3.1 Proximal humerus
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1 Introduction
The treatment of proximal humeral fractures (PHFs) is controversial for a number of reasons:
There is an ongoing debate about the benefits of operative versus nonoperative treatment even of displaced, unstable fractures.
The rate of “mechanical” complications after surgical treatment is 30–35% in prospective studies with surgical revision rates from 20–30% [1–3]. Nevertheless, up to 74% of PHFs actually received surgical treatment [4].
Multiple available operative options from pinning to arthroplasty with varying selection criteria are mainly based on bone and fracture characteristics without considering the patient′s functional status.
There is a lack of randomized studies investigating distinct fracture entities and treatment modalities.
Unspecific outcome measures. While using the Constant and Disabilities of the Arm, Shoulder, and Hand (DASH) scores, ceiling effects may make it difficult to detect substantial advantages of surgical fixation over nonoperative management [5]. If the scores or patient-reported outcome measures (PROMs) used were more precise, differences between different procedures might be detected more easily. A ceiling effect of a score describes the fact that a score at its upper end of values loses the ability to detect changes in a patient′s health status in a sufficient manner. Therefore ceiling effects can lead to artefactual data, eg, showing no effect of an intervention when in reality there is one.
More traditional ways to evaluate treatment results like range of motion (ROM), muscle strength, fracture reduction, and bone healing may not apply to the proximal humerus where objective parameters often do not match subjective appraisals [6].
Since there is no single clear-cut approach to a PHF, treatment recommendations depend largely on surgeon experience, skills, and preference. An improvement of this situation can only be achieved with larger and higher level clinical studies and specifically designed PROMs to address the geriatric population. This chapter summarizes the current situation from a practical approach to guide proper patient- and treatment-specific decision making. This seems to be the most important factor in achieving a good outcome as well as for the most appropriate treatment selection and avoidance of complications.
1.1 Epidemiology
Proximal humeral fractures:
Are the third most common fractures in adults older than 60 years.
Affect 70–80% of women with a history of osteoporosis who have fallen from a standing height [1].
Have been increasing by up to 15% in the past decades [7, 8]. There are major differences between ethnicities and the rate of fractures are significantly lower in countries like Japan [9] compared to Europe or America.
Interestingly, the clear rise in the rate of low-trauma PHFs in older Finnish women from the early 1970s until the mid- 1990s has stabilized at a high level. The reasons for this are largely unknown, but a cohort effect toward a healthier aging population with improved functional ability and reduced risk of injurious falls cannot be ruled out [10]. In Austria, on the other hand, this levelling off effect could not be confirmed and absolute numbers of PHFs are still rising due to increased life expectancy [11].
1.2 Etiology
Proximal humeral fractures occur mostly after low-energy falls [12].
Comorbidities increase the risk for PHFs. Factors like decreased neuromuscular response, delayed reaction time, cognitive impairment, impaired balance, intoxication as well as early menopause are all associated with PHFs [13].
Middle-aged patients who sustain PHFs are physiologically older than their numerical age indicates and have a higher incidence of medical comorbidities often related to alcohol, tobacco, and drug usage ( Case 1: Fig 3.1-1 ) [14].
CASE 1: Young woman suffering from alcoholism and severe osteoporosis, multiple fractures including bilateral proximal humeral fractures with special solution on one side
Patient
A 48-year-old woman with no obvious signs of dementia or confusion; she was cooperative. She was living with her husband and wanted to remain independent. Over the years, she sustained continuously major fractures of the distal radius, lumbar spine, and proximal tibia.
Comorbidities
Alcohol addiction
Nicotine abuse
Chronic obstructive pulmonary disease
Osteoporosis
Grand mal seizures
Multiple other comorbidities
Treatment and outcome
In 2005 the female patient sustained a subcapital fracture of the left humerus ( Fig 3.1-1a–c ). The fracture was treated nonoperatively leading to healing in malalignment. The bone was clearly osteoporotic, but no action was taken with regard to this.
In 2008 she presented with a fracture of the right proximal humerus ( Fig 3.1-1d–f ). The fracture was first treated nonoperatively, which resulted in a painful and debilitating condition. Since fracture healing was not to be expected, the decision to perform surgery was made.
