Management of Proximal Humeral Fractures

Proximal humeral fractures account for a significant proportion of upper limb injuries, particularly among older individuals with osteoporotic bone. Management ranges from conservative care—immobilisation in a sling with early supervised mobilisation—to a spectrum of surgical interventions tailored to fracture pattern, bone quality and patient factors. Minimally displaced two-part injuries often respond well to nonoperative treatment, whereas displaced three- and four-part fractures frequently demand anatomical realignment and stable fixation. Open reduction and internal fixation with locking plates remains a mainstay for restoring alignment in complex fractures, though mechanical complications such as screw cut-out, varus collapse and loss of medial support can compromise outcomes. Arthroplasty options, including hemiarthroplasty and reverse total shoulder arthroplasty, are reserved for comminuted injuries, severe tuberosity displacement or fracture-dislocations in elderly patients, offering predictable pain relief and functional restoration. Recent refinement of arthroscopic techniques—such as double-row suture bridge constructs for isolated tuberosity fragments—has provided minimally invasive alternatives. Optimal care hinges on accurate classification, patient-centred risk assessment and a balanced approach to mechanical stability and biological healing.

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Management of Proximal Humeral Fractures publication trend

The graph below shows the total number of articles in management of proximal humeral fractures across all publications each year (not limited to Nature Index journals).

Technical terms

Neer classification: A system dividing proximal humeral fractures into two to four parts based on displacement of key fragments.

Locking plate: An internal fixation device with screws that lock into the plate, enhancing stability in osteoporotic bone.

Hemiarthroplasty: Replacement of the humeral head with a prosthesis while retaining the native glenoid.

Reverse total shoulder arthroplasty: An implant configuration reversing the ball-and-socket relationship to improve deltoid function.

Double-row suture bridge: An arthroscopic technique using two rows of suture anchors to compress and stabilise tuberosity fragments.

References

1. Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3–4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial. PLOS Medicine (2023).
2. New technologies for the classification of proximal humeral fractures: Comparison between Virtual Reality and 3D printed models—a randomised controlled trial. Virtual Reality (2023).
3. Excellent clinical and radiological outcomes after arthroscopic reduction and double row‐suture bridge for large‐sized greater tuberosity fractures of the humerus. Knee Surgery, Sports Traumatology, Arthroscopy (2024).