Proximal humerus fractures (PHFs) most commonly affect elderly, osteoporotic women, although younger patients sustain them through high-energy trauma. Both incidence and the associated healthcare burden continue to rise with demographic ageing. Non-operative management is preferred for undisplaced fractures and for many elderly patients, whereas a range of internal fixation methods and arthroplasty options are available for more complex injuries. Patient age, comorbidities, functional demands and fracture pattern are the primary determinants of treatment selection, implant choice and expected outcome. Absolute indications for surgery include acute fracture-dislocations, open fractures and injuries with vascular or neurological compromise. Relative indications are based on the degree of displacement and the predicted failure of non-operative treatment, and include head-splitting fractures, severe varus, valgus or posterior tilt of the humeral head, anatomical neck fractures, calcar comminution, complete displacement of the humeral head from the shaft, significant displacement of the lesser or greater tuberosity, displaced three- and four-part fractures, and large impaction defects of the humeral head, particularly when associated with instability. It is important to recognise that the displacement thresholds in routine use are pragmatic and consensus-derived rather than validated, and that expert panels do not agree on a maximum acceptable deviation. Surgery is technically demanding, requiring anatomical reduction, calcar restoration, avoidance of varus, secure fixation of the tuberosities and correct patient and implant selection. Locked plating has been the most common operation, but is associated with high complication rates and has failed to show superiority over non-operative treatment in several large randomised controlled trials. Augmentation of fixation and intramedullary nailing may address calcar comminution, metaphyseal voids and varus collapse. Arthroplasty is increasingly used in elderly patients, with reverse shoulder arthroplasty now dominating over hemiarthroplasty. Results appear better than hemiarthroplasty and plate fixation in the single trial that has compared them directly, but the evidence remains limited. To support this narrative review a systematic search was undertaken to identify every randomised controlled trial of PHF management. This review synthesises and compares current evidence on the management options for PHFs and provides practical guidance on contemporary surgical strategies.

PurposeTo compare three medial open-wedge high tibial osteotomy (MOWHTO) techniques with respect to posterior tibial slope (PTS) preservation, coronal alignment correction, patellar height, and clinical outcomes.MethodsThis retrospective comparative study included 62 patients who underwent MOWHTO for medial compartment knee osteoarthritis with varus malalignment. Patients were grouped by osteotomy technique: monoplane anterior to the medial collateral ligament (MCL) (Group A, n=22), biplane anterior to the MCL (Group B, n=18), and monoplane posterior to the MCL (Group C, n=22). Radiographic outcomes included mechanical axis, PTS, Caton-Deschamps index, Insall-Salvati index, and Kellgren-Lawrence grade. Clinical outcomes included Lysholm and visual analog scale scores.ResultsAll groups achieved significant mechanical-axis correction (all p<0.001). Mean PTS increased in Groups A and B (+2.12°±3.22° and +3.39°±2.76°, respectively) but decreased in Group C (-0.88°±3.78°; between-group p<0.001). Group C showed significantly lower PTS change than Group A (p=0.011) and Group B (p<0.001). This effect remained significant after adjustment for age, sex, follow-up duration, preoperative PTS, correction magnitude, and preoperative Kellgren-Lawrence grade.ConclusionAnteromedial monoplane and biplane MOWHTO were associated with greater postoperative PTS increases than the posterior monoplane technique, despite comparable coronal alignment correction among the groups.

Cubitus varus is the most common long-term complication following supracondylar humeral fractures. Although traditional step-cut osteotomy yields reliable clinical outcomes, the intraoperative osteotomy direction and angle remain largely dependent on the surgeon's experience, resulting in suboptimal precision. Although digital three-dimensional (3D) planning and 3D-printed patient-specific guides have been shown to improve osteotomy accuracy, their application in adolescent patients with long-standing cubitus varus deformity has rarely been reported. We report an 18-year-old male patient who developed progressive cubitus varus deformity 13 years after conservative treatment of a right supracondylar humeral fracture. Preoperatively, the carrying angle was -19°, with mildly restricted elbow motion and no ulnar nerve symptoms. Using mirror-image-based 3D digital planning, we designed and 3D-printed a patient-specific step-cut osteotomy guide and performed corrective osteotomy with lateral locking plate fixation. Intraoperatively, the guide was stably apposed to the bone surface, enabling precise execution of the osteotomy without displacement or interference. At 12-month follow-up, both the carrying angle and humeral-elbow-wrist angle had improved from -19° to 6.5°, elbow flexion-extension range improved from 5°-120° to 0°-135°, and the Mayo Elbow Performance Score was 95. No complications such as nonunion or nerve injury occurred, and the patient was satisfied with the surgical outcome. The combination of digital 3D planning and 3D-printed guide-assisted step-cut osteotomy may significantly enhance osteotomy accuracy and surgical safety, offering an effective approach for treating long-standing cubitus varus in adolescents. Nevertheless, given that this is a single-case report, broader studies are warranted to confirm its advantages.