Proximal humerus fracture (PHF) treatment remains challenging. Multiple therapy options exist, and the optimal choice of management has been increasingly discussed in the literature. The aim of this study was to (1) analyze trends in the propensity of proximal humerus fracture treatments and (2) compare complication rates after joint replacement, surgical repair, and non-surgical treatment in terms of mechanical complications, union failure, and infection rates. In this cross-sectional study, patients aged 65 years or older with proximal humerus fractures occurring between 1 January 2009 and 31 December 2019 were identified from Medicare physician service claims records. The Kaplan–Meier method with the Fine and Gray adjustment was used to calculate the cumulative incidence rates for malunion/nonunion, infection, and mechanical complications for the following treatment categories: shoulder arthroplasty, open reduction and internal fixation (ORIF), and non-surgical treatment, respectively. Semiparametric Cox regression was performed incorporating 23 demographic, clinical, and socioeconomic covariates to determine risk factors. Between 2009 through 2019, conservative procedures decreased by 0.9%. ORIF procedures decreased from 9.51% (95% CI: 8.7–10.4) to 6.95% (95% CI: 6.2–7.7), whereas shoulder arthroplasties rose from 1.99% (95% CI: 1.6–2.4), to 5.45% (95% CI: 4.8–6.2). PHFs managed through ORIF were associated with higher union failure rates compared to conservatively treated fractures (HR = 1.31, 95% CI: 1.15–1.5,p< 0.001). The risk of developing an infection was increased after joint replacement compared to ORIF (2.66% vs. 1.09%, HR = 2.09, 95% CI: 1.46–2.98,p< 0.001). Mechanical complications were more common after joint replacement (6.37% vs. 4.85%, HR = 1.66, 95% CI: 1.32–2.09,p< 0.001). Complication rates differed significantly across treatment modalities. This should be considered when choosing a management procedure. Vulnerable elderly patient cohorts could be identified, and the optimization of modifiable risk factors might lead to a decrease of complication rates in both surgically and non-surgically treated patients.