Proximal Humerus Fractures in the Elderly: A Management Algorithm

Visual Element: An interactive X-ray viewer. Users can toggle between "Neer 2-part", "3-part", and "4-part" fractures, with overlays showing the deforming muscle forces (Rotator Cuff pull).

Proximal humerus fractures are the third most common osteoporotic fracture pattern, trailing only behind the proximal femur and distal radius. As our population ages and life expectancy increases, the incidence of these fragility fractures is skyrocketing. For orthopaedic surgery trainees preparing for fellowship exams, mastering the management of these injuries is non-negotiable—it is a guaranteed viva topic and a staple of daily trauma meetings.

The management of displaced proximal humerus fractures in the elderly remains one of the most fiercely debated and contentious topics in modern orthopaedics. For decades, the prevailing dogma was purely mechanical: we operated on displaced fractures to "restore anatomy," driven by the belief that anatomical restoration equated to functional recovery. Then came landmark studies like the PROFHER trial, which swung the pendulum violently towards non-operative care. More recently, with the exponential rise and biomechanical mastery of Reverse Total Shoulder Arthroplasty (RTSA), the pendulum is swinging back toward surgical intervention for specific patient subsets.

This article provides a nuanced, evidence-based algorithm for the modern orthopaedic registrar and surgeon, bridging the gap between textbook theory and real-world clinical decision-making.

Part 1: The Evidence (The Elephant in the Room)

To understand modern proximal humerus fracture management, you must understand the literature that has shaped our current guidelines. If you are sitting for your FRACS, FRCS, or ABOS exams, you will be expected to critically analyze these landmark papers.

The PROFHER Trial (2015)

The PRoximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial was a watershed moment in orthopaedic trauma.

• Design: A pragmatic, multicenter Randomized Controlled Trial (RCT) comparing surgical intervention (ORIF or Hemiarthroplasty) versus non-operative care (sling immobilization) for displaced proximal humerus fractures involving the surgical neck.
• Result: The study found no significant difference in the Oxford Shoulder Score, SF-12, or complication rates between the surgical and non-surgical groups at 2 years follow-up.
• Criticism & Nuance: While the headline "surgery equals sling" grabbed attention, trainees must understand the nuances:
  • Inclusion Dilution: The study included a high volume of 2-part surgical neck fractures. We already know these generally heal exceptionally well with conservative management, which likely diluted any potential benefit seen in more complex 3- and 4-part patterns.
  • Selection Bias: Surgeons were allowed to exclude patients if they felt there was a "clear indication" for surgery. Consequently, the most severe fractures or those in highly active patients may have bypassed randomization.
  • The Hemiarthroplasty Factor: When arthroplasty was performed, it was predominantly Hemiarthroplasty—a procedure we now know has highly unpredictable functional outcomes in fracture settings. Reverse Total Shoulder Arthroplasty (RTSA) was not widely utilized in this cohort.

The Rise of PROFHER-2 and RTSA Literature

Following PROFHER, the landscape shifted. Hemiarthroplasty fell out of favor, and RTSA emerged as the definitive arthroplasty option for complex fractures in the elderly. Current literature, including early data from PROFHER-2 and independent RCTs comparing RTSA to ORIF, suggests that while RTSA provides reliable pain relief and forward elevation, it is a salvage procedure that comes with its own unique set of catastrophic complications if they occur.

Part 2: The Decision Algorithm

So, who actually needs surgery? In the trauma meeting, the decision should never be based solely on the AP and lateral X-rays. We assess three critical pillars: the Patient, the Personality (of the fracture), and the Perfusion.

1. The Patient (The Most Important Variable)

You must treat the patient, not the radiograph. "Elderly" is a chronological term, not a physiological one.

• Physiological Age & Demand: A frail 85-year-old nursing home resident requires a painless shoulder to assist with nursing care (sling). A physiologically robust 75-year-old who plays golf and lives independently requires functional range of motion (consider surgery).
• Cognition & Compliance: Post-operative rehabilitation is grueling. If a patient has advanced dementia or cannot follow complex, multi-phased rehab instructions, surgical intervention (especially ORIF) is highly likely to fail.
• Medical Comorbidities: Assess ASA grade, cardiac risk, and bone quality. Severe osteoporosis makes ORIF a precarious undertaking due to the high risk of screw cut-out.

2. The Fracture Personality (Deforming Forces & Neer Classification)

Charles Neer's classification is based on the displacement of four key segments (Head, Greater Tuberosity, Lesser Tuberosity, Shaft). Displacement is defined as >1cm translation or >45 degrees angulation. Understanding the deforming forces is crucial:

• Greater Tuberosity (GT): Pulled superiorly and posteriorly by the supraspinatus and infraspinatus. If the GT heals >5mm displaced superiorly, it will impinge on the acromion, blocking abduction and forward elevation. Significant GT displacement is a strong indication for fixation.
• Lesser Tuberosity (LT): Pulled medially by the subscapularis.
• Shaft: Pulled medially and anteriorly by the pectoralis major.
• Head-Splitting Fractures: Cartilage damage and high risk of avascular necrosis (AVN) and early post-traumatic arthritis. -> Arthroplasty.
• Fracture-Dislocations: The articular surface is dislocated from the glenoid. Mandatory intervention is required (unless reduced closed and remarkably stable, which is rare).

3. The Perfusion (Hertel Criteria)

In 2004, Ralph Hertel published a landmark paper outlining the radiographic predictors of humeral head ischemia. The blood supply to the humeral head relies heavily on the ascending branch of the anterior circumflex humeral artery (yielding the arcuate artery) and significant intraosseous contributions from the posterior circumflex humeral artery.

• Clinical Application: If an elderly patient has a 4-part fracture with high Hertel risk factors for ischemia, attempting ORIF is often an exercise in futility. The head will likely collapse. In these scenarios, primary Reverse Total Shoulder Arthroplasty is the treatment of choice.

Part 3: Treatment Options Deep-Dive

Once you have synthesized the patient, personality, and perfusion, you must select the appropriate weapon from your surgical armamentarium.

Option A: Benign Neglect (Non-Operative Care)

• Indication: The vast majority (up to 80%) of proximal humerus fractures in the elderly. Low-demand patients. Valgus-impacted 2-part or 3-part patterns where the medial periosteum is intact and the fracture is inherently stable.
• Protocol: Broad arm sling for comfort for 2-3 weeks. Early mobilization is critical. Begin pendulum exercises immediately or within 7-10 days to prevent adhesive capsulitis. Progress to active-assisted range of motion at 3-4 weeks as callus forms.
• Outcome: High rate of radiographic malunion. However, older patients demonstrate remarkable adaptability. Functional scores (OSS, DASH) are often surprisingly good despite ugly X-rays.

Option B: ORIF (Locking Plate Technology)

• Indication: Younger or physiologically active elderly patients. Reconstructible fracture fragments. Intact medial hinge and low risk of AVN.
• Surgical Approach: Typically the Deltopectoral approach, though some favor the Anterolateral (deltoid-splitting) approach for direct lateral plating of varus-displaced fractures.
• Technique Pearls for the Trainee:
  • The Calcar Screw: This is the most biomechanically critical screw in your construct. You must place inferomedial screws into the inferior quadrant of the humeral head to restore the medial column and prevent varus collapse.
  • Cuff Sutures are Mandatory: Metal does not hold osteoporotic bone well. You must pass heavy non-absorbable sutures through the rotator cuff insertions (supraspinatus, infraspinatus, subscapularis) and tie them directly to the plate. This creates a tension-band effect and neutralizes the deforming muscle forces.
  • Fibular Strut Allograft: In severe osteoporosis with medial comminution, augmenting your plate with an intramedullary fibular strut graft can significantly increase construct stiffness and prevent varus collapse.
  • Avoid Superior Plate Placement: The plate must sit at least 5-8mm distal to the tip of the greater tuberosity to avoid subacromial impingement.