After the fracture was aligned ( Fig 3.1-1g ), an almost normal anatomical condition could be reestablished with a massive central allograft ( Fig 3.1-1h ). Then the plate was preliminarily fixed ( Fig 3.1-1i ).
The intraoperative ( Fig 3.1-1j–k ), 3-month ( Fig 3.1-1l ), and 1-year ( Fig 3.1-1m ) follow-up x-rays showed an uneventful clinical course. Range of motion was 120° of abduction/flexion and 60° of external rotation.
Treatment options
Nonanatomical fixation in valgus of the humeral head and massive shortening may result in an impaired functional outcome due to a shorter lever arm of the rotator cuff muscles.
Nailing: Head fragment is too short for stable anchorage of the fifth anchor point.
Hemiarthroplasty: Overtreatment when stable reconstruction is possible. Midterm function of the shoulder is questionable.
Reverse total shoulder arthroplasty is not indicated with intact rotator cuff and well-centered shoulder joint.
Key points
Central voids can be successfully filled with massive allografts to prevent early varus failure and subsidence of the head fragment with cut-through of the screws, even in patients with severe osteoporosis [15].
In a retrospective case series, this procedure leads to bony union in a noncompliant or high-risk patient population [16].
Treatment of the underlying osteoporosis may be challenging in noncompliant patients.
2 Diagnostics and classification
In order to give a viable therapeutic recommendation, the preoperative workup must go beyond fracture analysis, although there seems to be a high degree of uncertainty as how to measure and implement clinical information into the decision-making process.
In a recent study 238 surgeons rated 40 x-rays of patients with PHFs. Participants were randomly selected to receive information about the patient and mechanism of the injury. Patient information, particularly older age, was associated with a higher likelihood of nonoperative treatment recommendation rather than x-rays alone. Clinical information did not improve agreement with the actual treatment or the generally poor interobserver agreement on treatment recommendations [17].
2.1 Clinical evaluation
History and physical examination include:
Mechanism of injury
Vascular and neurological status, especially distal circulation and the axillary nerve function
Soft-tissue injuries, including the skin
Muscle status, specifically the muscles of the rotator cuff ( Diagnostics 1: Fig 3.1-2, Fig 3.1-3, Fig 3.1-4 )
Preinjury level of function
Occupation
Hand dominance
History of malignancy
History of previous fragility fractures
Rehabilitation potential
Presence of concomitant injuries
Geriatric workup including comorbidities, functional and mental status
Evidence of how the mental status may influence the outcome is poor. In most studies, patients with significant mental impairment are excluded or this factor is not considered at all. Advanced age and higher degrees of dementia with increased risk of postoperative delirium usually lead to nonoperative treatment ( Case 2: Fig 3.1-5 ).
Other patient factors like level of independence, housing situation, or the need to use walking aids also potentially affect outcomes after both operative and nonoperative management and should therefore be evaluated very carefully. Complications such as infection, nonunion, osteonecrosis, fixation failure, and compliance with rehabilitation can all be related to medical comorbidities [13]. Alcohol abuse particularly increases a patient′s risk of noncompliance and nonunion, and tobacco use increases the risk of nonunion [18].
DIAGNOSTICS 1: Evaluation of rotator cuff muscles status with standardized 2-D computed tomographic reconstructions
Patients
An 85-year-old woman with chronic rotator cuff deficiency and complete atrophy of the supra- and infraspinatus muscles ( Fig 3.1-2 ).
A 78-year-old woman with posterior and superior cuff deficiency ( Fig 3.1-3 ).
An 87-year-old man with no muscle atrophy or fatty degeneration of the rotator cuff muscles ( Fig 3.1-4 ).
Discussion
A fracture reconstruction in a patient like the one in Fig 3.1-3 does not seem to be indicated. Even if the pretrauma status of the computed tomographic angiography was compensated, the risk of decompensation after the reconstruction with the need of revision surgery is high; the authors recommend reverse shoulder arthroplasty in these cases.
