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1. Orthopaedic Surgery
Megan Sorich, DO
April 16, 2021
Proximal HumerusFractures in
the Elderly:
Options for treating complex fractures

2. Orthopaedic Surgery
Objectives
•Expand knowledge base on geriatric upper extremity
fractures
•Be able to examine that literature critically
•Identify treatment options for proximal humerus
fractures
•Recognize complexity of treating these patients with
complex fractures

3. Orthopaedic Surgery
Agenda
•Proximal HumerusFractures
•Incidence
•Classification
•Treatment options
•To fix or not to fix
•A review of the current literature
•Take home points

4. Orthopaedic Surgery
Incidence
•Proximal humerusis the 3
th
most common “osteoporotic fracture”
•Hip, Distal Radius
•70% occurring in patients over 60 years of age
•Highest incidence among 73 to 78 year olds
•Expected to double in the next 20-30 years
•3-4 times more common in females than males
*JSES. 2016;25, 704-713

5. Orthopaedic Surgery
NeerClassification
•>1 cm displaced
•45 degangulated
Poor inter and intra
observer reliability
-Sidor, et al JBJS 1993
-Gerber et al JBJS 1993
-Sallayet al JSES 2007

6. Orthopaedic Surgery
Proximal Humeral Anatomy
Understanding Fracture Patterns
•4 bony fragments
•Lesser Tuberosity
•Greater Tuberosity
•Head
•Shaft
Neer, JBJS ‘70

7. Orthopaedic Surgery
Common Fracture Pattern Frequently Missed
•When you see a greater
tuberosity fracture….
•Look for the surgical neck
nondisplacedfracture

8. Orthopaedic Surgery
X-Rays
AP view scapular plane
(Grashey)
AP view of shoulder

9. Orthopaedic Surgery
X-Rays
Scapular Y
Axillary Lateral

10. Orthopaedic Surgery
Role for Advanced Imagining?
•CT for surgical planning is helpful but not required

11. Orthopaedic Surgery
HertelJSES Vol 13 2004: 427-433

12. Orthopaedic Surgery
Bastian and HertelJSES 2008: 2-8
•Follow-up study by Hertelshowed that initial predictors
of humeral head ischemia doesn’t predict development of
AVN.
•80% of patients with “ischemic heads” did NOT collapse
•Fixation is worth considering even if signs of ischemia are
present

13. Orthopaedic Surgery
NonoperativeTreatment
•80-90% non-op -Neer(1970)
•Immobilize initially in slingfor pain control
•Passive ROM immediately
•Supine ER and FE
•Pendulums
•Active ROM at 4-6 weeks
•77% good to excellent results-Zuckerman (1995)
How do the patients do?

14. Orthopaedic Surgery
•The long-term functional outcomes (~2yrs), after a non-
operatively treated proximal humeral fracture, appears to be
good in almost two-third of the patients (66%)
•Only 10% still suffers from serious impairments or experiences
considerable disabilities in daily functioning
Who are those patients?

15. Orthopaedic Surgery
Surgical Options
•CRPP
•Threaded pins but do not cross cartilage
•Engage cortex 2 cm inferior to inferior border of humeral head
•Don’t get the axillary nerve
•ORIF
•Periarticular locking plate
•Delto-pec vs lateral approach
•IMN
•Hemiarthroplasty
•RTSA

16. Orthopaedic Surgery
Now let the controversy begin…
•“But the literature says that the operative patients do just the same
as the non-op patients”…..
•What’s the right answer?
•Or is there a right answer?

17. Orthopaedic Surgery
•250 patients aged 16 years or older (mean age, 66 years
[range, 24-92 years];
•192 [77%] were female; and 249 [99.6%] were white)
•32 acute UK National Health Service hospitals between
September 2008 and April 2011 within 3 weeks after
sustaining a displaced fracture of the proximal humerus
involving the surgical neck.
•Patients were followed up for 2 years

18. Orthopaedic Surgery
Inclusion criteria
•“The degree of displacement had to be sufficient for the treating
surgeon to consider surgical intervention but did not have to meet the
displacement criteria of Neer(1 cm or 45°angulation of displaced
parts, or both) for inclusion in the trial”
•Randomized Op vs Non-op
•Exclusion criteria “those patients with a clear indication for surgery”

19. Orthopaedic Surgery
Who were the surgeons? What did they do?
•109 operations were performed by 66 surgeons at 30 centers
•82% of operations were performed by an attending
•18% were performed by senior resident
•90 operations were ORIF with locking plate
•10 were hemiarthroplasty
•4 were intramedullary nails
•5 were “other”

20. Orthopaedic Surgery

21. Orthopaedic Surgery
•The results of the extended follow-up underpin [support] the
main findings of the PROFHER trial.
•There was no significant difference in patient-reported
outcome between operative and non-operative treatment for
the majority of adults with proximal humeral fractures
involving the surgical neck.

