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

A Comprehensive Review of Proximal Humerus Fractures: From Epidemiology to Treatment Strategies

This comprehensive review delves into the intricate landscape of proximal humerus fractures (PHFs), exploring their epidemiology, historical evolution, contemporary classification systems, treatment strategies, and outcome measures. PHFs present a complex orthopedic challenge, necessitating a nuanced understanding of their multifaceted dimensions. Despite their clinical significance, PHFs remain relatively understudied in population-based epidemiology. This review critically examines existing literature to uncover the incidence, prevalence, and demographic patterns associated with these fractures. A foundational understanding of the epidemiological landscape is crucial for effective preventive strategies and optimized fracture management. Tracing back to historical records, the review explores the evolution of diagnostic and therapeutic approaches for PHFs. From ancient treatment modalities documented on the Edwin Smith papyrus to contemporary X-ray-based classifications such as Neer and AO/OTA, a historical context is provided to understand the journey of managing these fractures. Navigating through a spectrum of treatment strategies, the review contrasts nonoperative approaches with various surgical interventions. The challenges and outcomes associated with conservative management are juxtaposed against methods like open reduction internal fixation and tension band osteosynthesis. Evidence synthesis guides clinicians in making informed decisions based on patient characteristics and fracture complexities. Central to assessing PHF management are patient-reported outcome measures. The review explores the significance of instruments such as the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire and the Constant-Murley score in evaluating treatment success. The shift toward subjective measures is discussed, considering their correlation with patient experiences and the concept of minimal clinically important difference. The impact of demographic factors, including age and gender, on PHFs is scrutinized. The association between these fractures and osteoporosis is highlighted, emphasizing the crucial role of bone health in fracture prevention and management. Through this comprehensive exploration, the review provides a robust foundation for understanding, evaluating, and advancing the management strategies for PHFs. The synthesis of historical perspectives, contemporary classifications, and treatment modalities serves as a valuable resource for the orthopedic community, fostering improved clinical decision-making and patient outcomes.

Proximal humeral multiple fragment fractures in patients over 55: Comparison between Conservative treatment and Plate Fixation

Proximal humerus fractures account for about 5% of fragility fractures. These involve a significant burden of disability and a reduced quality of life. This study aims to compare functional results and surgical outcomes (closed reduction and internal fixation with the internal closure system of the proximal humerus) and the conservative management of proximal humerus fractures by 2-, 3-, 4-parts, in patients older than 55 years. Between January 2017 and April 2019, 65 patients with 2, 3 or 4-part fractures were retrospectively analyzed: 29 patients (5 males and 24 females) with an average age of 70.8 ± 9.9 years treated non-surgically (conservative group (CG)) and 36 patients (11 males and 25 females) with an average age of 66.2 ± 7.1 years treated surgically with plate fixation (operating group (OG)). Using different evaluation scores, we compared the OG and the CG. Through the DASH score we have seen how at 12 months there is a satisfactory result in patients with conservative treatment (p = 0.0019). Constant-Murley scale shows no difference between the two treatments (p = 0.2300). BARTHEL scale and SST score did not give statistically satisfactory results. Also, after one year of follow-up, patients treated with conservative therapy had a higher improvement in their Range of Motion (ROM) values than patients treated with surgical treatment. The results in terms of pain in NPRS at 3, 6, 12 months are better for conservative groups (p = 0,0000). Our findings suggest that conservative treatment in proximal humeral fractures, particularly in multi-fragmented fractures in patients over 55 years of age, designs an excellent alternative to the surgical option.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.

MAIN RESULTS

We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).

AUTHORS' CONCLUSIONS

There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.

Shoulder-specific Outcome after Proximal Humerus Fracture Influences Medium-term Overall Quality of Life

BACKGROUND

Surgical treatment of proximal humerus fracture is an established procedure. Postoperative complications have been shown to have a significant impact on shoulder-specific outcome. Little is known to date about an influence on injury-independent quality of life.

AIM OF THE WORK

The aim of this retrospective study is to analyse whether patients with a poor functional outcome after surgically treated proximal humerus fracture also show a reduced general quality of life in the medium term. Emphasis is placed on the analysis of patients with poor functional outcome due to postsurgical complications.

