Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options

Introduction

Proximal humerus fractures (PHFs) make up 6% of all fractures and are common fragility fractures with peak incidence in the 60- to 90-year-old age group (1,2). PHFs are the third most common fracture in patients who are 65 years and older (3). The PHFs are most commonly classified using systems proposed by Neer’s and Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) which help to gauge the severity of fracture pattern and plan appropriate treatment strategies. The Neer’s classification system divides PHFs into 4 categories based on anatomic relationship of four anatomical structures of proximal humerus which are greater tuberosity, lesser tuberosity, articular surface and shaft (4). The fragments are considered separate if there is a displacement of >1 cm and/or 45° angulation. The AO/OTA system classifies PHFs into 3 main groups and additional subgroups based on fracture location, status of the surgical neck, and presence/absence of dislocation (5). It is usually advisable to acquire computed tomography (CT) scan with three-dimensional (3D) reconstruction for PHFs, unless simple two-part fracture pattern, in order to classify and plan the surgical treatment. The common treatment options for PHFs are non-operative, open reduction and internal fixation (ORIF), hemiarthroplasty, and reverse shoulder arthroplasty (RSA). Usually, a two-part PHF could be treated nonoperatively for minimally displaced fracture and ORIF for displaced fractures. On the other spectrum, elderly patients with three- or four-part displaced PHFs with low demand and activity level could be managed with nonoperative treatment, ORIF, RSA, if medically fit. The choice of surgical treatment is controversial in middle-aged and active elderly patients with three- or four-part displaced PHFs with options being nonoperative, ORIF, hemiarthroplasty, and RSA (6). The preferred option depends on expectations, fracture pattern, bone quality, and status of rotator cuff. The aim of this review article is to highlight the current literature on operative treatment options for three- or four-part PHFs in middle-aged and active elderly patients, providing guidance for clinicians in their decision-making. We present this article in accordance with the Narrative Review reporting checklist (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-11/rc)

Methods

This narrative review is based on literature review and the authors’ expertise in this area. Our literature search was performed in PubMed and Scopus for supporting data from studies published in English language, available from January 1953 to February 2024, using relevant keywords (Table 1). However, this is not a systematic review and does not comprehensively cover all published literature on this topic.

Nonoperative treatment

The effectiveness of nonoperative treatment in three- or four-part PHFs in middle-aged and active elderly is controversial. There are several studies that reported low functional scores and loss of range of motion in active and independent individuals with displaced 3- and 4-part PHFs treated with nonoperative management (7,8). Increasing fracture fragments and magnitude of displacement predicts worse outcomes, functional scores, and range of motion limitations with nonoperative treatment (9). On the other hand, meta-analyses on the topic have reported similar outcomes in terms of function and pain relief with nonoperative treatment and operative management and concerns of higher implant related complications and reoperations (10). A United States national insurance database study analyzing patients with PHFs over 10 years found that the risk of mortality was higher with operative treatment in patients older than 75 years, male sex, a concomitant fracture, osteoporotic fracture, and medical comorbidities such as congestive heart failure, and chronic obstructive pulmonary disease, cerebrovascular disease, and chronic kidney disease. The recent literature indicates that nonoperative treatment could be recommended when patients with PHFs meet five criteria: (I) impaction fractures, (II) no dislocation of humeral head, (III) humeral head and shaft angle between 100–160 degrees, (IV) minimal tuberosity displacement, and (V) minimal involvement of the articular surface (11,12). It is imperative that nonoperative treatment remains a popular option for patients with minimally displaced PHFs in middle-aged and active elderly patients (13,14).

Fracture fixation

The goal of fixation of PHFs is restoring alignment and rotation of humeral head with shaft and anatomic reduction of the joint surface and tuberosities. Among the operative treatment options, fracture fixation remains the most popular option for three- or four-part PHFs (6). The recent trend for treatment with PHFs, however, showed a decline in ORIF and hemiarthroplasty as the choice of procedure, especially in elderly population, with a rise in RSA (3). There are several methods of fixation of PHFs including but not limited to percutaneous k-wires, non-locking plate, and locking plate. The choice of surgery and type of fixation depends on age, fracture pattern, quality of bone, and surgeon’s discretion and specialty (trauma vs. shoulder) (15).

Closed reduction and percutaneous pinning could be used in PHFs in young patients with good bone quality, especially, valgus impacted type, without substantial comminution or a head-split fracture (16). The decision to undertake closed reduction and percutaneous pinning versus open reduction should be taken intraoperatively after attempting reduction under anesthesia as the clinical outcomes correlate directly with achievement of adequate reduction (16,17). However, there are concerns of loss of reduction, pin migration, pin tract infection, and neurovascular injury which hinders the popularity of this minimally invasive technique to treat PHFs (18,19). Differently from traditional percutaneous pinning, several previous studies using minimally invasive reduction and osteosynthesis system/MIROS wherein percutaneous wires are connected with an external fixator have demonstrated favorable clinical outcomes with low complication rates even in complex PHFs (20). Similarly, Gumina et al. while using three or four couples of blocked threaded wires connected with single external rod fixator construct demonstrated good biomechanical and clinical outcomes in more studies (21,22). Thus, in carefully selected patients, closed or mini open reduction and percutaneous pinning with external fixator application results in favorable outcomes.

