The epidemiology of proximal humeral fractures

Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial

BACKGROUND

There have been few randomized controlled trials evaluating nonoperative treatment of proximal humeral fractures. To investigate shortening the period of dependence, we assessed the feasibility and efficacy of early mobilization of the shoulder (within three days after the fracture) in comparison with those of conventional three-week immobilization followed by physiotherapy.

METHODS

We randomly assigned seventy-four patients with an impacted proximal humeral fracture to receive early passive mobilization or conventional treatment. The primary outcome was the overall shoulder functional status (as measured with the Constant score) at three months. The secondary outcomes were the Constant score at six weeks and at six months, the change in pain (on a visual analog scale), and the active and passive range of motion.

RESULTS

At three months and at six weeks, the early mobilization group had a significantly better Constant score than did the conventional-treatment group (between-group difference, 9.9 [95% confidence interval, 1.9 to 17.8] [p = 0.02] and 10.1 [95% confidence interval, 2.0 to 18.1] [p = 0.02], respectively) and better active mobility in forward elevation (between-group difference, 12.0 [95% confidence interval, 1.7 to 22.4] [p = 0.02] and 28.1 [95% confidence interval, 7.1 to 49.1] [p = 0.01], respectively). At three months, the early mobilization group had significantly reduced pain compared with the conventional-treatment group (between-group difference, 15.7 [95% confidence interval, 0.52 to 30.8] [p = 0.04]). No complications in displacement or nonhealing were noted.

CONCLUSIONS

Early mobilization for impacted nonoperatively treated proximal humeral fractures is safe and is more effective for quickly restoring the physical capability and performance of the injured arm than is conventional immobilization followed by physiotherapy.

The surgical approach for locking plate osteosynthesis of displaced proximal humeral fractures influences the functional outcome

This study evaluated the influence of the surgical approach for locking plate osteosynthesis in proximal humeral fractures during a 1-year period. We performed a comparative study in 83 patients to evaluate possible benefits for an early functional result for function, pain, activity levels, radiographic evaluation, and complications. In 39 cases, the extended anterolateral deltoid-splitting approach was used (group DS); in 44 cases, the deltopectoral approach was used (group DP). The clinical and radiologic follow-up took place 3, 6, and 12 months after the operation. The functional results in the adjusted Constant score after 3 months showed higher values for group DS of 57.9% vs group DP with 49.6%. After 6 months, no significant differences were seen, with 69.4% for group DS and 71.4% for group DP. Finally, after 12 months, group DP showed higher results at 81% compared with 73.1% for DS. In the subgroups of the Constant score, abduction and active anterior elevation showed particularly higher values in group DP. The duration of the operation was 67 minutes in group DS and 86 minutes in group DP. One case of avascular necrosis was observed in group DS and 3 in group DP. We conclude that the choice of approach for exposure of the proximal humerus region may influence the functional outcome. Stable osteosynthesis is important, but the outcome of operatively treated proximal humerus fractures is dependent on soft tissue management as well.

Two-part fractures and fracture dislocations

Proximal humeral fractures are common and are usually osteopenic or osteoporotic and about 85% occur in patients older than 50. Two-part fractures account for approximately 28% of proximal humeral fractures, with most being surgical neck fractures. This article discusses the management of two-part fractures and analyzes the use of nonoperative treatment, conventional plating, locked plating, antegrade intramedullary nailing, retrograde pinning, and Kirschner wires in their treatment. The literature indicates that nonoperative treatment is as effective as conventional plating, antegrade nailing, and Kirschner wiring in treating two-part surgical neck fractures in older patients. The early results of locked plating may be better, but more studies are required to prove this. This article gives the results of nonoperative treatment of all types of two-part fractures and fracture dislocations.

Percutaneous fixation of displaced proximal humeral fractures: indications based on the correlation between clinical and radiographic results

We evaluated 74 patients with displaced proximal humeral fractures (mean age, 70.9 years) treated with closed reduction and percutaneous pinning. Fractures were classified radiographically following Neer's system, and the quality of reduction was assessed according to Kristiansen and Kofoed. Patients were also evaluated clinically with the Constant scale. Overall, the reduction was good in 72% of fractures, but the probability of obtaining a satisfactory reduction of displaced tuberosities was significantly lower in comparison to the humeral head. Four-part fractures obtained the worst radiographic results. The mean Constant scores were 65.8 +/- 18 points for the injured shoulder and 79.5 +/- 9.1 points for the opposite shoulder. Clinical results correlated with the quality of reduction. Closed reduction and percutaneous pinning should be reserved for 2-part fractures, but the technique can also be used in 3-part fractures in elderly patients, in whom an incomplete reduction can yield satisfactory clinical results.

