UW Shoulder and Elbow Academy: Complex Proximal Humerus Fractures and Dislocations: Bill Obremskey on Decision Making

Monday, October 19, 2026

Complex Proximal Humerus Fractures and Dislocations: Bill Obremskey on Decision Making

William T. Obremskey, MD, MPH, of Vanderbilt Orthopedic Trauma and past president of the Orthopaedic Trauma Association, has generously allowed me to share the talk he gave at the 82nd Panhellenic Congress of Orthopaedic Surgery and Traumatology in Greece (October 14–17, 2026), “Complex Proximal Humerus Fracture and Dislocations: Decision Making for Selection.”

I was very impressed with the clear thinking and great cases examples in this presentation.

The talk opens with what Bill calls his "real disclosures": he is not sure which proximal humerus fractures need nonoperative care, ORIF, hemiarthroplasty, or reverse total shoulder. The evidence backs up that honesty. In the PROFHER randomized trial (JAMA 2015, 250 patients), surgical and nonsurgical treatment showed no difference in Oxford Shoulder Score or SF-12.

When he does operate, his principles are simple: get the anatomy back and keep it, fix the unstable fractures, repair the ligaments and tendons, and move the joint. In his words: "Reduction and motion are more important than approach, fixation or adjuvants. Life is motion; motion is life."

His "Shoulder Commandments" for ORIF:

Keep the head higher than the tuberosity
Avoid varus
Assess rotation
Use calcar screws
Repair the cuff to the plate
Consider small plates and adjuvants such as calcium phosphate or a fibular strut
Move the joint

The slides show his reduction techniques step by step. An elevator lifts the head, K-wires correct varus or pin a thin head to the glenoid, and additional mini-fragment plates support comminuted fractures. He also presents data favoring more than one plate over a single plate, with lower rates of cutout, nonunion and reoperation.

For fracture-dislocations, he points out that about a third have rotator cuff tears. These are often missed among the other injuries. If the patient can't move the shoulder, get an MRI or ultrasound, repair the cuff early, and start motion early. This is consistent with the AAOS guideline for anterior dislocations: consider repairing every injured structure.

The cases are the heart of the talk. They range from a 22-year-old after a car crash to a boat-propeller injury to bilateral posterior dislocations, many with follow-up out to a year. Several cases are courtesy of Dr. Mariel Rickert.

The technique pearls are Bill's experience, not trial evidence. But they come from a surgeon who says plainly what the evidence doesn't yet show.