Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options

Abstract

Background and objective: Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice.

Methods: PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design.

Key content and findings: Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs.

Conclusions: The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Keywords: Shoulder; fixation; fracture; proximal humerus; reverse arthroplasty.

Figure 1

Three- or four-part proximal humerus fractures in middle-aged patients could be best treated with fixation. (A)The anteroposterior plain radiograph of a 40-year-old female with proximal humerus fracture; (B) treated with open reduction and internal fixation using locking plate.

Figure 2

A 62-year-old male with post-traumatic three-part comminuted fracture of left shoulder as seen on (A) coronal section of CT scan. He was operated with (B) ORIF with locking plate with reduction in varus malalignment as seen on immediate postoperative radiograph. At three months after index ORIF surgery, the patient had persistent pain and stiffness in affected shoulder and the radiograph (C) showed progressive increase in varus malalignment of the humeral head, loss of fixation, and prominent screws in intraarticular space. After ruling out infection, the patient underwent reverse shoulder arthroplasty (D) with cemented stem and lateralized glenoid and tuberosity reconstruction and had satisfactory clinical result with good function and no pain. ORIF, open reduction and internal fixation; CT, computed tomography.