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. 2024 Dec 9;59(3):346–357. doi: 10.1007/s43465-024-01301-5

Proximal Humerus Fractures in the Elderly

Shailesh Pai 1,✉, Mohamed Faheem Kotekar 1, Siddharth M Pawaskar 1, M Ajith Kumar 1
PMCID: PMC11973005  PMID: 40201915

Abstract

Introduction

Proximal humerus fractures are the second most common upper limb injury among the elderly, with a notable increase in incidence attributed to osteoporosis. This chapter addresses the complexities involved in managing these fractures, particularly in older patients who may have unique challenges and risks.

Methods

A review of current management strategies for proximal humerus fractures in elderly patients was conducted, focusing on both conservative and surgical approaches. Conservative management was evaluated for its efficacy in treating minimally displaced fractures, especially in patients with lower functional demands or those unfit for surgical intervention. Surgical options, including open reduction and internal fixation (ORIF) with locking plates (PHILOS) and newer intramedullary nail designs (MULTILOC), were also examined. Additionally, minimally invasive techniques such as Resch and MIROS were considered for high-risk surgical candidates.

Discussion

Conservative management, while often preferred, carries potential complications such as malunion, nonunion, and stiffness, which can adversely affect patient outcomes. Surgical intervention is frequently required for displaced or complex fractures, with ORIF being the gold standard due to its ability to provide stability and enhance outcomes in osteoporotic bone. The introduction of innovative intramedullary nail designs and minimally invasive techniques offers promising alternatives, particularly for patients at high surgical risk, by reducing soft tissue disruption and facilitating quicker recovery.

Conclusion

Effective management of proximal humerus fractures in the elderly requires a tailored approach, balancing the benefits and risks of conservative versus surgical treatment. Ongoing advancements in surgical techniques and devices hold the potential to improve outcomes for this vulnerable population, emphasizing the importance of individualized care in fracture management.

Keywords: Proximal humerus fractures, Osteoporosis, Conservative management, PHILOS, MULTILOC nail, Reverse shoulder arthroplasty (RSA)

Introduction

Fractures of the proximal humerus are common injuries, accounting for approximately 10% of all fractures that happen in individuals aged 65 years or older [1, 2]. The incidence of these fractures increases significantly with advancing age, especially in women, due to the increased prevalence of osteoporosis in elderly females [3, 4]. Low-energy trauma such as falling from a standing height is the most common mechanism of injury for these fractures. In addition to the injury, poor bone quality has an influence on both the treatment strategies and the healing process [5, 6]. Management of these injuries in the elderly population becomes challenging due to the decreased bone quality and more complex fracture patterns, as these will hinder optimal outcomes, whether treated nonoperatively or surgical [7, 8].

The key objectives in the treatment of proximal humerus fractures are restoring shoulder function, alleviating pain, and preventing long-term complications such as malunion, nonunion, and stiffness [9, 10]. Treatment strategies range from conservative management for non-displaced fractures to surgical interventions, such as open reduction and internal fixation (ORIF) or shoulder arthroplasty, for displaced complex fractures [11, 12]. This study will discuss in detail the various treatment modalities, the challenges specific to managing these fractures, and strategies to enhance patient outcomes in elderly populations.

Epidemiology and Risk Factors

Proximal humerus fractures are common in the elderly population, with a notably higher incidence in women due to postmenopausal osteoporosis [2, 5]. The risk of sustaining these fractures escalates with age, making individuals over 65 the most affected demographic group [4, 6]. Elderly women represent 70% of cases, largely attributed to the higher prevalence of osteoporosis, which compromises bone strength and increases their susceptibility to fractures from low-energy trauma, such as falls [11].

Several risk factors contribute to proximal humerus fractures, including osteoporosis, advanced age, and a history of falls [12]. Osteoporosis significantly decreases bone strength, resulting in fractures that are sustained with minor trauma [7, 11]. In this age group, falls are more common due to impaired balance, muscle weakness, and visual impairments, which further heighten the risk of injury [13, 14]. Comorbidities such as diabetes, cardiovascular disease, and impaired mobility also increase the likelihood of fractures within this population [12, 15].

An analysis by Chesser et al. [16] highlighted treatment practices for displaced proximal humeral fractures in the elderly, which showed the predominance of conservative management within UK trauma units at that time. Gormeli et al. [17] illustrated that locking plate fixation, particularly for elderly patients with displaced fractures, yielded better outcomes, even in osteoporotic bone.

