Proximal humeral fractures are strongly correlated to osteoporosis and common among older patients. The goal of treatment is to reduce pain and regain function. Most proximal humeral fractures do not benefit from surgery, but surgery may be required in the most complex fractures. Patient comorbidity and poor bone quality seem to influence the overall outcome, as well as degenerative changes in the rotator cuff. The humeral bone itself almost always heals and the risk of continued pain is low. Regardless of the treatment modality range of motion is often reduced, but still, most elderly patients achieve an acceptable functional result. The literature is extensive, but the included patient cohorts are often heterogeneous, varying from a fit golf-playing older person to a demented nursing home resident, and the results are therefore difficult to transfer into clinical practice. In most patients, quality of life tends to depend more on low pain than the range of motion and strength, which are the typical focus areas in current shoulder scores. The methodological quality of clinical studies has historically been low, but within the last decades randomised clinical studies have gained ground, which hopefully permit an era of evidence-based and tested treatment algorithms. National treatment quality standards and registries are warranted for quality measurement to further improve the outcome.