Proximal Humerus Fractures - A Contemporary Narrative Review of Management Strategies

Proximal humerus fractures are a heterogeneous group of injuries with increasing incidence, particularly among older adults. Management remains controversial and is influenced by fracture morphology, patient characteristics, functional demands and evolving surgical options. Traditional classification systems, including Neer and AO/OTA, assist treatment planning but have limited reproducibility and predictive value. This contemporary narrative review integrates current evidence with expert clinical insight to provide a pragmatic framework for managing adult proximal humerus fractures. PubMed, Embase and the Cochrane Library were searched for studies published between 2000 and 2025, including randomised controlled trials, systematic reviews, meta-analyses and key cohort studies addressing operative and non-operative treatment. Undisplaced fractures are generally managed non-operatively with good outcomes. Fracture-dislocations and completely displaced humeral shaft injuries are biomechanically unstable and usually require early surgery. Most other fractures lie within a clinical grey zone in which treatment can be individualised according to age, fracture pattern, bone quality and functional demand. Younger patients with reconstructable fractures may benefit from early fixation, whereas some complex, non-reconstructable injuries can still achieve acceptable outcomes with conservative treatment. In elderly patients, early arthroplasty may be indicated for fractures extending into the proximal shaft, with delayed intervention suitable in selected cases. Advances in imaging, implant design and artificial intelligence may further improve patient-specific decision-making.