A cross-sectional survey comparing management of proximal humerus fractures across a multinational upper limb...

Proximal humerus fractures (PHFs) are the most common traumatic bony injury to the shoulder. There is lack of consensus in the optimal method of management for fractures with varying morphologies/patterns. This study assesses treatment choices for 3- or 4-part PHFs across surgeons from a multinational panel, focusing on operative versus non-operative strategies and whether inter-surgeon agreement exists within and between countries.

A prospective cross-sectional survey was completed by a cohort of consultant/attending-level shoulder surgeons from the United Kingdom, United States, India, and Australia. Treatment decisions for 20 individual cases were assessed with standardization of clinical data and imaging. The case range included patients with a breadth of demographics for age (20-80 years) and varying comorbidities including a comprehensive range of fracture morphologies for 3/4-part Neer PHFs with increasing severity, fragmentation, tuberosity displacement, and head split or dislocations. Statistical analysis was performed using a mixed-effects logistic regression model and Krippendorff's alpha. Statistical significance was set at P < .05.

Seventy-five surgeons worldwide responded to the study. There was surgeon representation from Asia (India, 26/75, 34.7%), Europe (UK, 24/75, 32.0%), North America (US, 18/75, 24.0%), and Oceania (Australia, 7/75, 9.3%). Thirty-nine (39/75, 52%) surgeons had over 10 years of experience in treating PHFs. International agreement was low between surgeons (K-A 0.238) regarding overall decision-making. After adjustment for surgeon country and patient demographics, patient age (<65 vs. ≥ 65 years) was not independently associated with the likelihood of recommending operative management (estimate 0.34, P = .67). There was a wide variation among surgeons, with 51.7% of UK-based, 72.3% of Indian, 57.8% of American, and 69.3% of Australian surgeons preferring operative management across the 20 cases. Likelihood for operative decision-making was more pronounced in Australia (P = .024) and India (P < .001), predominantly private healthcare systems, compared to the United Kingdom. There was no significant difference between the United States and the United Kingdom (P = .89). The commonest operative modality in all countries was open reduction and internal fixation. In all countries, reverse total shoulder arthroplasty was preferred to hemiarthroplasty. Intra-medullary nailing was the least recommended modality in the United Kingdom, while hemiarthroplasty was the least recommended in all others.

This study provides an insight into the international variation among surgeons where healthcare characteristics and patient factors contribute to the decision-making processes involved in the management of PHFs. Further research is required to develop standardized, evidence-based guidelines on the management of PHFs.