MATERIAL AND METHODS

Evaluation of all patients operated at one level 1 trauma centre with a proximal humerus fracture in the period 01.01.2005 to 31.12.2015 and follow-up using validated scores (Constant-Murley Score [CMS], EQ-5D). Two groups, group A with good outcome (∆CMS ≤ 15P.) and group B with poor outcome (∆CMS ≥ 16P.), were defined. Furthermore, descriptive variables including definition of a complication were defined in advance.

RESULTS

138 patients were included in the study (group A: 91, group B: 47). The mean follow-up was 93.86 months ± 37.33 (36-167). Group B had significantly more complications. Furthermore, patients with poor outcome regarding the shoulder (group B) were also found to have significantly lower EQ-VAS (78.9 ± 19.2 [20.0-100] vs. 70.4 ± 19.5 [15.0-98.0]; p = 0.008) and EQ index (0.91 ± 0.14 [0.19-1.00] vs. 0.82 ± 0.17 [0.18-1.00]; p < 0.001).

DISCUSSION

In conclusion, in the present study, the patients with poor outcome of shoulder function in CMS have significantly lower overall quality of life after a mean of more than 6 years of follow-up. The poor outcome was due to a significantly higher postoperative complication rate. This was independent of the fracture morphology present and the surgical procedure used.

Functional Outcome After Nonoperative Treatment of a Proximal Humeral Fracture in Adults

BACKGROUND

The functional outcome following nonoperative treatment of a proximal humeral fracture and the factors that influence it are poorly defined. We aimed to prospectively assess patient-reported outcome measures (PROMs) in a patient cohort at 1 year after the injury.

METHODS

In this study, 774 adult patients sustaining a proximal humeral fracture completed PROM assessments, including the Oxford Shoulder Score (OSS), the EuroQol-5 Dimensions-3 Levels (EQ-5D-3L), and visual analog scale (VAS) assessments of pain, health, and overall treatment satisfaction at 1 year. The mean patient age was 65.6 years, and 73.8% of patients were female. The influences of demographic and fracture measurements and complications on the OSS and EQ-5D-3L were assessed.

RESULTS

The 1-year mean scores were 33.2 points (95% confidence interval [CI], 32.1 to 34.2 points) for the OSS and 0.58 (95% CI, 0.55 to 0.61) for the EQ-5D-3L. There was considerable heterogeneity in the reported scores, and the 3 demographic variables of higher levels of dependency, higher levels of social deprivation, and a history of affective (mood) disorder were most consistently associated with poorer outcomes, accounting for between 37% and 43% of the score variation. The initial fracture translation potentially leading to nonunion accounted for 9% to 15% of the variation, and a displaced tuberosity fracture was also predictive of 1% to 4% of the outcome variation. There was evidence of a ceiling effect for the OSS, with 238 patients (30.8%) having a score of ≥47 points but a mean outcome satisfaction of only 72.9 points, and this effect was more pronounced in younger, active individuals. At the other end of the spectrum, 239 patients (30.9%) reported an OSS of ≤24 points, and 120 patients (15.5%) had a "worse-than-death" EQ-5D-3L score.

CONCLUSIONS

Nonoperative treatment of proximal humeral fractures produces considerable variation in shoulder-specific and general health outcomes at 1 year, and a substantial proportion of patients have poor perceived functional outcomes. The outcome for the majority of less-displaced fractures is mainly influenced by preexisting patient-related psychosocial factors, although the fracture-related factors of displacement, nonunion, and tuberosity displacement account for a small but measurable proportion of the variation and the poorer outcomes in the minority with more severe injuries.

LEVEL OF EVIDENCE

Prognostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Bone Allograft and Locking Plate for Severe Proximal Humeral Fractures: Early and Late Outcomes

Background

Early failure of osteosyntheses is common even with use of locking plates. In patients with comminuted fractures and epiphyseal osseous defects, we performed a series of osteosyntheses by locking plate in combination with an allograft bone augmentation. Because of encouraging short-term results in the literature, we assumed that the method could be a potential alternative to a reverse shoulder prosthesis.

Material/Methods

Twenty-six patients with a dislocated proximal humeral fracture (Neer IV/V/VI) were studied. A lyophilized allogeneic bone graft was used to reinforce the humeral head fragments before locking plate osteosynthesis. The outcomes of fractures were assessed with Disabilities of the Arm, Shoulder and Hand (DASH) and Constant-Murley (Constant) scores, range of motion, a visual analog scale, and with radiological testing. The Constant-Murley scores were the endpoint of our study.

