Abstract
Objectives
This study aimed to compare the clinical and functional outcomes of geriatric patients (≥65 years) with proximal humerus fractures treated with locking plate fixation or nonoperative management and to identify factors associated with the development of complications. We hypothesized that fracture pattern, rather than treatment modality alone, would be more strongly associated with functional outcomes and complication risk in this population.
Methods
Patients aged 65 years and older who were treated for proximal humerus fractures were included in this retrospective cohort study. Patients were divided into two groups according to treatment modality: surgical treatment with locking plate fixation and nonoperative management. Clinical outcomes were evaluated using the Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and Oxford Shoulder Score (OSS). To explore factors associated with functional outcomes and complications, multivariable linear and logistic regression models were constructed.
Results
No significant differences were observed between the groups in demographic characteristics, fracture side, or mechanism of injury (p>0.05). There were no statistically significant differences between the surgical and nonoperative treatment groups in VAS or DASH scores (p>0.05). Although unadjusted Oxford Shoulder Scores did not differ significantly between the groups (28.4±10.1 vs. 24.7±11.1; p=0.09), multivariable analysis identified nonoperative management as independently associated with lower Oxford Shoulder Scores after adjustment for confounders, with the surgical group serving as the reference category (β=−6.85; 95% CI: −11.15 to −2.55; p=0.002). In multivariable analysis, Neer fracture classification was independently associated with worse DASH scores (β=6.33; p=0.008). Additionally, Neer classification was identified as an independent risk factor for complication development, with odds ratios increasing with fracture complexity: 3-part vs. 2-part (OR 5.95; 95% CI 1.02–34.78; p=0.048), 4-part vs. 2-part (OR 12.98; 95% CI 2.19–76.86; p=0.005), and displaced 4-part vs. 2-part (OR 33.28; 95% CI 3.47–318.97; p=0.002). Treatment modality was not independently associated with complication development.
Conclusion
In patients aged 65 years and older, no significant difference in functional outcomes between surgical and nonoperative treatment of proximal humerus fractures was observed in this cohort. Fracture pattern appeared to be more strongly associated with functional outcomes and complication risk than treatment modality. Neer classification should be considered when determining the appropriate treatment strategy. Treatment decisions should primarily be based on fracture characteristics together with the patient’s overall clinical condition.
Keywords: Complications, functional outcomes, non-operative treatment, operative treatment, proximal humerus fracture
Proximal humerus fractures (PHFs) are common injuries with an increasing incidence, particularly among the elderly population. The rising incidence of these fractures parallels population aging, increasing rates of osteoporosis, and greater susceptibility to falls.[1] The underlying mechanism differs by age group: high-energy injuries are more commonly seen in younger patients, whereas fractures in older adults typically occur after low-energy trauma.[2] Approximately 70% of all proximal humerus fractures occur in patients older than 60 years.[3] The reported annual incidence is 110±2.7 per 100,000 persons.[4] Following vertebral and hip fractures, proximal humerus fractures rank as the third most common osteoporotic fracture.[5]
Epidemiological studies indicate that in the geriatric population aged over 65 years, the lifetime risk of sustaining a proximal humerus fracture is approximately three times higher in women than in men.[2,6] This higher prevalence among women is attributed to postmenopausal hormonal changes and osteoporosis.[3] These fractures may lead to functional impairment and decreased quality of life and have been associated with increased mortality within the first five years after injury in men over 60 years of age.[6] Moreover, proximal humerus fractures impose a substantial burden on healthcare systems. A prospective cost analysis conducted in France reported that the average annual cost associated with humeral fractures was approximately €10,319.[7] For this reason, clarifying optimal treatment strategies remains clinically relevant.
