Treatment of Proximal Humeral Fractures: A Critical Analysis Review

There is substantial variability in the treatment of proximal humeral fractures because of classification systems with poor interobserver reliability, rapid advances in technology (e.g., anatomically designed locking plates and reverse shoulder arthroplasty), and limited Level-I and II evidence for best treatments based on fracture patterns and physiological age. Almost three-quarters of proximal humeral fractures can be treated nonoperatively with good functional results as nearly 50% are nondisplaced or Neer one-part fractures. Another quarter occur in infirm patients or are characterized by fracture patterns that reliably heal well with minimal complications. Displaced fractures in physiologically young patients should preferentially be treated with open reduction and internal fixation (ORIF) as functional outcomes are generally good and anatomical restoration can improve the results of subsequent arthroplasty, if needed. Improved results with fixation have been reported in association with the use of bone substitutes, fibular strut allografts, and inferior head-supporting calcar screws to prevent humeral head displacement and screw perforation. A number of recent trials have brought into question the advantage of both ORIF and hemiarthroplasty over nonoperative treatment for patients over the age of sixty years who have three and four-part fractures without dislocations. Reverse shoulder arthroplasty initially showed varied results for the treatment of irreparable fractures in healthy older patients, but recent Level-I and II studies have shown an advantage over hemiarthroplasty. Medium and long-term data are still needed.