Proximal humerus fractures (PHFs) are a significant orthopedic issue, particularly in the elderly, comprising 10% of fractures in this group and ranking as the third most common geriatric fracture [1,2]. These metaphyseal humerus fractures, often linked to osteoporosis, are more prevalent in women [3]. With an aging population, PHF incidence is increasing. Approximately 85% of PHFs are minimally displaced and managed non-surgically, while 15% are complex, requiring advanced interventions [1,3]. In India, PHFs constitute 4–7% of adult fractures and 45–80% of humerus fractures, with a 2:1 female-to-male ratio due to osteoporosis [4,5]. They exhibit a bimodal distribution: high-energy trauma in younger patients and low-energy falls in older adults [4]. Surgical management, such as open reduction and internal fixation (ORIF) with locking plates, promotes early mobility and union [6], though 67–85% of cases are treated conservatively [4]. Complex fractures involving glenoid or coracoid injuries require precise diagnosis and tailored treatment [7]. PHF management depends on fracture pattern and patient factors. Non-operative treatment, involving immobilization and early mobilization, suits stable fractures, particularly in elderly patients [8,9]. Displaced three- and four-part fractures often require surgery to prevent complications like avascular necrosis [9,10]. Surgical options include ORIF, intramedullary nailing, hemiarthroplasty, and reverse shoulder arthroplasty (RSA) [8,10]. RSA is preferred for older patients with poor bone quality or rotator cuff issues [8,11]. Surgery carries higher risks and costs, with outcomes influenced by age, bone quality, comorbidities, and surgeon expertise [12]. Early rehabilitation is crucial for recovery [12,13]. Despite advances, optimal treatment for elderly patients with poor bone quality remains debated. The ProFHER trial showed comparable outcomes for conservative and surgical approaches in some cases [14]. ORIF risks include screw penetration and avascular necrosis [15,16], while RSA reduces complications in complex cases [8]. The PHILOS system benefits two-part fractures but is less effective for complex patterns [17]. Treatment must be individualized [18]. Prognostic factors, including age, sex, comorbidities, Neer classification, treatment timing, fixation technique, and rehabilitation, significantly affect outcomes [2,19–22]. This study uses the Oxford Shoulder Score to compare treatment modalities and prognostic factors in PHF recovery.   

This retrospective observational study was conducted at the Department of Orthopaedics, Era’s Lucknow Medical College & Hospital, Uttar Pradesh, India, to evaluate treatment outcomes and prognostic factors in patients with proximal humerus fractures (PHFs). The study spanned 18 months, during which patient records and follow-up data were systematically reviewed. A total of 80 patients with PHFs were included, selected based on specific inclusion and exclusion criteria. The sample size was determined using the formula: N=P0Q0{Z1-α/2+Z1-β√ P1Q1/P0Q0}2 /(P1-P0)2  where ( P0 = 0.532 ) (population incidence), ( P1 = 0.682 ) (study group incidence), ( Q0 = 1 - P0 = 0.468 ), ( Q1 = 1 - P1 = 0.318 ), ( α = 0.05 ) (type I error= 1.96 ), and ( β= 0.2 ) (type II error, ( Z = 0.84 )). This calculation yielded ( N =79.14 ), rounded to 80 patients [23,24].

Eligible patients were adults aged >18 years of any gender diagnosed with PHFs through medical records at Era’s Lucknow Medical College and Hospital until the sample size was met. Exclusion criteria included patients with associated shoulder dislocations, open fractures, severe soft-tissue injuries, polytrauma, pathological fractures (except osteoporotic), terminal illnesses, unwillingness to participate, or loss to follow-up. Data were collected using a standardized pilot tool designed to assess functional outcomes via the Oxford Shoulder Score (OSS), a validated 12-item questionnaire evaluating shoulder function and pain, scored from 0 (worst) to 48 (best). Patient records were retrieved from the hospital’s electronic database, and follow-up data were obtained from outpatient visits or telephonic interviews conducted at 3, 6, and 12 months post-treatment to monitor recovery and complications.

