Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient

Abstract

Introduction: Proximal humerus fractures are common in the elderly. The evaluation and management of these injuries is often controversial. The purpose of this study is to review recent evidence and provide updated recommendations for treating proximal humerus fractures in the elderly.

Methods: A literature review of peer-reviewed publications related to the evaluation and management of proximal humerus fractures in the elderly was performed. There was a focus on randomized controlled trials and systematic reviews published within the last 5 years.

Results: The incidence of proximal humerus fractures is increasing. It is a common osteoporotic fracture. Bone density is a predictor of reduction quality and can be readily assessed with anteroposterior views of the shoulder. Social independence is a predictor of outcome, whereas age is not. Many fractures are minimally displaced and respond acceptably to nonoperative management. Displaced and severe fractures are most frequently treated operatively with intramedullary nails, locking plates, percutaneous techniques, or arthroplasty.

Discussion: Evidence from randomized controlled trials and systematic reviews is insufficient to recommend a treatment; however, most techniques have acceptable or good outcomes. Evaluation should include an assessment of the patient's bone quality, social independence, and surgical risk factors. With internal fixation, special attention should be paid to medial comminution, varus angulation, and restoration of the calcar. With arthroplasty, attention should be paid to anatomic restoration of the tuberosities and proper placement of the prosthesis.

Conclusion: A majority of minimally displaced fractures can be treated conservatively with early physical therapy. Treatment for displaced fractures should consider the patient's level of independence, bone quality, and surgical risk factors. Fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options. 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.

Keywords: fragility fractures; geriatric trauma; osteoporosis; trauma surgery; upper extremity surgery.

Figure 1.

Anteroposterior view of the shoulder demonstrating tendinous attachments to the proximal humerus and the associated direction of fragment displacement. GT denotes greater tuberosity; LT, lesser tuberosity.

Figure 2.

Anteroposterior view of the shoulder illustrating the vascular supply to the proximal humerus. The arcuate artery is a branch of the anterior humeral circumflex artery and ascends along the intertubercular groove before entering the humeral head. The posterior humeral circumflex artery travels with the axillary nerve.

Figure 3.

Anteroposterior views of 3 shoulders demonstrating the most commonly encountered fracture patterns: minimally displaced (left) and surgical neck fractures (middle, right) with variable impaction and comminution.

Figure 4.

Anteroposterior views of the shoulder demonstrating the Tingart and DTI methods for measuring bone density. An explanation is provided in the table. DTI denotes deltoid tuberosity index.

Figure 5.

Illustration of common pin or wire trajectories utilized for percutaneous fixation or manipulation of 2- and 3-part fractures. Nonthreaded wires can be provisionally inserted and used to “joystick” fragments prior to placing threaded pins or a lateral plate.

Figure 6.

Postoperative AP view of a 3-part fracture treated with a locking plate. Note the screw traversing the inferomedial humeral head, which is important for providing a medial support in the calcar region (dotted circle). With significant medial bone loss, graft material, fibular struts, or cement can be used to augment the construct. Tuberosities can be captured with screws or sutured to the plate. AP denotes anteroposterior.

Figure 7.

Preoperative and postoperative X-rays illustrating a 2-part greater tuberosity fracture reduced with 2 lag screws. This technique works well for large fragments, but small fragments may be more stable with suture fixation.

Figure 8.

Axillary shoulder X-ray demonstrating a displaced fracture of the lesser tuberosity. This fragment is amenable to suture fixation.

Figure 9.

Preoperative and postoperative views of a patient sustaining a comminuted head splitting fracture. Top left: AP view of the shoulder illustrating a fracture through the anatomic neck. Top right: sagittal CT slice clearly demonstrating the humeral head in multiple pieces. Bottom: Postoperative images of a reverse shoulder prosthesis illustrating the reattached greater tuberosity. AP denotes anteroposterior; CT, computed tomography.