imaging necessary?. Journal of Trauma and Acute Care Surgery. 2009 Mar 1;66(3):951-3.
  54. ↑ Green M, Whetter R, Al-Dadah O. Proximal humerus fractures and shoulder dislocations: Prevalence of concomitant rotator cuff tear. Journal of Orthopaedics, Trauma and Rehabilitation. 2023 Jun;30(1):22104917221101409.
  55. ↑ Kamer L, Noser H, Popp AW, Lenz M, Blauth M. Computational anatomy of the proximal humerus: an ex vivo high-resolution peripheral quantitative computed tomography study. Journal of orthopaedic translation. 2016 Jan 1;4:46-56.
  56. ↑ 56.0 56.1 Shepherd, J., Saratzis, A., Pepper, C., Singh, H., & Messeder, S. J. (2024). A systematic review of proximal humerus fractures and associated vascular injuries. JVS-vascular insights, 2, 100065. https://doi.org/10.1016/j.jvsvi.2024.100065
  57. ↑ Amini B, Beckmann NM, Beaman FD, Wessell DE, Bernard SA, Cassidy RC, et al. ACR Appropriateness Criteria® Shoulder Pain–Traumatic. J Am Coll Radiol. 2018;15(5 Suppl).
  58. ↑ Cibulas A, Leyva A, Cibulas G 2nd, Foss M, Boron A, Dennison J, et al. Acute shoulder injury. Radiol Clin North Am. 2019;57(5):883-96.
  59. ↑ Monica J, Vredenburgh Z, Korsh J, Gatt C. Acute shoulder injuries in adults. Am Fam Physician. 2016;94(2):119-27.
  60. ↑ Couch BK, Maher PL, Fourman MS, Moloney GB, Siska PA, Tarkin IS. Increased medial displacement of the humeral shaft of at least 40% correlates with an increased incidence of nerve injury in proximal humerus fractures. Iowa Orthop J. 2021;41(1):163-6.
  61. ↑ 61.0 61.1 61.2 Girgin AB, Acar A, Torun Ö, Çevik HB. Osteoporotic fractures of the proximal humerus: an in-depth review of current management options. Current Osteoporosis Reports. 2025 Dec;23(1):51.
  62. ↑ Karita Y, Kimura Y, Sasaki S, Nitobe T, Tsuda E, Ishibashi Y. Axillary artery and brachial plexus injury secondary to proximal humeral fractures: A report of 2 cases. International journal of surgery case reports. 2018 Jan 1;50:106-10.
  63. ↑ Briese T, Theisen C, Schliemann B, Raschke MJ, Lefering R, Weimann A. Shoulder injuries in polytraumatized patients: an analysis of the TraumaRegister DGU®. European Journal of Trauma and Emergency Surgery. 2021 Dec;47(6):1921-30.
  64. ↑ 64.0 64.1 64.2 Pandey R, Raval P, Manibanakar N, Nanjayan S, McDonald C, Singh H. Proximal humerus fractures: A review of current practice. Journal of clinical Orthopaedics and Trauma. 2023 Aug 1;43:102233.
  65. ↑ 65.0 65.1 65.2 65.3 Richard GJ, Denard PJ, Kaar SG, Bohsali KI, Horneff JG, Carpenter S, Fedorka CJ, Mamelson K, Garrigues GE, Namdari S, Abboud JA. Outcome measures reported for the management of proximal humeral fractures: a systematic review. Journal of Shoulder and Elbow Surgery. 2020 Oct 1;29(10):2175-84.
  66. ↑ Song JQ, Deng XF, Wang YM, Wang XB, Xue Lİ, Bin YU. Operative vs. nonoperative treatment for comminuted proximal humeral fractures in elderly patients: a current meta-analysis. Acta Orthopaedica et Traumatologica Turcica. 2015 Jan 1;49(4):345-53.
  67. ↑ 67.0 67.1 Xie L, Ding F, Zhao Z, Chen Y, Xing D. Operative versus non-operative treatment in complex proximal humeral fractures: a meta-analysis of randomized controlled trials. Springerplus. 2015 Dec;4(1):1-9.
  68. ↑ 68.0 68.1 Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;(11):CD000434. Published 2015 Nov 11. doi:10.1002/14651858.CD000434.pub4
  69. ↑ Gracitelli MEC, Andrade-Silva FB, Zanesco L, Assunção JH, Kojima KE, Silva JS, et al. Proximal humeral fractures in patients over 60 years old: a randomized study of nonoperative versus operative treatment with locking plate. J Shoulder Elbow Surg. 2025;34(9):2165-2177.
  70. ↑ Abouelsoud M, Abdel Wahab MM, Kamal HM, Ali Mohamed AA. Locked plate fixation versus non-operative management for three and four-part proximal humeral fractures in elderly: a randomized controlled trial. Injury. 2026;57(11):113686.
  71. ↑ Murena L, Canton G, Ratti C, Hoxhaj B, Giraldi G, Surace MF, Grassi FA. Indications and results of osteosynthesis for proximal humerus fragility fractures in elderly patients. Orthopedic Reviews. 2020 Apr 28;12(1):8559.
  72. ↑ Maluta T, Amarossi A, Dorigotti A, Bagnis F, Samaila EM, De Luca L, Pezzè L, Magnan B. External fixation for proximal humerus fractures neer type 3 and 4: results of 17 cases. Acta Bio Medica: Atenei Parmensis. 2020 Dec 30;91(Suppl 14):e2020017.
