Orthopaedic surgery has been at the forefront of creating new information, establishing new principles of treatment, and solving both new and old problems of the musculoskeletal system. Proximal humerus fractures remain unresolved in many ways. Disagreement exists regarding the reliability of the classification system. The indications for surgical management continue to be modified. There are numerous fixation techniques, none of which are ideal for all cases [1]. Fractures of the proximal humerus are not uncommon, especially in older age groups. They have been reported to account for 4%–5% of all fractures [1, 2]. Approximately 85% of these fractures are minimally displaced or non-displaced and are effectively treated symptomatically with immobilization followed by early motion. The remaining 15% of fractures are displaced and unstable and may have a disrupted blood supply. The treatment of these fractures is therapeutically challenging. Displaced and unstable extra-articular fractures are most commonly treated with operative reduction and fixation using various techniques [3]. The treatment is more controversial for articular fractures, which carry a high risk of humeral head necrosis. In Neer's classification, these are two-part anatomical neck, three-part, and four-part fractures, and those with dislocation of the head of the humerus. A review of the published results suggests that there is no universally accepted form of treatment. Conservative management may be associated with non-union, malunion, and avascular necrosis, resulting in painful dysfunction [4, 5]. Proximal humeral fractures, whether caused by trauma or related to osteoporosis, require carefully planned individual treatment. A wide variety of treatment options have been described, beginning with percutaneous fixation, non-absorbable rotator cuff-incorporating sutures, and the use of tension band devices and intramedullary nails.

The use of methods of open reduction and internal fixation with the more contemporary use of locking plates has been advocated recently, and the role of hemiarthroplasty in the treatment of these fractures has also been advocated in both the acute setting and as a delayed procedure [6]. Current therapeutic options for proximal humerus fractures include humeral nails, plates, tension band wiring, and percutaneous or minimally invasive techniques such as pinning, intramedullary flexible nails, screw osteosynthesis, and hemiarthroplasties [3, 4]. The Choice of technique and devices depends on the quality of bone, soft tissue, age, and reliability of patients. However, the goal of Proximal Humerus fracture fixation should be stable reduction, allowing early fracture motion. This study was conducted to analyze fractures of the proximal humerus treated with the proximal humeral internal locking system (PHILOS) locking plate and document their clinical and functional outcomes.

This was a prospective observational study conducted in the Department of Orthopaedics, Osmania General Hospital, a tertiary care teaching hospital. Institutional Ethical approval was obtained for the study after duly following the protocol for human research based on the Helsinki declaration. Written consent was obtained from all the participants of the study after explaining the nature of the study in the vernacular language.

Inclusion Criteria

1. Patients of either sex aged ≥60 years.
2. Ipsilateral Neer’s two-, three-, and four-part fractures.
3. Fracture dislocations.
4. Isolated proximal humerus fractures.

Exclusion Criteria

1. Age <60 years.
2. Compound fractures.
3. Pathological fractures (tumors, metabolic bone disease).
4. Bilateral fractures.
5. Head-split fractures.
6. Associated neurovascular injury.
7. Patients are unfit for surgery due to comorbidities.

Based on the inclusion and exclusion criteria, a total of 30 cases were included in the study during the study period. The study included adult patients aged >60 years with proximal humerus fractures who fulfilled the inclusion and exclusion criteria. A minimum of 30 cases were enrolled.

Patient Assessment: Patients or attendants provided information about the mechanism and severity of trauma on admission. Vital signs and general condition were evaluated. Other injuries were ruled out by systematic clinical examination. On local inspection of the affected shoulder, swelling, deformity, loss of function, changed posture, and any neurological impairment, including axillary nerve involvement, were considered.

Radiological Assessment: of the cases was done by Anteroposterior and axillary radiographs of the proximal humerus were taken, and fractures were classified according to Neer’s classification.

