Original Research

Comparison of Locked Plate Fixation and Nonoperative Management for Displaced Proximal Humerus Fractures in Elderly Patients

Am J Orthop. 2015 April;44(4):E106-E112

Use of locked plate fixation for proximal humerus fractures in elderly patients has increased markedly in recent years. We conducted a study to compare outcomes of operative (locked plate fixation) and nonoperative management of these fractures.

From our database, we identified 207 displaced proximal humerus fractures that met all inclusion and exclusion criteria. For patients who accepted our invitation to return for evaluation, clinical outcome was assessed using several questionnaires: Constant; DASH (Disabilities of the Arm, Shoulder, and Hand); SMFA (Short Musculoskeletal Functional Assessment); and Patient Reported Outcomes Measurement Information System (PROMIS) Physical Function Computer Adaptive Test.

Of the 207 patients, 61 were managed operatively and 146 nonoperatively. Operative patients had lower rates of malunion but higher rates of complications, which included screw perforation, loss of fixation, infection, and secondary surgical procedures. Forty-seven patients (a mix of operative and nonoperative) accepted our invitation to return for clinical evaluation at a mean follow-up of 3.3 years. The 2 groups’ clinical outcomes were similar.

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References

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Proximal humerus fractures are increasingly common in the elderly population,¹ accounting for 10% of all these patients’ fractures.² The injuries result in substantial morbidity and are associated with significantly higher mortality rates for up to 4 years.³ With the recent advent of anatomical locking plates,^4,5 operative fixation of proximal humerus fractures in elderly patients has become more common.⁶ Although early clinical studies reported favorable outcomes, high complication rates have also been documented.^7-22

Investigators have recently compared outcomes of locked plate fixation and nonoperative treatment of proximal humerus fractures in elderly patients.^23-26 Fjalestad and colleagues²³ conducted a randomized clinical trial of locked plating versus nonoperative treatment of 3- and 4-part fractures in 50 patients age 60 years or older and found no significant differences in Constant score or patient self-assessment at 1 year. Similarly, Olerud and colleagues²⁵ conducted a randomized clinical trial of locked plating versus nonoperative treatment of 3-part fractures in 60 patients age 55 years or older. Although outcomes were better in the operative group, differences did not reach statistical significance, and the operative group’s reoperation rate was 30%.

Given this lack of conclusive outcomes data, optimal treatment of displaced proximal humerus fractures in elderly patients remains unknown. We conducted a study to compare outcomes of operative (locked plate fixation) and nonoperative management of displaced proximal humerus fractures in patients older than 60 years. Our hypothesis was that the clinical outcomes of these 2 treatment methods would be similar.

Materials and Methods

Selection Criteria

Our research protocol was approved by the Partners Human Research Committee. To determine the operative cohort, we queried our trauma database to identify all patients over age 60 years who sustained a displaced proximal humerus fracture between 2006 and 2009 and underwent surgical fixation. Cases were excluded if they presented more than 4 weeks after injury; if they represented a refracture, nonunion, or pathologic fracture; if the fracture was an isolated greater or lesser tuberosity fracture; if there was an associated neurovascular injury; if the injury radiographs were absent or inadequate; or if a fixation method other than locked plating was used. Applying these inclusion and exclusion criteria yielded 61 patients over age 60 years who underwent locked plating of a displaced proximal humerus fracture between 2006 and 2009.

The comparison group consisted of all patients who presented to our institutions with a displaced proximal humerus fracture during the same time period but instead had nonoperative treatment. To identify this group, we performed another database search for all patients over age 60 years who sustained a proximal humerus fracture between 2006 and 2009 (n = 452). Twenty-two patients were excluded for inadequate radiographs. To determine which of the other 430 patients had displaced fractures, Dr. Okike and Dr. Lee (orthopedic surgeons) reviewed injury radiographs and any computed tomography scans in duplicate and resolved discrepancies by consensus. Neer’s criteria were used to define displacement: Fractures displaced 1 cm or more and/or with angulation of 45° or more were displaced, and fractures not meeting these criteria were nondisplaced. In the assessment of displacement, interobserver reliability was substantial (overall agreement, 87.0% [374/430]; κ = 0.68). With use of these methods, 311 fractures were classified displaced and 119 nondisplaced. As with the operative group, cases were excluded if they presented more than 4 weeks after injury; if they represented a refracture, nonunion, or pathologic fracture; if the fracture was an isolated greater or lesser tuberosity fracture; if there was an associated neurovascular injury; if injury radiographs were absent or inadequate; or if the treatment method was operative or unknown. Applying these inclusion and exclusion criteria yielded 146 patients over age 60 years who had nonoperative treatment of a displaced proximal humerus fracture between 2006 and 2009.

Patient Characteristics

Dr. Makanji retrospectively reviewed the charts of all 207 patients (61 operative, 146 nonoperative). Information was recorded on patient age and sex, mechanism of injury, number of days between injury and presentation, any associated orthopedic injuries, side of injury, and treatment facility (trauma center A, trauma center B). In addition, a Charlson score was assigned to each patient on the basis of medical comorbidities.²⁷

Radiographs and any computed tomography scans were also assessed by Dr. Okike and Dr. Lee. Each fracture was assigned a Neer classification (2-part, 3-part, 4-part) and an AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) classification (A, B, C).²⁸ Displacement was categorized as varus angulation (neck–shaft angle, <130°), valgus angulation (neck–shaft angle, >140°), neutral angulation (neck–shaft angle, 135° ± 5°), or translation alone. In addition, all fractures were assessed for dislocation and medial comminution.²⁹