Proximal humerus fractures can be managed either nonoperatively or surgically, yet the optimal approach in older patients remains debated. Treatment decisions are influenced by fracture characteristics, patient comorbidities, and functional expectations. Although most elderly patients are treated nonoperatively, nearly one-third continue to undergo surgical fixation.[8] In a multicenter randomized controlled trial comparing nonoperative and surgical treatment in patients older than 60 years with Neer type II proximal humerus fractures, no clinically significant differences were observed between the groups.[9] Conversely, another study comparing operative and nonoperative treatment in completely displaced proximal humerus fractures reported superior functional outcomes and lower complication rates in surgically treated patients.[10]
Surgical treatment options for PHFs include locking plate fixation (LPF), intramedullary nailing (IMN), hemiarthroplasty (HA), reverse shoulder arthroplasty (RSA), and percutaneous Kirschner wire fixation. Among these, locking plate fixation is the most commonly performed surgical technique. Favorable outcomes have been reported with LPF in both younger and geriatric populations.[11] Nevertheless, complication rates as high as 15.4% have been documented. Furthermore, Barlow et al.[12] reported an overall complication rate of 44% and a failure rate of 34% following LPF. Increasing fracture complexity according to the Neer classification has been associated with higher failure rates.[12]
Although numerous studies have evaluated the clinical and functional outcomes of nonoperative and surgical treatment in patients aged 65 years and older with PHFs, considerable variability persists in radiological, clinical, and functional outcomes within this population. In this study, we examined the association between treatment modality and functional outcomes, as well as complication rates, with particular attention to the influence of fracture pattern.
Methods
Study Design and Setting
This study was conducted in accordance with the principles of the Declaration of Helsinki. Approval for this retrospective study was obtained from University of Health Sciences, Şişli Hamidiye Etfal Training and Research Hospital Ethics Committee (Decision No. 3362; date: March 3, 2026). Informed consent was obtained from all patients.
This retrospective comparative cohort study was conducted to compare nonoperative and operative treatment with locking plate fixation in geriatric patients aged 65 years and older with proximal humerus fractures (PHFs). Patients aged 65 years and older who received treatment for proximal humerus fractures at the Orthopedics and Traumatology Clinic between January 1, 2010, and December 31, 2025, were evaluated. After applying the inclusion and exclusion criteria, 103 patients remained for the final evaluation (Fig. 1).
Figure 1.
Patient selection flow chart.
Patients aged 65 years and older with radiologically confirmed proximal humerus fractures classified as Neer type II, III, or IV were eligible for inclusion. Patients with complete medical records in the hospital database, regular post-traumatic follow-up, and a minimum follow-up duration of six months were included. Patients younger than 65 years were not considered for the study. Cases involving pathological fractures secondary to malignancy, a history of previous shoulder surgery, concomitant fractures of the same extremity, open fractures, or impaired cognitive status were excluded. In addition, patients with incomplete medical records, irregular follow-up, less than six months of follow-up, or those who died during the follow-up period were not included in the final analysis (Fig. 1).
Patients were divided into two main groups according to treatment modality. Group 1 (surgical treatment group) consisted of patients treated with locking plate fixation. Group 2 (nonoperative treatment group) included patients managed nonoperatively with immobilization using a sling or Velpeau bandage. Treatment decisions were made by the attending orthopedic surgeon based on several clinical factors, including fracture displacement and complexity according to the Neer classification, patient age, comorbidity burden (ASA score), bone quality, functional status prior to injury, and anesthesia risk. In general, surgical fixation was preferred for displaced multipart fractures in patients with acceptable operative risk, whereas nonoperative management was favored for less displaced fractures or in patients with significant comorbidities. However, because this was a retrospective study, no formal standardized treatment protocol was applied, and individual surgeon judgment played a role in final treatment allocation.
During data collection, demographic characteristics (age, sex), fracture side, mechanism of injury, comorbidities (ASA score), fracture morphology (Neer and AO-OTA classifications), union status, time to union, and complications were obtained from the hospital information system, imaging records, and patient files. After obtaining institutional ethics committee approval, patients were contacted by telephone to assess treatment outcomes. Functional evaluation was performed using the Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) score, and Oxford Shoulder Score (OSS). Functional status and quality of life were recorded accordingly.
