Consensus statement on the treatment of proximal humerus fractures: a Delphi approach by the Neer Circle of the American Shoulder and Elbow Surgeons.

BACKGROUND: The treatment of patients who sustain a proximal humerus fracture (PHF) remains controversial. The purpose of this study was to find consensus among experts using a validated iterative process in the treatment of patients after a PHF.

METHODS: The Neer Circle is an organization of shoulder experts recognized for their service to the American Shoulder and Elbow Surgeons. Consensus among 86 identified experts from this group was sought with a series of surveys using the Delphi process. The first 3 surveys included vignettes with 2-, 3-, and 4-part fractures, under 2 scenarios: (1) a healthy 55-year-old and (2) and a 75-year-old with significant medical comorbidities. Within each vignette, respondents were asked about their preference on computed tomography (CT) use, and whether they would select operative or nonoperative treatment. A final survey was administered to elicit respondent preferences on general treatment approaches regardless of specific vignette characteristics.

RESULTS: Consensus was reached on the value of CT scans with 3D reconstructions, age as an important factor in determining treatment, functional demand, fracture pattern, bone quality, and the presence of more significant medical comorbidities, all of which would strongly impact decision making. Experts agreed that medial calcar involvement would have no impact on their decision, and gender and nondominant arm involvement would have a low impact. Consensus was reached in the following scenarios for an operative treatment in a young and healthy patient: 2-part shaft fracture (vignette 3, 98%), 3-part varus fracture (vignette 5, 98%), 3-part valgus fracture (vignette 7, 98%), 4-part fracture (vignette 9, 100%), 4-part dislocation fracture (vignette 11, 98%), and 4-part valgus impacted fractures (vignette 13, 95%); for older unhealthy patients, in 4-part dislocation fractures (vignette 12, 100%). In the remainder of scenarios, there was no consensus reached for preferred treatment, either operative or nonoperative. Finally, there was no consensus on preferred rehabilitation protocols, whether for nonoperative management or postoperative care.

CONCLUSION: In conclusion, this study demonstrates that consensus when managing PHFs is limited to specific scenarios, whereas lack of consensus still exists in others. The presented study advocates nonoperative treatment of PHFs in the sicker patient and surgical treatment methods for 3-part and 4-part fractures in the young, healthy patient.