OR2.2 | Proximal Humerus Fracture Management — Summary & Reflection

KEY TAKEAWAYS

Proximal humerus fractures are the third most common adult fracture, predominantly low-energy osteoporotic injuries in elderly women. The Neer classification defines displacement by part-number: one-part (~80%, all non-operative), two-part (select operative), three- and four-part (operative vs arthroplasty by age and bone quality). The axillary nerve -- tested via sensation over the regimental badge area and deltoid contraction -- is the key nerve at risk; injury occurs in up to 45% of cases and must be documented. The anterior humeral circumflex artery (arcuate artery) is the principal blood supply to the humeral head; its disruption in four-part fractures creates an AVN risk of 13-34%. In elderly patients with four-part fractures, primary hemiarthroplasty or RTSA is preferred over ORIF. Post-traumatic shoulder stiffness is the most common complication of both non-operative and operative management and is prevented by early, supervised physiotherapy.

REFLECT

Consider the management dilemma for an 82-year-old active gardener with a four-part proximal humerus fracture and good pre-morbid shoulder function. She asks why you are recommending arthroplasty rather than 'just fixing the bone.' How would you explain avascular necrosis, the limitations of locking plate fixation in osteoporotic bone, and the expected functional recovery with a reverse total shoulder arthroplasty? What elements of shared decision-making are relevant here, and how would you document the consent discussion?