Fractures of the proximal humerus: Does age precludes operative treatment?

Background: Fractures of the proximal humerus are extremely common, and these are true osteoporotic fractures. Due to rich vascularity and broad cancellous surfaces most of these fractures can be effectively treated nonoperatively as this imparts a high propensity for healing. In addition, many of these fracture patterns result in adequate bone contact and minimal displacement with acceptable alignment. For displaced fractures open reduction and internal fixation can improve outcomes, depending on the pre-injury functional status of the patient. Unique operative treatment challenges include obtaining and maintaining reduction of small bone fragments with strong muscle forces especially in osteoporotic bone. Many options are feasible, including plates, nails, sutures, and other novel devices. Now locking plates are being used more commonly and for a successful result technical details are critical and this minimizes loss of reduction, the risk of implant failure, and reoperation. To our knowledge, very few studies were done on the outcome of operative treatment of these osteoporotic fractures.
Material and Methods: During this observational study, we analyzed all operatively treated proximal humerus fractures between January 2015 and December 2020. Patient selection was on clinical grounds, based on physical, mental, and social criteria. To investigate functional outcome, pain, and ADL limitations we used the DASH Questionnaire. Documented complications were also evaluated.
Results: There were total of 128 patients with displaced proximal humerus fractures treated surgically: 30 two-part, 64 three-part, and 34 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Overall good results were obtained with the modern locking plates (mean DASH 34.4). In highly comminuted fractures prosthetic treatment were used and this resulted in poorer function (mean DASH 72.9). Again in this sub group persistent pain and ADL limitations were more present (64 and 50% in patients with 4-part fractures vs. 14% in 2-part fractures). Fracture-related and non-fracture-related complication rates were low (non-union 3%; 2 myocardial infarction) and there were no postoperative deaths within 3 months of surgery.
Conclusion: It is justifiable to consider surgical treatment in selected comminuted dislocated proximal humerus fractures in patients aged 75 and older.