The study assessed multiple variables influencing functional outcomes: patient age and sex, comorbidities (evaluated using the Charlson Comorbidity Index), fracture geometry (classified per Neer’s system, ranging from one- to four-part fractures), timing and duration of treatment initiation (from injury to intervention), type of fracture reduction (open or closed), fixation method (e.g., open reduction and internal fixation [ORIF] with locking plates, percutaneous pinning, external fixation, or conservative management with sling immobilization), and rehabilitation protocols (including physiotherapy duration and frequency). Treatment modalities were categorized as non-operative (sling immobilization followed by early mobilization within 2–3 weeks) or operative (ORIF with locking plates, intramedullary nailing, hemiarthroplasty, or reverse shoulder arthroplasty). Surgical procedures followed standardized protocols, with ORIF using locking compression plates (e.g., PHILOS system) for displaced fractures and RSA for complex cases with rotator cuff involvement. Postoperative rehabilitation involved a phased approach: immobilization for 1–2 weeks, followed by passive range-of-motion exercises (weeks 2–6), active exercises (weeks 6–12), and strengthening (beyond 12 weeks).

Patient history included presenting complaints (e.g., pain, swelling, limited motion), duration of symptoms, past medical history, family history, personal history (e.g., smoking, alcohol use), and presence of deformity. Clinical examination comprised general assessment (pallor, icterus, clubbing, lymphadenopathy, edema, vitals: pulse rate, blood pressure, respiratory rate, temperature), systemic evaluation (cardiovascular, central nervous, abdominal, respiratory systems), and local examination of the injured shoulder, including inspection for swelling or deformity, palpation for tenderness, and range-of-motion testing. The OSS was administered at follow-up to quantify functional outcomes.

Statistical Analysis:

Data were analyzed using statistical software (SPSS.16), with continuous variables (e.g., OSS scores) compared using ANOVA, and categorical variables (e.g., treatment type, Neer classification) analyzed via chi-square tests. Multivariate regression was employed to identify prognostic factors influencing outcomes, with a significance threshold of p < 0.05.

*ANOVA for continuous variables; †Chi-square test

Table 3 shows that, no significant differences were found in complications (chi-square = 16.29, p = 0.36) or clinical outcomes (chi-square = 4.56, p = 0.871). ORIF with plating had the lowest complication rate (90.0% complication-free), primarily minor infections and non-unions, while CRIF groups showed higher rates of pin tract infections (5–15%) and stiffness (10–15%). U-slab had the highest non-union rate (15%). Clinically, U-slab achieved the most Excellent outcomes (40%), while CRIF with K-wire had the highest Poor outcomes (35%), but all groups had comparable functional results. These findings contrast with prior Oxford Shoulder Score (OSS) data showing significant differences (p = 0.0001), suggesting categorical outcomes are less sensitive than continuous measures like OSS. Surgical duration was significantly shorter for CRIF with K-wire (43.95 ± 14.78 minutes) compared to ORIF (71.05 ± 24.96 minutes) and CRIF with external fixation (54.10 ± 16.08 minutes) (p < 0.001, ANOVA).

Table 4: Univariate Analysis to Find Effects of Techniques & Follow up time over OSS Score, Dependent: OSS Score

A univariate analysis was conducted to assess the impact of surgical technique and follow-up duration on the OSS. The baseline OSS score was 31.48 (p < 0.001), indicating the estimated score without the influence of follow-up time or surgical technique. The effect of follow-up duration on OSS score was not statistically significant (B = 0.16, p = 0.519, effect size = 0.006), suggesting that the time elapsed since surgery did not have a major impact on OSS score improvement. ORIF with plating had a significant negative effect on OSS score (B = -13.20, p < 0.001, effect size = 0.241), indicating significantly lower functional outcomes compared to the reference group (CRIF with external fixation). CRIF with K-wire fixation (B = -1.34, p = 0.614) and U-slab application (B = -1.70, p = 0.530) did not show significant differences in OSS scores compared to CRIF with external fixation, suggesting that their functional outcomes were similar. The results indicate that ORIF with plating was associated with significantly lower OSS scores, implying poorer functional outcomes. In contrast, CRIF with K-wire fixation, U-slab application, and CRIF with external fixation had comparable outcomes. Additionally, follow-up duration did not significantly influence OSS scores, suggesting that differences in functional recovery were primarily driven by the surgical technique rather than the duration of follow-up.

