What is the recommended treatment for a proximal humerus fracture?

Proximal Humerus Fracture Treatment

Most proximal humerus fractures should be treated non-operatively, as this approach achieves good functional outcomes in 80-90% of patients without the increased complication risk associated with surgery. 1, 2

Treatment Algorithm by Fracture Pattern

Non-Displaced or Minimally Displaced Fractures

• Treat conservatively with immobilization and early mobilization
• Expected outcomes: Good to excellent function in 80-90% of cases 1, 3
• This represents the majority of proximal humerus fractures

Displaced 3-Part and 4-Part Fractures

The treatment remains controversial, but the evidence strongly favors a conservative approach in most cases:

Non-operative treatment is recommended for elderly patients (>65 years) with displaced fractures 2. A systematic review and meta-analysis of 1,743 patients found:

• No functional difference between operative and non-operative treatment (mean difference -0.87,95% CI -5.13 to 3.38)
• Major reinterventions occurred MORE frequently in the operative group
• These findings held true across both RCTs and observational studies

Indications for Surgical Intervention

Consider surgery only in these specific scenarios 3:

1. Severe humeral head compromise:

   • Fracture-dislocation
   • Severe head impaction
   • Split of the humeral head itself

2. Gross instability:

   • Non-impacted fractures with severe instability between humeral shaft and head

3. Tuberosity displacement:

   • Displacement that will lead to symptomatic malunion
   • Final proximal humerus shape will compromise function

Surgical Options When Indicated

For unreconstructible fractures requiring surgery 1, 4:

• Reverse shoulder arthroplasty is the preferred option for:

  • Geriatric patients with pre-existing rotator cuff dysfunction
  • Failed first-line treatment
  • Unreconstructible fracture patterns in elderly patients
  • Provides predictably good functional outcomes 4, 5

• Open reduction and locking plate osteosynthesis:

  • Associated with considerable complications 1
  • Declining utilization trend 6

• Hemiarthroplasty:

  • Outcome closely related to tuberosity healing 1
  • May not provide reliable function 4
  • Reserved for younger/middle-aged patients when fixation not feasible
  • Declining utilization trend 6

Critical Pitfalls to Avoid

1. Over-treatment: The evidence clearly shows that operative treatment does not improve functional outcomes in the average elderly patient and increases complication rates 2

2. Ignoring bone quality: In patients with poor bone quality, likely rotator cuff degeneration, or suspected humeral head ischemia, arthroplasty is preferable to fixation 1, 5

3. Delayed assessment: All patients ≥50 years with fragility fractures require systematic evaluation for subsequent fracture risk and osteoporosis treatment 1

Imaging After Initial Radiographs

If radiographs show a proximal humerus fracture, obtain CT without contrast 7, 8:

• CT is the best examination for delineating fracture patterns
• Superior to radiography for characterizing displacement and complexity
• 3D reconstructions help with surgical planning when needed
• MRI is inferior to CT for fracture characterization

Note: Rotator cuff tears occur in up to 40% of proximal humerus fractures, but delayed repair (up to 4 months) does not adversely affect outcomes 7. Immediate soft tissue diagnosis is not required in the acute fracture setting.

Contemporary Trends

Recent data shows increasing utilization of reverse total shoulder arthroplasty for all fracture types, with declining use of ORIF and hemiarthroplasty 6. This reflects recognition that arthroplasty provides more predictable outcomes in elderly patients with complex fractures compared to fixation attempts in poor bone quality.