Introduction
Proximal humerus fractures are a common injury, particularly in the elderly, and can result in significant pain, functional impairment, and reduced quality of life [
1,
2]. The management of proximal humerus fractures remains a subject of debate, with a range of available treatment options, including non-operative and operative approaches. Effective management of these fractures is crucial for optimal patient-reported outcome and quick return to functional activities. The treatment decision for proximal humerus fractures is influenced by various factors such as patient age, health status, type of fracture, and patient’s demands [
3]. Currently, there is no established guideline for treatment decisions in PHF, so that choice of treatment for the individual patient remains challenging in clinical practice [
4].
Non-operative treatment is commonly used in elderly patients or those with medical comorbidities that increase perioperative risk of surgical complications [
5,
6]. Non-operative treatment usually includes sling immobilization of the affected arm for a period of time to allow initiation of fracture healing [
7] and concomitant physical therapy to help maintain range of motion and prevent muscle wasting.
Surgical treatment of proximal humerus fractures is typically reserved for complex fractures, displaced fractures, or fractures with joint surface involvement [
8,
9]. The goal of surgical treatment is to restore normal alignment and function of the shoulder, reduce pain, and prevent long-term complications such as stiffness, weakness, and osteoarthritis. The choice of surgical approach depends on the specific characteristics of the fracture, including the location, degree of displacement, number of fragments, and associated injuries [
3,
10] and ultimately the preferences of the treating surgeon.
Recent literature suggests that an individualized and evidence-based approach is required for effective management of these fractures, taking relevant parameters into consideration such as the patient’s age, medical comorbidities, and functional goals [
3,
4]. To investigate a current consensus among experts on the most important factors influencing the treatment decision of proximal humerus fractures, a Delphi consensus study was conducted. The Delphi consensus methodology is a well-established technique for achieving consensus among a panel of experts, and anonymous feedback and iterative rounds of questioning are used to refine and clarify opinions. This method has been successfully applied in various medical fields to reach agreement on best practices and guidelines.
Discussion
Consensus in this Delphi process for treatment of PHF was obtained for fracture-related factors, including head-split fracture, dislocated tuberosity, and fracture dislocation, as well as patient-related factors, such as age and rotator cuff tear arthropathy.
Proximal humerus fractures are a common injury with an incidence of 6.6 cases per 1000 person years. Thus, PHF are the third most common fracture type in patients over 60 years of age, what accounts for 4–6% of all fractures [
1].
While there is still controversy regarding the right treatment for PHF [
2], a structural evaluation of relevant treatment influencing factors could assist in decision-making for clinicians who are performing therapy in patients with PHF.
Head-split fractures refer to fractures that involve at least 20% of the articular surface of the humeral head and extend into the metaphysis [
12]. These fractures are often challenging to manage, as they can involve the blood supply to the humeral head and are associated with elevated rates of avascular necrosis [
12]. The Delphi consensus study found that the head-split component of humeral head fractures was important to consider in the decision-making process for selecting the treatment of proximal humerus fractures. For patients with head-split fractures, surgical intervention may be recommended [
8], as non-surgical management is associated with a higher risk of complications, including avascular necrosis [
12]. However, the choice of surgical intervention may depend on the extent of the fracture, the patient’s age, and their functional demands [
2,
7].
The tuberosities are bony protrusions on the proximal end of the humerus, which provide attachment sites for the rotator cuff tendons. Dislocation of any one of the tuberosities can significantly impact the management of the fracture [
32,
33]. For patients with a dislocated tuberosity, surgical intervention may be recommended to restore the attachment of the rotator cuff tendons [
34]. However, this may depend on the extent of the fracture and the patient’s age and condition of the rotator cuff. A recently published randomized controlled trial with long-term outcome evaluation of dislocated PHF with affected tuberosities showed that there was no better outcome in patients who were surgically treated [
2]. Nevertheless, there are other studies that indicate better functional outcome after surgical treatment for those PHF [
9]. Regarding reverse shoulder arthroplasty for treatment of PHF, dislocated tuberosities can have a high impact on the surgical results [
32].
