Proximal humeral fracture is a common injury in middle-aged and elderly people, especially elderly patients with osteoporosis due to bone loss, which can lead to fractures due to low-energy injury. As the population ages, the prevalence of proximal humeral fractures is likely to continue to increase. In the absence of open or neurovascular injury, the indications for surgery for proximal humeral fractures are controversial. Typically, the same fracture type can be treated non-surgically, with open reduction internal fixation, or joint replacement, depending on several variables including patient age, comorbidities, activity level, and treatment expectations. The purpose of this paper is to review surgical considerations in the surgical treatment of proximal humeral fractures in older adults with osteoporosis.

Yunlu Wang, Xiyong Li, Lun Liu, Songfeng Li, Pengfei Han. Research Progress in Surgical Treatment of Proximal Humeral Fractures in Elderly Osteoporotic Humerus. Frontiers in Medical Science Research (2023) Vol. 5, Issue 5: 30-35. https://doi.org/10.25236/FMSR.2023.050505.

[1] Maier, D., Jaeger, M., Izadpanah, K., Strohm, P. C., & Suedkamp, N. P. (2014). Proximal humeral fracture treatment in adults. The Journal of Bone and Joint Surgery. American Volume, 96(3), 251–261. https://doi.org/10.2106/JBJS.L.01293

[2] Lu, V., Jegatheesan, V., Patel, D., & Domos, P. (2023). Outcomes of Acute versus Delayed Reverse Shoulder Arthroplasty for Proximal Humerus Fractures in the Elderly: A Systematic Review and Meta-Analysis. Journal of Shoulder and Elbow Surgery, S1058-2746(23)00303–8. https: // doi. org/ 10. 1016/ j.jse.2023.03.006

[3] Namdari, S., Voleti, P. B., & Mehta, S. (2012). Evaluation of the osteoporotic proximal humeral fracture and strategies for structural augmentation during surgical treatment. Journal of Shoulder and Elbow Surgery, 21(12), 1787–1795. https://doi.org/10.1016/j.jse.2012.04.003

[4] Siris, E. S., Adler, R., Bilezikian, J., Bolognese, M., Dawson-Hughes, B., Favus, M. J., Watts, N. B. (2014). The clinical diagnosis of osteoporosis: a position statement from the National Bone Health Alliance Working Group. Osteoporosis international: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, 25(5), 1439–1443. https://doi.org/10.1007/s00198-014-2655-z

[5] H, Z., W, N., S, G., X, L., & A, Z. (2009). [Long PHILOS locking compression plate for treatment of proximal humerus and humeral shaft fractures]. Zhongguo xiu fu chong jian wai ke za zhi = Zhongguo xiufu chongjian waike zazhi = Chinese journal of reparative and reconstructive surgery, 23(4). Retrieved from https://pubmed.ncbi.nlm.nih.gov/19431978/

[6] Neer, C. S. (1970). Displaced proximal humeral fractures. I. Classification and evaluation. The Journal of Bone and Joint Surgery. American Volume, 52(6), 1077–1089.

[7] Carofino, B. C., & Leopold, S. S. (2013). Classifications in brief: the Neer classification for proximal humerus fractures. Clinical Orthopaedics and Related Research, 471(1), 39–43. https: // doi. org/ 10.1007/s11999-012-2454-9

[8] Fric, V., & Sosna, A. (1995). [Contribution to the problem of classification of fractures of the proximal end of the humerus in adults.]. Acta Chirurgiae Orthopaedicae Et Traumatologiae Cechoslovaca, 62(4), 196–206.

