Management of Proximal Humeral Fractures: A Review

Grayson Domingue, MD; Ian Garrison, MD; Richard Williams, MD; John T. Riehl, MD


Curr Orthop Pract. 2021;32(4):339-348. 

In This Article

Abstract and Introduction


Proximal humeral fractures are a common orthopaedic injury. Although many proximal humeral fractures are managed nonoperatively, operative management can result in improved functional outcome when appropriately indicated. Commonly utilized surgical treatment options include open reduction internal fixation (ORIF), arthroplasty, percutaneous fixation, and intramedullary fixation. The most commonly used classification remains the Neer fracture classification. The authors present a comprehensive review of the epidemiology, relevant anatomy, biomechanics, clinical presentation, diagnosis, and management of proximal humeral fractures.


Proximal humeral fractures (PHF) are commonly seen in elderly patients and represent up to 5.7% of all orthopaedic fractures.[1] They are the third most common osteoporotic fracture.[1] The incidence of PHF sharply increases in patients who are older than 50 and account for approximately 85% of all PHF.[2] The incidence has been reported at 114 per 100,000 person years in women and 47 per 100,000 person years in men.[3] There is a predominance in women that is attributed to the increased risk of osteoporosis in this population. Additionally, Launonen et al.[3] have shown a clear seasonal predominance in winter that is believed to be caused by freezing temperatures with icy roads. Although age correlates with incidence, Clement et al.[4] demonstrated that social independence is a predictor of outcome while age is not.

This type of fracture presents most frequently as a low-energy fall onto an outstretched arm in an adult with osteoporotic bone. When encountered in younger patients, this type of fracture is usually caused by high-energy trauma. Less common causes of injuries include electric shock, seizure, excessive shoulder abduction, and pathologic processes. Although this injury can present alone, it is important for orthopaedic practitioners to evaluate every patient for other injuries with a high index of suspicion for other osteoporotic fractures, such as distal radial and vertebral fractures. The incidence of associated axillary artery injury is low. When present, it is more often associated with glenohumeral dislocation.[5] When seen in fractures without glenohumeral dislocation, it is most often present in Neer two-part surgical neck fractures with medialization of the shaft fragment.[6] These circumstances bring to bear a heightened suspicion for vascular compromise with potential for venous thromboembolism or compartment syndrome.[6,7] PHF carries important consequences for our society and communities, as risk of mortality is five times higher than age- and gender-adjusted controls during the first 30 days after fracture in this patient population.[8]