Case Report - Volume 2 - Issue 2

Humerus fracture in an elder patient without movement disability. A case report

Maria Kampouraki1*; Christos Chatzis2 ; Maria Bakola3 ; Evelin Fachouri4 ; hrysanthi Tsiogia5 ; Georgia Kavakopoulou6 ; Konstantina Mavridou7 ; Konstantina-Soultana Kitsou8 ; Dimitris Karanasios9

1General Practitioner, Senior Consultant in Nea Madytos Health Center, Thessaloniki, Greece. email:
2General Practitioner, Senior Consultant in Nea Madytos Health Center, Thessaloniki, Greecee.
3Derviziana Primary Health Center,Ioannina, Greece.
4General Practitioner, Thessaloniki,Greecee.
5General Practitioner in Nea Madytos Health Center, Thessaloniki, Greece. email
6General Practitioner, in Nea Madytos Health Center, Thessaloniki, Greece.
7Department of Skin and Venereal diseases, University Hospital of Ioannina, Ioannina, Greece.
8Medical Schoool,University of Patras, Greece.
9Chief Director of New Madytos Health Center,General Practitioner / Family Doctor,President of HIPPOCRATES (Association of GP/FM in Greece), Thessaloniki, Greece. email:

Received Date : Mar 01, 2022
Accepted Date : Mar 31, 2022
Published Date: Apr 13, 2022
Copyright:© Kampouraki Maria 2022

*Corresponding Author : Kampouraki Maria, General Practitioner, Senior Consultant in Nea Madytos Health Center, Thessaloniki, Greece.


Α 75 years old patient visited the emergency department of a rural health center due to right shoulder pain after a severe fall occurred one year ago causing humerus fracture. Due to COVID-19 pandemic never showed his x-rays to a physician or visited another primary care setting. Describing his symptoms referred pain and movement disability only for the first 10 days after the fall, then recovery took another two weeks without immobilization in a sling or physiotherapy. Regarding this case report there is a huge heterogeneity in humerus treatment especially in elder population without specific recommendations for the proper procedure.


Humerus fractures are common osteoporotic fractures in the elderly .The majority of the fractures are minimally displaced and respond acceptably to non operative management [1]. An assessment of the patient’s bone quality, social independence, and surgical risk factors is needed [1]. It is referred that social independence is a predictor of outcome, whereas age is not [1].Due to the unclear evidence-based treatment of choice the surgeon should consider the comfort level with the specific procedures in order to choose [1].

 Humerus fractures account for 6% of all fractures in the Western world [2]. Around 85% occur in people older than 50, and the incidence peaks in the 60- to 90-year-old age-group with a female to male ratio of 70:30 [2].The anatomy of the area helps stabilizing the shoulder due to tendons that produce reliable deforming forces on bone fragments [3]. The glenohumeral joint is stabilized by the articular cartilage, labrum, ligaments, rotator cuff, and deltoid [3]. Most humeral heads have a diameter between 4 and 5 cm, and the head is slightly offset medially and posteriorly in relation to the humeral shaft [3]. The pectoralis major tendon inserts 5 to 6 cm from the top of the humeral head, which is a tool for estimating prosthetic stem length in severe fractures without landmarks [4]. Humeral shortening greater than 1cm can impair deltoid function, whereas humeral lengthening and retroversion can impair tuberosity healing [4].The supraspinatus and teres minor insert on the greater tuberosity and produce a posterosuperior deformity [4]. The subscapularis inserts on the lesser tuberosity and produces medial deformity [4]. The pectoralis major inserts into the medial humeral shaft and deforms medially, while the deltoid inserts into the lateral humerus and deforms laterally [5].The most commonly injured nerves in descending order are the axillary, suprascapular, radial, musculocutaneous, median, and ulnar nerves [6]. These are most commonly traction injuries that fully recover [6].

There is a widely used classification for humerus fractures (Neer classification) based on 4 fracture parts: the greater tuberosity, the lesser tuberosity, the humeral head, and the humeral shaft [7]. A full description of the classification and its subtypes can be found in an article by Carofino and Leopold [7]. A fragment is considered displaced if it is separated more than 1 cm or angulated more than 45 but there is no evidence-based indication for this definition of displacement [8].Outcomes and rates of rotator cuff injury correlate with the classification [8].

Case presentation

A 75 years old male patient with hypertension known from his medical history visited the emergency department of our rural health center because he felt pain in the right shoulder. He referred a fall a year ago with severe pain and movement disability for the first two weeks. He was never examined for osteoporosis and never immobilized after the accident the shoulder with a sling or visited a physiotherapist or a physician. The past x-rays showed right humerus fracture while the present did not. There was a full recovery without any special treatment or medical advice. The patient referred that due to COVID-19 pandemic did not visited a medical center or other primary care setting. He was advised to visit an orthopedic specialized in shoulder pain rehabilitation but the patient denied. He was also advised to be examined for osteoporosis.

