What is the preferred timing for surgery after proximal humerus fractures: an e-modified Delphi Survey Study.

Background: Certain clinically selected proximal humerus fractures (PHFs) require operative treatment to preserve shoulder function. There is no consensus on the timing of surgery after PHFs, and guidelines are lacking. This study utilized the Delphi method to (1) find consensus on the preferred timing for multiple PHF patterns potentially requiring operative treatment and (2) assess statistical stability of consensus. Methods: A three-round electronic modified Delphi study was conducted between May and October 2025. Sixty-one shoulder experts from Australia, Europe, Asia, and North America participated. The expert panel assessed preferred time to surgery for PHF patterns potentially requiring surgery (either open reduction and internal fixation or arthroplasty) according to literature. The established timeframes were (a) within 2 days, (b) 3-5 days, (c) 6-14 days, or (d) after 14 days of initial trauma. Consensus was predefined as ≥80% agreement among experts and stable consensus as ≥80% agreement in both second and third rounds. Results: For open reduction and internal fixation, consensus was observed to treat PHFs with ≥35% intra-articular involvement within 3-5 days, and plexopathy with distal motor and/or sensory symptoms within 2 days. Stable consensus was reached to treat dislocation of the humeral head to the axilla and vascular compromise with adequate distal perfusion within 2 days. Closed vascular injury with active bleeding in hemodynamically unstable patients or distal vascular deficits should be treated immediately but could wait up to 2 days in hemodynamically stable patients with adequate distal perfusion. For arthroplasty, consensus was achieved to treat PHFs with varus malalignment of the humeral head or (almost) complete translation of the shaft within 6-14 days. Stable consensus was observed to perform arthroplasty within 2 days for PHFs with dislocation of the humeral head to the axilla with plexopathy or vascular compromise with adequate distal perfusion within 2 days. Conclusion: This study provides insights on consensus among international shoulder surgeons for preferred timing of surgery for PHFs for urgent indications. Importantly, consensus was not achieved for most non-emergent PHFs, underscoring the area of uncertainty in clinical practice regarding the optimal treatment window. This study highlights the absence of agreement and lack of high-quality evidence to guide physicians on the timing of operative treatment for PHFs and can be a starting point for further clinical research and developing guidelines on the timing of surgical interventions for PHFs.