Minimally invasive application of the non-contact-bridging (NCB) plate to the proximal humerus: an anatomical study

OBJECTIVES

To describe a minimal anterolateral acromial approach for minimally invasive (MI) treatment of fractures of the proximal humerus (PH) with the Non-Contact-Bridging (NCB) plate.

DESIGN

1) Cadaver study and 2) clinical case series.

SETTING

1) University Institute of Anatomy and the 2) University Level I trauma center. SPECIMENS/PATIENTS: 1) Ten fresh frozen human humeri and 2) 22 patients with 22 isolated proximal humeral fractures.

INTERVENTION

1) Minimal anterolateral acromial approach with MI application of the NCB-PH plate followed by dissection of the axillary nerve and 2) MI fracture fixation using this approach and technique of plate insertion.

MAIN OUTCOME MEASURES

1) Integrity of the axillary nerve and evaluation of its relationship to the implant, and 2) early postoperative functional results.

RESULTS

In the cadaver study, the nerve directly crossed over the percutaneously inserted plate in all the arms. The nerve then divided into two branches anterior to the plate in eight arms and divided into two branches directly over the plate in two arms. One branch of the axillary nerve in one arm was injured. In the clinical case series, no intraoperative complications relating to the approach or the implant occurred. No symptoms of axillary nerve lesion have been detected so far in the early follow-up.

CONCLUSIONS

The minimal anterolateral acromial approach is suitable for MI technique to apply the NCB-PH. The relationship of the axillary nerve to the plate is anatomically close. We recommend that strict bone contact be maintained during plate insertion and that screw insertion complies with the guidelines provided for this technique. In a small clinical cases series, the plate and screws were inserted in accordance with these guidelines and no axillary nerve lesions have yet been detected.

Current concepts in plate and screw fixation of osteoporotic proximal humerus fractures

Most surgeons feel that angular stable implants have improve the ability to obtain reliable fixation of an osteoporotic fracture of the proximal humerus fracture, but complications such as varus fracture collapse and screw penetration of the articular surface remain problematic. The use of limited drilling, blunt tipped locking bolts and routine incorporation of the rotator cuff into the internal fixation construct may help limit these complications. It may be of benefit to replace the concept of standard screw fixation of the osteoporotic proximal humerus with a concept of an angular stable scaffold support of the subchondral bone combined with fixation that does not rely on bone quality and utilizes the more predictable fixation of sutures through the rotator cuff attachments.

Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment

INTRODUCTION

A variety of different treatment options are available for displaced three- or four-part fractures. In a retrospective cohort study we evaluated the results of intramedullary nailing with the ACE nail and conservative treatment of displaced proximal humeral fractures.

MATERIALS AND METHODS

Twenty-four patients suffered a neer 4, 5 or 6 proximal humeral fracture who were treated with intramedullary nailing. Sixteen patients received conservative treatment for their Neer 4, 5 or 6 fracture.

RESULTS

Taking critical remarks in consideration, the results of intramedullary nailing are not very satisfactory compared to the conservative-treated group. However functional results of our operative group are comparable to those from other studies in literature.

CONCLUSION

Displaced three- or four-part proximal humeral fractures can be treated by intramedullary nailing. Familiarity with the fracture deformity and experience with the surgical techniques are critical for successful operative treatment outcome. Most complications in the operative treatment group can be avoided; inadequate reduction can lead to wrong insertion place with secondary problems (dislocation and subacromial impingement). Also future improvements in osteosynthesis like angle stable screw fixation (osteoporosis) and minimally invasive device will probably decrease the complication rate.

