Fractures of the Humeral Proximal Extremity in Three and Four Fragments in the Elderly Patient: Conservative Treatment or Reverse Arthroplasty?

Abstract

Objective This study compared functional results in two cohorts of older adults with three- and four-part proximal humeral fractures (PHFs) per Neer's classification treated with reverse shoulder arthroplasty (RSA) or nonoperative management.

Materials and Methods Ambispective, non-randomized study with two cohorts of patients aged 75 or older treated with RSA (n = 15) or nonoperative management (n = 16) with a minimum follow-up period of 12 months. We analyzed the American Shoulder and Elbow Surgeons (ASES), Constant-Murley, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores and the visual analog scale (VAS) for pain at 3, 6, and 12 months. In addition, we recorded radiological findings and surgical complications.

Results The mean Constant-Murley score at 12 months was significantly higher for the RSA group (75.1 +/- 10.3 vs. 51.9 +/- 12.4, p = 0.001). There were no differences in ASES, DASH, and VAS scores. Statistically significant differences for flexion and external rotation in abduction favored the RSA group (128.9 +/- 17.0 versus 99.3 +/- 20.1, p = 0.001, and 35.7 +/- 13.9 vs. 23.4 +/- 15.5, p = 0.032, respectively). For the RSA group, tuberosity positioning was correct in 43% of subjects. These patients presented better scores than those with malpositioned or absent tuberosities but with no statistical significance. Complications in the surgical group were not higher.

Conclusions Nonoperative treatment is a valid option regarding pain and functionality in elderly patients with three- and four-part PHFs. Characteristics of patients with high demands who may be candidates for the initial surgical treatment remain to be defined.

Level of Evidence Level III

Keywords

proximal humeral fracture - elderly - nonoperative treatment - reverse shoulder arthroplasty

Publication History

Received: 02 August 2022

Accepted: 21 November 2023

Article published online:
03 May 2024

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