Background <p>The incidence of closed proximal humerus fractures (CPHF) is steadily increasing worldwide. Open reduction internal fixation (ORIF) remains the most common surgical technique while reverse shoulder arthroplasty (RSA) is becoming a noteworthy approach. The optimal management of CPHF (ORIF vs. RSA) remains complex and continually evolving.</p> Methods <p>This retrospective cohort study utilized data from the National Inpatient Sample (2016–2019). Patients with proximal humerus fractures (PHF) treated with ORIF or RSA were included. Demographics, fracture characteristics, comorbidities, and complications were analyzed. Binary logistic regression identified risk factors for complications.</p> Results <p>A total of 11,667 patients with CPHF were included (ORIF, <i>n</i> = 2,657 vs. RSA, <i>n</i> = 1,932). Patients undergoing ORIF were younger and incurred lower hospital charges (<i>P</i> &lt; 0.001). Female gender, elective admission rate, and Charlson comorbidity index were significantly higher in those who underwent RSA. Both groups differed in rates of major complications and postprocedural pain (<i>P</i> &lt; 0.001). Implant-related complications (<i>P</i> = 0.046) and total complications (<i>P</i> = 0.157) showed no significant difference. For patients undergoing RSA, those with 3-part fractures (OR = 0.08, 95% CI 0.01–0.50, <i>P</i> = 0.006) and 4-part fractures (OR = 0.04, 95% CI 0.01–0.23, <i>P</i> &lt; 0.001) had significantly lower odds of implant-related complications compared to those with 1-part fractures.</p> Conclusion <p>RSA may be a considered option for elderly patients with 3- or 4-part fractures and significant comorbidities, as it was associated with fewer major complications and served as a protective factor for implant-related issues. ORIF presents a viable option for 1- or 2-part fractures, given its association with lower postprocedural pain.</p> Level of evidence <p>Level III.</p>