Review Question - QID 218139

The optimal management of geriatric proximal humerus fractures is dependent upon a number of factors including, but not limited to, patient age, fracture pattern, patient comorbidities, and surgeon preference. While multiple treatment strategies can be attempted for this patient, reverse total shoulder arthroplasty (RSA) following failed nonoperative management is associated with better functional outcomes than RSA following failed open reduction and internal fixation (ORIF) (Answer 4).

Proximal humerus fractures are common injuries and are the third most common non-vertebral fracture pattern seen in patients over the age of 65. These injuries represent 4-6% of all fractures, and females sustain these injuries twice as often as men. There is a direct relationship between patient age and increasing fracture complexity, and fractures involving the surgical neck are the most common subtype. Risk factors for these fractures include osteoporosis, diabetes, epilepsy, and, as previously mentioned, female gender. In older patients, these fractures typically occur secondary to low-energy falls.

Proximal humerus fractures are classified according to the Neer classification (Illustration A), which is based on the anatomic relationship of four segments: the greater tuberosity, the lesser tuberosity, the articular surface, and the shaft. A fracture segment is considered a part if there is greater than 1 cm of displacement or greater than 45° of angulation. The optimal treatment for these injuries remains controversial. Overall, a majority of geriatric proximal humerus fractures can be initially treated nonoperatively. With respect to operative interventions, closed-reduction with percutaneous pinning (CRPP), open reduction and internal fixation (ORIF), intramedullary nailing and a variety of arthroplasty solutions have been described as viable strategies for the treatment of these fractures.

Rangan et al., in the landmark PROFHER (proximal fracture of the humerus evaluation by randomization) trial, sought to determine the optimal treatment for adults with displaced fractures of the surgical neck of the proximal humerus. Their study was a multicenter, parallel-group, randomized controlled clinical trial that originally recruited 250 patients with a mean age of 66 years. Approximately 77% of the patients in the trial were female, and 215 patients had complete two-year follow-up data. Patients were randomized to undergo either nonsurgical management with a sling, or operative treatment based on surgeon preference. Overall, the authors found no difference in functional outcome scores, complications, or revision rates between the two treatment arms. While these results seem to support nonoperative management for all adults with these fractures, the study does have limitations that limit the generalizability of the authors' findings. First, a majority of the fractures were one- and two-part fractures. Second, the recruitment period occurred during the nascency of the concept of RSA for fracture. A follow-up trial, PROFHER II, is currently underway, which aims to build upon the findings of this landmark trial.

Shannon et al. investigated outcomes following primary, acute RSA versus salvage RSA following failed osteosynthesis for geriatric proximal humerus fractures. Their study cohort included 18 patients who underwent primary RSA and 26 patients who underwent RSA following failed ORIF. Overall, there were no differences in patient outcomes between the two cohorts (acute RSA vs. RSA following failed ORIF), but patients who underwent salvage RSA more frequently experienced complications (8% vs. 5%) and instability. Overall, the authors conclude that both acute RSA and RSA following failed ORIF are viable treatment options, with comparable outcomes, but that salvage RSA is associated with higher complication rates.

Santana et al. investigated outcomes following RSA for proximal humeral fracture sequelae (PHFS) for fractures initially treated nonoperatively versus those initially treated with ORIF. This retrospective study included 27 patients: 9 treated with RSA for PHFS following failed nonoperative management and 18 treated with RSA for PHFX following ORIF. Overall, both groups demonstrated improvement in constant scores, but patients who were initially managed conservatively had significantly better Constant scores, forward elevation, and external rotation than those who were initially treated with ORIF. Overall, the authors conclude that patients developing PHFS after conservative treatment exhibit more favorable outcomes compared to patients developing PHFX after ORIF.

Figure A is an AP radiograph of the left shoulder demonstrating a four-part proximal humerus fracture. Illustration A is a figure depicting the Neer classification.

Incorrect Answers:
Answer 1: patients who undergo RSA following failed ORIF exhibit higher complication rates than patients who undergo primary, acute RSA.
Answer 2: studies have demonstrated that immediate physical therapy is associated with improved functional outcomes and that prolonged immobilization is unnecessary.
Answer 3: hemiarthroplasty is typically indicated for head-splitting fractures in younger patients. In this geriatric patient with a four-part proximal humerus fracture, either nonoperative management, ORIF, or RSA would be more appropriate.
Answer 5: RSA following failed ORIF exhibits higher rates of instability compared to primary RSA.