What is the appropriate treatment for an 80‑year‑old patient with a closed proximal humerus fracture and humeral head dislocation?

Treatment Recommendation for Closed Proximal Humerus Fracture with Humeral Head Dislocation in an 80-Year-Old

For an 80-year-old patient with a closed proximal humerus fracture and humeral head dislocation, reverse shoulder arthroplasty is the most appropriate treatment, as this represents a complex fracture-dislocation pattern that will not achieve satisfactory functional outcomes with conservative management and carries high complication rates with open reduction and internal fixation in this age group.

Immediate Management Approach

First, perform closed reduction of the dislocation urgently to minimize neurovascular compromise and soft tissue damage. After reduction, obtain CT imaging without IV contrast to fully characterize the fracture pattern, assess humeral head viability, and evaluate tuberosity comminution 1. The presence of both fracture and dislocation indicates a severe injury pattern that fundamentally alters treatment strategy.

Why Surgery is Mandatory in This Case

The combination of proximal humerus fracture with humeral head dislocation represents one of the specific scenarios where conservative treatment should be avoided 2. This pattern indicates:

• The humeral head is severely compromised by the dislocation
• Gross instability exists between the humeral shaft and humeral head
• High risk of symptomatic malunion and avascular necrosis

Conservative treatment is contraindicated when the humeral head is severely compromised, which includes fracture-dislocations 2. While most proximal humeral fractures can be treated non-operatively with good functional outcomes 3, fracture-dislocations are explicitly excluded from this recommendation.

Surgical Option Selection

Reverse Shoulder Arthroplasty (Recommended)

Reverse shoulder arthroplasty provides satisfactory shoulder function in geriatric patients and should be the primary consideration 3. At age 80, this patient meets the criteria for:

• Geriatric age with likely pre-existing rotator cuff dysfunction
• High probability of poor bone quality
• Fracture-dislocation pattern suggesting severe soft tissue disruption
• Need for reliable functional outcome with lower revision risk

The EULAR/EFORT guidelines specifically state that reverse shoulder arthroplasty "may provide satisfactory shoulder function in geriatric patients with pre-existing rotator cuff dysfunction or after the failure of first-line treatment" 3.

Why Not Hemiarthroplasty?

While hemiarthroplasty is an option for fracture-dislocations 4, 5, 6, its outcome is "closely related to tuberosity healing" 3. In an 80-year-old with fracture-dislocation:

• Tuberosity comminution is likely present
• Poor bone quality compromises tuberosity fixation
• If tuberosities fail to unite or mal-unite, function is poor 5
• Early hemiarthroplasty (within 4 weeks) shows better outcomes than delayed surgery 4, but reverse arthroplasty eliminates dependence on tuberosity healing

Why Not Open Reduction and Internal Fixation?

Open reduction and locking plate osteosynthesis is "associated with considerable complication" in this population 3. At age 80 with fracture-dislocation:

• Bone quality is inadequate for reliable fixation
• High risk of fixation failure, non-union, and avascular necrosis 7
• Likely requires conversion to arthroplasty if complications occur

Surgical Timing

Surgery should be performed as early as possible, ideally within 4 weeks of injury 4. The decision for prosthetic humeral head replacement should be made early after trauma, as outcomes after early replacement are significantly better than delayed replacement (UCLA score P=0.02; Constant-Murley score P=0.01) 4.

Critical Technical Considerations

Regardless of whether reverse arthroplasty or hemiarthroplasty is chosen, surgical success depends on:

• Correctly restoring humeral height
• Proper humeral version
• Accurate tuberosity positioning (though less critical for reverse arthroplasty) 5

Postoperative Rehabilitation Protocol

Based on systematic review of rehabilitation protocols 8:

• Sling immobilization: 3 weeks
• Pendulum exercises: Begin post-operative day 1
• Passive range of motion: Begin at 2 days post-operatively
• Active-assisted ROM: Begin at 3 weeks
• Unlimited ROM: At 6 weeks
• Strengthening exercises: At 6 weeks
• Remove all restrictions: At 6 weeks

Mandatory Secondary Prevention

This patient requires systematic evaluation for osteoporosis and secondary fracture prevention 3:

• Enroll in Fracture Liaison Service (FLS) for coordinated care
• Initiate bisphosphonate therapy (alendronate or risedronate first-line) 3
• Ensure calcium 1000-1200 mg/day and vitamin D 800 IU/day 3
• Implement multidimensional fall prevention program 3

Common Pitfalls to Avoid

1. Do not attempt conservative management despite guidelines stating most proximal humerus fractures can be treated non-operatively—fracture-dislocations are the exception
2. Do not delay surgical decision-making beyond 4 weeks, as outcomes deteriorate significantly
3. Do not choose hemiarthroplasty without considering that tuberosity healing is unpredictable in this age group
4. Do not forget osteoporosis management—this fracture pattern indicates severe bone fragility requiring immediate pharmacological intervention