Patient-Specific Predictors
Age and comorbidities
Research consistently identifies advanced age and pre-existing medical conditions as primary predictors of mortality following a proximal humeral fracture (PHF). Studies have shown that patients over 80 years of age face a significantly higher mortality risk than younger cohorts, with one study finding that mortality rates at 48 months peaked at over 50% for patients in this age bracket.
The Charlson Comorbidity Index (CCI) is a widely used tool for stratifying mortality risk based on comorbidities. A higher CCI score, indicating more significant medical problems, is strongly associated with a higher mortality rate in elderly PHF patients. Common comorbidities that negatively impact outcomes include:
- Cardiovascular diseases, such as congestive heart failure and ischemic heart disease
- Chronic respiratory diseases
- Neurological or psychiatric disorders, including dementia
- Malignancies
- Liver disease
Functional and social independence
An individual's pre-fracture functional status and level of independence are also powerful predictors of survival. Patients who relied on a cane, walker, or wheelchair for ambulation before their fracture, or those who require assistance with daily living activities, are at a higher risk of mortality. Factors related to social independence, such as living in a nursing home or an assisted living facility, have also been shown to increase mortality risk. This underscores the broader impact of a fragility fracture on an already vulnerable population, which can lead to a decline in overall health and well-being.
Body mass index (BMI)
Evidence also points to low BMI (under 25 kg/m²) as an independent predictor of increased mortality in elderly PHF patients. This is likely a reflection of overall frailty and poorer nutritional status, which can impede recovery and increase susceptibility to complications.
Treatment-Related Predictors
Operative versus nonoperative management
Choosing between surgical (operative) and nonsurgical (nonoperative) treatment can significantly influence outcomes. Studies indicate that patients who receive nonoperative treatment tend to have a higher mortality rate. However, this is largely attributed to selection bias, as surgeons typically reserve surgical intervention for healthier, more robust patients who are better candidates for the procedure. For frail patients with multiple comorbidities, the risks of surgery, including anesthesia and hospital-acquired infections, may outweigh the potential benefits. Conversely, surgical treatment with procedures like open reduction and internal fixation (ORIF) or reverse total shoulder arthroplasty (RTSA) is associated with a lower mortality rate in appropriately selected patients.
Role of the surgeon and treatment strategy
For patients with a high Charlson Comorbidity Index (CCI), specifically those with a score greater than 5, some studies have shown that surgical intervention can lead to a higher mortality risk compared to conservative management. This highlights the need for careful consideration of the patient's preoperative health status when deciding on a therapeutic strategy. A multidisciplinary approach, involving geriatricians, orthopaedic surgeons, and rehabilitation providers, is crucial for assessing patient frailty and risk, particularly for those requiring inpatient admission.
Comparison of Risk Factors
| Predictor | Level of Risk for Mortality | Rationale | Management Consideration |
|---|---|---|---|
| High Comorbidity Index | High | Indicates multiple pre-existing health conditions, increasing overall frailty and reducing tolerance for stress and injury. | Thorough pre-operative medical optimization and careful consideration of treatment risks vs. benefits. |
| Advanced Age (>80) | High | General physiological decline and greater likelihood of chronic diseases. | Focus on fall prevention and conservative management unless the patient is otherwise robust. |
| Low Pre-fracture Functionality | High | Signifies pre-existing frailty and poor physical reserve, hindering recovery. | Intensive post-fracture rehabilitation and care coordination to mitigate further decline. |
| Male Sex | Higher than women | Studies have shown that men often face a higher mortality risk, particularly in the initial post-fracture period. | Tailored care plans, as men in this demographic often have more comorbidities. |
| Nonoperative Treatment | High (with caution) | Reflects patient selection bias; healthier patients are more often chosen for surgery. | Decision-making based on a comprehensive assessment of frailty, not just fracture severity. |
The Frailty and Mortality Connection
A proximal humeral fracture in an elderly patient is often a sentinel event that uncovers underlying frailty, not merely an isolated injury. Frailty is a state of increased vulnerability resulting from age-related decline in function across multiple physiological systems. It is a better predictor of overall mortality and adverse outcomes than chronological age alone. The stress of a fracture and the subsequent need for hospitalization or prolonged recovery can destabilize an already frail individual, leading to a cascade of complications. These can include hospital-acquired infections, delirium, loss of mobility, and further functional decline, all of which contribute to the increased mortality risk. For this reason, a comprehensive orthogeriatric approach, focused on managing the fracture within the context of the patient's overall health, is highly beneficial.
Conclusion: Navigating Risk and Optimizing Care
Understanding what predictors of mortality in elderly patients with proximal humeral fracture exist is the first step toward creating effective and personalized care plans. While the fracture itself is a significant event, it is the patient's overall health, particularly comorbidities and pre-existing frailty, that ultimately dictates the prognosis. Age over 80, a high comorbidity burden (high CCI score), male sex, low pre-fracture functional status, and low BMI are all strong predictors of increased mortality. By recognizing these risk factors, healthcare teams can provide targeted interventions, such as intensive medical optimization and post-fracture rehabilitation, to help mitigate risks and improve survival rates.
