What is the optimal treatment plan for an older adult with a comminuted right proximal humerus fracture, potential osteoporosis, and a history of falls or trauma?

Treatment of Comminuted Right Proximal Humerus Fracture

Primary Treatment Recommendation

Most comminuted proximal humerus fractures in older adults should be treated non-operatively with immobilization in an orthosis for 3 weeks followed by early rehabilitation, as this approach provides good functional outcomes in the majority of cases. 1, 2

Treatment Algorithm Based on Fracture Pattern and Patient Factors

Non-Displaced or Minimally Displaced Fractures

• Treat conservatively with orthosis immobilization for 3 weeks maximum 2
• Begin immediate pendulum exercises within pain tolerance even during immobilization period 3
• This represents the vast majority of proximal humerus fractures in elderly patients and achieves satisfactory outcomes 1, 4

Displaced Three-Part Fractures

• Open reduction with locking plate osteosynthesis is the standard operative procedure 4, 5
• However, this carries considerable complication risk in elderly osteoporotic patients 1
• Critical technical requirements include:
  • Restoration of medial calcar support to prevent varus collapse 4
  • Avoidance of residual varus displacement of humeral head 4
  • Early reduction and fixation if metaphyseal head extension is short or absent to prevent humeral head ischemia 4
  • Consider bone augmentation techniques in severe osteoporosis 4

Displaced Four-Part Fractures

In elderly patients with osteoporosis, hemiarthroplasty or reverse shoulder arthroplasty should be performed rather than attempting open reduction and internal fixation. 5, 1

• Reverse shoulder arthroplasty is preferred over hemiarthroplasty as it provides more reliable functional outcomes, particularly when:
  • Pre-existing rotator cuff dysfunction is present 1, 4
  • Patient has advanced bone loss making anatomical reduction impossible 2
  • Tuberosity healing is questionable 1
• Hemiarthroplasty outcomes depend entirely on anatomical tuberosity healing and rotator cuff function restoration, which is unreliable in elderly patients 1, 4

Alternative Surgical Options

• Interlocking or reconstructive intramedullary nailing produces comparable results to locking plate fixation 2
• Minimal-invasive osteosynthesis or percutaneous pinning should be avoided due to high risk of pin migration and malunion 6

Critical Predictors of Poor Outcome Requiring Primary Arthroplasty

Evaluate these morphologic criteria that predict humeral head ischemia and fixation failure:

• Short or absent metaphyseal head extension 4
• Disruption of medial periosteal hinge 4
• Severe local bone mineral density loss 4
• Patient inability to cooperate with postoperative rehabilitation 2

Immediate Postoperative/Post-Injury Management

Pain Control

• Multimodal analgesia prioritizing non-opioid analgesics 7
• Adequate pain relief is essential for early mobilization 1

Rehabilitation Protocol

• Begin rehabilitation immediately—do not delay beyond 3 weeks of immobilization to avoid harmful effects 3
• Early controlled stress through fracture site optimizes bone repair without increasing complications 3
• Immediate pendulum exercises and passive range of motion 3
• Progress to active-assisted exercises at 3-6 weeks 3
• Gradual strengthening and balance training long-term 1, 7

Avoid Common Pitfalls

• Do not immobilize routinely for longer than 3 weeks—this is outdated practice that worsens outcomes 3
• Electrotherapy and hydrotherapy do not enhance recovery 3
• Joint mobilization has limited evidence of efficacy 3

Mandatory Secondary Fracture Prevention

Every patient aged 50+ with this fragility fracture requires systematic osteoporosis evaluation and treatment. 1, 7

Diagnostic Workup

• DXA scanning of spine and hip 1, 7
• Spine imaging (radiography or VFA) to detect subclinical vertebral fractures 1
• Serum calcium, vitamin D, parathyroid hormone levels 8, 9
• Falls risk assessment 1
• Review clinical risk factors and identify secondary causes of osteoporosis 1, 7

Pharmacological Treatment

• Prescribe alendronate or risedronate as first-line agents for 3-5 years initially 7
• These drugs reduce vertebral, non-vertebral, and hip fracture risk 1, 7
• Regularly monitor tolerance and adherence 1, 7

Non-Pharmacological Interventions

• Calcium 1000-1200 mg/day and vitamin D 800 IU/day supplementation 7
• Smoking cessation and alcohol limitation 1, 7
• Long-term balance training and multidimensional fall prevention 1, 7

Multidisciplinary Coordination

• Implement Fracture Liaison Service (FLS) model with dedicated coordinator to ensure systematic secondary fracture prevention 1, 8
• Coordinate between orthopedic surgeon, rheumatologist/endocrinologist, and primary care physician 1
• Patient education about disease burden, risk factors, and treatment duration 1, 7