For complex proximal humeral fractures in older adults, the choice between reverse total shoulder arthroplasty and open reduction with internal fixation is increasingly relevant. This systematic review and meta-analysis compared outcomes between the two approaches across the available comparative literature. The evidence suggests that reverse arthroplasty can provide a more predictable functional pathway in selected older patients with complex fracture patterns, particularly when tuberosity healing or rotator-cuff function is a concern. However, the literature is heterogeneous, and not every patient benefits equally from replacement. Clinical outcomes, complications, implant-related issues and the type of fracture all influence the balance between procedures. The paper reinforces a key point in contemporary shoulder trauma: the decision should be based on fracture biology and expected shoulder function rather than a simple “operate versus do not operate” framework. Reverse arthroplasty is particularly attractive when reconstruction is unlikely to restore a functioning cuff-tuberosity unit, but fixation may still be appropriate in patients with better bone stock, reconstructible anatomy and realistic healing potential. The findings therefore support a selective, patient-specific strategy rather than routine replacement for all complex proximal humerus fractures.