The fracture of the proximal humerus accounts for 5 % of all fractures and the typical trauma mechanism in young patients is high energy trauma often associated with neurovascular affection. In the elderly with osteoporotic alterations of the proximal humerus the main trauma mechanism is a fall from standing height in terms of a low energy trauma [1].

The decision for operative or conservative treatment depends on several factors including the biological age of the patient, concomitant diseases and the associated potential risks of anaesthesia, the patient´s compliance and the existing bone stock. In addition, the type of fracture is an important factor in the decision making regarding conservative versus surgical therapy. In general, all minimally displaced fractures with a fragment dislocation <5 mm, a deviation of the axis <20° and a displacement of the tubercula <2 mm are suitable for conservative treatment. It has to be pointed out that a short immobilization period for 1 week is often necessary, but physical therapy should be started as soon as the pain level allows it.

In this context Koval et al. [2] could show that the beginning of physical therapy within 14 days after the incident leads to improved results. In addition, a dynamic evaluation of the fracture under fluoroscopic guidance is recommended to be able to distinguish relatively stable impacted fractures from unstable fracture types.

In our University setting the shoulder is immobilized in a sling for 1 week along with physical therapy of elbow and wrist. Consecutively depending on the pain, back an forth swinging of the arm is allowed. Finally passive and active-assisted mobilization of the arm up to 90° abduction and flexion is performed for the first 6 weeks after trauma unless exercises with free range of motion can be performed. In their series of 125 valgus-impacted fractures treated conservatively Court-Brown et al. [3] showed that 80 % of the elderly patients had good to excellent results though residual deficits in strength and range of motion were noticed. Therefore in case of an active, high demanding patient at an age >60 years suffering from only slightly displaced fractures we would tend to recommend surgical intervention to avoid an immobilization period as described for the conservative treatment regime above and a potentially faster recovery.

Surgical intervention in proximal humerus fractures is recommended for all types of displaced fractures as long as operative treatment is possible. Concerning the tubercula a displacement greater than 2 mm is inacceptable as secondary impingement might arise. According to Neer [4] those fractures running through the surgical neck along with an ad latus dislocation of 10 mm and a retroversion up to 45° would be suitable for conservative treatment. However, our own algorithm for treating proximal humerus fractures only accepts a maximal displacement of 5 mm ad latus and a retroversion of the humeral head of 20°. Further absolute indications for operative treatment comprise fractures with multiple metaphyseal fragments, fractures running through the anatomical neck, head-split fractures and fractures with concomitant dislocation of the shoulder or affection of vessels/nerves.

For the operative intervention there are various different treatment options available reaching from reconstructive procedures like implanting minimal invasive K-wires [5, 6], locking plates [7–9], or proximal humerus nails [10, 11] to performing arthroplasty either in terms of implanting an anatomic [12, 13] or reverse prosthesis [14–16]. Thus the surgeon needs to carefully evaluate the patient’s fracture data to be able to find the best treatment option in terms of operative treatment for the individual patient.

In this context it should be mentioned that the percutaneous treatment of fractures using K-wires for fracture reduction is soft tissue sparing, but the reduction of the fracture might be difficult and the fixation of the fracture by K-wires is often not stable enough for early mobilization, so that we do not recommend this technique.

In our setting locking plates are used on a routine basis to treat humeral head fractures [17, 18]. As standard approach a modified deltoideo-pectoral approach is recommended, using the anatomic interval between the Deltoid and the Pectoralis major muscle. Therefore this approach is soft- tissue sparing and does neither endanger the axillary nerve nor the deltoid function. However, nowadays still several publications exist, which could not find an affection of the deltoid muscle in the treatment of humeral head fractures using the delta split approach [19]. The fracture is reduced and the plate itself might be used as a tool for the reduction of the displaced head. Cortical screws are used to fix the plate on the shaft and then in a next step the displaced humeral head is reduced against the plate. It is appropriate and in most of the cases important to use additional cerclages to fix the tubercula against the plate. The position of the plate and the length of the screws need to be checked on x-ray to avoid a secondary impingement or an affection of the glenoid.

In contrast, implanting a proximal humerus nail via a delta split approach the rotator cuff needs to be incised along the fibers. This implant can be useful in the treatment of fractures with metaphyseal fragments. Nevertheless, the removal of proximal humeral nails might be sometimes difficult and concomitant injuries of the rotator cuff are described. Still, the results of humeral head fractures treated with plates or with nails are similar and so the use of the implant depends on the surgeons’ preferences and skills.