History of Proximal Humerus Fracture Treatment in the Elderly

The management of these fractures has seen considerable advancements over the past century. Initially, these fractures were predominantly treated with conservative measures, as non-surgical methods were the standard of care, due to the frailty of elderly patients and the limited availability of effective surgical techniques [18, 19]. During the early twentieth century, treatment involved immobilization in slings or shoulder immobilizers, followed by gradual mobilization through pendulum exercises [20, 21]. However, outcomes were frequently unsatisfactory for displaced fractures, often resulting in malunions and shoulder stiffness [22].

By the mid-twentieth century, improvements in surgical techniques and anesthesia facilitated a broader adoption of operative management, especially in younger patients or those with higher functional demands [9, 23]. Despite the medical advancements and increasing lifespan, the issue of osteoporotic bone in elderly patients often rendered fixation methods unreliable, leading to common complications like screw pull-out and nonunion [24].

The introduction of Neer’s classification system in the 1960s marked a pivotal moment in the assessment and management of these fractures. This classification system provided a structured framework for evaluating fracture severity and guiding treatment options [18].

Later, with the advent of angular stable locking systems, such as the PHILOS, the surgical treatment of these fractures was revolutionized. Locking plates allowed screws to securely lock into the plate, forming a fixed-angle construct. This construct was less dependent on bone quality and had an advantage in these osteoporotic bones [25, 26]. More recently, reverse shoulder arthroplasty (RSA), which emerged in the early 2000s, has become a preferred surgical option for elderly patients with complex fractures and rotator cuff deficiencies. RSA addresses rotator cuff dysfunction by using the deltoid muscle to restore shoulder function, leading to better outcomes in patients with severe fractures or soft tissue damage [27, 28].

Currently, treatment is highly personalized, with both conservative and surgical options considered based on the patient’s overall health, the complexity of the fracture, and their functional requirements. Innovations such as the PHILOS plate, MULTILOC nail, and RSA have broadened treatment possibilities; however, challenges, including osteoporosis and the risk of complications such as nonunion and avascular necrosis (AVN), highlight the need for refinement in these surgical techniques [25, 27–30].

Classification of Proximal Humerus Fractures

Classification systems for proximal humerus fractures are vital for guiding treatment decisions and predicting patient outcomes. The two most commonly utilized classification systems are the Neer classification and the AO/OTA classification, which assess the complexity and displacement of fracture fragments. These systems enable surgeons to evaluate fracture severity and determine the most appropriate management strategy, whether conservative or surgical[18, 19].

Neer Classification

The Neer classification system, introduced by Charles Neer in 1970, is based on the displacement of four key anatomical segments of the proximal humerus (Fig. 1):

  1. the humeral head,

  2. the greater tuberosity,

  3. the lesser tuberosity,

  4. the humeral shaft.

Fig. 1.

Fig. 1

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The four anatomical segments of the proximal humerus

In the original description, a fracture was classified as displaced if there was more than 1 cm of separation or greater than 45 degrees of angulation between the fragments. The Neer classification divides fractures into two-part, three-part, and four-part categories, depending on the number of displaced fragments. Its prevalence patterns are shown in Table 1. This classification is particularly useful as it correlates fracture complexity with the risk of complications such as avascular necrosis (AVN), nonunion, and functional impairment [18, 25, 26].

Table 1.

Neer classification and prevalence patterns

graphic file with name 43465_2024_1301_Tab1_HTML.jpg

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Two-part fractures: These involve the displacement of one of the four major anatomical segments, typically the surgical neck or the greater tuberosity. They are the simplest type of fractures and often have favorable outcomes with either conservative treatment or ORIF, depending on the patient’s overall health and functional needs [22].

Three-part fractures: These involve the displacement of two anatomical segments, usually the humeral head along with either the greater or lesser tuberosity. These fractures are more complex and carry a higher risk of AVN and nonunion, particularly in elderly patients with osteoporosis. Surgical management is often indicated [25].

Four-part fractures: These are the most complex type of proximal humerus fractures, involving the displacement of all four major anatomical segments. Such fractures pose a significant concern due to their high risk of AVN, resulting from the disruption of the blood supply to the humeral head [18, 24]. Based on the patients’ quality of life and activity level, and the surgeon’s expertise, treatment is prescribed. Results are often equivocal with both operative and nonoperative methods in these four-part fractures [27, 28, 31].