[9] Cruz, M. A., Mouraria, G. G., Kikuta, F. K., Zogbi, D. R., Coelho, S. de P., & Etchebehere, M. (2023). The Hertel classification can’t predict the risk of humeral head osteonecrosis after osteosynthesis using an anterolateral approach. Clinics (Sao Paulo, Brazil), 78, 100173. https: // doi. org/ 10.1016/j.clinsp.2023.100173

[10] Martínez-Sola, R., León-Muñoz, V. J., Najem-Rizk, A. N., Soler-Vasco, B., Arrieta-Martínez, C. J., López-Sorroche, E., … Santonja-Medina, F. (2021). “Absolute” inter-observer classifications agreement for proximal humeral fractures with a single shoulder anteroposterior X-ray. Journal of Orthopaedic Surgery (Hong Kong), 29(2), 23094990211010520. https: // doi. org/ 10. 1177/ 23094990211010520

[11] Mj, T., J, L., D, Z., Jj, W., & M, A. (2006). Proximal humeral fractures: regional differences in bone mineral density of the humeral head affect the fixation strength of cancellous screws. Journal of shoulder and elbow surgery, 15(5). https://doi.org/10.1016/j.jse.2005.09.007

[12] Ho, C. A., Podeszwa, D. A., Riccio, A. I., Wimberly, R. L., Ramo, B. A., Yang, M., & Patel, S. (2020). Pathologic arterial changes in neurovascularly intact Gartland III supracondylar humerus fractures: a pilot study. Journal of Pediatric Orthopedics. Part B, 29(2), 137–144. https: // doi. org/1 0. 1097/ BPB.0000000000000697

[13] Krappinger, D., Roth, T., Gschwentner, M., Suckert, A., Blauth, M., Hengg, C., & Kralinger, F. (2012). Preoperative assessment of the cancellous bone mineral density of the proximal humerus using CT data. Skeletal Radiology, 41(3), 299–304. https://doi.org/10.1007/s00256-011-1174-7

[14] Spross, C., Kaestle, N., Benninger, E., Fornaro, J., Erhardt, J., Zdravkovic, V., & Jost, B. (2015). Deltoid Tuberosity Index: A Simple Radiographic Tool to Assess Local Bone Quality in Proximal Humerus Fractures. Clinical Orthopaedics and Related Research, 473(9), 3038–3045. https: // doi. org/ 10.1007/s11999-015-4322-x

[15] Ng, A. J.-H., Arora, V., Tang, H. H.-F., Treseder, T., Jain, A., & Wagner, T. (2016). Axillary Artery Injury Associated with Proximal Humeral Fractures: Review of Long-Term Vascular, Orthopedic, and Neurologic Outcomes. Annals of Vascular Surgery, 33, 210–219. https: // doi. org/ 10. 1016/ j. avsg. 2015. 10.038

[16] Wilkinson, E. B., Williams, J. F., Paul, K. D., He, J. K., Hutto, J. R., Narducci, C. A., … Ponce, B. A. (2021). MRI evaluation of axillary neurovascular bundle: Implications for minimally invasive proximal humerus fracture fixation. JSES international, 5(2), 205–211. https: // doi. org/ 10. 1016 /j. jseint. 2020.11.002

[17] Rasmussen, S., Hvass, I., Dalsgaard, J., Schiøttz-Christensen, B., & Holstad, E. (1993). [Displaced proximal humeral fracture--conservative treatment]. Ugeskrift for Laeger, 155(30), 2341–2342.

[18] Soler-Peiro, M., García-Martínez, L., Aguilella, L., & Perez-Bermejo, M. (2020). Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review. Journal of Orthopaedic Surgery and Research, 15(1), 347. https://doi.org/10.1186/s13018-020-01880-7

[19] Clement, N. D., Duckworth, A. D., McQueen, M. M., & Court-Brown, C. M. (2014). The outcome of proximal humeral fractures in the elderly: predictors of mortality and function. The Bone & Joint Journal, 96-B(7), 970–977. https://doi.org/10.1302/0301-620X.96B7.32894

[20] Rämö, L., Taimela, S., Lepola, V., Malmivaara, A., Lähdeoja, T., & Paavola, M. (2017). Open reduction and internal fixation of humeral shaft fractures versus conservative treatment with a functional brace: a study protocol of a randomised controlled trial embedded in a cohort. BMJ open, 7(7), e014076. https://doi.org/10.1136/bmjopen-2016-014076

[21] H, F., Rm, H., Rb, B., M,  van H., D,  van der V., & Fjp, B. (2019). [Proximal humerus fractures; conservative or surgical treatment?]. Nederlands tijdschrift voor geneeskunde, 163. Retrieved from https://pubmed.ncbi.nlm.nih.gov/30638000/