Closed reduction and internal fixation (CRIF) using intramedullary nail with locking screws is another option for fixation of PHFs with advantages of a minimally invasive approach reducing vascular insult to fracture fragments and potential complications of infection and loss of fixation with percutaneous pinning (23,24). The advances in intramedullary humeral nail design with introduction of multiple locking screw mechanism and reduced iatrogenic trauma to rotator cuff tendons due to improvisation in nail entry point in rotator interval or through supraspinatus muscle medially instead through the tendons, have led to increased interest in their use for PHFs (25-27). Previous studies have found no difference in clinical outcomes between PHFs patients treated either with intramedullary nailing or locking plate (28). While controversial, there are concerns of higher complication rates with intramedullary nailing as compared to plating group especially related to persistent pain due to impingement, stiffness, and reoperation (29-31). The risk factors associated with higher complication and reoperation rate with use of intramedullary nailing for PHFs are reported as four-part fractures and nonsufficient anatomical reduction of fracture especially medial calcar hinge and metaphyseal head extension of less than 8 mm similar to Hertel’s criteria (32,33). In the opinion of the authors, intramedullary nailing may be recommended in cases involving two-part surgical neck fractures, or three- and four-part fractures with metaphyseal or diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures (27,34).

ORIF using locking plate is a popular choice for PHFs using either deltopectoral or direct lateral deltoid splitting approach (Figure 1). A meta-analysis of 6 studies reported that the direct lateral deltoid splitting approach had advantages of significantly shorter operative time and lower humeral head necrosis rate (1% vs. 4.8%) with similar complication rate and functional outcome than deltopectoral approach (35). In our experience, direct lateral deltoid splitting is preferred for another reason of easier access to greater tuberosity displacement posteriorly than in deltopectoral approach. ORIF with plate for PHFs has been criticized for complication rate of 20–30% mainly due to screw penetration in joint, subacromial impingement of plate placed superior to greater tuberosity, and avascular necrosis (36,37). The outcomes of ORIF for PHFs could be optimized by vigilance of surgeon on three factors: anatomical reduction, avoidance of screw penetration in joint, and placement of superior edge of plate below the greater tuberosity. In order to prevent screws from penetration in the joint, they should be positioned 5 to 10 mm away from the articular surface (12). In elderly patients with osteoporosis, augmentation of ORIF with fibular strut graft or acrylic cement leads to improved construct stability (38).

Figure 1 Three- or four-part proximal humerus fractures in middle-aged patients could be best treated with fixation. (A)The anteroposterior plain radiograph of a 40-year-old female with proximal humerus fracture; (B) treated with open reduction and internal fixation using locking plate.

Whether avascular necrosis after PHFs should be considered as a complication with associated poor outcomes is controversial (39-41). Interestingly, the rate of symptomatic avascular necrosis after nonoperatively treated PHFs is just 1.6% (36,42). Hertel et al. in their study of 100 patients with PHFs who underwent ORIF found that the predictors of avascular necrosis were posteromedial metaphyseal head extension less than 8 mm, disruption of medial hinge, and fracture patterns involving the anatomic neck (34). Combining all three factors led to a 97% positive predictive value for developing avascular necrosis. Head splitting fractures has been thought to be an important risk factor for osteonecrosis especially when they occur with tuberosity fractures (43). While the rate of avascular necrosis after ORIF (7.9%) is reported to be higher than nonoperative treatment (2%), the functional outcomes in patient with avascular necrosis are similar to those without it (39-41). Gerber et al. in a comparative study of 25 patients with posttraumatic avascular necrosis of humeral head reported better range of motion and function in 13 patients with anatomical alignments compared to 12 patients who had malunion (44). These studies resound with our clinical experience that adequately reduced PHFs in elderly that achieve union in good alignment will retain favorable function even with avascular necrosis.

Hemiarthroplasty

Hemiarthroplasty was introduced in 1955 by Neer for acute and chronic PHFs with or without dislocation and avascular necrosis (45). The current literature indicates that the use of hemiarthroplasty in the setting of 3- and 4-part PHFs in elderly patients leads to variable outcomes comparable to nonoperative treatment and poorer than in young patients (46-48). On the other hand, several clinical studies in patients with acute PHFs with long-term follow up found a prosthesis survival rate of 88–97% with favorable function and range of motion (49,50). Poor clinical outcomes in 3- and 4-part PHFs treated with hemiarthroplasty are correlated with humeral length increase >1 cm, rotator cuff deficiency, tuberosities resorption and migration and reduction in the acromion-humeral distance (49,51,52). Some authors have advised to confirm rotator cuff integrity in patients with PHFs on preoperative MRI while making a decision between hemiarthroplasty and RSA (53,54). Notably, the popularity of hemiarthroplasty as a choice of prosthesis has reduced in joint registries (55), which has also been our clinical experience in past decade. We believe that hemiarthroplasty is still a valuable tool in treating carefully selected active patients with unreconstructible PHFs with good tuberosity bone stock and intact or restored rotator cuff integrity.