Arthroscopical Findings after Antegrade Nailing of a Proximal Humeral Fracture : Case Report and Review of the Literature

Proximal humeral fractures represent up to five percent of all fractures in adults, commonly found in elderly patients. The final functional results after different operative procedures are among other factors dependent on whether or not a rotator cuff lesion is pre-existent, prior to the fracture, and how its surgical therapy is carried out. However, to what extent prior rotator cuff tears in this special patient group contribute to the functional outcome remains widely unclear. In our institution antegrade intramedullary nailing is the treatment of choice for proximal humeral fractures. One critical point of this technique is the unavoidable split of the rotator cuff on the approach to the proximal humerus and the insertion of the nail through the incised cuff. We report on a case of an impingement after antegrade intramedullary nailing of a proximal humeral fracture. Diagnostic glenohumeral arthroscopy revealed neither a residual lesion of the former rotator cuff incision nor a chondral lesion at the former insertion site of the nail. In the same session subacromial decompression and a nettoyage of adhesions were performed. We assume that splitting the rotator cuff for the insertion of an antegrade nail in a proximal humeral fracture is less relevant than previously assumed and described.

Operative treatment of greater tuberosity fractures of the humerus--a biomechanical analysis

BACKGROUND

Fractures of the greater tuberosity of the humerus present with increasing frequency. However, no biomechanical data about the optimal fixation technique of greater tuberosity fractures is available. This biomechanical cadaver study compares the stability of three standard fixation techniques used for the treatment of greater tuberosity fractures of the proximal humerus.

METHODS

In 21 fresh frozen proximal humeri, standardized fractures of the greater tuberosity were created. The specimens were randomly assigned to one of three operation techniques: wire tension banding, two cancellous screws and transosseous sutures. These constructs were mechanically tested by applying an increasing force to the supraspinatus tendon. Load to 5mm displacement (load to 5mm yield point) and load to failure (maximum stretch strength) were measured in Newton (N).

FINDINGS

Load to 5mm yield point values showed no significant differences between tension banding (498 N, SD 153) and two cancellous screws (400 N, SD 174) (P>0.01). Both techniques showed significantly higher values than transosseous sutures (185 N, SD 132) (P<0.01). Load to failure values were significantly higher for tension banding (1054 N, SD 125) than screws (842 N, SD 140) and sutures (480 N SD 101) (P<0.01). The difference between screws and sutures was also significant (P<0.01).

INTERPRETATION

Tension banding and two cancellous screws provided the strongest fixation for isolated fractures of the greater tuberosity.

Die Non-Contact-Bridging (NCB) Platte

BACKGROUND

Fractures of the proximal humerus are common in elderly patients, especially in osteoporotic bone. Requirements for surgical treatment are high primary stability to allow early functional physiotherapy. The Non-Contact Bridging (NCB) Plate for the proximal humerus (PH) is a new head locking system for treating fractures of the proximal humerus which allows minimally invasive surgery (MIS).

METHODS

In this contribution, the implant and technique are described, as well as the analysis of the first clinical results after 61 procedures.

RESULTS

In a mainly elderly patient population (mean: 73 years, range: 50-91 years) 61 minimally-invasive procedures were performed. The placement of screws led to a high primary stability. Primary implant failure occurred in one case (1.69%). The average constant score after 6 months was 62 points (age related mean 72).

CONCLUSIONS

Using the MIS-technique, the NCB-PH plate provides high primary stability, allowing functional treatment without postoperative limitations. The first clinical results show a good functional outcome in a mainly elderly patient population.

Ergebnisse nach Versorgung instabiler proximaler Humerusfrakturen mittels winkelstabiler Platte

BACKGROUND

Fixed-angle implants are being increasingly used in surgery of fractures of the proximal humerus. The aim of this retrospective investigation was to evaluate the outcome after fracture reduction utilizing a fixed-angle plate (Königsee).

MATERIALS AND METHODS

Between January 2003 and April 2004, 58 patients were operated, 52 of whom received a fixed-angle implant; 46 cases were harvested for a follow-up examination. Each patient was re examined clinically and radiologically at least 6 and 18 months after surgery. The functional outcome was evaluated using the Constant Score and the Simple Shoulder Test. The results were compared to results of other investigations.

RESULTS

The mean patient age was 68.8 years (34-94 years). Fractures were classified using the Neer Classification: 12 were classified as two-part, 25 as three-part, and 9 as four-part fractures. Three of the three-part and four of the four-part fractures were rated as luxation fractures. The overall functional outcome of all cases was good. More than 18 months after surgery the mean general "Constant Score" was 57; the mean side-related "Constant Score" was 89%. The Simple Shoulder Test revealed a pain-free range of motion in 41 (89.1%) of the individuals. The majority of the patients were satisfied with the results regarding remaining range of activity of the injured limb. In five cases significant complications occurred. In two cases the head of the humerus collapsed, and in one case a necrosis of the head occurred. In one individual the implant broke after an additional trauma. In this case a re-osteosynthesis utilizing a tibia plate was performed and the patient was excluded from further follow-up investigations. One soft tissue infection occurred after initial surgery.