[22] Hak, D. J., Fader, R., Baldini, T., & Chadayammuri, V. B. S. (2017). Locking screw-plate interface stability in carbon-fibre reinforced polyetheretherketone proximal humerus plates. International Orthopaedics, 41(9), 1735–1739. https://doi.org/10.1007/s00264-017-3562-7

[23] Kuang, G.-M., Wong, T. M., Wu, J., Ouyang, J., Guo, H., Zhou, Y., … Lu, W. (2018). Augmentation of a Locking Plate System Using Bioactive Bone Cement-Experiment in a Proximal Humeral Fracture Model. Geriatric Orthopaedic Surgery & Rehabilitation, 9, 2151459318795312. https: // doi. org/ 10. 1177/ 2151459318795312

[24] Sproul, R. C., Iyengar, J. J., Devcic, Z., & Feeley, B. T. (2011). A systematic review of locking plate fixation of proximal humerus fractures. Injury, 42(4), 408–413. https: // doi. org/ 10. 1016 /j. injury. 2010.11.058

[25] Jost, B., Spross, C., Grehn, H., & Gerber, C. (2013). Locking plate fixation of fractures of the proximal humerus: analysis of complications, revision strategies and outcome. Journal of Shoulder and Elbow Surgery, 22(4), 542–549. https://doi.org/10.1016/j.jse.2012.06.008

[26] Neer, C. S. (1963). PROSTHETIC REPLACEMENT OF THE HUMERAL HEAD: INDICATIONS AND OPERATIVE TECHNIQUE. The Surgical Clinics of North America, 43, 1581–1597. https: // doi. org/ 10.1016/s0039-6109(16)37147-x

[27] Zhang, X., Zhang, Y., Guo, T., Liu, L., & Cheng, W. (2021). Humeral Head Replacement in the Treatment of Comminuted Proximal Humeral Fracture. Orthopaedic Surgery, 13(1), 28–34. https://doi.org/10.1111/os.12732

[28] Schultz, B. J., Lowe, D. T., Egol, K. A., & Zuckerman, J. D. (2021). Shoulder Hemiarthroplasty for Proximal Humerus Fracture. Journal of Orthopaedic Trauma, 35(Suppl 2), S3–S4. https: // doi. org/ 10. 1097/BOT.0000000000002158

[29] Aaron, D., Parsons, B. O., Sirveaux, F., & Flatow, E. L. (2013). Proximal humeral fractures: prosthetic replacement. Instructional Course Lectures, 62, 155–162.

[30] Grassi, F. A., Alberio, R., Ratti, C., Surace, M. F., Piazza, P., Messinese, P., … Murena, L. (2020). Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont. Orthopedic Reviews, 12(Suppl 1), 8659. https://doi.org/10.4081/or.2020.8659

[31] Kozak, T., Bauer, S., Walch, G., Al-Karawi, S., & Blakeney, W. (2021). An update on reverse total shoulder arthroplasty: current indications, new designs, same old problems. EFORT open reviews, 6(3), 189–201. https://doi.org/10.1302/2058-5241.6.200085

[32] Fraser, A. N., Bjørdal, J., Wagle, T. M., Karlberg, A. C., Lien, O. A., Eilertsen, L., … Fjalestad, T. (2020). Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly: A Multicenter Randomized Controlled Trial. The Journal of Bone and Joint Surgery. American Volume, 102(6), 477–485. https://doi.org/10.2106/JBJS.19.01071

[33] Yahuaca, B. I., Simon, P., Christmas, K. N., Patel, S., Gorman, R. A., Mighell, M. A., & Frankle, M. A. (2020). Acute surgical management of proximal humerus fractures: ORIF vs. hemiarthroplasty vs. reverse shoulder arthroplasty. Journal of Shoulder and Elbow Surgery, 29(7S), S32–S40. https: // doi. org/ 10.1016/j.jse.2019.10.012

[34] Chae, J., Siljander, M., & Wiater, J. M. (2018). Instability in Reverse Total Shoulder Arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons, 26(17), 587–596. https: // doi. org/ 10. 5435/ JAAOS-D-16-00408