Summary

This study indicates that operative intervention by ORIF or RSA is associated with significantly lower risk of mortality following proximal humerus fracture compared to nonoperative management.

Abstract

Introduction

Proximal humerus fractures are the third most common fracture among older adults, representing 5-6% of all fractures (1). Despite their prevalence, optimal management remains debated. While substantial research has focused on mortality rates and risk factors associated with other fractures such as hip and distal radius fractures, there is a paucity of literature examining mortality rates and risk factors for mortality after proximal humerus fractures. Therefore, the purpose of this study was to evaluate long-term mortality following proximal humerus fractures treated nonoperatively, with open reduction internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA). We hypothesized that operative management with ORIF and RSA would be associated with lower long-term mortality compared to nonoperative treatment.

Methods

This was a retrospective cohort study of patients with a proximal humerus fracture evaluated by a two fellowship-trained orthopaedic surgeons from 2010-2023. Age, sex, mortality, date of injury, and date of death were collected for all patients, if applicable. Treatment modality was collected for each patient: nonoperative treatment, open reduction internal fixation (ORIF), or reverse shoulder arthroplasty (RSA). Chi-square tests were conducted to examine the association between treatment modality and mortality. Univariate Cox regression analysis was used to evaluate the impact of treatment on survival time; the Log-rank test was used to compare survival distributions among treatment groups.

Results

A total of 417 patients (mean age 68.0 ± 16.1) were identified and included in this study. For treatment modalities, 251 patients were treated nonoperatively with immobilization (60.2%), 112 were treated with ORIF (26.9%), and 54 with RSA (12.9%). The mortality rate for the entire cohort was 12.7%, with 53 of 417 patients reported as deceased. The 90-day mortality rate was 1.68%, the 1-year mortality rate was 3.36%, and the 5-year mortality rate was 10.55%.

There were no significant differences in mortality rates between the three treatment groups: nonoperative (36 out of 251), ORIF (9 out of 112), and RSA (8 out of 54) (p=0.220). Treatment with ORIF and RSA were both associated with a lower hazard of mortality compared to nonoperative treatment, with hazard ratios of 0.45 (95% CI: 0.21 - 0.98, p=0.045) and 0.32 (95% CI: 0.15 - 0.70, p=0.004), respectively (Figure 1). When controlling for age and gender, only RSA showed a significantly lower mortality rate (95% CI: 0.16 – 0.80, p=0.011).

Conclusion

Proximal humerus fractures represent significant risk of mortality after injury, including higher mortality rates compared to other upper extremity fragility fractures such as distal radius fractures, as reported in recent literature (2-3). Our data indicates that operative intervention by ORIF or RSA is associated with significantly lower risk of mortality following proximal humerus fracture compared to nonoperative management, as results showed that patients live longer following proximal humerus fracture when treated operatively with ORIF or RSA compared to nonoperative management.