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Project Title: Current concepts - management of proximal humeral fractures in elderly. A narrative, literature review . Initially I would like to have Project Summary (1000 words) within 2 days

Running head: PROJECT PROPOSAL
Current concepts- management of proximal humeral fractures in elderly. (A narrative,
literature review)
Name of the Student
Name of the University
Author Note

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Introduction and Existing knowledge
A bone fracture refers to the medical situation that is characterised by a complete or
partial break in the bone continuity. In countless cases, the bones generally get divided into
numerous segments and these may be the direct consequence of stress, high force, or trauma
injury due to particular clinical conditions like osteoporosis, bone cancer, osteogenesis
imperfect and osteopenia (1). Proximal humerus fractures are characterised by a break in the
upper region of the bone and it is commonly associated with auxillary artery or nerve injury.
While diagnosing older adults with proximal humerus fracture, the Neer classification is
generally employed owing to the fact that it categorises the fractures based on the number of
fragments and the occurrence of displacement (2). In addition, elderly patients are also
diagnosed with the AO/OTA classification system that classifies fractures based on whether it
is bifocal or unifocal, and whether or not it passes through articular surfaces (3).
Fractures of the proximal humerus from low energy trauma are common among
elderly patients. 70% of inpatient fractures are potentially osteoporotic in a study by Court-
Brown et al (4) and more than 75% of those are older patients. Despite the availability of a
range of treatment options, the management of complex proximal humeral fractures in elderly
remains demanding (5). Non-operative management has good clinical results in minimally
displaced, stable fractures (5). In unstable fractures, surgical treatment strategies like primary
locking plate fixation, locking nail, hemiarthroplasty, distally inserted intramedullary K-
wires, and reverse shoulder arthroplasty (RSA) have been utilized variably. If the reduction
of fracture fragments is inadequate with compromised blood supply to the head fragments,
RSA need to be considered.
There is growing evidence for the fact that larger tuberosity fractures having around .5
mm displacement generally get benefited by surgical fixations that decreases the hazard of

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subacromial impingement. Moreover, smaller tuberosity fracture characterised by internal
rotation impingement have also been found to gain benefit from surgical interventions, upon
the failure of nonsurgical management. When compared to different segments of the
proximal humerus, there are no soft-tissue attachments in the anatomic neck, besides a weak
blood supply, which in turn increases the risk of osteonecrosis (6).
The general incidence of proximal humeral fractures is progressively increasing,
nonetheless there is little evidence for the mortality rates, following these fractures amongst
elderly patients. With an increase in life expectancy, the understanding of mortality predictors
and rates will become increasingly more significant. Findings from a study that assessed 205
older adults with proximal humerus fractures found that 81% were subjected to non-operative
treatment and the 30-day mortality rate was an estimated 2% (7). Mortality increased by 12%
with each added year of patient oldness and there were no differences between males and
females.
Recently, reconstructive surgery with locked plating has shown good results in
younger individuals, with stronger bones providing a stable fixation conducive for fracture
healing. The same is not true in older, weak, osteoporotic bones. Locking plate fixation has
been associated with non-union, screw loosening, cut outs, hardware failure, intra-articular
screw penetration, osteonecrosis, arthrosis, osteopenia, infection, nerve injury, malunion,
rotator cuff impairment, and impingement. These complications potentially lead to delayed
functional recovery in elderly patients and revision operation rates are up to 13.8% (8). On
conducting an observational comparative study for 147 isolated proximal humeral fracture
older adult patients, it had been found that 53 historical and 83 prospective patients had been
subjected to nonoperative treatment. The prospective patients demonstrated 1.6 times
increased likelihood of losing some amount of self-dependence and a decrease (12.2-5.7%)

