Decision making in displaced fractures of the proximal humerus: fracture or surgeon based?

The aim of this study was to analyse the factors that influence surgeon decision-making in the treatment of proximal humerus fractures that might be considered for arthroplasty or open reduction and internal fixation.

A total of 217 surgeons evaluated radiographs and clinical vignettes of ten patients with fractures of the proximal humerus. In addition to radiographs, we provided patient age, sex, trauma mechanism, activity level (sedentary-vigorously active), and physical status (normal healthy-moribund). Observers were asked to: (1) choose open reduction and internal fixation or hemiarthroplasty (closed question, one option) and (2) to briefly describe the factors that led to their decision (open-ended question). We assessed interobserver reliability using the Fleiss generalized kappa and analysed factors that influenced decision-making according to treatment choice.

Internal fixation was the preferred treatment for the majority of fractures. The overall multirater agreement was fair (κ = 0.30), with a 75 % proportion of agreement. When asked to describe the factors that influenced decision-making, surgeons favouring internal fixation described patient-based factors in 52 %, fracture morphology in 51 %, surgeon factors in 42 %, and bone quality in 11 %. In contrast, fracture morphology was the most common factor (67 %) described by surgeons recommending replacement. Patient age, sex, activity level, physical status and the presence of angular displacement were associated with a recommendation for internal fixation.

There is substantial variation in recommendations for internal fixation vs. arthroplasty for fractures of the proximal humerus that arises in large part from patient and surgeon factors.