The Neer classification is particularly effective in guiding decisions regarding the necessity of surgical intervention. For instance, non-displaced two-part fractures may be managed conservatively, while three- and four-part fractures typically require surgical treatment to restore function and prevent complications [9].

Hertel et al. also described patterns which had a higher risk of AVN. Disruption of medial hinge, calcar segment shorter than 8 mm, and a fracture of the anatomical neck gave a positive predictive value of 0.97 [32].

HGLS Classification

HGLS classification (binary LEGO system) by Hertel et al. describes proximal humerus fractures based on the four anatomical segments as described by Neer and where the fracture line crosses these fragments. There are 12 different fracture types according to Hertel. As shown in Fig. 2, this classification includes six different types of two-part fractures, five different types of three-part fractures, and one type of four-part fracture [33].

Fig. 2.

Fig. 2

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The Lego classification by Hertel et al. The four fragments are the humeral head (red), greater tuberosity (blue), lesser tuberosity (yellow), and the shaft of the humerus (green). The various combinations of fracture patterns are shown

AO/OTA Classification

The AO/OTA classification system is another widely employed method for classifying proximal humerus fractures. This classification offers a detailed and systematic approach based on the involvement of the articular surface and the extent of comminution. The AO/OTA classification divides proximal humerus fractures into three main types, with each type further subdivided according to fracture complexity [23, 24].

Type A: These are extra-articular fractures. Type A fractures typically affect the surgical neck and are considered less complex. They can be managed conservatively if there is minimal displacement, or treated with ORIF if significant displacement is present [24, 26].

Type B: These are partial articular fractures. Type B fractures frequently involve either the greater or lesser tuberosity and are more complex than Type A fractures. Surgical intervention is often required to restore normal shoulder mechanics, particularly if the greater tuberosity is displaced [23].

Type C: These are complete articular fractures, where the humeral head is entirely separated from the shaft. Type C fractures are often comminuted and carry a higher risk of AVN and nonunion. Surgical intervention, ORIF or arthroplasty, is usually necessary to restore function [24, 26, 27, 34].

The AO/OTA classification system is useful for surgical planning, as it provides in-depth details on fracture morphology and the degree of comminution. This classification is valuable in cases involving the articular surface, as it helps predict the likelihood of post-traumatic arthritis and guides the selection of appropriate surgical approaches [23, 34].

Investigations

The assessment of proximal humerus fractures in elderly patients has two objectives.

  1. To identify the fracture pattern.

  2. To assess the bone quality and degree of osteoporosis.

This necessitates imaging techniques to guide treatment and improve outcomes, particularly in those with osteoporotic bone. Radiographs serve as the primary imaging modality for evaluating the fracture. Standard radiographic views include anteroposterior (AP), scapular Y, and axillary lateral views of the shoulder [5, 6, 13]. The AP view provides a comprehensive overview of the fracture and its alignment, while the scapular Y view is essential for assessing the relationship between the humeral head and the glenoid, especially in dislocation cases [12]. The axillary lateral view is critical for evaluating the alignment of the humeral head with the glenoid and is particularly useful in cases of fracture–dislocation or significant displacement. The Velpeau view can also be done, which could detail the fracture personality without the need to move the injured arm (Fig. 3).

Fig. 3.

Fig. 3

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Radiographs of shoulder AP and Velpeau lateral views in a 75-year-old female with proximal humerus fracture

For more complex fractures, particularly those involving multiple fragments or the articular surface, computed tomography (CT) scans may be required. CT imaging provides three-dimensional reconstructions of the fracture, offering a more detailed understanding of the fracture pattern and the degree of comminution [6, 13, 34]. The head split fractures which can easily be missed out on plain radiographs could be picked up on CT (Fig. 4). This information is invaluable for preoperative planning, aiding in the selection of surgical approaches and fixation techniques.

Fig. 4.

Fig. 4

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A head split pattern in the humeral head

In elderly patients suspected of having osteoporosis, dual-energy X-ray absorptiometry (DEXA) is recommended to assess bone mineral density, which is essential for managing the fracture and preventing future injuries [6, 7].

In cases with potential vascular compromise or when detailed information regarding soft tissue damage is necessary, magnetic resonance imaging (MRI) or angiography is indicated. MRI is particularly beneficial for evaluating the integrity of the rotator cuff, especially in patients with pre-existing conditions or when planning for shoulder arthroplasty [6, 28, 29].

