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Proximal Humerus Fractures

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

This article is currently under review and may not be up to date. Please come back soon to see the finished work! (8/10/2026)

Definition/Description

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]

Features

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 ischemia 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 intrinsic 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 four-part classification system describes PHFs by the number of displaced segments or parts, and additional categories for articular fracture and dislocation.[39] The (GT), lesser tuberosity, articular surface, and humeral diaphysis are the potential segments involved.[40] It is defined that the segment is displaced when there is greater than 1 cm separation or 45° angulation.[41]

  • One-Part fractures: One-part fractures are those in which no fragment meets the displacement criteria, regardless of the number or location of fracture lines.[42]
  • Two-Part fractures: One segment is displaced, which is the GT, lesser tuberosity, or articular segment at the level of the anatomical neck or surgical neck.[43]
  • Three-Part fractures: Three-part fractures involve displacement of the surgical neck and one tuberosity, while the remaining tuberosity remains attached, resulting in rotational deformity.[41]
  • Four-Part fractures: Four-part fractures is a complex fracture that involves displacement of the humeral head, greater tuberosity, lesser tuberosity, and humeral shaft as four separate fragments.[42] In classic four-part fractures, the articular segment is typically displaced and loses contact with the glenoid and severe injuries associated with a high risk of avascular necrosis of the humeral head.[44]
  • Valgus-Impacted Four-Part Fractures: Valgus-impacted fractures are characterized by lateral-sided comminution, with the humeral head articular surface facing superiorly or superolaterally and the head impacted in a valgus position.[45]
  • Fracture Dislocations and Articular Surface Injuries: Separate categories were added for dislocations, as they represent more severe injuries and are more likely to develop avascular necrosis and heterotopic ossification.[41] Likewise, articular surface fractures fell into a separate category due to their unique management considerations. There are two types, which are head-splitting fractures and impaction fractures.[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 categorizes 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

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: 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 (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: Can be used for accurate diagnosis and guiding management of co-existing arterial injury.[56]

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: 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

• Constant-Murley score[65]

• Disabilities of the Arm, Shoulder, and Hand score[65]

• Visual Analogue Scale[65]

• American Shoulder and Elbow Surgeons score[65]

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 individualized according to fracture severity and pattern, patient characteristics, and clinical progress; the following protocol provides a structured approach to rehabilitation:[3]

Aim: Restoring range of motion, normal shoulder strength, and function

Within a week after PHF

  • Early passive mobilisation of the shoulder in forward elevation, abduction, and external rotation with respect to patients’ tolerance (External rotation should be limited to 30°-40° for the first 3 weeks to restrict rotational stress to the fracture)  
  • Education to prevent the complications caused by the immobilisation)
  • Pain control
  • Active mobilisation of the neck, elbow, wrist, and hand

3 to 5 weeks

  • Active-assisted mobilisation


< 4 weeks >

  • Submaximal isometric exercises in flexion, abduction, and internal rotation


< 4 to 6 weeks >

  • Active mobilisations (when the sling is no longer needed and when adequate fracture consolidation is achieved; start in the supine position and gradually progress to the sitting position)


< 8 to 12 weeks >

  • Strengthening exercises of the rotator cuff and scapulathoracic muscles


< 12 weeks >

  • Functional exercises
  • Return to leisure or sport activities (depends on the patients’ tolerance and personal demands)


< 8 to 16 weeks >

  • Return to work (depends on the patients’ physical work demands)

Surgical Fracture Management

Recent evidence has indicated that surgery has no significant advantage over conservative treatment, even for complex fractures, in terms of functional outcomes and health-related quality of life in elderly patients.[67]  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]

List of common surgical complications

Most common surgical complications in surgical management of PHFs are:[3]