Management Protocol of the patients in this study was by dividing the patients into two groups:

1. The Conservative Group was managed by immobilization with U-slab/arm pouch followed by a structured physiotherapy protocol. Early mobilization, including Codman’s pendulum exercises, was initiated after 2–6 weeks, progressing to active and resistance exercises as per Neer’s three-phase rehabilitation program.
2. Surgical Group: underwent open reduction and internal fixation (ORIF) with PHILOS locking plate under general anesthesia through a deltopectoral approach. Intraoperative fluoroscopy was used to confirm anatomical reduction and implant placement. In the postoperative period, patients were prescribed antibiotics, analgesics, and immobilized with a sling. Passive range-of-motion exercises were initiated within the first week, progressing to active mobilization after 2–3 weeks, depending on fracture stability.

Follow-up and Outcome Measures: Patients had 6-week intervals of follow-up up to radiological union and once at 12 months after injury. The evaluation of clinical outcomes was determined by the Neer shoulder scoring system (maximum 100 points: pain 35, function 30, range of motion 25, anatomy 10). Radiological union, range of motion, and complications like infection, malunion, avascular necrosis, or implant failure were recorded.

Statistical analysis: All the available data were refined and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 26 in Windows format. Continuous variables were represented as mean, standard deviation, frequency, and percentages. The categorical variables were analyzed by comparing functional outcomes (Neer's scores) between conservative and surgical groups, which will be done using the independent t-test. Fisher's exact test where applicable) will be applied to categorical data such as complication rates. A p-value < 0.05 will be considered statistically significant.

A total of n=30 geriatric cases of Proximal Humerus Fractures were included in the study. The summary of the baseline demographic and clinical characteristics of the 30 patients studied is presented in Table 1. The mean age was 67.6 ± 4.2 years, and there was no significant age difference in the conservative and surgical groups. Most of them were 60-65 years old (40%), then 66-70 years old (30%), and 71-75 years old (30%). Male 56.7 percent of the cohort. The most frequent mechanism of injury was falls (60%), followed by road traffic accidents (40%). The right-sided injuries (53.3%) were a little more than the left-sided (46.7%). In the above classification, Neer's Classification was applied, and it was found that 3-part fractures were much more common in the surgical group (66.7% vs. 20%; p = 0.02).

Details of the surgical approach adopted in the cases of the study are given in Table 2. A critical analysis of the table shows that PHILOS plating (73.3%), then K-wire fixation (26.7%), was mostly used in the cohort. 50% of the patients reported within 2 days of injury, and the other half reported between 3 and 5 days, with no significant differences between groups, indicating access to care in a timely manner. This shows that there was a prompt presentation to the hospital after injury. The table also shows that PHILOS plate fixation was the standard surgical choice adopted in geriatric proximal humerus fractures at our tertiary care center.

Table 3 shows the results of the radiological outcome in the two groups of cases. 60% of cases showed union in 8 weeks, and union was more frequent in the surgical group (66.7% versus 53.3%) and those managed conservatively. In 2 patients, non-union was found (6.7%), both were in the surgical group. Fracture-type analysis showed faster union with conservative treatment in 2-part fractures, and faster union with surgery occurred in 3- and 4-part fractures. In particular, 4-part fractures treated surgically union occurred in 8 weeks, whereas those treated conservatively led to delayed union. These findings indicate that surgical care has the potential to provide faster recovery by healing more complex fractures, as simple fractures respond well to conservative therapy.

Table 4 describes complications recorded in the two groups of cases in the study. The overall complication rate was 30% of all patients. Conservative management was more commonly associated with varus malunion in 26.7% of cases, and surgical management showed higher rates of non-union, 13.3%. Surgical site infections were also found in 13.3% of cases, and implant failure occurred in one case. The remaining 70% of cases were without any complications, which shows the favourable outcome of our cohort. This shows that overall, both methods are effective provided the cases are selected carefully.