CASE 2: Evaluation of mental status and comorbidities
Patient
A 90-year-old slow-go, ie, unfit, female patient, was living in a nursing home and required a walker to assist with ambulation.
Comorbidities
Dementia
Coronary heart disease
Hypertension
Multiple falls
A pertrochanteric fracture 2 years ago, treated with a cephalomedullary nail with an augemented head neck element or so-called proximal femoral nail antirotation plus augmentation
Osteoporosis
Treatment and outcome
The female patient had a displaced 2-part proximal humeral fracture ( Fig 3.1-5a–b ) and an undisplaced superior and inferior anterior pelvic ring fracture ( Fig 3.1-5c ). Her therapy comprised shoulder sling, pain medication, and pain-adapted mobilization. She was hospitalized for 16 days, mobilized to sit in a wheelchair, and transferred to a nursing home ( Fig 3.1-5d ).
The follow-up x-rays at 6 weeks showed a rapid ongoing healing process in varus malalignment ( Fig 3.1-5e–g ). She had only little pain and could reach her head with her hand. She did not walk any more but was satisfied with her situation and refused further followups. Her situation was still the same 2 years later.
Discussion
From a geriatric standpoint, everything should be done to get the patient out of bed: adapt pain medication, keep motivating her and help her to walk again. Bed rest with loss of muscle mass, staring at the ceiling all the time and eating in bed has to be avoided. Nutritional aspects should also be considered.
To answer the question if surgical treatment under a nerve block would improve the patient′s prognosis, her prefracture status needs to be carefully evaluated (ie, “What was she really able to do?“) as well as her mental status, ability to cooperate, and motivation. This may take a few days. Finally her risk for surgery must be estimated.
In this case, despite a low risk for surgery, nonoperative treatment was recommended, because the patient had poor cognitive function and did not require high functional demands. In her case bone healing took place quickly despite her severe osteoporosis. Surgical stabilization would most probably not have caused any change in the rehabilitation process.
From a surgical standpoint, if a nailing procedure would have been chosen, a low risk for failure would have been expected.
To describe the functional status of the patient, a simple distinction between go-go, slow-go and no-go patients ( Table 3.1-1 , see topic 3.1 in this chapter) is useful. The Parker Mobility Score and the WHO performance status ( Table 3.1-2 , see topic 3.3 in this chapter) may also be helpful.
2.2 Imaging
2.2.1 Plain x-rays
Surgeons can only make clear and unambiguous statements if the fracture is clearly visualized by x-ray(s). If criteria are defined to classify and treat PHFs, the proximal humerus must be displayed in a manner that those criteria can be reliably evaluated.
The trauma series consists of a true AP view, an axial view, and an outlet view. The first two x-rays are most important to check the displacement of fragments and the instability of the fracture. Acute pain should be treated before images are taken.
Analyzing the projection of the proximal humerus in published serial x-ray studies suggests that the position of the patient′s arm often varies within one case. Recommendations about the “standard position” also vary widely. According to geometrical studies by Hengg et al [20], especially different degrees of internal rotation (IR) distort the measurement of the head-shaft angle on the AP view substantially: 30°, 45°, and 60° of IR result in a projection of the head-shaft angle of 144°, 150°, and 159°. Standardized and above all comparable visualizations of the proximal humerus are therefore crucial to make decisions and to collate results ( Diagnostics 2: Fig 3.1-6 ).
DIAGNOSTICS 2: Comparable projections are of utmost importance
The true AP view ( Diagnostics 3: Fig 3.1-7, Fig 3.1-8 ) shows:
DIAGNOSTICS 3: True AP view
Varus and valgus deformity and amount of displacement
Medial displacement of the shaft consistently produced by the pectoralis major muscle
Posterosuperior displacement of the greater tuberosity (GT)
Rotational displacement of the head fragment is due to the pull of the subscapularis (SSC) in 3-part GT fractures. This pathology needs to be derotated in percutaneous procedures. When placing the arm in a sling or holding it in a relieving posture, this type of view cannot be achieved.
