Nonoperative Treatment of Proximal Humerus Fractures

Proximal humerus fractures are common but debilitating injuries, which result in significant dysfunction for the patient and both diagnostic and treatment challenges for the physician. Knowledge of the complex bone and soft tissue anatomy of the shoulder is paramount in successful treatment of proximal humerus fractures. Proximal humerus fractures account for 5 % of all fractures, and they are third in frequency among the most common types of fractures [1–3]. In general, there is a unimodal distribution of these injuries. The vast majority are low energy fractures occurring in elderly individuals with more high energy and complex fractures in younger patients happening less frequently [4–6]. Incidence does tend to increase with age, and elderly individuals who sustain these fractures are more commonly female, over the age of 60, and have a history of osteoporosis [3, 7, 8]. Nearly 3⁄4 of proximal humerus fractures occur in patients older than 60 who have fallen from a standing height [2, 4]. The majority of proximal humerus fractures in this demographic are relatively non-displaced and can be treated successfully without surgery [9]. Risk factors for proximal humerus fractures include elderly patients, low bone mineral density, impaired vision and balance, no history of hormone replacement therapy, smoking, >3 chronic illnesses, and previous fragility fracture [4, 10, 11]. Younger patients sustain proximal humerus fractures as a result of motor vehicle accidents, seizures, electric shock, and fall from greater than a standing height [12]. These injuries tend to involve more significant bony and soft tissue disruption and accordingly are treated with surgical intervention [2, 11]. Regardless of the age of the patient or mechanism of injury, restoration of pain-free functional range of motion remains the primary treatment goal of these injuries [13]. Some difficulty in clinical assessment and classification of proximal humerus fractures has resulted in a lack of standardization over treatment protocols [9]. Numerous factors contribute to post injury functional outcomes; therefore, a large debate exists over appropriate treatment [14, 15]. In addition, a lack of high-level evidence with regards to treatment and outcomes after proximal humerus fractures despite the relative frequency of the injury has resulted in a lack of consensus based protocol driven treatment [14, 16, 17]. Recent advances in technology have provided new treatment options without substantiation over historical options [9]. There currently exists several dilemmas such as when to perform surgery and which surgery is the most appropriate method of treatment, which have yet to be definitively determined. High-level outcome based studies are currently being performed to help answer questions but uncertainty still remains [18]. Regardless of T. Twiss (*) Department of Orthopaedic Surgery, Freeman Health System, 3105 McClelland Boulevard, Joplin, MO 64804-1640, USA e-mail: [email protected]