Figure 1: Presents the humerus fracture after the fall a year ago.

Figure 2: Presents the humerus bone, fully recovered.

There are not specific recommendations for humerus fracture treatment especially in elder patients. There is a lot of debate whether should the fracture surgically be repaired or conservatively. This unique case report that the patient experienced no severe pain or movement disability (there was no fragment displacement though) two weeks after the fall helps to conduct the conclusion that for elder patients conservative treatment may be cost effective for health systems.


The main finding of Heath Technology Assessment (HTA), which is a scientific methodology used to gather and summarize scientific data to influence clinical decision making on the use of health technologies, for measuring the effectiveness of humerus treatment is that there was no proven benefit with surgical intervention of moderately displaced humerus fractures compared to non-operative treatment with immobilization in a sling [9]. Moreover, the health economic evaluation showed that surgical treatment of a proximal humeral fracture was considerably more expensive (USD 3478 to USD 7688) than non-operative treatment9. Many areas under investigation in this HTA analysis lacks sufficient scientific data to express any certitude regarding efficacy, effectiveness, complications and cost-effectiveness [9].

In addition Launonen et al., found no benefit of surgical treatment in patients over 60 years of age, with 3- or 4-parts fracture as compared to non-surgical treatment [10]. Instead they found more complications in the group of surgically treated patients than in the non-operative group [10]. Equal findings regarding functional outcome and complications were reported in a systematic review by Beks et al., 2018 [11]. Indicators of physiologic age are bone quality and social independence, which is more important than chronologic age when weighing treatment options [1]. In a prospective study of 30 patients, nearly 40% of proximal humerus fractures were associated with rotator cuff tears [12]. Functional loss correlated with tears at the time of injury [13].

Regarding outcomes between elderly patients and younger patients following surgical fixation of humerus fractures there is no significant difference [14-16].A study of 637 proximal humerus fractures showed that social independence, not age, was a predictor of outcome [17]. There is a 2012 Cochrane review of 23 randomized controlled trials with significant heterogeneity among studies [18] supporting what already mentioned before that there is insufficient evidence to provide individual recommendations for humerus fractures proper treatment. In general, minimally displaced fractures, poor surgical candidates, and low demand patients are treated conservatively [1]. Displaced, comminuted, or angulated fractures occurring in good surgical candidates are treated with percutaneous techniques, intramedullary nailing, plating, or arthroplasty [1]. Around 50% to 65% of all humerus fractures are minimally displaced fractures of the greater tuberosity and/or surgical neck that respond well to nonoperative management [19]. On the other hand for displaced fractures fixation with percutaneous techniques, intramedullary nails, locking plates, and arthroplasty are all acceptable treatment options [1].

The few studies that have been published about the proper treatment and outcomes regarding to humerus fracture have had short time perspectives and showed conflicting results [20-22]. This underlines the need for more well-designed cost-effectiveness studies [9]. It is preferable instead of prolonged hospital stays, home care and short time stays in home for the elderly in contrast to younger population that rehabilitation costs may be a higher priority [9]. It seems controversial that the incidence of expensive fracture surgery is increasing despite the lack of scientific evidence of its effectiveness [9]. A British study showed that a great amount of resources could be saved if non-operative treatment is chosen instead [23]. In addition over the past decade, most of older adults with proximal humerus fractures continue to receive non operative treatment [24].

Acknowledgments: For this case report there was no funds or grant from any source.


