Intramedullary nailing versus locking plate fixation for proximal humerus fractures: a systematic review and meta-analysis of randomized controlled trials

Proximal humerus fractures (PHFs) are common in the elderly and may require surgical fixation, yet controversy persists regarding the optimal technique-open reduction and internal fixation (ORIF) versus intramedullary nailing. This study synthesizes high-quality randomized controlled trials (RCTs) evidence to determine the relative efficacy, safety, and functional outcomes. A systematic review was performed by searching PubMed, the Cochrane Library, and Embase through February 2026. Eligible RCTs compared intramedullary nailing and plate fixation for PHFs, evaluating range of motion (ROM), strength, complications, reoperation rates, and patient-reported outcomes (PROs). Six RCTs comprising 404 PHFs were included (204 nails, 200 plates). Mean patient age was 69.3 years (nail) and 68.5 years (plate), with average follow-up of 30.6 months. There were no significant differences between intramedullary nailing and locking plate fixation in DASH score (MD, -0.66; 95% CI, -11.94 to 10.62; P=.91), VAS pain (MD, -0.40; 95% CI, -0.93 to 0.13; P=.14), Constant score (MD, 1.33; 95% CI, -2.72 to 5.37; P=.52), or ASES score (MD, 0.74; 95% CI, -5.25 to 6.74; P=.81). Complication rates (RR, 0.69; 95% CI, 0.21-2.25; P=.53) and reoperation rates (RR, 1.5; 95% CI, 0.49-4.59; P=.48) were also not significantly different between fixation methods. In a post hoc fracture-type analysis, nail fixation was associated with higher Constant scores in 3- and 4-part fractures (MD, 6.87; 95% CI, 3.02-10.73; P=.0005), whereas no significant difference was observed in 2-part fractures (MD, -2.43; 95% CI, -5.32 to 0.46; P=.10). Intramedullary nailing and locking plate fixation provide no statistically significant difference in functional and clinical outcomes for PHFs. Complication and reoperation rates varied across studies, with no significant pooled differences between fixation methods. Further high-quality randomized studies are needed to clarify whether specific patient or fracture subgroups may benefit from one fixation strategy over the other.