22. Orthopaedic Surgery
•Thoughtful critique on the PROFHER study
•Same critiques as we mentioned
•Recognizes that this is a difficult problem, but there is no
clear answer

23. Orthopaedic Surgery
If we decide to operate what do we do??
Or not do??

24. Orthopaedic Surgery
•Comparing ORIF to Hemi
•At 3 years ORIF had better outcome scores
•Loss of fixation was seen in patients with >20 degrees of initial
varusangulation of the humeral head
•Hemi patients did worse when tuberositieswere malunitedor did
not heal

25. Orthopaedic Surgery
•Review of literature and current trends in proximal humerusfx
•Underlying factors related to the patient (e.g., comorbidity, functional
demand), the fracture (e.g., osteoporosis), and the surgeon (e.g., experience)
•Increased complications in osteoporotic patients
•“Reverse shoulder arthroplasty may provide satisfactory shoulder function in
geriatric patients with preexisting rotator cuff dysfunction or after the failure
of first-line treatment.”

26. Orthopaedic Surgery
•Meta-analysis looking at non-op, HA, ORIF and rTSA
•Conclusion
•Hemi and ORIF have the worst clinical outcomes (malunited
tuberositiesand failure of fixation from osteoporosis)
•“rTSAis the optimum treatment method for elderly patients with
fracture of 3-or 4-part proximal humeral because of the higher
Constant score and lower risk of reoperation.”

27. Orthopaedic Surgery
•Compared cost-effectiveness btw non-op, HA, rTSA
•Hemi is not cost-effective
•Non-op is cost-effective
•rTSA“can be cost-effective”

28. Orthopaedic Surgery
•Retrospective chart review
•125 proximal humerusfractures treated with ORIF
•2 groups 78pts (55-69); 49pts (70+)
•95% union rate in 6 months
•No difference in ROM or complication rates
•“Physicians should not exclude patients
forrepairofproximalhumerusfracturesbased on
chronologicalagecutoffs.”

29. Orthopaedic Surgery
•Review article
•A majority of proximal humerusfracturescan be treated conservatively
•Treatment for displacedfracturesshould consider thepatient's level of
independence,bonequality, and surgical risk factors.
•There is no clear evidence-based treatment of choice, and the surgeon should
consider their comfort level with various procedures during the decision-making
process.

30. Orthopaedic Surgery
•38 pts s/p rTSAfor 4 part proximal humerusfractures
•14 had healed tuberosities
•24 had unhealed tuberosities
•No significant differences infunctionaloutcomesand ROM
between the 2 groups except for external rotation, which
was better in thehealedtuberositygroup.

31. Orthopaedic Surgery
•CharlsonComorbidity Index
•Body mass index (<25)
•American Society of Anesthesiologists (ASA) disease severity
score (3-4)
•Reliance on a cane/walker/wheelchair at the time
offracturepredictedmortalityat 2 years
•20% of studypatientsexperienced a loss in ambulatory status by at
least 1 level at 1 year post fracture.

32. Orthopaedic Surgery
•Norway
•124 patients C2 and B2 (OTA) proximal humerusfracture patient ages
65-85;
•Randomized to ORIF or RTSA (60 received ORIF ; 64 received rTSA)
•Primary outcome: Constant Score (Pain, ROM, and ADLs) objective
•Secondary outcome: Oxford shoulder score (PRO Pain and ADLs)
Subjective

33. Orthopaedic Surgery
•“What would not be appropriate is to conclude that reverse TSA is better than
ORIF for proximal humeral fractures.”
•Surgeon skill set, perhaps the ORIF surgeons were trauma trained vs rTSAwere
shoulder trained
•Limited outcome, only 2 years what if… at 5 years if the rTSArevision rate is
25% perhaps this is misleading data

34. Orthopaedic Surgery
Take Home Points…
•Proximal humerusfractures are increasing
•No clear management answer (except hemi is not the answer)
•Be critical when you read literature
•Look at the entire picture of the patient
•Work within your skill set

35. Orthopaedic Surgery
Practical thoughts…
•What about ambulation devices?
•How do we take this into consideration when dealing with
proximal humerusfractures?
•No literature

36. Orthopaedic Surgery
One last thing…
•Please do not forget this is an osteoporotic
fracture and needs bone health work up

37. Orthopaedic Surgery
Thank you