Upper Limb · 4 min read
Proximal Humerus Fractures: The Evidence Has Changed — Has Your Practice?
Proximal humerus fractures are the third most common fragility fracture. The PROFHER trial changed what evidence supports for most of them. Yet surgical fixation rates have not fallen proportionately. The gap between the evidence and what is being done is a failure of implementation — and it matters for every patient who sustains this injury.
The PROFHER trial — a landmark UK multicentre randomised controlled trial published in The Lancet in 2015 — compared surgical treatment against non-operative management for displaced two and three-part proximal humerus fractures. At two years, there was no significant difference in Oxford Shoulder Score, SF-12, or EQ-5D between surgical and non-operative groups. The result was robust, the trial well-conducted, and its clinical implication clear: for the majority of displaced proximal humerus fractures in the adult population, surgery does not produce superior patient-reported outcomes compared to non-operative management with early physiotherapy.
What PROFHER does and does not say
PROFHER does not say that surgery is never indicated for proximal humerus fractures. It says that the default assumption — that displaced fractures require fixation — is not supported by the best available evidence for most patients. Specific subgroups remain where surgical management has a defensible evidence base: vascular injury requiring repair, open fractures, fracture-dislocations where the humeral head cannot be reduced, and selected four-part fractures in younger higher-demand patients where arthroplasty may offer better function than the natural history of avascular necrosis.
The surgical decision should be made for the individual patient — integrating fracture pattern, patient age and functional demand, bone quality, comorbidities, and patient preference after a genuinely informed discussion — not for the radiograph. A highly displaced three-part fracture in a 78-year-old with moderate functional demands may be best managed with a sling and structured physiotherapy. The same fracture pattern in a 58-year-old manual worker who needs reliable overhead function requires a different conversation.
The implementation gap
National registry data in multiple countries shows that surgical fixation rates for proximal humerus fractures did not fall substantially following PROFHER publication. This is a textbook implementation failure — evidence generated, disseminated, and then not translated into consistent practice change. Understanding why implementation failed is as important as the trial itself: surgeon training biases, patient expectations shaped by an assumption that displaced fractures need fixing, and the absence of structured implementation pathways all contribute.
The PROFHER evidence removes the assumption that surgery is the default for displaced proximal humerus fractures — and places the decision where it belongs: in a genuinely informed conversation with each patient.
💬 Has PROFHER changed your surgical threshold for proximal humerus fracture management — and if not, what evidence would need to exist to change it?