Table 5 shows the functional outcomes of the cohort using Neer’s criteria. Overall, we found 56.7% of cases achieved excellent results, and there was no difference between the conservative group and surgical group (53.3% vs 60%) and (p=0.72). Satisfactory outcomes by Neer's criteria were more common in conservatively treated cases compared to surgical cases (26.7% vs. 13.3%). Unsatisfactory results were found in 23.3% of cases, which were found to be slightly higher in the surgical group (26.7%), and (p = 0.65), therefore not significant. Finally, both the treatment methods provided acceptable functional recovery, although the surgical approach provided slightly better results for complex fractures. Therefore, it is important to apply an individualized treatment plan for each case based on the complexity of fractures. 

Proximal femur fractures (PHFs) occur more frequently in geriatric patients due to fragile bones. It accounts for about 5 – 6% of all fractures occurring in elderly patients [7]. The optimal management in such cases is a matter of debate, and both conservative management and surgical management are used based on the age of the patient, fracture type, bone quality, and functional demands [8, 9]. The current study was primarily designed to evaluate the functional and radiological outcome of conservative versus surgical management in geriatric patients (>60 years) with special attention to union rate, complications, and functional recovery. Fall was the most common injury mechanism in our cohort, and most of the patients were aged 60 to 70 years, as has already been reported that osteoporosis and low-energy trauma are among the most important risk factors [10]. The two groups were also well matched in terms of age and sex, reducing baseline bias. The majority of patients in our series were 60 – 70 years old, and the most frequent mechanism of injury was falls. Our results were consistent with previous studies, where they found osteoporosis and low-energy trauma are important risk factors for proximal humerus fractures in geriatric cases [10]. Our baseline data suggest that both groups of cases included in our study were well matched for age as well as sex distribution, and minimizing baseline bias (Table 1). The analysis of radiological outcomes of our cohort shows that 60% of cases achieved radiological union within 8 weeks following treatment, with a slight tendency to favor surgical management (66.7% vs. 53.3%) in the conservative group, although the values were not statistically significant. Fjalestad et al. [11] in a similar study have found that no significant differences in union time existed between surgically treated cases versus conservatively managed cases for displaced PHFs in the geriatric population. In our study, an analysis of fracture type found that simpler fractures (2-part) had healed better with conservative management. Whereas the three- and four-part fractures showed a faster union rate following surgical intervention. Our results were found to agree with those of Court-Brown et al. [12], where they found that fracture complexity is the primary factor in deciding the modality of treatment apart from other considerations.

The assessment of complications in this study found that surgically managed cases had 33.3% of complications as compared to the conservatively managed group with 26.7% of complications, although the differences were not statistically significant. Surgical complications included non-union, surgical site infections in 13.3% cases each, followed by implant failure in 6.7% cases. Conservatively managed cases showed varus malunion in all 26.7% of cases with no other complications reported (Table 4). Our findings are in concordance with those reported by the Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) trial, [13] where they found no significant differences in rates of complications between conservatively and surgically managed cases, although the profile of complications in the two groups remained distinct. On a functional level, the results of our cohort were found to be excellent by Neer's classification in 56.7% of the cases. The results were slightly better in the surgical group as compared to the conservative group for the excellent category (60% vs. 53.3%). This is consistent with a meta-analysis conducted by Launonen et al. [14], which did not reveal any obvious benefits of surgical intervention among elderly PHFs, particularly in less complex fractures. However, when it comes to three- and four-part fractures, surgical repair has been found to yield better results in terms of restoring their alignment and shoulder function [15]. The most common technique in our study was PHILOS plating, which is biomechanically stable and has the advantage of early mobilization [16].

One of the clinical implications of our research is the personalized treatment to be applied in each case. Conservative therapy is effective in cases of stable and minimally displaced fractures, whereas surgery is beneficial when the fracture is complicated and anatomical reduction and fixation could be difficult to achieve with conservative management, and such cases will benefit from surgical treatment and prevent the occurrence of long-term disability. Recent guidelines on management of proximal humerus fractures in the elderly have also suggested that a patient-specific approach will lead to better outcomes [17, 18]. As with other studies, our study also had limitations, which include a relatively modest sample size and short follow-up durations, which were due to constraints on the duration of the study. Therefore, such studies must be conducted in a larger population with multicentre findings and long-term follow-up to evaluate some of the late complications, such as avascular necrosis or post-traumatic arthritis. Despite these limitations, our findings support individualized decision-making in geriatric PHFs, balancing functional expectations, fracture morphology, and surgical risks.