This retrospective study of 80 patients with proximal humerus fractures (PHFs) compared four treatment modalities: ORIF with plating, CRIF with K-wire fixation, U-slab (non-operative), and CRIF with external fixation (n=20 each). We aimed to compare functional outcomes (Oxford Shoulder Score [OSS] and clinical outcomes) and identify prognostic factors. Our findings align with the PROFHER trial [97], showing no significant difference in clinical outcomes (χ²=4.56, p=0.871), emphasizing individualized treatment based on fracture type, age, and comorbidities.

Non-operative U-slab treatment yielded the highest excellent outcomes (40%), suitable for non-displaced fractures, particularly in elderly patients, though non-union risk (15%) persists [25]. CRIF methods (K-wire, external fixation) showed comparable outcomes with higher stiffness and pin tract infections (5–15%) [26]. ORIF, despite fewer complications (90% complication-free), had significantly lower OSS (19.69–22.82 vs. ~28–32, p=0.0001), declining over 26–30 months, indicating poorer long-term function [27]. ORIF’s longer surgical duration (71.05 ± 24.96 minutes, p<0.001) reflects its complexity [26].

No significant associations were found between treatment and age (χ²=3.68, p=0.931) or sex (χ²=1.78, p=0.620). Clinically, younger patients (20–34 years) favoured CRIF/U-slab, while elderly patients (≥65) leaned toward non-operative treatment [28]. Sex differences were minimal, with external fixation outcomes sex-neutral, though males may face higher surgical risks in other contexts.

Despite the lack of statistical significance, broader literature indicates that sex may influence surgical outcomes. Specifically, Koeppe et al. (2021) [29] found that males over 65 years face significantly higher risks of mortality, surgical complications, and revision rates after reverse total shoulder arthroplasty (RTSA), although no significant sex-based differences were observed following locking plate fixation (LPF). In contrast, Banerjee et al. (2023)[30] reported that sex does not significantly affect functional outcomes or union rates in patients treated with external fixation. These findings suggest that while sex may not influence the initial treatment allocation, it should be considered in clinical decision-making due to its potential impact on postoperative risk, particularly in elderly male patients undergoing RTSA.

Multivariate analysis confirmed ORIF’s inferior OSS (β=-4.8, p=0.008) compared to CRIF external fixation, with age ≥50 (β=-2.3, p=0.031), Neer three-/four-part fractures (β=-3.1, p=0.012), and comorbidities (β=-2.0, p=0.042) predicting poorer outcomes, while early treatment (<3 days, β=2.5, p=0.025) and rehabilitation ≥12 weeks (β=3.0, p=0.009) improved OSS [25]. Follow-up duration was non-significant (p=0.519). Non-operative and CRIF methods are preferable for simpler fractures or elderly patients, while ORIF suits displaced fractures in younger individuals despite functional limitations [27]. Emerging evidence suggests reverse shoulder arthroplasty may benefit complex elderly cases, warranting further study [28,31]. Despite the lack of statistical significance in our dataset, these trends suggest that age remains a key clinical consideration in selecting treatment modalities for proximal humerus fractures. Limitations include small sample size (n=20 per group) and retrospective design, potentially masking subtle differences. Future studies should use continuous outcome measures for greater sensitivity.

This retrospective study of 80 patients with proximal humerus fractures compared four treatments: ORIF with plating, CRIF with K-wire, U-slab (non-operative), and CRIF with external fixation. Non-operative and CRIF methods yielded significantly better Oxford Shoulder Scores (OSS, ~28–32 vs. 19.69–22.82, p=0.0001) than ORIF, with U-slab showing the most excellent outcomes (40%). ORIF had fewer complications (90% complication-free) but longer surgical duration (p<0.001). Age, fracture complexity, and comorbidities predicted poorer OSS. Non-operative/CRIF approaches are preferable for simpler fractures, while ORIF suits displaced fractures, despite functional limitations. Future studies should explore reverse shoulder arthroplasty.

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