The axial view ( Diagnostics 4: Fig 3.1-9, Fig 3.1-10 ):
DIAGNOSTICS 4: Axial view
Is paramount to assess anterior or posterior displacement of the humeral head in relation to the glenoid
Determines anteversion and retroversion
Displays displacement and fragmentation of the GT ( Diagnostics 5: Fig 3.1-11 ) and the overlap of the head by the minor tuberosity
Shows posterior dislocation of the humeral head associated with PHF, which is often missed without an appropriate axillary lateral view. Alternatively, a dynamic investigation under image intensifier may be performed
DIAGNOSTICS 5
The Velpeau view is an alternative to the axial view and can be obtained with the arm in a sling.
The lateral view (= lateral scapula, = Y view, = outlet view) ( Diagnostics 6: Fig 3.1-12, Fig 3.1-13 ) is easy to shoot in the trauma situation but often very difficult to interpret because of poor quality and superimposed structures. It is definitely the third most important view of the trauma series. If only two views are done, they should be the true AP and axial views.
DIAGNOSTICS 6: Lateral view
The lateral view shows:
Greater tuberosity posterior displacement due to the pull of the infraspinatus (ISP) and supraspinatus (SSP) muscles.
The relation of the head fragment to the glenoid.
2.2.2 Computed tomographic scan
In most hospitals, a CT scan is part of the standard workup of PHFs. Certainly, if surgical treatment is an option, a CT scan with 3-D reconstructions adds important information in fracture dislocations, humeral head-split fractures, and comminuted fractures. Three-dimensional CT scan reconstructions have been shown to provide the highest interobserver agreement with regard to classification and treatment recommendations among upper-extremity specialists [21].
CT scans:
Help to precisely determine fracture lines and pieces, ie, fracture characteristics needed for surgical planning.
Provide enhanced understanding of fracture comminution, impaction, humeral head involvement and its size and remaining thickness, and additional glenoid articular surface injury ( Case 3: Fig 3.1-14 ).
Allow for manual 2-D reconstructions along the axes of the humerus to show the exact angulation and displacement of fragments as well as the length of the metaphyseal fracture extension.
Facilitate soft-tissue imaging specifically rotator cuff muscles. In case of a rotator cuff arthropathy with limited preoperative function and an indication for surgery, an inverse prosthesis instead of fracture fixation is indicated.
CASE 3: Importance of a detailed computed tomographic analysis
Patient
An 80-year-old woman sustained a low-energy proximal humeral fracture and a distal radial fracture of the left upper extremity.
Comorbidities
No relevant comorbidities besides osteoporosis—already treated
Treatment and outcome
The AP and lateral views showed a 2-part fracture of the surgical neck (HGL-S) and the medial calcar seemed comminuted ( Fig 3.1-14a–b ). Both fractures were initially treated nonoperatively. After 10 days, progressive tilting of the head fragment with pronounced displacement was visible in the lateral view ( Fig 3.1-14c–d ). In addition, the patient was unable to participate in rehabilitation because of pain. The surgeon and patient decided on plating. The 2-D computed tomographic scans showed the narrow head fragment ( Fig 3.1-14e–f ). Only very few thread pitches of the locked screws could be anchored.
Intraoperative x-rays demonstrated a residual varus position of the head fragment and a lack of medial support due to “wrong impaction” ( Fig 3.1-14g–h ).
Insufficient medial support and residual varus together with the small osteoporotic head fragment led to a mechanical varus failure. After 4 weeks ( Fig 3.1-14i ) and 6 months ( Fig 3.1-14j–k ) the fracture was malunited with a severe varus deformity; since the screws did not perforate, the patient was not revised.
Discussion
In cases such as shown in Fig 3.1-14 , a sustainable medial bone contact can only be achieved by reducing the head fragment into a slight valgus position. Because the length of the proximal humerus is then reduced, the plate must be placed in a nonanatomical position, ie, with a gap between lateral cortex and the plate.
An impaction with valgus position and with additional cement augmentation of the screws might have helped, but if in doubt a structural allograft could definitely provide the mechanical stability for a functional rehabilitation as desired in orthogeriatrics.
In a surgical neck 2-part fracture we would not consider arthroplasty.