Proximal humerus fractures (PHFs) are common in the geriatric population due to osteoporosis, and they present a unique challenge due to existing comorbidities and functional demands. Our study shows that conservative management provides satisfactory results in stable two-part fractures. Surgical intervention with PHILOS plating provides faster union and better functional outcomes in complex three- and four-part fractures. The assessment of complications showed that union occurred more commonly in conservatively managed groups, as infections and non-union were found in the surgically managed group, apart from implant-related complications. Therefore, an individualized treatment plan tailored to fracture type, patients' fitness, quality of bone, and functional expectations is essential. There is a need to conduct long-term studies with a larger sample size to further refine treatment guidelines.

1. Gerald R. Williams and Kirk L. Wong. Two-part and three-part fractures Management of proximal and distal humerus fracture. Orthop Clin North Am. Jan 2000; (1): 1-21.
2. Lind T, Kronerk, Jensen J. The epidemiology of fractures of proximal humerus. Arch Orthop Trauma Surg. 1989; 108: 285.
3. Lous U, Bigiliani, Chapter 9. The shoulder, Vol-1 Ed. Charles Rockwood, Frederick A. Fractures of proximal humerus. In Rockwood CA, Matsen. Philadelphia: W.B. Saunders, 1990: p. 278-334.
4. Scott E. Powell, Robert W. Chandler. Fractures of the proximal humerus. Chapter- 11, In: Text book of Operative techniques in upper extremity sports injuries. Ed. Frank W. Jobe, Mosby, 1995: p.313-340.
5. Zyto K. Non-operative treatment of communited fracture of proximal humerus in elderly patients. Injury, 1998; 29: 349-52.
6. Zyto K, Wallace WA, Frostick SP, Preston BJ. Outcome after hemiarthroplasty for three- and four-part fracture of the proximal humerus. J Shoulder Elbow Surg, 1998; 7: 85-89.
7. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006;37(8):691–7.
8. Handoll HH, Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;(11): CD000434.
9. Rangan A, Handoll H, Brealey S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037–47.
10. Kannus P, Palvanen M, Niemi S, et al. Epidemiology of osteoporotic humeral fractures in the elderly. Ann Intern Med. 2000;133(3):205–11.
11. Fjalestad T, Hole MO, Jorgensen JJ, Stromsoe K, Kristiansen IS. Health and cost consequences of surgical vs conservative treatment for a comminuted proximal humeral fracture in elderly patients. Acta Orthop. 2010;81(4):481–6.
12. Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humeral fractures. Acta Orthop Scand. 2001;72(4):365–71.
13. Rangan A, Brealey S, Keding A, et al. The PROFHER trial: A pragmatic multicentre randomized controlled trial of surgical vs non-surgical treatment of displaced proximal humeral fractures in adults. Health Technol Assess. 2015;19(24):1–280.
14. Launonen AP, Lepola V, Flinkkilä T, et al. Conservative treatment, plate fixation, or prosthesis for proximal humeral fracture: a prospective randomized study. Bone Joint J. 2015;97-B(12):1729–37.
15. Olerud P, Ahrengart L, Ponzer S, Saving J, Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20(5):747–55.
16. Südkamp N, Bayer J, Hepp P, et al. Open reduction and internal fixation of proximal humeral fractures with use of the locking proximal humerus plate. J Bone Joint Surg Am. 2009;91(6):1320–8.
17. Beks RB, Ochen Y, Frima H, et al. Operative vs nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. J Shoulder Elbow Surg. 2018;27(8):1526–34.
18. Gupta AK, Harris JD, Erickson BJ, et al. Surgical management of complex proximal humerus fractures. A systematic review of 92 studies including 4500 patients. J Orthop Trauma. 2015;29(1):54–59.