Fractures of the proximal humerus are common in older patients, and the incidence of these fractures in the United States is expected to notably increase with the aging population. Nonoperative procedures have been preferred in elderly patients with stable fracture patterns to avoid complications associated with osteoporotic bone. However, more complex and unstable fracture patterns often necessitate operative techniques to allow for more anatomical healing. Although proximal humerus fractures have been thoroughly examined, systemized, and studied, no clear method to choosing an appropriate surgical treatment or candidate has been accepted. I reviewed the role of the following factors on successful treatment with ORIF: anatomical structures; blood vessels and morphological features of the humeral head; clinical evaluation, assessment, and outcomes; and surgical variables such as approach to the shoulder, plating techniques, position and placement of screws, medial calcar supports, augmentation of implants, and level of experience and familiarity of surgeons with the operation. Based on the complex nature of proximal humerus fractures, effective surgical treatment may be determined by the circumstances unique to each case.

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