What is the best management approach for bilateral humerus fractures in the elderly?

Management of Bilateral Humerus Fractures in the Elderly

Most proximal humeral fractures in elderly patients can be treated non-operatively with good functional outcomes, as surgical intervention carries significant risks of complications without proven superior outcomes.1

Assessment and Initial Evaluation

• Evaluate fracture pattern and stability using radiographic imaging
• Assess comorbidities, functional status, mobility, and pain level
• Consider bone quality and potential underlying osteoporosis
• Determine if patient uses upper extremities for mobility aids (walkers, canes)
• Differentiate between pathologic and traumatic fractures

Treatment Algorithm

Non-operative Management (First-line for most cases)

• Indicated for most proximal humeral fractures in elderly patients 1
• Particularly appropriate for:
  • Non-displaced or minimally displaced fractures (<2 cm)
  • Moderate to low activity demands
  • Patients with significant comorbidities
  • Higher surgical risk patients

Surgical Management

• Consider only for specific situations:
  • Severely displaced fractures (>2 cm displacement)
  • Young-elderly with high physical demands
  • Failed conservative management
  • Open fractures

Surgical Options:

1. Open Reduction and Internal Fixation (ORIF)

   • Higher complication rate (44%) including mechanical failure, wound issues, and neuropathies 2
   • 2.8 times greater risk of in-hospital death compared to non-operative treatment 3

2. Arthroplasty

   • Consider for comminuted fractures with poor bone quality
   • 23% complication rate, but complications often more severe 2
   • 4.4 times greater risk of in-hospital adverse events compared to non-operative treatment 3

Rehabilitation Protocol

• Early mobilization tailored to fracture stability
• Progressive weight-bearing as tolerated
• Balance training and multidimensional fall prevention 1, 4
• Regular follow-up with radiographic evaluation at 6 weeks, 3 months, 6 months
• Assess for osteoporosis and consider treatment 1

Complications to Monitor

• Malunion (common with conservative treatment)
• Neuropathies (especially ulnar nerve)
• Mechanical failure of fixation
• Wound complications
• Infection
• Non-union
• Ossifications (can affect functional outcomes)

Important Considerations

• Bilateral fractures may significantly impact independence and ability to perform activities of daily living
• Elderly patients may rely on upper extremities for mobility aids, affecting treatment decisions
• Cost analysis shows surgical treatment is significantly more expensive than non-operative management (at least $3900-5500 higher) 5
• Systematic reviews show no clinically important differences in functional outcomes between surgical and non-surgical treatment for moderately displaced proximal humerus fractures 5

Postoperative Care (if surgery performed)

• Appropriate pain management
• Antibiotic prophylaxis
• Correction of postoperative anemia
• Regular assessment of cognitive function
• Assessment for pressure sores
• Monitoring of nutritional status and renal function
• Wound assessment and care
• Early mobilization 1

The evidence strongly suggests that non-operative treatment should be the first choice for most elderly patients with bilateral humerus fractures, as surgical intervention carries higher risks without proven superior outcomes, particularly in this vulnerable population.