A fracture dislocation of the proximal humerus refers to a severe injury where the humeral head is dislocated from its socket in the glenoid and also sustains a fracture. These fractures can be challenging to manage, as they involve both the proximal humerus and the shoulder joint [
35]. The current Delphi consensus study found that an additional occurrence of glenohumeral dislocation is also considered a clinically important factor in the decision-making process for treatment of proximal humerus fractures. Fracture dislocations of the shoulder are often treated surgically because they can be associated with significant displacement and comminution of the fragments [
35], as well as damage to the surrounding soft tissue structures, such as the rotator cuff [
36]. Yet, the kind of treatment varies depending on the patient’s age, bone density and associated bony defects [
35,
37].
Patient age, as a patient-related factor which achieved consensus in our conducted Delphi process, is known to be an important factor that influences the management of proximal humerus fractures [
5]. Younger patients tend to have better bone quality and may be able to tolerate surgical intervention better, while older patients may have poorer bone quality [
6] and may be at a higher risk of perioperative and postoperative complications such as need for revision and non-union [
38]. For younger patients, surgical intervention may be recommended and head-preserving treatment should be the prioritized aim for this patient group. However, in older patients, non-operative management may be considered in most cases apart from fracture dislocations, especially if patients have pre-existing comorbidities [
2].
Rotator cuff tear arthropathy refers to the development of osteoarthritis as a result of massive rotator cuff tears and subsequent cranialization of the humeral head. The existence of rotator cuff tear arthropathy can significantly impact the treatment decisions in the management of proximal humerus fractures, as it can limit the applicability of head-preserving treatment options due to poor expectable functional results and may require more elaborate treatment. For patients with significant rotator cuff tear arthropathy, shoulder replacement surgery should be considered to address the arthritic changes and the loss of function of the rotator cuff [
39]. However, careful consideration is needed when selecting patients for this shoulder replacement surgery [
40].
This survey is constrained by the limitations of the Delphi method in general, including the selection of the panel, the definitions of the factors and questions. Also, the conduct of the survey, the analysis of the responses, and the final decision are bound to the Delphi method.
At the same time, conducting the survey within the Research and Development Committee of the German, Austrian and Swiss Shoulder and Elbow Society (DVSE) with a 100% response rate can be considered a major strength of this investigation, as a high level of experience among the participants could be assumed. While there is a prior Delphi study focussing on exploring post-treatment complications associated with proximal humerus fractures [
41], we are not aware of any similar work that has been conducted to evaluate treatment influencing factors in PHF of shoulder experts. Hao et al. evaluated in 2021 how differently orthopaedic shoulder and trauma surgeons decide in their treatment options for PHF and what factors they found relevant [
10]. They reported that non-surgical management or reverse shoulder arthroplasty were the preferred treatment regimens for elderly patients with complex fracture patterns and poor bone quality, osteoarthritis, or rotator cuff dysfunction [
10]. Fractures with good bone quality of younger patients were preferentially treated with osteosynthesis or hemiarthroplasty [
10]. Cosic et al. recently showed better quality of life for surgically treated patients with highly displaced PHF [
9]. This disagrees with the results of the ProFHER study, in which surgical therapy for PHF was not able to show superiority in the long term [
2].
In Switzerland, Spross et al. conducted a prospective study in 2019 of the treatment of PHF based on a treatment algorithm they developed on their own [
3]. In the first step of their algorithm, they distinguish between young healthy and active patients, usually under 65 years of age, and older patients over 65 years of age. This emphasizes the relevance of this factor. In young patients, the method of treatment is then selected based on the fracture pattern. For older patients, further patient-related factors are relevant in the decision-making algorithm [
3].
It is important to state that the management of proximal humerus fractures should be individualized based on the patient’s unique circumstances. A treatment algorithm solely based on a fracture classification therefore is not appropriate and is not alone sufficient for clinical application. Factors such as the patient’s overall health status, functional demands, and expectations for recovery should also be considered in the decision-making process. Shared decision-making between the patient and their healthcare provider can help ensure that the treatment plan aligns with the patient’s goals and demands.
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