2.2.3 Magnetic resonance imaging
Magnetic resonance imaging (MRI) adds little to the initial evaluation of PHFs [22].
2.2.4 Local bone quality
Promising attempts have been made to experimentally measure the local bone quality (LBQ) with a torque measurement tool (DensiProbe) which was adapted to a standard locking plate. The mechanical peak torque correlates with the local bone mineral density (BMD) and screw failure load in anatomical specimens [23].
With modern picture archiving and communication systems, the local bone density (LBD) can be measured in standardized regions of interest given in Hounsfield units [24] and converted into BMD values. The aforementioned measurement gives an estimate of the LBQ.
The significance of local osteoporosis for the outcome of the treatment is unclear. In a multicenter trial, patients with mechanical complications after plate fixation of unstable PHFs had the same low BMD as patients with uneventful healing [1].
Experiments with anatomical specimens have shown that periimplant polymethylmethacrylate (PMMA) cement augmentation cannot be injected through a cannulated screw into cancellous bone with normal density [25, 26]. If implant augmentation is intended, the LBQ needs to be determined.
There is a linear biomechanical correlation between LBQ and cycles to failure [27, 28]. Common sense dictates that osteoporosis is clinically associated with increased rates of comminution and defects due to impaction, loss of fixation and reduction after surgical management.
Recent clinical trial results suggest that LBQ constitutes at most one contributing factor to fixation failures after plating [1, 28].
For the typical patient with PHF, LBQ must be expected [1].
2.3 Soft-tissue injuries
With fractures of the GT or LT, the rotator cuff is essentially nonfunctional, as expected [13]. Conversely, we may presume that a 4-part PHF only occurs with an intact rotator cuff. Without a functioning rotator cuff, displaced avulsion fractures are rare due to the lack of pulling forces. With a preexisting cuff arthropathy, 2-part fractures are more likely.
A complete rotator cuff examination cannot usually be performed in an acute setting due to pain and swelling, but the rotator cuff function should be monitored throughout the typical clinical course to ensure adequate function [22]. Due to the age of most patients who sustain PHFs previous rotator cuff injuries are likely, and a new rotator cuff tear can certainly occur in conjunction with PHFs [29]. As an indirect measurement, the status of the rotator cuff muscle can be determined with the CT scan ( Diagnostics 1: Fig 3.1-2, Fig 3.1-3, Fig 3.1-4 ).
2.4 Instability and displacement
Instability and displacement are often used as criteria for determining the treatment strategy. Imaging usually only shows a momentary situation of unstable fractures. Whether or not fracture fragments are displaced may depend on the position of the arm while x-rays or CT scans were taken.
If in doubt, perform repeat x-rays examinations to help rule out misinterpretation or secondary displacement.
Signs for stability are [21, 30]:
Minimal comminution
Three or fewer fragments
Absence of significant tuberosity displacement
Cortical contact
Relative impaction of the shaft into the head
No history of dislocation
If the fracture is stable, gentle and careful movements of the affected arm can be performed with no or very little pain during a physical examination. This should only be done after imaging, though.
Signs of instability are:
Significant displacement with segments angulated more than 45° or displaced more than 0.5–1 cm from their normal anatomical position, best detected on the axial view [31].
A difference in fragment angulation between plain x-rays and CT scans with 2-D reconstruction along the axes of the humerus.
Extraordinary pain which does not subside with adequate pain medication within a few days.
2.5 Classification
Codman′s 4-part model laid the foundations of modern understanding of PHFs. All of the following classifications were based on the four parts, ie, the shaft, GT, LT, and the head fragment. The most common classifications used over the last decades were the Neer and the AO/OTA classifications. Both systems are characterized by a poor interobserver reliability [32, 33] which improves with advanced imaging like 3-D CT scans [34], education and experience [35].
2.5.1 Neer′s classification
Neer focused on the patterns of displacement rather than the location of fracture lines. In his retrospective study he attempted to identify fractures that would benefit from open reduction. Similar to Hertel, he also wanted to predict the risk of avascular necrosis (AVN) which again would have an impact on decision making (see topic 2.5.2 in this chapter). Neer′s system remains the most commonly used today, because it is easy to apply and yet has a prognostic value. Four-part fractures generally have worse outcomes than 2- and 3-part fractures regardless of the treatment.