CONCLUSION

It has been shown that results after fixation of proximal humerus fractures with fixed-angle implants are good. The functional outcome is good and complications are rare. Our results correlate with other investigations regarding fracture reduction using fixed-angle plates and nails.

[Operative treatment of proximal humeral fractures with helix wire]

BACKGROUND

Between 1 January 2000 and 31 December 2002, a total of 50 patients with a dislocated or unstable fracture of the proximal humerus were treated surgically with a titanium helix wire introduced retrogradely into the medullary cavity.

MATERIAL AND METHODS

Fracture classification showed 8 cases of a two-fragment fracture, 32 cases of a three-fragment fracture, and 10 cases of a so-called four-fragment fracture. A retrospective radiographic and medical review of all 50 patients showed postoperative complications in 24% of the cases; in 8 cases (16%) secondary loss of retention occurred with consecutive projection of the helix wires into the subacromial joint space. There were two cases each (4%) of perforation of the helix wire into the joint space without loss of retention and fracture dehiscence because of a blocking mechanism by the helix wire in the subcapital fracture gap. The postoperative revision rate was 18% (9/50) as a result. Of 50 patients with a titanium helix wire, 38 (76%) were reviewed after an average of 23 months (12-31). Radiologically partial necrosis of the head of the humerus was seen in two patients and there was necrosis of the head of the humerus with pseudarthrosis in one patient, which had a negative effect on the Constant score.

RESULTS

Because of a change of procedure (n=5) and intercurrent deaths (n=5) only 2 of 12 patients, in whom complications had occurred postoperatively, could be followed up clinically; the results of the follow-up are sure to be distorted by this selection effect. Of 38 patients, 32 (84%) showed very good to good results functionally; the average Constant score was 74 points and the average age- and sex-specific corrected score was 92%.

DISCUSSION

Thus, the procedure does not achieve better functional results compared to other rigid and semirigid internal fixation methods while it has a high complication and revision rate compared to other rigid and semirigid internal fixation methods. Moreover, early functional treatment is not possible so that the titanium helix wire represents a retention aid rather than stable internal fixation. Overall we cannot recommend the procedure for the operative management of proximal humerus fractures further and have abandoned it ourselves.

Treatment of anterior fracture-dislocations of the proximal humerus by open reduction and internal fixation

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury).

Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries.

A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated.

Mechanism of injury and morphology of the greater tuberosity fracture

Only a few publications discuss the mechanism of injury and morphology of the greater tuberosity fracture. Often, it is described as an avulsion fracture of the rotator cuff. The exact pathobiomechanics is uncertain. We performed a retrospective study and evaluated the mechanism of injury, fracture morphology, and displacement in 103 patients over a 16-year period. Fifty-nine patients sustained a greater tuberosity fracture as part of a traumatic shoulder dislocation. In 44 cases, an isolated greater tuberosity fracture was diagnosed. Of the patients, 47.6% reported a direct mechanism of injury and 32% reported an indirect mechanism of injury. There was one abduction-external rotation injury thought to be the cause of the greater tuberosity fracture. Of the patients, 20.4% were unable to reconstruct the mechanism of injury. Radiologic evaluation revealed an inferior displacement of the fracture on the anteroposterior view in 25% of cases. Our data contradict the theory that this fracture is the result of a bony avulsion of the rotator cuff. Potential mechanisms of injury are discussed. We conclude that there has to be a specific mechanism of injury for greater tuberosity fractures. Further investigations would be beneficial.

Fixation of proximal humerus fractures using the PHILOS plate: early experience

Proximal humeral fractures, especially in elderly patients, remain a challenging problem for the surgeon because the complication rate for these fractures still remains high. The internal locked system (PHILOS) plate is a new device used for proximal humerus fracture fixation is designed to decrease the high complication rate. We prospectively evaluated our early experience using this system. Twenty patients with fractures of the proximal humerus were treated with a PHILOS plate from September 2001 to January 2004 at Princess Alexandra Hospital in Harlow, UK. Functional assessment was done using the Constant shoulder score. Two patients who had brachial plexus injury were evaluated only with the visual analogue score because we thought that the Constant objective assessment would be unreliable. Complications were monitored. The mean Constant score was found to be 76.1% (range, 30-100%). The preliminary results seem to be satisfactory. According to our experience, the plate design provides stable fixation with a good functional outcome and eliminates most hardware problems such as failure and impingement syndrome. The PHILOS plate is suitable for the majority of fractures providing that the correct surgical technique is used.

