title: Factors associated with the decision for operative versus non-operative treatment of displaced proximal humerus fractures in the elderly.
abstract: BACKGROUND
  In the management of displaced proximal humerus fractures in the elderly, wide variation has been documented. However, no prior study has investigated the factors that currently lead surgeons to treat patients with surgical fixation, arthroplasty or non-operative management. The purpose of this study was to identify the factors associated with treatment selection in the management of displaced proximal humerus fractures in individuals over the age of 60 years. To this end, we conducted a retrospective review of all such injuries that presented to our two level-I trauma centres between 2006 and 2009.
  
  
  METHODS
  From our prospectively collected trauma database, we identified 229 displaced proximal humerus fractures that met all inclusion and exclusion criteria. Data were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for treatment. The choice of management was recorded, and logistic regression was used to identify factors associated with the decision for treatment.
  
  
  RESULTS
  In the multivariate analysis, the predictors of operative intervention as opposed to non-operative treatment were younger patient age (p = 0.038), associated orthopaedic injuries requiring surgery (p = 0.012), higher Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification (p = 0.012), translation-type displacement (p = 0.0012) and associated glenohumeral dislocation (p = 0.0006). In addition, shoulder and upper extremity specialists were found to choose operative intervention significantly more frequently than orthopaedic trauma specialists (49.1% vs. 26.1%, adjusted relative risk (RR) 1.96, p = 0.012). Factors associated with the decision for arthroplasty as opposed to fixation were higher Charlson score (p = 0.045), higher Neer classification (p = 0.012), and higher AO classification (p = 0.0097).
  
  
  CONCLUSIONS
  In this study of displaced proximal humerus fractures in the elderly, the decision for surgery was influenced by the patient's age, the presence of associated orthopaedic injuries, the severity of the fracture and the presence of an associated glenohumeral dislocation. In addition, treatment by a shoulder or upper extremity specialist (as opposed to an orthopaedic trauma specialist) was associated with a higher likelihood of operative intervention. Further investigation into the resultant clinical outcomes is required to determine whether the use of these characteristics to select operative candidates is appropriate and beneficial for patients.
authors.affiliation: Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, MA, USA. okike@post.harvard.edu
authors.forename: Kanu
authors.initials: K
authors.lastname: Okike
authors.forename: Olivia C
authors.initials: OC
authors.lastname: Lee
authors.forename: Heeren
authors.initials: H
authors.lastname: Makanji
authors.forename: Mitchel B
authors.initials: MB
authors.lastname: Harris
authors.forename: Mark S
authors.initials: MS
authors.lastname: Vrahas
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D001178:Arthroplasty / Q000379:methods*; D003657:Decision Making; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016059:Range of Motion, Articular; D020127:Recovery of Function; D012189:Retrospective Studies; D012784:Shoulder Fractures / Q000453:epidemiology / Q000534:rehabilitation / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology