Proximal Humerus Fracture in an Elderly Patient with a “Terrible Triad” and Comorbidity
A 76-year-old right-handed woman falls onto her outstretched arm and presents with a painful, swollen right shoulder. She has a history of a previous right shoulder dislocation 10 years ago, hypertension, and mild cognitive impairment. X-rays show a 4-part proximal humerus fracture with 45 degrees of varus angulation, a displaced greater tuberosity fragment, and a head that appears subluxated. CT confirms a head-split component and a displaced greater tuberosity. She lives with her daughter, is independent with a stick, and is on apixaban for AF (last dose 18 hours ago). She is in significant pain and the family asks whether she will regain use of her arm.
1. How do you classify this fracture, and what are the key prognostic factors for functional outcome?
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Classification: This is a 4-part proximal humerus fracture (Neer classification) - head, shaft, greater tuberosity, and lesser tuberosity all displaced. There is a head-split component on CT, which is a poor prognostic feature. The apparent subluxation raises concern for a fracture-dislocation, and the history of prior dislocation is relevant.
Key prognostic factors:
- Head-split component: high risk of avascular necrosis (AVN) and failure of fixation; often an indication for arthroplasty.
- Displacement and angulation: 45 degrees varus and displaced tuberosity increase nonunion/malunion risk.
- Age and bone quality: elderly, likely osteoporotic - fixation may fail.
- Comorbidity and cognition: mild cognitive impairment affects rehabilitation potential and compliance.
- Prior dislocation: may indicate capsulolabral damage and instability; also raises AVN risk.
- Vascular supply: the anterolateral ascending branch of the anterior circumflex is critical; disruption increases AVN risk.
- Patient factors: hand dominance, pre-injury function, social support, and expectations.
Counseling: be honest - functional recovery is uncertain, and the head-split makes AVN and reoperation more likely. Set realistic goals: pain relief, some functional range, and independence in ADLs.
2. Compare non-operative management, open reduction and internal fixation (ORIF), and arthroplasty (hemiarthroplasty vs reverse shoulder arthroplasty) for this patient, and justify your recommendation.
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Options:
- Non-operative: sling and early gentle mobilization. Avoids surgery but high risk of malunion, nonunion, stiffness, and poor function in a 4-part fracture with head-split. Suitable only for low-demand, medically unfit patients. This patient is independent with a stick, so non-operative is likely to leave her with a painful, stiff shoulder.
- ORIF (locking plate): preserves the head and tuberosities, but in a 4-part fracture with head-split and osteoporotic bone, the risk of AVN, screw cut-out, and failure is high. Elderly patients with head-split are poor candidates.
- Hemiarthroplasty: replaces the head; tuberosity healing is critical for function. In elderly patients with a head-split and displaced tuberosities, hemiarthroplasty has unpredictable results and high rates of tuberosity failure.
- Reverse shoulder arthroplasty (RSA): increasingly favored in elderly patients with 4-part fractures, especially with head-split or tuberosity compromise, because it does not depend on tuberosity healing or rotator cuff integrity for function. Good pain relief and reliable forward elevation.
Recommendation: For a 76-year-old with a 4-part fracture, head-split, and displaced tuberosity, I would recommend reverse shoulder arthroplasty (or hemiarthroplasty if RSA is unavailable), because fixation is likely to fail and hemiarthroplasty depends on tuberosity healing. RSA gives more predictable function in this age group. Non-operative management would likely leave her with a painful, stiff shoulder and loss of independence.
Caveat: consider her cognitive impairment and ability to participate in rehabilitation; RSA still requires some rehab but is more forgiving.
3. She is on apixaban and is 18 hours from her last dose. How do you manage the perioperative anticoagulation, and what are the ethical considerations in obtaining consent from a patient with mild cognitive impairment?
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Perioperative anticoagulation:
- Apixaban is a direct oral factor Xa inhibitor with a half-life of ~12 hours; 18 hours since last dose means residual effect is likely but declining. For major surgery, guidelines suggest stopping apixaban at least 48 hours before (longer if renal impairment) - she is earlier than ideal.
- Check renal function (eGFR) - apixaban clearance is renal; impaired renal function prolongs effect.
- Consider reversal if urgent surgery is needed: andexanet alfa (where available) or prothrombin complex concentrate (PCC). Fresh frozen plasma is less effective. Discuss with hematology/anesthesia.
- Bridging: for AF, bridging is generally not required for most procedures, but the team should weigh stroke risk (CHA2DS2-VASc) against bleeding risk.
- Timing: if surgery can wait 24–48 hours, do so with analgesia and sling immobilization; if the fracture is unstable or neurovascular compromise exists, proceed with reversal and accept bleeding risk.
- Post-op: restart apixaban once hemostasis is secure, usually 24–48 hours, per hematology/anesthesia.
Ethical considerations:
- Capacity: mild cognitive impairment does not automatically mean lack of capacity. Assess specifically for this decision - can she understand, retain, weigh, and communicate? Use a structured assessment and involve her daughter as a supporter.
- Best interests: if she lacks capacity for this decision, act in her best interests, considering her known wishes, values, and prior independence.
- Consent for arthroplasty should include risks: infection, dislocation, nerve injury, periprosthetic fracture, loosening, need for revision, and the possibility of incomplete functional recovery.
- Document the capacity assessment, the discussion, and who consented.
- Avoid paternalism: involve her as much as possible; her daughter should support, not replace, her decision-making where capacity exists.