Management Options

The management of proximal humerus fractures in elderly patients requires a careful evaluation of fracture type, the patient's functional demands, comorbidities, and the overall health status. The primary goals of treatment are to restore function, alleviate pain, and minimize complications such as malunion, nonunion, and avascular necrosis (AVN). Management strategies could be broadly classified into two main approaches: conservative treatment and surgical intervention.

Conservative treatment is mostly reserved for non-displaced or minimally displaced fractures, especially in elderly patients with low functional demands or those patients who are unfit for surgery [35–37]. Surgical intervention is generally indicated for displaced or multi-part fractures, where conservative management is unlikely to restore adequate function [9, 22]. The treatment considerations are usually individualized in these elderly patients weighing the merits and demerits of each option. A dislocated humeral head and grossly displaced greater tuberosity could be considered relative contraindication for conservative options, especially if the patient is not unfit for surgical procedure.

Nonoperative Management

Patients with severe osteoporosis may also be poor candidates for surgical intervention, as the poor bone quality compromises the quality of implant purchase, thereby increasing the risk of fixation failure [11, 15]. The focus of conservative treatment is to allow the fracture to heal naturally in an acceptable alignment, thereby maintaining as much shoulder function as possible [22, 35] (Fig. 5).

Fig. 5.

Fig. 5

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Valgus impacted proximal humerus fracture managed conservatively

Initially, the shoulder is typically immobilized in a sling for a period of 2–3 weeks to aid fracture stabilization and reduce pain. Pain management, often involving nonsteroidal anti-inflammatory drugs (NSAIDs), is usually used during this phase. Early mobilization is also essential to prevent shoulder stiffness. After the initial immobilization period, passive mobilization exercises without active abduction of the shoulder, such as pendulum exercises, are introduced to maintain movement while avoiding excessive stress on the fracture site. This is encouraged within the sling. After 3 weeks, the rehabilitation is focused on the restoration of range of motion and strength through physical exercises [35–38].

While conservative management does avoid the risks associated with surgery, it is fraught with potential complications like malunion, nonunion, and shoulder stiffness [10–12]. Malunion, especially those involving the greater tuberosity, can lead to functional limitations, while nonunion can result in chronic pain and may require secondary surgical intervention. Shoulder stiffness, a frequent complication, can significantly impact a patient’s ability to perform daily routine activities which could be debilitating to these elderly individuals. This would often require prolonged physical therapy [9, 24, 25]. Progress in functions and relief from pain may occur up to 6 months following the injury. Zyto [39] studied the conservative treatment of comminuted proximal humerus fractures in elderly patients, concluding that while nonoperative methods can negate surgical risks, they often result in significant malunion and suboptimal functional outcomes. Malunion is inevitable when these fractures are treated nonoperatively. However, satisfactory patient-reported outcomes may be obtained due to the limited needs of the elderly patients suffering these fractures.

The success of conservative management requires frequent monitoring of the healing process and ruling out secondary displacements in the alignment through regular radiographic imaging and timely initiation of rehabilitation. In instances where complications arise or conservative treatment is insufficient, a switch to surgical intervention may be required [22, 25].

Surgical Management

The grossly displaced and/or dislocated humeral heads will require surgical intervention in most cases. The primary objectives are to restore anatomical alignment, stabilize the fracture, and initiate early mobilization, thereby reducing the risk of complications such as stiffness, malunion, or nonunion. Fixation failure of implants due to the reduced quality of purchase in these osteoporotic bones is a high risk. But modern techniques with improvements in the implant designs do address these challenges effectively [9, 24–26].

ORIF with Locking Plate—PHILOS Plate

Open reduction and internal fixation (ORIF) using the PHILOS plate is considered a gold standard in managing displaced proximal humerus fractures. The PHILOS plate provides angular stability through the use of locking screws, creating a stable construct that distributes forces evenly across the bone, providing advantage in patients with osteoporotic bone, where traditional screws may fail. The plate is anatomically contoured to fit the proximal humerus, minimizing soft tissue irritation, and allows for multi-directional screw placement to stabilize complex fractures involving the humeral head and tuberosities [25, 26, 34] (Fig. 6).

Fig. 6.