Reverse shoulder arthroplasty

Grammont revolutionized RSA design and shoulder surgery in general by introducing medialized glenoid design prosthesis (56). Introduced for treatment of cuff tear arthropathy, RSA is now used for expanded indications including 3- and 4-part fractures, especially in elderly (57,58). A meta-analysis of RSA done for PHFs using 66 studies (3,117 shoulders) and RSA done for other indications than PHFs using 134 studies (11,651 shoulders) found worse clinical outcomes and range of motion in RSA for fracture group without any difference in complication rate (59). Nonetheless, there has been increased use of RSA for 3- and 4-part PHFs in active elderly patients as unlike other operative methods of ORIF and hemiarthroplasty, it has predictable results despite rotator cuff insufficiency and poor bone stock (6,55) (Figure 2). The clinical studies on efficacy of RSA for 3- and 4-part fractures in elderly show favorable results in comparison to hemiarthroplasty and ORIF. A study of patients over 70 years with 3- and 4-part PHFs with 81 patients in each comparison group showed RSA group to have better functional scores and range of motion including external rotation than ORIF with similar complication rate and risk of revision (60). As compared to hemiarthroplasty, RSA has been shown to have better clinical outcomes and a similar complication rate for the treatment of comminuted PHFs in the elderly (61). This underlines the importance of correct choice of first arthroplasty in elderly patients with PHFs.

Figure 2 A 62-year-old male with post-traumatic three-part comminuted fracture of left shoulder as seen on (A) coronal section of CT scan. He was operated with (B) ORIF with locking plate with reduction in varus malalignment as seen on immediate postoperative radiograph. At three months after index ORIF surgery, the patient had persistent pain and stiffness in affected shoulder and the radiograph (C) showed progressive increase in varus malalignment of the humeral head, loss of fixation, and prominent screws in intraarticular space. After ruling out infection, the patient underwent reverse shoulder arthroplasty (D) with cemented stem and lateralized glenoid and tuberosity reconstruction and had satisfactory clinical result with good function and no pain. ORIF, open reduction and internal fixation; CT, computed tomography.

One wonders if it would be a good idea to give a trial of nonoperative or ORIF treatment for active elderly patients with PHFs and reserve RSA as a salvage option. In a multicenter study of patients treated with RSA for 2-, 3-, and 4-part PHFs either <4 weeks since surgery (acute group, 102 patients) or >4 weeks after RSA (delayed group, 38 patients), authors found similar pain relief, function, range of motion, and complication rate at midterm follow up (62). A meta-analysis of 16 studies on RSA done for PHFs in elderly patients comparing results of early RSA versus delayed RSA after a trial of nonoperative treatment found similar pain relief, function, range of motion, and complication rate (63). In a small size cohort study with 18 patients with RSA for acute PHFs and 26 patients with RSA for failed ORIF, found similar function, pain relief, and range of motion, however, the complication rate in acute PHF group (5%) were lower than post-ORIF RSA group (8%) (64). The authors recommended a trial of ORIF in carefully selected patients as outcomes of a salvage RSA are acceptable. Notably, in a series of 35 patients with conversion of failed hemiarthroplasty done for PHFs to RSA showed improved pain relief, function, and range of motion but had complications in 32% patients (64). In our experience, middle-aged and active elderly population with 3- and 4-part PHFs with good bone stock should be given a trial of nonoperative treatment in minimally displaced and ORIF with locking plate in displaced fracture patterns. RSA is reserved as a salvage surgery in middle-aged and active elderly patients who continue to remain symptomatic after failed nonoperative or ORIF. RSA is indicated as a first treatment in elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and unconstructable 3- and 4-part PHFs.

Conclusions

The treatment of choice in middle-aged and active elderly patients with 3- and 4-part PHFs is controversial. Patients with minimally displaced fractures should be treated nonoperatively. CRIF with intramedullary nailing is a viable option in cases of 2-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced 3- and 4-part PHFs fractures with intact rotator cuff muscles should be treated with ORIF using locking plate if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed ORIF treated with salvage RSA have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Joint for the series “Controversies in Shoulder Surgery and Algorithmic Approach to Decision Making”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-11/rc

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Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://aoj.amegroups.com/article/view/10.21037/aoj-24-11/coif). The series “Controversies in Shoulder Surgery and Algorithmic Approach to Decision Making” was commissioned by the editorial office without any funding or sponsorship. P.M. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

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