gms | German Medical Science

Objectives: The treatment of patients who suffer a proximal humeral fracture (PHF) remains controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after a PHF.

Methods: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 86 identified experts from this group was sought with a series of surveys using the Delphi process. The first three surveys included vignettes with 2-part, 3-part, and 4-part fractures, under two scenarios, (1) a healthy 55-year-old and (2) and a 75-year-old with significant medical comorbidities. Within each vignette, respondents were asked about their preference on CT utilization, and whether they would select operative or nonoperative treatment. A final survey was administered to elicit respondent preferences on general treatment approaches regardless of specific vignette characteristics.

Results and conclusion: Consensus was reached on the value of CT scans with 3D reconstructions, age as an important factor in determining treatment,functional demand, fracture pattern, bone quality, and the presence of more significant medical comorbidities would strongly impact decision making.Experts agreed that medial calcar involvement would have no impact on their decision, and gender and non-dominant arm involvement would have a low impact.

Consensus was reached to utilize RSA for elderly patients with fracture dislocations of the proximal humerus. No consensus was reached in the optimal management of 3-part fractures, in the young, healthy patient.Further no consensus was reached in the management for a 2-part varus fracture in a young healthy patient and for an older, unhealthy patient with either a 2-part shaft fracture, 3-part varus fracture, 3-part valgus fracture, 4-part fracture, or 4-part valgus impacted fracture.Finally, there was no consensus on preferred rehab protocols, whether for nonoperative management or postoperative care.

In conclusion, this study demonstrates that consensus when managing proximal humerus fractures, is limited to specific scenarios, while lack of consensus still exists in others. The presented study advocates non-operative treatment of proximal humerus fractures in the sicker patient and surgical treatment methods for 3-part fractures in the young, healthy patient.