Option C: Hemiarthroplasty (HA)

• Status: Largely Obsolete for acute fractures in the elderly.
• The Rationale: Hemiarthroplasty relies entirely on anatomical healing of the greater and lesser tuberosities around the metal stem to restore rotator cuff function. In osteoporotic bone, these tuberosities frequently resorb, pull off, or fail to unite.
• The Consequence: Without functioning tuberosities, the rotator cuff is useless. The unopposed deltoid pulls the humerus proximally, resulting in "Anterosuperior Escape." The patient is left with a painful shoulder and pseudo-paralysis (inability to actively elevate the arm above 90 degrees).

Option D: Reverse Total Shoulder Arthroplasty (RTSA)

• Status: The Gold Standard for complex, un-reconstructible 3- and 4-part fractures in the elderly, or those with high ischemia risk.
• Biomechanical Magic: The RTSA fundamentally alters shoulder biomechanics (Grammont principles). By medializing the center of rotation and lowering the humerus, it dramatically increases the lever arm and resting tension of the deltoid muscle. It allows the patient to actively elevate their arm without a functioning rotator cuff.
• The Tuberosity Dilemma in RTSA: While the RTSA provides elevation via the deltoid, it does not provide active external rotation. If you resect the tuberosities or fail to repair them, the patient will be able to raise their arm but will struggle to externally rotate (e.g., they will hit themselves in the face when trying to eat, or be unable to comb their hair).
• Modern Technique: Use a "fracture specific" RTSA stem (often coated for ingrowth with specific suture windows). Meticulously tag and repair the tuberosities around the prosthesis using a cerclage technique. Healing of the greater tuberosity in RTSA significantly improves external rotation and overall patient satisfaction.

Part 4: Complications to Consent For

When consenting a patient for surgical intervention, a structured approach is required. For proximal humerus fractures, the specific risks are profound.

1. Nerve Injury: The Axillary Nerve is at highest risk. It runs transversely roughly 5-7cm distal to the lateral edge of the acromion. It must be protected, especially during deltoid-splitting approaches or when passing cerclage wires.
2. Avascular Necrosis (AVN): Even with perfect ORIF, the blood supply may have been irreparably damaged at the time of injury. Counsel the patient that AVN may develop months to years later, potentially necessitating a secondary conversion to arthroplasty.
3. Varus Collapse and Screw Cut-out: The absolute nemesis of proximal humerus ORIF. As the head collapses into varus, the screws (which are locked at a fixed angle to the plate) penetrate the articular cartilage, destroying the glenoid. This requires urgent revision hardware removal and arthroplasty.
4. Infection (The C. acnes Threat): Cutibacterium acnes is a slow-growing, anaerobic, gram-positive bacillus that lives deep in the sebaceous glands of the shoulder. It is the leading cause of insidious shoulder periprosthetic joint infections (PJI). Routine skin prep often fails to eradicate it. Many centers now mandate pre-operative Benzoyl Peroxide washes and dual prophylactic antibiotics (e.g., Ceftriaxone + Vancomycin or Clindamycin) to combat this specific pathogen.
5. Post-Traumatic Stiffness: Adhesive capsulitis is incredibly common, regardless of operative or non-operative management.

Conclusion

The management of proximal humerus fractures in the elderly is an exercise in clinical judgment, not just pattern recognition on a radiograph.

Treat the Patient, Not the X-Ray.

• If the patient is low demand, frail, or cognitively impaired -> Sling and early mobilization.
• If the patient is physiologically active, has good bone stock, and the fracture is reconstructible (intact medial hinge) -> ORIF with meticulous technique.
• If the patient is physiologically active but the fracture is non-reconstructible, head-splitting, or carries a high risk of ischemia -> Reverse Total Shoulder Arthroplasty with tuberosity repair.

Orthopaedic surgery training requires you to master these nuances. By applying a systematic algorithm evaluating the patient, the fracture personality, and the perfusion, you can navigate this contentious topic with confidence both in the operating theatre and in your final fellowship examinations.

Rehab Protocol PDF

Download the standard rehabilitation protocols for Non-op, ORIF, and Reverse Shoulder.