Statistical Analysis
Data were analyzed using SPSS software (version 29.0, IBM Corp., Armonk, NY, USA). Baseline demographic and clinical characteristics were summarized using appropriate descriptive measures. Continuous variables were reported using measures of central tendency and dispersion, whereas categorical variables were expressed as counts and percentages. Group comparisons between surgical and nonoperative treatments were performed according to variable type. Continuous data were analyzed using the independent-samples t-test after verifying variance homogeneity with Levene’s test. Categorical variables were compared using the chi-square test. To explore factors associated with functional outcomes and complications, linear and logistic regression models were constructed. The overall fit of the linear models was evaluated using the F statistic. For logistic regression, model calibration was assessed using the Hosmer–Lemeshow test. Multivariable models incorporated age, ASA score, treatment type, and Neer fracture classification. Collinearity diagnostics were examined prior to modeling, and no meaningful multicollinearity was observed. All analyses were two-sided, with statistical significance defined as p<0.05.
A post hoc power assessment was performed for the primary outcome measures (VAS, DASH, and Oxford Shoulder Score). The observed effect sizes were small for VAS (d=0.20) and negligible for DASH (d=0.03), corresponding to limited statistical power. For the Oxford Shoulder Score, a small-to-moderate effect size (d=0.35) yielded approximately 45% power. Based on this estimate, roughly 130 participants per group would be necessary to achieve 80% power. These results suggest that the current sample size may not be sufficient to detect small intergroup differences.
Results
Patient Characteristics
Between January 1, 2010, and December 31, 2025, a total of 103 patients treated for proximal humerus fractures were included in the study. Group 1 (surgical treatment) comprised 46 patients (44.7%), whereas Group 2 (nonoperative treatment) included 57 patients (55.3%). The mean age was 72.7±6.5 years in Group 1 and 72.9±6.3 years in Group 2, with no significant difference between the groups (p=0.89). In Group 1, 34 patients (73.9%) were female and 12 (26.1%) were male. In Group 2, 38 patients (66.7%) were female and 19 (33.3%) were male. Although females constituted the majority in both groups, there was no statistically significant difference in sex distribution (p=0.43). Regarding fracture side, right-sided fractures were observed in 26 patients (56.5%) in Group 1 and 26 patients (45.6%) in Group 2. No significant difference was found between the groups (p=0.27). In both treatment groups, injuries most frequently resulted from low-energy mechanisms (71.7% in Group 1 and 64.9% in Group 2). Traffic accidents and high-energy trauma were less common causes. No statistically significant difference was observed between the groups regarding the mechanism of trauma (p=0.74). A statistically significant difference was observed in ASA scores between the groups (p=0.027). In Group 1, a higher proportion of patients had ASA II and III scores (ASA I: 10.9%, ASA II: 41.3%, ASA III: 47.8%), whereas patients with ASA I were more frequently managed nonoperatively in Group 2 (31.6%) (Table 1).
Table 1.
Demographic and Clinical Characteristics
| Variable | Surgical (n=46) Group 1 | Nonoperative (n=57) Group 2 | p |
|---|---|---|---|
| Age (years), mean±SD | 72.7±6.5 | 72.9±6.3 | 0.89 |
| Female sex, n (%) | 34 (73.9) | 38 (66.7) | 0.43 |
| Male sex, n (%) | 12 (26.1) | 19 (33.3) | |
| Right side fracture, n (%) | 26 (56.5) | 26 (45.6) | 0.27 |
| Left side fracture, n (%) | 20 (43.5) | 31 (54.4) | |
| Low-energy fall, n (%) | 33 (71.7) | 37 (64.9) | 0.74 |
| Traffic accident, n (%) | 9 (19.6) | 13 (22.8) | |
| High-energy fall, n (%) | 4 (8.7) | 7 (12.3) | |
| ASA I, n (%) | 5 (10.9) | 18 (31.6) | 0.027 |
| ASA II, n (%) | 19 (41.3) | 14 (24.6) | |
| ASA III, n (%) | 22 (47.8) | 25 (43.8) |
n: number of patients, %: percentage, ASA Score: American Society of Anesthesiologists Score
Fracture Characteristics
Fracture patterns differed between the groups when classified using the Neer system. In the surgical cohort (Group 1), four-part fractures constituted the largest proportion (32.6%), followed by three-part fractures (26.1%), four-part fracture-dislocations (26.1%), and two-part fractures (15.2%). In contrast, two-part fractures were more frequent in the nonoperative group than in the surgical group (35.1% vs. 15.2%); within the nonoperative group, three-part fractures were the most common pattern (40.4%), followed by four-part fractures (24.6%). The distribution of fractures according to the Neer classification differed significantly between the groups (p<0.001). Two-part fractures were more common in the nonoperative group, whereas four-part fracture-dislocations were observed only in the surgical group. According to the AO/OTA classification, no significant difference was found between the groups (p=0.26) (Table 2).