Open reduction internal fixation Shoulder replacement
Avascular necrosis Joint instability/dislocation
Screw cut out Implant malpositioning
Nonunion Implant loosening
Malunion Infection (Propionibacterium acnes)
Persistent joint dislocation Biceps pathology
Infection (Propionibacterium acnes) Axllary nerve palsy
Capsulitis Brachial plexus palsy
Rotator cuff tear Hemiarthroplasty: rotator cuff failure
Biceps pathology Reverse arthroplasty: glenoid notching
Axillary nerve palsy Periprosthetic fracture
Brachial plexus palsy Heterotopic ossification
Heterotopic ossification

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.[69][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.[70]
  • Open reduction and plating for example, buttress plates, angle blade plates and proximal humeral locking plates.[71][72] 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.[73]
  • 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.[74]
  • Intramedullary nailing either antegrade or retrograde insertion; nowadays, intramedullary nails are 'locked' into place, generally using screws.[75]
  • 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.[76][77]

Rehabilitation Post-Surgical Treatment

Rehabilitation protocols are often variable because restrictions will depend on the concomitant injuries and surgical protocols, such as associate shoulder dislocation or concomitant rotator cuff repair. [3]

After Open Reduction Internal Fixation (ORIF)

This protocol is criteria-based as well as time-based (depending on tissue healing).[1][78] Treatment selection should be individualized according to the patient’s functional needs, bone quality, and fracture characteristics, with clinical decision-making guided by an evidence-based treatment algorithm.[79] The expected outcome timeframes included in this protocol may vary depending on surgeon preference, additional procedures performed, and/or complications.

The following are the phases of rehabilitation:[80]

< Phase I: Immediate post-operation (1-4 weeks after surgery) >

Goals

  • Minimise pain and inflammatory response
  • Protect fracture and optimise bony healing
  • Restore shoulder passive range of motion (PROM)
  • Maintain elbow, wrist and hand function


Precautions

  • No abduction past 90°
  • Shoulder external rotation 0°-40°
  • No lifting greater than 1lb
  • No driving until adequate ROM, sling is discharged, and no narcotic pain medication is being used
  • No motions into painful ranges


Interventions

  • Sling: For at least 3 weeks
  • Pain/Swelling management: Cryotherapy and modalities as indicated
  • Range of motion/mobility: Shoulder PROM / shoulder pendulums / elbow, wrist and hand AROM
  • Strengthening: Ball squeezes / scapular retraction and mobility exercises


Criteria to progress

  • Wean from sling at 4 weeks
  • Adequate pain control
  • Full elbow AROM
  • Shoulder PROM flexion to 140°, external rotation to 40°, abduction to 90°


< Phase II: Intermediate post-operation (4-8 weeks after surgery) >

Goals

  • Full shoulder PROM
  • Initiate shoulder active assisted range and active range of motion (AAROM/AROM)
  • Start active range of motion at 6 weeks
  • Initiate gentle elbow isotonic strengthening
  • Initiate shoulder isometrics
  • Minimise compensatory motions of involved upper extremity
  • Encourage return to normal ADLs within lifting precautions


Precautions

  • No lifting greater than 2lbs before 6 weeks
  • Start shoulder AROM at 6 weeks post-op
  • No forceful end range over pressure to involved shoulder
  • No isotonic strengthening of the shoulder


Interventions

  • Continue with Phase I interventions
  • AAROM: Lawn chair progression / table slides, rail slides, wall slides / pully
  • AROM: Supine shoulder AROM flexion / side-lying shoulder ER with towel roll under arm / side-lying shoulder abduction to 90° / side-lying shoulder flexion / low punch
  • Strengthening: shoulder isometric flexion, extension, internal rotation and external rotation / biceps curls / triceps extension / prone rows


Criteria to progress

  • Full shoulder PROM
  • Full elbow AROM
  • Adequate pain control
  • Good tolerance to shoulder isometrics and elbow strengthening


< Phase III: Late post-operation (8-12 weeks after surgery) >

Goals

  • Full shoulder AROM
  • Initiate shoulder strengthening
  • Progress elbow and wrist strengthening
  • Adequate pain control


Precautions

  • No lifting greater than 10bls
  • No painful or forceful stretching
  • No excessive weight bearing on involved extremity


