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

Outcome Measures

All follow-up radiographs were reviewed to assess for nonunion (defined as lack of healing by 12 months), malunion, and humeral head avascular necrosis. Operative patients’ follow-up radiographs were reviewed to determine frequency of screw perforation and/or loss of fixation, and their medical records were reviewed to assess for other complications, including infection, neurovascular injury, and return to operating room for any other reason. Nonoperative patients’ medical records were reviewed to determine if surgical treatment was subsequently required.

To determine clinical outcomes, we asked patients to return for clinical evaluation, which included use of 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.

Statistical Analysis

Chi-square test was used to compare the characteristics of patients who returned for clinical evaluation, Fisher exact test was used for tables with multiple cells less than 5, Student t test was used to compare clinical outcomes between operative and nonoperative groups. P < .05 was considered statistically significant, and all tests were 2-sided. Statistical analysis was performed using SAS Version 9 (SAS, Cary, North Carolina).

Results

Of the 207 patients who met the inclusion and exclusion criteria, 61 were treated operatively (locked plate open reduction and internal fixation) and 146 nonoperatively. Mean age was 76.9 years. One hundred fifty-five (74.9%) of the patients were female. Medical comorbidities were common (average Charlson score, 6.6). Most patients (185/207; 89.4%) were injured in a fall. There were 129 two-part fractures, 63 three-part fractures, and 9 four-part fractures (Table 1).

Operative patients’ complications included screw perforation (35.6%; 21 of the 59 cases with radiographs) and loss of fixation (17.5%; 10/57). Four (6.6%) of the 61 operative patients developed an infection. In sum, 8 (13.1%) of operative patients required another surgery (Table 2).

Among nonoperative patients, malunion at time of healing was common (86.9%; 113 of the 130 cases with radiographs). Eighty-six malunions (66.2% of the 130 cases) healed in varus, 25 (19.2%) in valgus, and 2 (1.5%) with translation alone. Uncommon among nonoperative patients were nonunion (1.4%; 2/143) and avascular necrosis (2.2%; 3/136). Two (1.4%) of the 146 nonoperative patients subsequently underwent surgery for malunion (Table 2).

Forty-seven patients accepted our invitation to return for clinical evaluation. Mean follow-up was 3.3 years (range, 1.4-6.4 years). Of these patients, 25 had been treated operatively (Figures 1A, 1B) and 22 nonoperatively (Figures 2A, 2B). Complication rates for patients who returned for clinical evaluation were similar to those for the entire cohort, with the exception of secondary surgical procedures (Table 3). There were no significant differences between operative and nonoperative patients in the group that returned for clinical evaluation (Table 4).

Regarding clinical outcome scores, there were no significant differences between operative and nonoperative patients (Table 5). In particular, there were no differences in SMFA Functional index (18.4 vs 19.7; P = .78), SMFA Bothersome index (20.8 vs 23.6; P = .61), DASH scores (26.5 vs 25.1; P = .79), Constant scores (58.0 vs 59.7; P = .74), or PROMIS Physical Function Computer Adaptive Test scores (43.9 vs 45.0; P = .70).

Discussion

In this observational study of displaced proximal humerus fractures in an elderly population, operative treatment (vs nonoperative treatment) had a lower malunion rate but was associated with more complications, including screw perforation, loss of fixation, and unplanned return to the operating room. Among patients who returned for clinical evaluation at a mean follow-up of 3.3 years, there were no significant operative–nonoperative differences.

Our results are similar to those recently reported by other investigators. In Norway, Fjalestad and colleagues²³ conducted a randomized controlled trial of locked plating versus nonoperative treatment in 50 patients over age 60 years with a 3- or 4-part proximal humerus fracture. At 12 months, there was no significant difference between the operative and nonoperative groups’ Constant scores.

Similarly, Olerud and colleagues²⁵ in Sweden conducted a trial in which 60 patients over age 55 years with a 3-part fracture of the proximal humerus were randomized to locked plating or nonoperative treatment. At 2 years, there were no significant operative–nonoperative differences on several outcome measures: Constant scores, DASH scores, EQ-5D (EuroQol) scores. Thirty percent of operative patients required a secondary procedure to treat infection, nonunion, avascular necrosis, screw perforation, stiffness, or impingement.

Our study benefited from having a large sample size (207) of consecutive patients with displaced proximal humerus fractures, but it also had its limitations. In this retrospective study, treatment assignment was not randomized. We were also limited by the large number of patients who did not return for clinical evaluation (160/207; 77.3%), including 52 (25.1%) found to be deceased, 27 (13.0%) who could not be reached, and 81 (39.1%) who declined our request (in many cases because of difficulties traveling to the trauma center). These challenges are inherent to research in the elderly population. As a result, the number of patients who returned for clinical evaluation (47/207; 22.7%) was lower than expected, which may have underpowered the study. In addition, treatment protocols were not standardized; patients were managed by a number of different surgeons. On the other hand, this wide variety of surgeons, including orthopedic trauma and upper extremity specialists, may increase the generalizability of our results.