Table 2.
Fracture Classification
| Classification | Surgical (n=46) Group 1 | Nonoperative (n=57) Group 2 | p |
|---|---|---|---|
| Neer 2-part, n (%) | 7 (15.2) | 20 (35.1) | <0.001 |
| Neer 3-part, n (%) | 12 (26.1) | 23 (40.4) | |
| Neer 4-part, n (%) | 15 (32.6) | 14 (24.6) | |
| Displaced 4-part fracture, n (%) | 12 (26.1) | 0 (0) | |
| AO/OTA Type A, n (%) | 13 (28.3) | 25 (43.9) | 0.26 |
| AO/OTA Type B, n (%) | 24 (52.2) | 23 (40.4) | |
| AO/OTA Type C, n (%) | 9 (19.6) | 9 (15.8) |
n: number of patients, %: percentage, AO: Arbeitsgemeinschaft fur Osteosynthesefragen; OTA: Orthopaedic Trauma Association classification system
Clinical and Radiological Outcomes
Clinical evaluation at the last follow-up included VAS, DASH, and Oxford Shoulder Score assessments. Pain levels were low in both groups, with mean VAS scores of 2.6±1.5 in the surgical group and 2.9±1.5 in the nonoperative group, showing no significant difference (p=0.26). Functional outcomes measured using the DASH score were comparable between the groups (36.7±19.1 vs. 37.3±19.2; p=0.87). Oxford Shoulder Scores tended to be higher in surgically treated patients (28.4±10.1) than in those managed nonoperatively (24.7±11.1); however, this difference did not reach statistical significance (p=0.09). Patients in Group 1 were followed for a longer period on average (8.7±3.3 months) than those in Group 2 (6.2±3.7 months), and this difference was significant (p<0.001). Radiographic union rates were similar between the groups, occurring in 80.4% of surgically treated patients and 75.4% of those treated nonoperatively (p=0.83). The mean time to union was longer in Group 1 (4.7±2.3 months) than in Group 2 (3.5±1.8 months), and this difference was statistically significant (p=0.014) (Table 3).
Table 3.
Clinical and Radiological Outcomes
| Outcome | Surgical (n=46) Group 1 | Nonoperative (n=57) Group 2 | p |
|---|---|---|---|
| VAS score (final follow-up), mean±SD | 2.6±1.5 | 2.9±1.5 | 0.26 |
| DASH score (final follow-up), mean±SD | 36.7±19.1 | 37.3 ± 19.2 | 0.87 |
| Oxford Shoulder Score, mean±SD | 28.4±10.1 | 24.7±11.1 | 0.09 |
| Follow-up duration (months), mean±SD | 8.7±3.3 | 6.2±3.7 | <0.001 |
| Time to union (months), mean±SD* | 4.7±2.3 | 3.5±1.8 | 0.014 |
n: number of patients, %: percentage, VAS: Visual Analogue Scale; DASH: The Disabilities of the Arm Shoulder and Hand; SD: standard deviation
* Time to union calculated only in patients with radiographic union.