Interventions

  • Continue with Phase I-II interventions
  • AAROM: Standing shoulder flexion/abduction with dowel
  • AROM: Standing shoulder elevation / standing shoulder PNF diagonals / Prone I, Prone Y, Prone T
  • Stretching: Doorway stretch / Pec and biceps stretch / cross body stretch
  • Strengthening: Rows / straight arm pull-down / resisted shoulder external and internal rotation (neutral shoulder position) / low punch with resistance / supine shoulder protraction


Criteria to progress

  • Full shoulder AROM with appropriate mechanics
  • No pain or compensatory strategies with strengthening exercises


< Phase IV: Advanced strengthening (12 weeks after surgery) >

Goals

  • Progress shoulder strength with heavier resistance and compound movements
  • Return to normal functional activities
  • Continue to improve shoulder ROM in needed


Interventions

  • Continue with Phase II-III interventions
  • Strengthening: Rhythmic stabilisations / push up progression (wall, counter top, knees, high plank) / high plank stability progression / scaption raises / resisted shoulder diagonals / resisted shoulder external and internal rotation at 90 ° / quadruped stability progression / shoulder plyometrics / interval return to sports training if appropriate


Criteria to progress

  • 80% or > strength of involved upper extremity compared to uninvolved arm with dynamometry testing
  • No pain with progressive strengthening exercises
  • Low level to no disability score on patient reported outcome measure


[81]

[82]

Resources

Interventions for treating proximal humerus fractures in adults

Proximal humeral fractures: current concepts in classification, treatment and outcomes

Management of proximal humerus fractures in adults

[83]

[84]

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  2. ↑ 2.0 2.1 Jo MJ, Gardner MJ. Proximal humerus fractures. Curr Rev Musculoskelet Med. 2012;5(3):192-198. doi:10.1007/s12178-012-9130-2
  3. ↑ 3.0 3.1 3.2 3.3 3.4 3.5 3.6 Lowry V, Bureau NJ, Desmeules F, Roy JS, Rouleau DM. Acute proximal humeral fractures in adults. Journal of Hand Therapy. 2017 Apr 1;30(2):158-66.
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  5. ↑ Sahara W, Sugamoto K, Nakajima Y, Inui H, Yamazaki T, Yoshikawa H. Three-dimensional morphological analysis of humeral heads: a study in cadavers. Acta Orthop. 2005;76(3):392-396.
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  18. ↑ Duran S, Çayhan V, Günaydın E. Correlation of the depth, medial wall and opening angle of the bicipital groove and the dimensions of long head of the biceps tendon. Anatomy. 2023 Aug 1;17(2):49-54.
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  26. ↑ 26.0 26.1 26.2 26.3 Koeppe J, Stolberg-Stolberg J, Fischhuber K, Iking J, Marschall U, Raschke MJ, et al. The incidence of proximal humerus fracture-an analysis of insurance data. Dtsch Arztebl Int. 2023;120(33-34):555-556. doi:10.3238/arztebl.m2023.0132.
  27. ↑ Iglesias-Rodríguez S, Domínguez-Prado DM, García-Reza A, Fernández-Fernández D, Pérez-Alfonso E, García-Piñeiro J, et al. Epidemiology of proximal humerus fractures. J Orthop Surg Res. 2021;16(1):402.
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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 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. ↑ 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. ↑ 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. ↑ 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.
  70. ↑ 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.
  71. ↑ 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.
  72. ↑ 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.
  73. ↑ 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.
  74. ↑ 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.
  75. ↑ 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.
  76. ↑ 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.
  77. ↑ Limb R, Kenyon P. The evolution of the reverse total shoulder replacement. Orthopaedics and Trauma. 2026 May 13.
  78. ↑ 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
  79. ↑ 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.
  80. ↑ Mammoth Orthopedic Institute. Rehabilitation guidelines for proximal humerus fracture – ORIF. Mammoth Lakes (CA): Sierra Park Physical and Occupational Therapy; 2016.
  81. ↑ 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]
  82. ↑ 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]
  83. ↑ 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]
  84. ↑ 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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