Neer randomly defined the borderline between displaced and nondisplaced at a displacement of 1 cm and an angulation of 45°. A fracture that is below this threshold is called 1-part fracture irrespective of the number of fragments.
These criteria have evolved to make a displacement of 5 mm or more an acceptable indication for fixation provided the direction of displacement creates a functional limitation. A good example is the superior displacement of the GT, which has the potential of restricting abduction.
2.5.2 Hertel′s classification
Hertel [36] fundamentally changed the approach by using a binary system based on Lego bricks. He proposed fracture planes instead of fracture fragments. To classify a fracture, possible fracture planes between head and GT, GT and shaft, head and LT, LT and shaft, and finally between GT and LT need to be identified.
This results in six options for 2-part fractures, five for 3-part fractures and obviously just one 4-part fracture. In contrast to Neer, Hertel rated any cortical discontinuity as a fracture irrespective of the amount of displacement or angulation. Particular attention has to be paid to seven other parameters, such as the length of the posteromedial metaphyseal head extension, the integrity of the medial hinge with displacement of the shaft in respect to the head, the displacement of the tuberosities, the amount of angular displacement of the head, the occurrence of glenohumeral dislocation, a head impression fracture, a head-split component and the mechanical quality of the bone.
2.5.3 Hertel′s modified classification
Sukthankar et al [37] modified Hertel′s system by replacing numbers with a comprehensive nomenclature. H(ead), G(reater) and L(esser tuberosity) and S(haft) identify possible fracture parts, a fracture plane is represented by a hyphen (-) and represents a cortical disruption between the parts, regardless of displacement and angulation. H-G-L-S therefore indicates the classic 4-part fracture. The letter “d”(dislocation) as a prefix to “H” and “c” followed by the length of the intact calcar fragment in millimeters as postfix in brackets can be added as well as “a” for the head-neck angulation. The simplicity and intuitive nature of this nomenclature may be the reason for a higher reliability compared to the original Hertel, AO/OTA, and Neer systems.
Prediction of head necrosis does not play an important role in decision making in geriatric patients. Fracture pattern interpretation mainly serves to differentiate stable from unstable fractures and to forecast the likelihood of achieving a stable fixation.
2.6 Summary
Clinical evaluation:
In addition to fracture pattern analysis, the patient′s functional and cognitive status must be considered to determine the best approach.
Nonfracture-related geriatric parameters play an important role in choosing the adequate therapeutic approach for each individual patient.
Imaging:
The main purpose of imaging PHF is to determine instability and fragment displacement.
Standardized views are paramount to determine angulation, displacement, and detection of any changes postoperatively.
The axial view displays instability and displacement between shaft and head and should be part of the standard trauma x-ray series.
CT scans should be used for precise fracture analysis and measurement of local bone density. Two- and three-dimensional reconstructions are essential for precise classification and surgical planning.
Classification:
Codman′s 4-part model and Neer′s classification (1970) are still the basis for understanding PHFs [31].
Hertel′s system and the HGLS classification are recommended for more detailed description of the fracture situation.
Other factors like the degree of shaft displacement and angulation/rotation of the head fragment should also be described.
3 Decision making
Since little high-level evidence exists, there is still much uncertainty about which patients will benefit from nonoperative treatment, plate fixation, nailing, or arthroplasty [38, 39]. Overall, conflicting results between studies favoring operative intervention and others failing to show much benefit for more displaced and unstable fractures have been described. This demands careful consideration of the patient-specific benefits and risks of operative and nonoperative therapy [22].
Older patients tend to have worse functional outcomes [30]. This trend has been attributed to factors such as fragility, cognitive deficits, rotator cuff injuries, osteoporosis, and poor rehabilitation potential [40].
The indication for surgery in PHFs is usually a relative one. Therefore comorbidities play an important role in deciding whether or not to perform surgery. In cases where deterioration of comorbid medical conditions like renal insufficiency is likely to happen, it is usually better to refrain from surgery even if the fracture type would justify it.
