Proximal humerus fractures: A review of current management evidence and guidance on contemporary surgical strategies.

Proximal humerus fractures (PHFs) most commonly affect elderly, osteoporotic women, although younger patients sustain them through high-energy trauma. Both incidence and the associated healthcare burden continue to rise with demographic ageing. Non-operative management is preferred for undisplaced fractures and for many elderly patients, whereas a range of internal fixation methods and arthroplasty options are available for more complex injuries. Patient age, comorbidities, functional demands and fracture pattern are the primary determinants of treatment selection, implant choice and expected outcome. Absolute indications for surgery include acute fracture-dislocations, open fractures and injuries with vascular or neurological compromise. Relative indications are based on the degree of displacement and the predicted failure of non-operative treatment, and include head-splitting fractures, severe varus, valgus or posterior tilt of the humeral head, anatomical neck fractures, calcar comminution, complete displacement of the humeral head from the shaft, significant displacement of the lesser or greater tuberosity, displaced three- and four-part fractures, and large impaction defects of the humeral head, particularly when associated with instability. It is important to recognise that the displacement thresholds in routine use are pragmatic and consensus-derived rather than validated, and that expert panels do not agree on a maximum acceptable deviation. Surgery is technically demanding, requiring anatomical reduction, calcar restoration, avoidance of varus, secure fixation of the tuberosities and correct patient and implant selection. Locked plating has been the most common operation, but is associated with high complication rates and has failed to show superiority over non-operative treatment in several large randomised controlled trials. Augmentation of fixation and intramedullary nailing may address calcar comminution, metaphyseal voids and varus collapse. Arthroplasty is increasingly used in elderly patients, with reverse shoulder arthroplasty now dominating over hemiarthroplasty. Results appear better than hemiarthroplasty and plate fixation in the single trial that has compared them directly, but the evidence remains limited. To support this narrative review a systematic search was undertaken to identify every randomised controlled trial of PHF management. This review synthesises and compares current evidence on the management options for PHFs and provides practical guidance on contemporary surgical strategies.