Is arthroplasty necessary for three and four-part proximal humerus fractures in elderly?

Management of proximal humerus fractures in elderly



Humerus fractures, Elderly patients, Revers shoulder arthroplasty


Background/Aim: Proximal humerus fractures are common in elderly patients. Treatment of three and four-part fractures is especially controversial in these patients. In recent years, surgical options have been widely used, especially among shoulder surgeons. The purpose of this study was to compare clinical results of conservative and arthroplasty methods.

Methods: Between 2016 and 2020, 30 patients who were treated for Neer type 3 and type 4 proximal humeral fractures were included in the study. Patient data were evaluated retrospectively and then divided into three groups. Group 1 was treated conservatively, group 2 underwent hemiarthroplasty; and group 3 underwent reverse total shoulder arthroplasty. CONSTANT and visual analog scale (VAS) scores and radiological results at six months were evaluated retrospectively from patient records. At the last control they have been evaluated with CONSTANT, University of California/Los Angeles. (UCLA), and VAS scores.

Results: Twenty-three (76.7%) of the patients included in the study were females. The mean age was 73.5 (5.7) years. The mean follow-up period was 33 (2.5) months. The mean follow-up periods in groups 1–3 were 33.3 (2.9), 32.8 (2), and 32.2 (2.9) months, respectively. When the CONSTANT scores of the patients were compared at the sixth month, they were observed to be better in the reverse total shoulder arthroplasty group (P = 0.001). Final control CONSTANT scores in the hemiarthroplasty group were lower than in the other groups (P = 0.001) and similar in the reverse shoulder prosthesis and conservative treatment group (P = 1). When the UCLA scores of all groups were compared, the mean UCLA scores were found to be significantly higher in groups 1 and 3 compared to group 2 (P = 0.001). When the VAS scores of the patients were compared, a significant difference between all groups was detected (P < 0.05). The highest VAS scores were observed in group 2, the second highest in group 1, and the lowest in group 3.

Conclusion: For treatment of proximal humerus fractures in the elderly, patients should be evaluated according to activity levels and expectations, and surgical treatment should be suggested rather than ordered.


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FleiCourt-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691-7. doi: 10.1016/j.injury.2006.04.130 DOI:

Barrett JA, Baron JA, Karagas MR, Beach ML. Fracture risk in the U.S. Medicare population. J Clin Epidemiol. 1999;52(3):243-9. doi: 10.1016/S0895-4356(98)00167-X DOI:

Bahrs C, Bauer M, Blumenstock G, Eingartner C, Bahrs SD, Tepass A, et al. The complexity of proximal humeral fractures is age and gender specific. J Orthop Sci 2013;18(3):465-70. doi: 10.1007/s00776-013-0361-x DOI:

Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006;(442):87-92. doi: 10.1097/01.blo.0000194672.79634.78 DOI:

Launonen AP, Lepola V, Saranko A, Flinkkilä T, Laitinen M, Mattila VM. Epidemiology of proximal humerus fractures. Arch Osteoporos. 2015;10(1):1-5. doi: 10.1007/s11657-015-0209-4 DOI:

Neer CS 2nd. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Jt Surg Am. 1970;52(6):1077-89. DOI:

Court-Brown CM, McQueen MM, Garg A. The epidemiology and outcome of proximal humeral fractures. J Orthop Trauma. 2000;14(2):118. doi: 10.1097/00005131-200002000-00013 DOI:

Rabi S, Evaniew N, Sprague SA, Bhandari M, Slobogean GP. Operative vs non-operative management of displaced proximal humeral fractures in the elderly: a systematic review and meta-analysis of randomized controlled trials. World J Orthop. 2015;6(10):838-46. doi: 10.5312/wjo.v6.i10.838 DOI:

Fraser AN, Bjørdal J, Wagle TM, Karlberg AC, Lien OA, Eilertsen L, et al. Reverse shoulder arthroplasty is superior to plate fixation at 2 years for displaced proximal humeral fractures in the elderly: a multicenter randomized controlled trial.J Bone Jt Surg – Am. Vol 2020;102(6):477-85. doi: 10.2106/JBJS.19.01071 DOI:

Cai M, Tao K, Yang C, Li S. Internal fixation versus shoulder hemiarthroplasty for displaced 4-part proximal humeral fractures in elderly patients. Orthopedics. 2012;35(9):1340-6. doi: 10.3928/01477447-20120822-19 DOI:

Fjalestad T, Hole M, Hovden IAH, Blücher J, Strømsøe K. Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma. 2012;26(2):98-106. doi: 10.1097/BOT.0b013e31821c2e15 DOI:

Huttunen TT, Launonen AP, Pihlajamäki H, Kannus P, Mattila VM. Trends in the surgical treatment of proximal humeral fractures - a nationwide 23-year study in Finland. BMC Musculoskelet Disord. 2012;13. doi: 10.1186/1471-2474-13-261 DOI:

