Pucker sign in proximal humerus fracture: Case report and review of the literature.

Introduction: Proximal humerus fractures (PHFs) are among the most common upper limb fractures, particularly in elderly patients after low-energy falls. The Case report: A 31-year-old male with a history of multiple sclerosis presented with a proximal humerus fracture (AO/OTA 11A2.2) and an evident pucker sign following a low-energy fall. Closed reduction under mild sedation was successfully achieved, followed by intramedullary nailing without complications. Postoperative recovery was uneventful, and early mobilization was initiated, although long-term follow-up was unavailable due to patient relocation. Discussion: A systematic literature review identified twelve published cases of PHFs associated with a pucker sign. The mean patient age was 46.3 years, with equal sex distribution. Closed reduction succeeded in 41.7% of cases, whereas 58.3% required open reduction and internal fixation. Successful closed reduction was generally limited to minimally displaced extra-articular fractures (AO/OTA 11A2-A3), while fully displaced fractures consistently required open management. Early recognition and sedation-assisted reduction improve outcomes and prevent skin necrosis or neurovascular compromise. Conclusion: The pucker sign in proximal humerus fractures is a rare but significant indicator of soft tissue entrapment. Prompt identification and timely reduction, closed or open, are essential to avoid complications. Increased awareness and additional case reporting are needed to establish standardized management strategies for this uncommon but clinically relevant presentation.