Union Status and Complications
Nonunion was observed in 13.0% of patients in Group 1 and 15.8% in Group 2. Malunion occurred in 6.5% and 8.8% of patients, respectively. There were no statistically significant differences between the groups regarding nonunion or malunion rates. Overall complication rates were 30.4% in Group 1 and 29.8% in Group 2 (p=0.33). Avascular necrosis was more frequently observed in the surgical group (23.9% vs. 15.8%), whereas delayed union was more common in the nonoperative group (14.0% vs. 6.5%); however, these differences were not statistically significant (p>0.05) (Table 4).
Table 4.
Union Status and Complications
| Variable | Surgical (n=46) Group 1 | Nonoperative (n=57) Group 2 | p |
|---|---|---|---|
| Union achieved, n (%) | 37 (80.4) | 43 (75.4) | 0.83 |
| Non-union, n (%) | 6 (13.0) | 9 (15.8) | |
| Malunion, n (%) | 3 (6.5) | 5 (8.8) | |
| Any complication, n (%) | 14 (30.4) | 17 (29.8) | 0.33 |
| Avascular necrosis, n (%) | 11 (23.9) | 9 (15.8) | |
| Delayed union, n (%) | 3 (6.5) | 8 (14.0) |
n: number of patients, %: percentage
Multivariable Analysis
Multivariable linear regression demonstrated that increasing Neer fracture severity was associated with higher DASH scores (β=6.33; p=0.008). When the Oxford Shoulder Score was analyzed, both treatment type (β=−6.85; 95% CI: −11.15 to −2.55; p=0.002) and Neer fracture classification (β=−4.12; 95% CI: −6.59 to −1.66; p=0.001) were significantly associated with the outcome. In this model, the surgical group served as the reference category; the negative coefficient for treatment group indicates that nonoperative management was associated with lower Oxford Shoulder Scores than surgical treatment after adjustment for age, ASA score, and Neer fracture classification. It is noteworthy that the unadjusted comparison of Oxford Shoulder Scores between the groups did not reach statistical significance (28.4±10.1 vs. 24.7±11.1; p=0.09). This discrepancy likely reflects the unequal distribution of important prognostic variables between the groups at baseline, particularly Neer fracture classification (p<0.001) and ASA score (p=0.027). After controlling for these confounders, the adjusted analysis revealed a statistically significant treatment effect. In the logistic regression analysis, Neer fracture classification was significantly associated with an increased risk of complications. Treatment modality and ASA score were not independently associated with complications (Table 5).
Table 5.
Multivariable regression analysis of factors associated with functional outcomes and complications
| Outcome | Variable | β or OR (95% CI) | p |
|---|---|---|---|
| A) DASH Score (Linear Regression, R2=0.095) | Treatment group (ref: surgical) | 5.15 (−2.88 to 13.18) | 0.206 |
| Age | 0.34 (−0.28 to 0.96) | 0.281 | |
| ASA score | −1.98 (−7.46 to 3.51) | 0.476 | |
| Neer classification | 6.33 (1.72 to 10.95) | 0.008 | |
| B) Oxford Shoulder Score (Linear Regression, R2=0.187) | Treatment group (ref: surgical) | −6.85 (−11.15 to −2.55) | 0.002 |
| Age | −0.24 (−0.58 to 0.09) | 0.149 | |
| ASA score | 0.09 (−2.84 to 3.03) | 0.950 | |
| Neer classification | −4.12 (−6.59 to −1.66) | 0.001 | |
| C) Complication Development (Logistic Regression, Nagelkerke R2=0.213) | Treatment group (ref: surgical) | 2.39 (0.77 to 7.43) | 0.134 |
| Age | 0.99 (0.92 to 1.07) | 0.853 | |
| ASA score (overall) | — | 0.117 | |
| ASA 2 vs. ASA 1 | 1.01 (0.20 to 5.20) | 0.990 | |
| ASA 3 vs. ASA 1 | 0.31 (0.06 to 1.75) | 0.185 | |
| Neer classification (overall) | — | 0.014 | |
| 3-part vs. 2-part | 5.95 (1.02 to 34.78) | 0.048 | |
| 4-part vs. 2-part | 12.98 (2.19 to 76.86) | 0.005 | |
| Displaced 4-part vs. 2-part | 33.28 (3.47 to 318.97) | 0.002 |
β: regression coefficient, OR: odds ratio, CI: confidence interval, DASH: Disabilities of the Arm, Shoulder and Hand, p: p-value.