  1. Schumaier A, Grawe B. Proximal Humerus Fractures: Evaluation and Management in the Elderly Patient. Geriatr Orthop Surg Rehabil. 2018; 9:2151458517750516. [DOI:10.1177/2151458517750516].
  2. Calvo E, Morcillo D, Foruria AM, Redondo-Santamaría E, Osorio-Picorne F, Caeiro JR. Nondisplaced proximal humeral fractures: high incidence among outpatient-treated osteoporotic fractures and severe impact on upper extremity function and patient subjective health perception. J Shoulder Elbow Surg. 2011; 20(5):795-801. [DOI:10.1016/j.jse.2010.09.008].
  3. Boileau P, Walch G. The three-dimensional geometry of the proximal humerus. J Bone Joint Surg Br. 1997; 79-B(5):857-865.
  4. Murachovsky J, Ikemoto RY, Nascimento LGP, Fujiki EN, Milani C, Warner JJP. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral length with hemiarthroplasty for fracture. J Shoulder Elbow Surg. 2006; 15(6):675–678. [DOI:10.1016/j.jse.2005.12.011].
  5. McLaurin TM. Proximal humerus fractures in the elderly are we operating on too many? Bull Hosp Jt Dis N Y N. 2004; 62(1-2):24-32.
  6. Visser CP, Coene LN, Brand R, Tavy DL. Nerve lesions in proximal humeral fractures. J Shoulder Elbow Surg. 2001; 10(5):421-427. [DOI:10.1067/mse.2001.118002].
  7. Carofino BC, Leopold SS. Classifications in brief: the Neer classification for proximal humerus fractures. Clin Orthop. 2013; 471(1):39-43. [DOI:10.1007/s11999-012-2454-9].
  8. Gallo RA, Sciulli R, Daffner RH, Altman DT, Altman GT. Defining the relationship between rotator cuff injury and proximal humerus fractures. Clin Orthop. 2007; 458:70-77. [DOI:10.1097/BLO.0b013e31803bb400].
  9. Mellstrand Navarro C, Brolund A, Ekholm C, et al. Treatment of humerus fractures in the elderly: A systematic review covering effectiveness, safety, economic aspects and evolution of practice. PLoS One. 2018; 13(12):e0207815. [DOI:10.1371/journal.pone.0207815].
  10. Launonen AP, Lepola V, Flinkkila T, Laitinen M, Paavola M, Malmivaara A. Treatment of proximal humerus fractures in the elderly: a systemic review of 409 patients. Acta orthopaedica. 2015; 86(3):280-5. [PMCID: PMCPMC4443467 DOI:10.3109/17453674.2014.999299].
  11. Beks RB, Ochen Y, Frima H, Smeeing DPJ, van der Meijden O, Timmers TK, et al. Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al.]. 2018. [DOI:10.1016/j.jse.2018.03.009].
  12. Gallo RA, Sciulli R, Daffner RH, Altman DT, Altman GT. Defining the relationship between rotator cuff injury and proximal humerus fractures. Clin Orthop. 2007; 458:70-77. [DOI:10.1097/BLO.0b013e31803bb400].
  13. Fjalestad T, Hole MØ, Blücher J, Hovden IAH, Stiris MG, Strømsøe K. Rotator cuff tears in proximal humeral fractures: an MRI cohort study in 76 patients. Arch Orthop Trauma Surg. 2010; 130(5):575-581. [DOI:10.1007/s00402-009-0953-2].
  14. Grawe B, Le T, Lee T, Wyrick J. Open reduction and internal fixation (ORIF) of complex 3- and 4-part fractures of the proximal humerus: does age really matter? Geriatr Orthop Surg Rehabil. 2012; 3(1):27-32. [DOI:10.1177/2151458511430662].
  15. Hinds RM, Garner MR, Tran WH, Lazaro LE, Dines JS, Lorich DG. Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation. J Shoulder Elbow Surg. 2015; 24(6):889–896. [DOI:10.1016/j.jse.2014.10.019].
  16. Goch AM, Christiano A, Konda SR, Leucht P, Egol KA. Operative repair of proximal humerus fractures in septuagenarians and octogenarians: does chronologic age matter? J Clin Orthop Trauma. 2017; 8(1):50–53. [DOI:10.1016/j.jcot.2017.01.006].
  17. Clement ND, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of proximal humeral fractures in the elderly: predictors of mortality and function. Bone Joint J. 2014; 96-B(7):970-977. [DOI:10.1302/0301-620X.96B7.32894].
  18. Handoll HHG, Ollivere BJ, Rollins KE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2012; 12:CD000434. [DOI:10.1002/14651858.CD000434.pub3].
  19. Bergdahl C, Ekholm C, Wennergren D, Nilsson F, Möller M. Epidemiology and patho-anatomical pattern of 2,011 humeral fractures: data from the Swedish Fracture Register. BMC Musculoskelet Disord. 2016; 17:159. [DOI:10.1186/s12891-016-1009-8].
  20. Corbacho B, Duarte A, Keding A, Handoll H, Chuang LH, Torgerson D, et al. Cost effectiveness of surgical versus nonsurgical treatment of adults with displaced fractures of the proximal humerus: Economic evaluation alongside the profher trial. Bone and Joint Journal. 2016; 98B(2):152-9. [PMID: 20160156676; PMCID: PMC26850418].
  21. Nwachukwu BU, Schairer WW, McCormick F, Dines DM, Craig EV, Gulotta LV, et al. Arthroplasty for the surgical management of complex proximal humerus fractures in the elderly: A cost-utility analysis. Journal of Shoulder and Elbow Surgery. 2016; 25(5):704-13. [PMID: 20160224309 DOI:10.1016/j.jse.2015.12.022].
  22. Fjalestad T, Hole MO, Jorgensen JJ, Stromsoe K, Kristiansen IS. Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients. Injury. 2010; 41(6):599-605.
  23. Dean BJ, Jones LD, Palmer AJ, Macnair RD, Brewer PE, Jayadev C, et al. A review of current surgical practice in the operative treatment of proximal humeral fractures: Does the PROFHER trial demonstrate a need for change? Bone & joint research. 2016; 5(5):178-84. [PMCID: PMCPMC4921043. DOI:10.1302/2046-3758.55.2000596].
  24. Patel AH, Wilder JH, Ofa SA, et al. Trending a decade of proximal humerus fracture management in older adults. JSES Int. 2021; 6(1):137-143. [DOI:10.1016/j.jseint.2021.08.006].