Fig. 6

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A proximal humerus fracture fixed with a PHILOS plate

Augmentations that may be Considered in Osteoporotic Bones

The variable-angle locking plates aids the surgeon to direct screws toward the better bone stock which gives better anchorage compared to fixed-angle screws, which may end up in bone voids. Cement-augmented screws may be considered to enhance the stability and have better pull-out resistance, thereby reducing fixation failures. In cases of medial column comminution or weakness, additional support may be provided using medial calcar screws or a fibular strut graft to prevent varus collapse [34]. With these techniques, the PHILOS plate has demonstrated good functional outcomes and reduced implant failure rates in elderly patients with complex fractures.

Complications and Outcomes

Complications with the use of the PHILOS plate include screw penetration into the joint, which can lead to cartilage damage, pain leading to reduced range of movements, and potential arthritis. Varus collapse is another risk due to poor stability. Screw cut outs may occur due to the poor purchase of the implant. Surgical site infection should also be considered especially in patients with uncontrolled diabetes and those with chronic renal failure or compromised immune systems. Axillary nerve is at risk if a trans-deltoid surgical approach is used.

ORIF with Intramedullary Nail

Open reduction and internal fixation (ORIF) using intramedullary nailing using the newer nail design (MULTILOC nail) represents another effective surgical option for the treatment of proximal humerus fractures, especially two-part fractures involving the surgical neck. Intramedullary nailing offers a minimally invasive alternative to locking plates, allowing for fracture stabilization with reduced disruption of soft tissues. The MULTILOC humerus nail is designed to provide multiplanar fixation, enhancing stability in the osteoporotic bone and has shown promising results in the treatment of complex fractures such as three- and four-part fractures too [29, 30, 40]. The straight nail design with an anchoring point in the humeral head is able to overcome the varus deforming forces. This design offers both angular stability and rotational control, which are crucial in osteoporotic bone, where traditional intramedullary nails may fail to maintain fixation [29, 30]. The minimally invasive nature of this procedure also allows for quicker recovery and less postoperative pain, making it an appealing option for elderly patients with surgical neck fractures [32, 39] (Fig. 7).

Fig. 7.

Fig. 7

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A proximal humerus fracture (AP, internal rotation and external rotation AP views) fixed with a MULTILOC nail

Complications and Outcomes

Iatrogenic complications associated with intramedullary nailing include the potential for rotator cuff damage, particularly if the entry point is not chosen carefully. The MULTILOC nail is designed to mitigate this risk by utilizing a more anatomically favorable medial entry point; however, improper technique can still lead to rotator cuff injury, resulting in pain and functional impairment.

Shoulder Arthroplasty

In situations where fracture fixation is not feasible due to poor bone quality or complex fracture patterns where the head cannot be reconstructed, or in delayed presentations, shoulder arthroplasty becomes the preferred surgical intervention. Two primary types of arthroplasty are commonly utilized in the management of these injuries: hemiarthroplasty and reverse shoulder arthroplasty (RSA).

Hemiarthroplasty

Hemiarthroplasty is typically indicated for elderly patients with low functional demand and complex fractures that are unsuitable for fixation, but where the rotator cuff is intact (Fig. 8). This procedure provides significant pain relief and restores some shoulder function; however, outcomes are heavily influenced by the integrity of the rotator cuff. The anatomical healing of the greater tuberosity also is essential for good outcomes. In cases with pre-existing rotator cuff degeneration, functional outcomes may be poor, and hemiarthroplasty may not lead to the desired improvement in shoulder function although pain relief is achieved [27, 41–43].

Fig. 8.

Fig. 8

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A hemireplacement arthroplasty

Reverse Shoulder Arthroplasty (RSA)

Reverse shoulder arthroplasty (RSA) is increasingly employed for elderly patients with complex fractures or those with compromised rotator cuff function (Fig. 9). Initially developed to treat rotator cuff arthropathy, RSA has emerged as a reliable alternative for managing fractures that are too complicated for conventional fixation or where rotator cuff damage is significant. The patient achieves a considerably higher range of movements when compared to hemiarthroplasty and is not dependent on the integrity of the rotator cuff or the healing of tuberosities [42]. This is also beneficial in those patients who had a preexisting painful shoulder due to arthritis. It is also the preferred option in situations where previous fixation surgeries have failed, or complications such as nonunion, malunion, or implant failure have occurred [42, 44].

Fig. 9.