Bell JE, Leung BC, Spratt KF, Koval KJ, Weinstein JD, Goodman DC, et al. Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly. J Bone Jt Surg - Ser A. 2011;93(2):121-31. doi: 10.2106/JBJS.I.01505 DOI:

Constant CR,Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987;(214):160-4. DOI:

Amstutz HC, Sew Hoy AL, Clarke IC.UCLA anatomic total shoulder arthroplasty. Clin Orthop Relat Res. 1981;(155):7-20. DOI:

Harvey N, Dennison E, Cooper C. Epidemiology of osteoporotic fractures. Prim Metab Bone Dis Disord Miner Metab Seventh Ed. Published online 2019;197-203. doi: 10.1002/9780470623992.ch38 DOI:

Mighell MA, Kolm GP, Collinge CA, Frankle MA. Outcomes of hemiarthroplasty for fractures of the proximal humerus. J Shoulder Elb Surg. 2003;12(6):569-77. doi: 10.1016/S1058-2746(03)00213-1 DOI:

Handoll HH, Keding A, Corbacho B, Brealey SD, Hewitt C, Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Jt J. 2017;99B(3):383-92. doi: 10.1302/0301-620X.99B3.BJJ-2016-1028 DOI:

Reitman RD, Kerzhner E. Reverse shoulder arthoplasty as treatment for comminuted proximal humeral fractures in elderly patients. Am J Orthop. (Belle Mead NJ) 2011;40(9):458-61.

Çelik C, Gümüştaş SA, Çeçen GS, Bulut G, Bekler Hİ. Proksimal humerus çok parçalı kırıklarında plak osteosentez ve hemiartroplasti sonuçlarının orta dönem takip ile değerlendirilmesi. Ulus Travma ve Acil Cerrahi Derg. 2016;22(4):379-85. doi: 10.5505/tjtes.2016.90402 DOI:

Brorson S, Rasmussen JV, Frich LH, Olsen BS, Hróbjartsson A. Benefits and harms of locking plate osteosynthesis in intraarticular (OTA Type C) fractures of the proximal humerus: a systematic review. Injury. 2012;43(7):999-1005. doi: 10.1016/j.injury.2011.08.025 DOI:

Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg. 2012;20(1):17-27. doi: 10.5435/JAAOS-20-01-017 DOI:

Babhulkar A, Shyam AK, Sancheti PK, Shah K, Rocha S. Hemiarthroplasty for comminuted proximal humeral fractures. J Orthop Surg. (Hong Kong) 2011;19(2):194-9. doi: 10.1177/230949901101900213 DOI:

Kralinger F, Schwaiger R, Wambacher M, Farrell E, Menth-Chiari W, Lajtai G, et al. Outcome after primary hemiarthroplasty for fracture of the head of the humerus. J Bone Jt Surg - Ser B. 2004;86(2):217-9. doi: 10.1302/0301-620X.86B2.14553 DOI:

Plausinis D, Kwon YW, Zuckerman JD. Complications of humeral head replacement for proximal humeral fractures. Instr Course Lect 2005;54:371-80. DOI:

Mata-Fink A, Meinke M, Jones C, Kim B, Bell JE. Reverse shoulder arthroplasty for treatment of proximal humeral fractures in older adults: a systematic review. J Shoulder Elb Surg. 2013;22(12):1737-48. doi: 10.1016/j.jse.2013.08.021 DOI:

Gallinet D, Clappaz P, Garbuio P, Tropet Y, Obert L. Three or four parts complex proximal humerus fractures: hemiarthroplasty versus reverse prosthesis: acomparative study of 40 cases. Orthop Traumatol Surg Res. 2009;95(1):48-55. doi: 10.1016/j.otsr.2008.09.002 DOI:

Boyle MJ, Youn SM, Frampton CMA, Ball CM. Functional outcomes of reverse shoulder arthroplasty compared with hemiarthroplasty for acute proximal humeral fractures. J Shoulder Elb Surg. 2013;22(1):32-7. doi: 10.1016/j.jse.2012.03.006 DOI:

Garrigues GE, Johnston PS, Pepe MD, Tucker BS, Ramsey ML, Austin LS. Hemiarthroplasty versus reverse total shoulder arthroplasty for acute proximal humerus fractures in elderly patients. Orthopedics. 2012;35(5):703-8. doi: 10.3928/01477447-20120426-25 DOI:

Lopiz Y, Alcobía-Díaz B, Galán-Olleros M, García-Fernández C, Picado AL, Marco F. Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial. J Shoulder Elb Surg. 2019;28(12):2259-71. doi: 10.1016/j.jse.2019.06.024. DOI:






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How to Cite

Demirtas Y, Kaya O, Emet A. Is arthroplasty necessary for three and four-part proximal humerus fractures in elderly? Management of proximal humerus fractures in elderly. J Surg Med [Internet]. 2022 Dec. 17 [cited 2024 May 25];6(12):971-6. Available from: