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, after the hip and distal radius. As the population ages, the incidence is skyrocketing.

The management of these fractures is one of the most contentious topics in orthopaedics. For decades, we operated on displaced fractures to "restore anatomy." Then came the PROFHER trial, which swung the pendulum violently towards non-operative care. Now, with the rise of Reverse Total Shoulder Arthroplasty (RTSA), the pendulum is swinging back.

This article provides a nuanced, evidence-based algorithm for the modern surgeon.

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

The PROFHER Trial (2015)

• Design: Multicenter RCT comparing Surgery vs. Sling for displaced proximal humerus fractures.
• Result: No significant difference in Oxford Shoulder Score at 2 years.
• Criticism:
  • Included many 2-part surgical neck fractures (which heal well conservatively).
  • Surgeons excluded patients with clear indications for surgery (selection bias).
  • Used Hemiarthroplasty (which has poor outcomes) rather than Reverse.
• Take Home: "Nailing the X-ray does not fix the patient." Most elderly patients do remarkably well with non-operative care, even with malunion.

Part 2: The Decision Algorithm

So, who needs surgery? We assess the Patient, the Personality (of the fracture), and the Perfusion.

1. The Patient

• Physiological Age: A frail 75-year-old is different from an active, tennis-playing 75-year-old.
• Cognition: Can they follow rehab?
• Expectations: Do they need to put their hand over their head, or just feed themselves?

2. The Fracture Personality (Neer Classification)

• Head-Splitting: High risk of AVN and arthritis. -> Arthroplasty.
• Fracture-Dislocation: Mandatory surgery (unless reduced closed and stable).
• Greater Tuberosity Displacement: > 5mm displacement causes impingement and loss of abduction. -> Fixation.

3. The Perfusion (Hertel Criteria)

Predictors of Ischemia (AVN):

1. Calcar Length: < 8mm of metaphyseal bone attached to the head.
2. Medial Hinge: Disrupted.
3. Basicervical fracture line.

• If High Risk of Ischemia -> Arthroplasty (in elderly).

Part 3: Treatment Options

Option A: Benign Neglect (Non-Operative)

• Indication: 80% of fractures. Low demand patients. Valgus impacted patterns (stable).
• Protocol: Sling x 2 weeks. Pendulums immediately. Active assist at 4 weeks.
• Outcome: High rate of malunion, but functional scores are often surprisingly good (Adaptation).

Option B: ORIF (Locking Plate)

• Indication: Young/Active elderly. Reconstructible fragments. Intact calcar.
• Technique Pearls:
  • Calcar Screw: The most important screw. Must support the medial column to prevent varus collapse.
  • Suture the Cuff: Tie the rotator cuff to the plate to neutralize deforming forces.
  • Avoid Screw Penetration: Joint penetration leads to rapid chondrolysis.

Option C: Hemiarthroplasty (HA)

• Status: Obsolete for fractures.
• Why: It relies entirely on tuberosity healing for function. In osteoporotic bone, the tuberosities resorb or fail to unite. The result is a painful shoulder with no active elevation ("Anterosuperior Escape").

Option D: Reverse Total Shoulder (RTSA)

• Status: The Gold Standard for complex elderly fractures.
• Mechanism: Medializes the center of rotation and increases the deltoid lever arm. Does not rely on the rotator cuff for elevation.
• Tuberosity Repair: While the RTSA works without the cuff, repairing the tuberosities improves External Rotation (essential for eating/grooming). Use a "fracture specific" stem with suture holes.

Part 4: Complications to Consent For

1. Nerve Injury: Axillary Nerve (runs 5-7cm below acromion).
2. AVN: Even with fixation. (Counsel patient regarding secondary conversion to arthroplasty).
3. Varus Collapse / Screw Cut-out: The most common failure of ORIF.
4. Infection: Cutibacterium acnes (C. acnes) is the nemesis of shoulder surgery.

Conclusion

Treat the Patient, Not the X-Ray.

• If the patient is low demand -> Sling.
• If the patient is active and the fracture is reconstructible -> ORIF.
• If the patient is active but the fracture is non-reconstructible (or high ischemia risk) -> Reverse.

Rehab Protocol PDF

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