Discussion
In the present retrospective cohort of patients aged 65 years and older, we compared locking plate fixation with nonoperative treatment for proximal humerus fractures. In this age group, these fractures are frequently related to underlying osteoporosis, and the optimal management strategy remains debated in the literature.[13–15]
Baseline characteristics such as age, sex distribution, fracture laterality, and trauma mechanism were comparable between the groups. The predominance of female patients is consistent with previously published data linking postmenopausal bone loss to increased fracture susceptibility.[16] Similarly, the high proportion of low-energy trauma mechanisms observed in our cohort reflects the fragility fracture pattern typically described in elderly individuals.[17]
When treatment-related outcomes were examined, no statistically significant differences were detected between the operative and nonoperative groups in terms of pain scores, functional assessment tools, or overall complication rates. Instead, fracture morphology appeared to play a more influential role. Specifically, fracture complexity according to the Neer classification was associated with both functional deterioration and complication risk.
In our series, two-part fractures were predominantly managed nonoperatively, whereas four-part fractures and fracture-dislocations were more frequently treated surgically. This distribution mirrors common clinical practice patterns. Previous studies have reported satisfactory outcomes with nonoperative treatment in two-part and selected three-part fractures.[18,19] Furthermore, meta-analyses focusing on three- and four-part fractures have not consistently demonstrated superior functional outcomes with surgical intervention compared with nonoperative management.[20,21] The absence of meaningful differences in VAS, DASH, and Oxford Shoulder Score values between the groups in our cohort supports these observations.
Conversely, some authors have reported improved function following surgical fixation, albeit with higher complication rates.[22,23] A recent meta-analysis including complex Neer type 3 and 4 fractures suggested a higher likelihood of surgical treatment in more displaced fracture patterns.[24] In our cohort, displaced multifragmentary fractures were preferentially treated surgically, which aligns with these contemporary treatment tendencies.
Even among more complex fracture patterns, the lack of a pronounced functional advantage for surgery suggests that outcomes in elderly patients may be influenced by multiple factors beyond fixation method alone. Osteoporosis severity, comorbid medical conditions, rehabilitation adherence, and baseline functional capacity likely contribute to recovery trajectories.[25-27] For this reason, a comprehensive geriatric evaluation prior to treatment selection may be beneficial.[28]
Complication rates did not differ significantly between the groups. Previous meta-analyses have reported higher rates of avascular necrosis and implant-related reoperation following surgical fixation.[25,29] In our cohort, avascular necrosis was numerically more frequent in the surgical group, whereas malunion, nonunion, and delayed union were observed more often in the nonoperative group; however, these differences did not reach statistical significance. The limited sample size and heterogeneity in fracture distribution may partly explain these findings.
Multivariable analyses provided additional insight. Neer fracture classification remained independently associated with higher DASH scores and increased complication risk, reinforcing the concept that increasing fracture complexity negatively affects both functional recovery and complication probability. Similar trends have been reported in prior meta-analyses examining three- and four-part fractures.[20,29]
Treatment modality was also identified as an independent predictor of the Oxford Shoulder Score in the multivariable model, with nonoperative management associated with lower scores compared with the surgical reference group (β=−6.85; p=0.002). This finding contrasts with the unadjusted comparison, in which the difference between the groups did not reach statistical significance (p=0.09). The divergence between these results is likely attributable to the unequal distribution of key prognostic variables at baseline: more complex fractures (Neer 4-part and displaced 4-part) were concentrated in the surgical group, whereas simpler 2-part fractures predominated in the nonoperative group. In the unadjusted analysis, this imbalance may have attenuated the apparent functional advantage of surgical treatment. Once Neer classification, ASA score, and other covariates were accounted for, the adjusted model revealed a statistically significant association between treatment modality and Oxford Shoulder Score. However, the clinical significance of this difference should be interpreted with caution given the observational design, nonrandomized treatment allocation, and modest sample size of the present study.