General remarks and thoughts:
The severity of comminution in displaced fractures may have a more significant effect on functional outcomes than the choice of treatment; there is also a clear difference in prognosis between 3- and 4-part fractures, but not between 2- and 3-part fractures [5]. In many studies 4-part fractures yielded worse outcomes compared to 2- or 3-part fractures regardless of the treatment chosen [41].
The functional outcome is difficult to assess, as many variables contribute to a successful patient outcome. Fortunately, functional expectations for older individuals are lower than for younger patients—a less than satisfactory result for a young patient can therefore be completely acceptable for an older person. Even with decreased outcome scores, older patients’ perception of outcome and quality of life can be acceptable [30].
As evidence supporting routine operative treatment is limited and complication rates are high, decision making should include individual factors such as living situations, comorbidities, and the patient′s attitude towards surgery. With surgeons’ increasing knowledge about appropriate patient selection and limits of specific procedures, results become more predictable. That means, however, that more than one operative method is necessary to address different situations.
If we think about operative fixation, it seems expedient to ask what kind of difference the patient will experience after surgery. There must be some tangible benefit in terms of an increased functional result. This also holds true if an older patient′s functional status benefits from immediate use of the injured extremity by using a cane, for instance ( Case 4: Fig 3.1-15 ).
It is helpful to discuss all relevant aspects among the interdisciplinary team members in addition to the patient and relatives. If the patient seems motivated to make use of an expedited rehabilitation process after surgery and has no contraindications, the patient may receive the same treatment as a younger adult ( Case 5: Fig 3.1-16 ).
With enhanced techniques like the use of fibular strut grafting or allograft bone blocks, better and more reliable results can be achieved both in younger and in geriatric patients ( Case 6: Fig 3.1-17 ) [16, 42].
As in other areas, outcomes may also be correlated with the level of surgeon experience, the time of surgery and the soft-tissue handling. These potentially important factors are hardly ever reported or investigated in studies and neither is the precise amount of displacement with a standardized CT scan measurement.
CASE 4: Potential benefit of operative fixation in geriatric patients
Patient
A 90-year-old woman sustained a left pertrochanteric fracture after a fall from standing height and was treated with a proximal femoral nail antirotation (PFNA) plus augmentation. She was living alone and mostly self-reliant with some help from her daughter who lived close by. No signs of dementia and she was cooperative and go-go, ie, fit. Osteoporosis treatment was initiated and the patient has been using a walking cane ever since.
Comorbidities
Hypertension
Chronic renal deficiency
Heart failure
Osteoporosis (T-score: spine = -3.6, hip = -3.6).
Treatment and outcome
Five months later the patient presented with a 2-part surgical neck fracture (HGL-S) after a low-energy trauma at home with medial comminution and varus displacement ( Fig 3.1-15a–e ). After careful and extensive consultation with the team, the patient and her daughter decided on operative treatment. Stable fixation was achieved with PHILOS augmentation ( Fig 3.1-15f–g ). Nonanatomical plate position was chosen to maintain the medial support, which was achieved by slight shortening and impaction of the shaft into the head, as well as a slight valgus position of the head fragment. Periimplant augmentation with 0.5 cc of polymethylmethacrylate cement per cannulated screw was used. With this measure, additional fixation was added. Five days after surgery, pain restricted the patient′s mobilization and usage of the affected arm ( Fig 3.1-15h ); this made it impossible for her to return home as early as possible and to limit care dependency to a minimum. After 12 days the patient was transferred to the internal medicine and rehabilitation department.
Six weeks postoperatively a comparison with previous x-rays was not possible, as they were blurred by different projections. Active flexion and abduction was 140°, active rotation in 90°, and abduction 80°. She used a cane to support the right side; she was pain free (i–l) and back home.
Other treatment options
Nonoperative treatment: The patient would be unable to use crutches at least for some time because of pain and she would depend on care. It is likely that the fracture would displace more and could lead to a more restricted functional outcome.
Proximal nailing would be a good alternative, as the reduction in valgus and shortening would be beneficial.
Hemiarthroplasty and reverse arthroplasty are not an option for this type of fracture (overtreatment).
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