LEVEL OF EVIDENCE

Therapeutic study, level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

Evaluation and management of valgus impacted four-part proximal humerus fractures

A valgus impacted, four-part humerus fracture is an uncommon but important injury to recognize in patients with orthopaedic trauma. Recognizing this fracture pattern and understanding the pathoanatomy of it are essential to providing appropriate care. The treatment options for valgus impacted, four-part humerus fractures range from nonoperative care to hemiarthroplasty. The peer-reviewed literature provides insight into the important factors to consider in deciding how to treat patients with valgus impacted, four-part humerus fractures. Recently, less invasive surgical techniques have been reported as a way to preserve the blood supply to the articular fracture fragment, which decreases the risk of developing avascular necrosis. Even though these techniques are becoming more popular, they are not indicated for all patients. Surgeons must use an individualized approach for each patient with this fracture. Satisfactory results have been reported for the nonoperative and operative techniques used to treat valgus impacted, four-part humerus fractures. However, less invasive procedures may help to achieve a more favorable clinical outcome. Limiting the surgical approach and achieving stabilization with minimal fixation helps to preserve the viability of the humeral head and to prevent postoperative morbidity related to osseous and soft tissue healing. Hemiarthroplasty becomes a reasonable treatment option in older patients with substantial displacement of the fracture fragments and poor bone quality that would not support internal fixation.

LEVEL OF EVIDENCE

Therapeutic study, level V (expert opinion). See Guidelines for Authors for a complete description of levels of evidence.

Characteristics of an isolated greater tuberosity fracture of the humerus

BACKGROUND

Most classification systems tend to include isolated greater tuberosity fractures in the group of proximal humeral fractures. The purpose of this study was to elucidate demographic differences between isolated greater tuberosity fractures and the other proximal humeral fractures.

METHODS

Altogether, 610 proximal humeral fractures were divided into isolated greater tuberosity fractures of the proximal humerus (group I) and all other proximal humeral fractures (group II). The two groups were analyzed according to their incidence, age and sex distribution, presence of dislocation, and associated chronic medical problems.

RESULTS

Group I comprised 18.9% and group II 81.1% off all fractures. The mean age of group I was 42.8 years, and that of group II was 54.2 years. Of the 115 (67.8%) patients in group I, 78 (67.8%) were male. In contrast, most of the group II patients were female (332/495, 67.1%). A higher incidence of glenohumeral dislocation occurred in group I (6.9%) than in group II (3.4%). Of the 495 group II patients, 175 (35.4%) had medical problems, including endocrine, cardiovascular, pulmonary, hepatic, and renal disease, whereas only 15 of the 115 (13%) patients in group I had such problems.

CONCLUSIONS

Patients with isolated greater tuberosity fractures of the proximal humerus were different demographically, and their treatment and classification should be considered separately from that for other proximal humeral fractures.

Fractures in the proximal humerus: functional outcome and evaluation of 70 patients treated in hospital

INTRODUCTION

Patients with proximal humeral fractures are mostly elderly. In addition to the proximal humeral fracture, they often have other injuries related to poor bone quality. The surgical treatment of proximal humeral fractures in elderly patients with comminuted fractures is associated with several problems and a high frequency of complications. The aims of this study were to evaluate patients with a proximal humeral fracture treated in a hospital, assess the outcome of the fracture treatment, and decide whether surgical treatment of displaced proximal humeral fractures is superior to conservative treatment or not.

MATERIALS AND METHODS

Patients with fractures of the proximal part of the humerus treated in our hospital were followed during two different periods (14 and 10 months). The study in the first time period was retrospective in design, while in the second period the patients were followed prospectively. Seventy patients, (71% women) with a mean age of 71 years, were included in the study. A functional test was performed within 12-14 months after the injury using a modified Rowe shoulder score. Surgical treatment was performed in 15 patients (21%). Neither the surgical approach nor the implants used for osteosynthesis were standardized. Fifty-five patients (79%) were treated conservatively with a modified Velpeau bandage or a sling.