Although overall union rates were similar, time to union was longer in the surgically treated group. It should be acknowledged that treatment allocation was not randomized but reflected fracture severity and patient condition, as evidenced by the significant baseline differences in Neer classification (p<0.001) and ASA score (p=0.027) between the groups. This imbalance introduces confounding that multivariable adjustment can only partially address, and between-group comparisons should be interpreted accordingly. This finding may reflect the greater fracture complexity in the surgical group, as well as possible alterations in fracture biology associated with surgical intervention.[30] Additionally, follow-up duration was longer in the operative cohort, potentially because of closer postoperative surveillance and complication monitoring.[31]
Several limitations should be considered. The retrospective design carries inherent risks of information and selection bias. Treatment allocation was not randomized, and group sizes were modest, limiting statistical power, particularly for patient-reported outcome measures. A post hoc power analysis revealed small effect sizes for VAS (d=0.20) and negligible effect sizes for DASH (d=0.03), with the Oxford Shoulder Score yielding approximately 45% power—well below the conventional 80% threshold. These findings suggest that the current sample may have been underpowered to detect small but clinically meaningful between-group differences, and the results should be interpreted accordingly. Differences in follow-up duration and the absence of long-term functional assessment further limit interpretation. Finally, reliance on patient-reported instruments such as VAS, DASH, and the Oxford Shoulder Score introduces the possibility of subjective variation.
Despite these limitations, the study contributes additional data to the ongoing discussion regarding the management of proximal humerus fractures in the elderly. The use of multiple validated functional measures allowed a multidimensional assessment, and multivariable regression analysis strengthened the evaluation of independent predictors. Overall, the findings underscore the central role of fracture pattern in determining both functional outcomes and complication risk in this population.
Conclusion
In geriatric patients with proximal humerus fractures, no significant differences between surgical and nonoperative treatment were observed in terms of pain, functional outcomes, or overall complication rates in this cohort. However, fracture complexity—particularly as defined by the Neer classification—emerged as the principal determinant of both functional outcomes and complication risk. Treatment planning in elderly patients should incorporate fracture type, overall health status, comorbidities, and functional expectations. When patients are carefully selected, both treatment options may lead to comparable clinical outcomes. Management decisions should be tailored to fracture characteristics and patient-specific factors.
Footnotes
Please cite this article as ”Balkanli B, Ipek E, Altuntas Y, Bozca MA, Erkan BK, Eren OT. Locking Plate Fixation versus Nonoperative Management in Patients Aged ≥65 Years with Proximal Humerus Fractures: Clinical and Functional Outcomes from a Retrospective Cohort Study. Med Bull Sisli Etfal Hosp 2026;60(3):295-303”.
Disclosures
Ethics Approval
Ethics committee approval for this study was obtained from the Şişli Hamidiye Etfal Training and Research Hospital (Approval no: 3362; date: March 3, 2026)
Informed consent
Informed consent was obtained from all patients.
Conflict of Interest
The authors declare that there is no conflict of interest.
Financial Disclosure
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Use of AI for Writing Assistance
This study did not utilize artificial intelligence (AI)-assisted technologies, chatbots, or image generators in its production.
Authorship Contributions
Concept – B.B., E.I., Y.A., M.A.B., B.K.E., O.T.E.; Design – B.B., E.I., Y.A., O.T.E.; Supervision – B.B., E.I., Y.A., B.K.E., O.T.E.; Materials − B.B., E.I., Y.A., M.A.B., B.K.E.; Data collection &/or processing – B.B., M.A.B., B.K.E.; Analysis and/or interpretation – B.B., E.I., M.A.B., O.T.E.; Literature search – B.B., E.I., Y.A., M.A.B., B.K.E., O.T.E.; Writing – B.B., E.I., Y.A., M.A.B., B.K.E., O.T.E.; Critical review – B.B., E.I., Y.A., M.A.B., B.K.E., O.T.E.
Peer-review
Externally peer-reviewed.
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