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was also observed in the risk of local adverse events, though there were no differences in
quality of life and mean shoulder function between the aforementioned groups (9).
A meta-analysis of randomised controlled trials was based on the evidence that
proximal humerus fractures display high incidence among older adult patients, particular 3-
or 4- part fractures. The researchers recognised the four main modalities of treatment such as,
nonoperation, hemiarthroplasty (HA), open reduction and internal fixation (ORIF), and
reverse shoulder arthroplasty (RSA). On analysing the findings from seven randomised
controlled trials included in the research, it was found that RSA has been identified as a
beneficial choice of treatment for the management of 3-or 4-part fracture amongst elderly
patients and this treatment has been allied with positive clinical outcomes. In addition, the
impact of this treatment on decreased rates of reoperation has established its efficacy (10).
Nonetheless, the researchers stated that ORIF treatment had poor health outcomes for
patients. With the aim of determining the postsurgical outcome of ORIF on patients aged
more than 70 years, researchers conducted another study amid 90 proximal humerus fracture
patients and subjected them to telephone-based assessments. Fair outcomes were observed
during the first and second interviews with DASH 12.5 (0–64.2) and 18.3 (0–66.7), CS 91
(range 40–100) and 65.5 (23–86), and OSS 58 (33–60) and 55 (25–60) points. Additionally,
the test-retest correlations were r = 0.77, r = 0.67, and r = 0.71 for DASH, CS, and OSS (11).
Thus, the elderly patients demonstrated good subjective health outcomes following the
surgical treatment, thereby establishing ORIF as a good treatment modality.
Moreover, recent evidence has also elucidated the fact that reverse shoulder
arthroplasty (RSA) is a more advantaged treatment modality for the effective management of
proximal humerus fracture amid the elderly patients, when compared to hemiarthroplasty
(HA). The meta-analysis compared eight studies that included 160 patients with RSA and 421
with HA. On following the patients for a year, it was observed that there was a significant

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correlation of RSA with less rate of complications, increased tuberosities, greater American
Shoulder and Elbow Surgeons (ASES) score, and enhanced active forward elevation, thus
highlighting its significance in treatment of the elderly patients (12).
Hypothesis / aim of study
A humerus fracture refers to break in the upper arm humerus bone and the most
common symptoms of this ailment are swelling, pain and bruising. The affected patient often
demonstrated a decreased capability to move the arm and associated complications comprise
of injury to nerves to arteries, concomitant with compartment syndrome (13). Physical trauma
like falls are the primary reason for humerus fracture. This paper aims to understand and
provide a birds view of the critical role of fracture patterns (i.e.,displaced fracture with varus
deformity, medial proximal comminution, angulated humeral head, displaced humeral
tuberosities) and classifications, patient factors including bone quality (assessed by screening
for local BMD and the patients' biological age), implant design, surgeon factors and others
which have a bearing on the outcomes of open reduction and internal fixation in the elderly
patients (14).
Further, this article explores the newer operative strategies like double-plate fixation,
bone augmentation which are extending the indications for open surgery. In this group of
patients, reverse shoulder arthroplasty (RSA) can be considered after failure of first-line
treatment. Importance of anatomical reduction of medial cortices and other intraoperative
techniques are elaborated in detail. Subsequently constituted concepts on how to improve or
mitigate adverse factors, understand when to utilize alternative surgical or non-surgical
means to achieve satisfactory results.

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Methodology
The research adopted the methodology of a narrative or traditional literature review
that refers to a critical, comprehensive and objective assessment of contemporary evidences
on the phenomenon that is being investigated. Use of this approach helped in establishment
of a theoretical framework and also highlighted the focus of the research (15). This narrative,
literature review was synthesised with Embase, MEDLINE and Google Scholar databases.
Key words and search terms represent the principal concepts of a particular research
phenomenon and absence of appropriate keywords often increases the difficulty of extracting
pertinent articles. Some keywords that were used for extracting the articles were namely,
“proximal humerus fracture”, “management”, “classification”, and “locking plate fixation”.
These search terms were combined using boolean operators ‘AND’ and ‘OR’ that helped in
broadening and/or narrowing the search hits. Article references were also searched where
necessary to increase the yield. Peer-reviewed articles published in English language, on or
after 2006, on the topic of proximal humerus fracture in elderly were considered eligible for
the study (16).
Achievability
The above mentioned databases are readily available for literature search and
narrative review. Large numbers of overlapping reviews related to interventions to improve
clinical outcomes and patient satisfaction in elderly patients with proximal humerus fractures
have been identified, which serves well for this narrative review. While Embase contains
more than 60.000 Emtree-terms, MEDLINE contains not less than 26.000 MeSH-terms on
biomedical literature, thus establishing their benefit in extraction of scholarly evidences (17).

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Novelty
This review signposts to clinicians and supports clinical decisions by providing a
comprehensive working concepts at one place on the management of proximal humeral
fractures in elderly. This is one of the first narrative reviews that has been done to explore the
efficacy of different interventions that are commonly implemented for the management of
proximal humerus fracture in elderly. Inclusion of recently published articles also increased
the reliability of the findings.

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References
1. Low SA, Low PS, Galliford C, Kopecek J, Yang J, inventors; University of Utah
Research Foundation (UURF), Purdue Research Foundation, assignee. Bone fracture
repair by targeting of agents that promote bone healing. United States patent
application US 16/264,364. 2019 May 30.
2. Sumrein BO, Mattila VM, Lepola V, Laitinen MK, Launonen AP, Paloneva J,
Jonsson K, Wolf O, Ström P, Berg H, Felländer-Tsai L. Intraobserver and
interobserver reliability of recategorized Neer classification in differentiating 2-part
surgical neck fractures from multi-fragmented proximal humeral fractures in 116
patients. Journal of shoulder and elbow surgery. 2018 Oct 1;27(10):1756-61.
3. Pace G, Zale C, Chan J, Armstrong AD, Boateng HA, Kim HM. Clinical Results of
Conservative Treatment of Severe Proximal Humerus Fractures Requiring Surgical
Treatment in Old Patients. Techniques in Shoulder & Elbow Surgery. 2019 Sep
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4. Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006
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5. Howard L, Berdusco R, Momoli F, Pollock J, Liew A, Papp S, Lalonde KA, Gofton
W, Ruggiero S, Lapner P. Open reduction internal fixation vs non-operative
management in proximal humerus fractures: a prospective, randomized controlled
trial protocol. BMC musculoskeletal disorders. 2018 Dec;19(1):1-0.
6. Kancherla VK, Singh A, Anakwenze OA. Management of acute proximal humeral
fractures. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2017
Jan 1;25(1):42-52.

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7. Hofmann KJ, Prokuski VC, Allar BG, Tybor D, Ryan SP. Predictors of mortality after
isolated proximal humeral fractures in elderly patients. Current orthopaedic practice.
2018 Jul 1;29(4):322-5.
8. Kavuri V, Bowden B, Kumar N, Cerynik D. Complications associated with locking
plate of proximal humerus fractures. Indian journal of orthopaedics. 2018
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9. Rikli D, Feissli S, Müller AM, Steinitz A, Suhm N, Jakob M, Audigé L. High rate of
maintaining self-dependence and low complication rate with a new treatment
algorithm for proximal humeral fractures in the elderly population. Journal of
Shoulder and Elbow Surgery. 2020 Feb 10.
10. Du S, Ye J, Chen H, Li X, Lin Q. Interventions for Treating 3-or 4-part proximal
humeral fractures in elderly patient: A network meta-analysis of randomized
controlled trials. International Journal of Surgery. 2017 Dec 1;48:240-6.
11. Ziegler P, Stierand K, Bahrs C, Ahrend MD. Mid-term results after proximal humeral
fractures following angular stable plate fixation in elderly patients—which scores can
be evaluated by a telephone-based assessment?. Journal of Orthopaedic Surgery and
Research. 2020 Dec;15(1):1-9.
12. Wang J, Zhu Y, Zhang F, Chen W, Tian Y, Zhang Y. Meta-analysis suggests that
reverse shoulder arthroplasty in proximal humerus fractures is a better option than
hemiarthroplasty in the elderly. International orthopaedics. 2016 Mar 1;40(3):531-9.
13. Makhni MC, Makhni EC, Swart EF, Day CS. Distal Humerus Fractures. InOrthopedic
Emergencies 2017 (pp. 145-149). Springer, Cham.
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Predicting failure after surgical fixation of proximal humerus fractures. Injury. 2011
Nov 1;42(11):1283-8.

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15. Pautasso M. The Structure and Conduct of a Narrative Literature Review. A Guide to
the Scientific Career: Virtues, Communication, Research and Academic Writing.
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of searches for 120 systematic reviews in Embase, MEDLINE, and Google Scholar: a
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