Fig. 9

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Intraoperative imaging for reverse shoulder arthroplasty

Reuther et al. [45] compared the functional outcomes between shoulder hemiarthroplasty and RSA, demonstrating that RSA provides superior results in terms of restoring shoulder elevation and reducing pain in cases of displaced proximal humerus fractures. Grubhofer et al. [46] studied RSA outcomes in patients with nonunion following surgical neck fractures, revealing that RSA not only alleviated pain, but also significantly improved function. Cazeneuve and Cristofari [47] reported favorable results with the Grammont reverse shoulder arthroplasty in patients with complex proximal humerus fracture sequelae, particularly in those with compromised rotator cuff function. Long-term studies indicate that RSA yields durable outcomes, with high patient satisfaction rates and low revision surgery rates [27, 43–45].

Complications and Outcomes of RSA

While RSA is more predictable with its outcomes, it is not without potential complications. Common issues include scapular notching, which occurs when the humeral component impinges on the scapula, leading to bone wear and potential weakening. Dislocation can also happen if the components are not adequately tensioned or if the deltoid muscle does not function properly due to axillary nerve damage that may occur during the initial trauma. Infection is another risk, particularly in elderly patients with compromised immune systems or other comorbidities [42, 43, 45].

Minimally Invasive Techniques: Resch and MIROS Techniques

Minimally invasive surgical techniques, such as the Resch and MIROS (Minimally InvasiveReduction and Osteosynthesis System) techniques, present alternative treatment options for elderly patients with proximal humerus fractures with significant comorbidities that increase the risks associated with open surgery. These techniques focus on stabilizing the fracture while preserving soft tissue integrity, leading to fewer complications such as infections, reduced postoperative stiffness, and shorter recovery times [48, 49].

Resch Technique

The Resch technique involves closed reduction of the fracture, followed by percutaneous insertion of screws or K-wires to maintain alignment of the fracture fragments. This minimizes disruption to surrounding soft tissues, significantly lowering the risk of infection and postoperative stiffness, making it an appealing option for elderly patients. This technique is primarily indicated for less complex fractures, such as two- or three-part fractures, where adequate fracture reduction can be achieved without the need for open surgery. Postoperative management encourages early passive mobilization exercises to mitigate the risk of shoulder stiffness, followed by more active rehabilitation as healing progresses. The minimally invasive nature of the Resch technique also contributes to reduced postoperative pain and a quicker return to functional activities compared to open reduction and internal fixation (ORIF) [48, 49].

MIROS Technique

The Minimally Invasive Reduction and Osteosynthesis System (MIROS) technique provides another minimally invasive option, utilizing external fixation (Fig. 10). In the MIROS technique, small pins are inserted into the bone through tiny incisions, and these pins are connected to an external frame that supports the fracture. This external fixation allows for the fracture to heal while minimizing disturbance to the surrounding tissues. The advantage of this technique over the Resch technique is that since the pins are cross-linked, they act like a combined unit thereby providing better stability and reducing incidence of pin-site infections. Also, early postoperative functional range of movements can be encouraged to achieve a painless functional shoulder and good outcomes [49–51].

Fig. 10.

Fig. 10

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Proximal humerus fixed with MIROS technique. Also seen is acromial fixation with a plate

Complications

The management of proximal humerus fractures, particularly in elderly patients, may lead to several potential complications arising from both conservative and surgical treatments. Common complications include shoulder stiffness, malunion, nonunion, avascular necrosis, and persistent pain. With surgical intervention, additional complications, namely, screw penetration, mechanical impingement, rotator cuff damage, implant failure, and infection may lead to poor functional outcomes (Fig. 11).

Fig. 11.

Fig. 11

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a Screw penetration, b avascular necrosis, and c varus collapse

Conclusion

Proximal humerus fractures pose a challenge to every orthopedic surgeon. In the presence of poor bone stock as seen in the elderly, the treatment of these fractures becomes more complex. Simple fracture patterns like undisplaced and valgus-impacted fractures do well with conservative management. Complex three- or four-part fractures mostly require surgical intervention, but have significant high complications rate thereby leading to poor functional outcome. There is no clear consensus regarding the management of these fractures, and meta-analyses and systematic reviews have failed to provide evidence-based guidelines. Hence, the treatment strategy for these injuries should be decided with shared decision-making and based on patient preferences, comorbidity, functional level, age, bone quality, and surgeon’s skill.

Data availability

Not applicable.

Declarations

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical standard statement

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

For this type of study informed consent is not required.

Footnotes

Publisher's Note

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