  73. ↑ Brunner F, Sommer C, Bahrs C, Heuwinkel R, Hafner C, Rillmann P, Kohut G, Ekelund A, Muller M, Audigé L, Babst R. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. Journal of orthopaedic trauma. 2009 Mar 1;23(3):163-72.
  74. ↑ Schliemann B, Wähnert D, Theisen C, Herbort M, Kösters C, Raschke MJ, Weimann A. How to enhance the stability of locking plate fixation of proximal humerus fractures? An overview of current biomechanical and clinical data. Injury. 2015 Jul 1;46(7):1207-14.
  75. ↑ Foruria AM. Plate fixation of proximal humerus fractures: how to get it right and future directions for improvement. Current Reviews in Musculoskeletal Medicine. 2023 Oct;16(10):457-69.
  76. ↑ Chen H, Zhao Z, Zhu Z. Proximal humerus fracture. In Orthopaedic Trauma Surgery: Volume 1: Upper Extremity Fractures and Dislocations 2023 May 6 (pp. 49-94). Singapore: Springer Nature Singapore.
  77. ↑ Dilisio MF, Nowinski RJ, Hatzidakis AM, Fehringer EV. Intramedullary nailing of the proximal humerus: evolution, technique, and results. Journal of shoulder and elbow surgery. 2016 May 1;25(5):e130-8.
  78. ↑ Lee DH, Choi YS, Potter HG, Endo Y, Sivakumaran T, Lim TK, Chun TJ. Reverse total shoulder arthroplasty: an imaging overview. Skeletal Radiology. 2020 Jan;49(1):19-30.
  79. ↑ Limb R, Kenyon P. The evolution of the reverse total shoulder replacement. Orthopaedics and Trauma. 2026 May 13.
  80. ↑ Almirah A, Alkholidy G, Alrabeei G, Abdulmughni Y, Hutaif M, Ahmed F. Functional outcomes and postoperative shoulder stiffness in patients with proximal humerus fractures treated with PHILOS plating: A retrospective study. Journal of Emergency Medicine, Trauma & Acute Care. 2025 Sep 30;2025(3).
  81. ↑ Canbora MK, Kose O, Polat A, Konukoglu L, Gorgec M. Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: A prospective study. Int J Shoulder Surg. 2013;7(3):105-109. doi:10.4103/0973-6042.118911
  82. ↑ Spross C, Zdravkovic V, Manser M, Farei-Campagna JM, Jacxsens M, Jost B. Outcomes of management of proximal humeral fractures with patient-specific, evidence-based treatment algorithms. JBJS. 2021 Oct 20;103(20):1906-16.
  83. ↑ Mammoth Orthopedic Institute. Rehabilitation guidelines for proximal humerus fracture – ORIF. Mammoth Lakes (CA): Sierra Park Physical and Occupational Therapy; 2016.
  84. ↑ Walter N, Szymski D, Riedl M, Kurtz SM, Alt V, Lowenberg DW, Lau EC, Rupp M. Proximal humerus fractures in the elderly US population: a cross-sectional study of treatment trends and comparison of complication rates after joint replacement, open reduction and internal fixation, and non-surgical management. Journal of clinical medicine. 2023 May 17;12(10):3506.
  85. ↑ Penn Medicine. Shoulder Surgery Rehab: Exercises for the First Six Weeks | Martin Kelley, DPT of Penn Rehab. Available from: https://www.youtube.com/watch?v=hsauKSU_Qww [last accessed 6/11/2022]
  86. ↑ Penn Medicine. Shoulder Surgery Rehab: Exercises for 7-12 Weeks After Surgery| Martin Kelley, DPT of Penn Rehab. Available from: https://www.youtube.com/watch?v=0F8VcqYCq-8 [last accessed 6/11/2022]
  87. ↑ Bahrs C, Rolauffs B, Südkamp NP, Schmal H, Eingartner C, Dietz K, Pereira PL, Weise K, Lingenfelter E, Helwig P. Indications for computed tomography (CT-) diagnostics in proximal humeral fractures: a comparative study of plain radiography and computed tomography. BMC musculoskeletal Disorders. 2009 Apr 2;10(1):33.
  88. ↑ Budharaju A, Hones KM, Hao KA, Wright JO, Fedorka CJ, Kaar SG, Bohsali KI, Wright TW, Patrick MR, King JJ. Rehabilitation protocols in proximal humerus fracture management: a systematic review. Shoulder & elbow. 2024 Jul;16(4):449-58.
  89. ↑ Caforio M, Maniscalco P. The importance of early rehabilitation in proximal humeral fracture: a clinical trial of efficacy and safety of a new endomedullary nail. Journal of Back and Musculoskeletal Rehabilitation. 2017 Mar;30(2):195-202.
  90. ↑ OrthoClips. Proximal Humerus Fractures 1 (OTA lecture series III u03a). Available from: https://www.youtube.com/watch?v=eZO-fWOlFGE [last accessed 6/11/2022]
  91. ↑ WesternTrust. Physiotherapy Exercises following a Proximal Hummus Fracture. Available from: https://www.youtube.com/watch?v=TREhz8tagS4 [last accessed 6/11/2022]
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