RESULTS

The fractures were classified according to AO into type A (27%), type B (58%) and type C (14%). Osteoporotic risk factors were present in many of the patients, mainly characterized by other skeletal injuries than the proximal humeral fracture (43%). In the group of complex, displaced, non-impacted fractures B2, B3, C2, C3 included (20 fractures), the group treated conservatively had a mean Rowe score of 48/75 (64% of maximum score) and SD 16.8, while in the surgically treated group the mean score was 28/75 (38% of maximum score) and SD 8.1. The difference between the two treatments was significant, with a p-value of 0.01 in favour of the conservatively treated group.

CONCLUSION

The number of patients in each of the fracture groups was low, but surgery did not benefit the patients with complex, displaced fractures in this study.

Treatment of osteoporotic fractures

Fractures are the most common problem associated with osteoporosis and despite advances in prevention and treatment of osteoporosis the number of fractures continue to increase. Along with the three classic locations hip, spine and wrist, there are several other fractures that commonly are related to osteoporosis. The weak bone makes it difficult to achieve a stable bone-implant construct and general weakness of the patient often prevents reduction of load on the injured extremity during healing. The main treatment goal should be preservation of function even at the expense of restoration of exact anatomy. By development of dynamic load-sharing implants and less invasive techniques the results following fixation of osteoporotic fractures has improved. A new strategy has also been to develop materials that will enhance the strength of the cancellous bone that surrounds the metal implant. By using bioactive cement in conjunction with metal implants improved strength has been shown in internally fixed metaphyseal fractures. Encouraging results have also been reported after cement injection into compressed vertebral fractures, so called vertebroplasty. The specific demands involved in the treatment of osteoporotic fractures calls for specific solutions. Apart from augmentation of the cancellous bone and development of new load-sharing devices, endoprosthetic replacement with specially designed fracture prosthesis has become more frequent.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Proximal humeral fractures are common yet the management of these injuries varies widely. In particular, the role and timing of any surgical intervention have not been clearly defined.

OBJECTIVES

To collate and evaluate the scientific evidence supporting the various methods used for treating proximal humeral fractures.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register, the Cochrane Central Register of Controlled Trials, PEDro, MEDLINE (1966 to May week 4 2003), EMBASE (1980 to 2003 week 22), CINAHL (1982 to May week 3 2003), AMED (1985 to May 2003), the National Research Register (UK), Current Controlled Trials, and bibliographies of trial reports. The search was completed in May 2003.

SELECTION CRITERIA

All randomised studies pertinent to the treatment of proximal humeral fractures were selected.

DATA COLLECTION AND ANALYSIS

Independent quality assessment and data extraction were performed by two reviewers. Although quantitative data from trials are presented, trial heterogeneity prevented pooling of results.

MAIN RESULTS

Twelve randomised trials were included. All were small; the largest study involved only 86 patients. Bias in these trials could not be ruled out. Eight trials evaluated conservative treatment, three compared surgery with conservative treatment and one compared two surgical techniques. In the 'conservative' group there was very limited evidence indicating that the type of bandage used made any difference in terms of time to fracture union and the functional end result. However, an arm sling was generally more comfortable than a body bandage. There was some evidence that 'immediate' physiotherapy, without routine immobilisation, compared with that delayed until after three weeks immobilisation resulted in less pain and both faster and potentially better recovery in patients with undisplaced two-part fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated pain in the short term without compromising long term outcome. Two trials provided some evidence that patients, when given sufficient instruction to pursue an adequate physiotherapy programme, could generally achieve a satisfactory outcome if allowed to exercise without supervision. Operative reduction improved fracture alignment in two trials. However, in one trial, surgery was associated with a greater risk of complication, and did not result in improved shoulder function. In one trial, hemi-arthroplasty resulted in better short-term function with less pain and less need for help with activities of daily living when compared with conservative treatment for severe injuries. Fracture fixation of severe injuries was associated with a high rate of re-operation in one trial, comparing tension-band wiring fixation with hemi-arthroplasty. There was very limited evidence that similar outcomes resulted from mobilisation at one week instead of three weeks after surgical fixation.

REVIEWER'S CONCLUSIONS

Only tentative conclusions can be drawn from the available randomised trials, which do not provide sufficient evidence for many of the decisions that need to be made in contemporary fracture management. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether operative intervention, even for specific fracture types, will produce consistently better long term outcomes. There is a need for good quality evidence for the management of these fractures.