Results

The Neer classification of the fractures was type IV in 4 patients, type V in 20 patients, and type VI in 2 patients. The mean DASH score was 52.85 (range, 4.17–79.3) and the mean Constant score was 39.26 (range, 17–88). We observed late necrosis of the humeral head in 15 of 24 patients (62.5%), although early radiological follow-up showed that the humeral head had been anatomically reconstructed.

Conclusions

Long-term follow-up demonstrated inferior functional results, as displayed by poor Constant scores. There was a high incidence of necrosis, in spite of initial anatomical reconstruction. Biointegration of the allogeneic bone graft and revascularization of the humeral head fragments could be impaired in geriatric patients who have gross dislocation. Therefore, augmentation of the humeral head with allogeneic bone grafts cannot be recommended in these patients.

How to Assess Shoulder Functionality: A Systematic Review of Existing Validated Outcome Measures

The objective of this review was to compile validated functional shoulder assessment tools and analyse the methodological quality of their validations. Secondarily, we aimed to provide a comparison of the tools, including parameter descriptions, indications/applications, languages and operating instructions, to choose the most suitable for future clinical and research approaches. A systematic review (PRISMA) was conducted using: PubMed, WoS Scopus, CINHAL, Dialnet and reference lists until 2020. The main criteria for inclusion were that papers were original studies of validated tools or validation studies. Pre-established tables showed tools, validations, items/components, etc. The QUADAS-2 and COSMIN-RB were used to assess the methodological quality of validations. Ultimately, 85 studies were selected, 32 tools and 111 validations. Risk of bias scored lower than applicability, and patient selection got the best scores (QUADAS-2). Internal consistency had the highest quality and PROMs development the lowest (COSMIN-RB). Responsiveness was the most analysed metric property. Modified UCLA and SST obtained the highest quality in shoulder instability surgery, and SPADI in pain. The most approached topic was activities of daily living (81%). We compiled 32 validated functional shoulder assessment tools, and conducted an analysis of the methodological quality of 111 validations associated with them. Modified UCLA and SST showed the highest methodological quality in instability surgery and SPADI in pain.

Prediction of Nonunion After Nonoperative Treatment of a Proximal Humeral Fracture

BACKGROUND

The prevalence of nonunion after a proximal humeral fracture (PHF) and the risk factors for its occurrence are poorly defined. We aimed to estimate the rate of nonunion in nonoperatively treated patients and to produce a clinical model for its prediction.

METHODS

Two thousand two hundred and thirty adult patients (median age, 72 years [range, 18 to 103 years]; 75.5% were female) with a PHF underwent assessment of fracture union using standard clinical evaluation and conventional radiographs. We assessed the prevalence of nonunion and measured the effect of 19 parameters on healing. Best statistical practices were used to construct a multivariate logistic regression model. The PHF assessment of risk of nonunion model (PHARON) was externally validated in a subsequent prospectively collected population of 735 patients, treated by the same protocol in our institution.

RESULTS

Overall, 231 (10.4%) of 2,230 patients developed nonunion. Only 3 (0.8%) of 395 patients with a head-shaft angle (HSA) of >140° developed nonunion; in this cohort, none of the measured candidate variables were independently predictive of nonunion on multivariate logistic regression analysis. In the larger cohort of 1,835 patients with an HSA of ≤140°, 228 (12.4%) developed nonunion. Decreasing HSA, increasing head-shaft translation (HST), and smoking were independently predictive of nonunion on multivariate analysis. The prevalence of nonunion was very low (1%) in the majority with both an HSA of >90° and HST of <50%, whereas the risk was much higher (83.7%) in the 8.3% with an HSA of ≤90° and HST of ≥50%. In both groups, the prevalence of nonunion was much higher in smokers.

CONCLUSIONS

The prevalence of nonunion after PHF is higher than previously reported. Most patients have favorable risk-factor estimates and a very low risk of this complication, but a smaller subgroup is at much higher risk. The risk can be accurately estimated with PHARON, using standard clinical assessment tools.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nail Versus Plate: A Biomechanical Comparison of a Locking Plate Versus an Intramedullary Nail With an Angular Stable Locking System in a Shoulder Simulator With Active Muscle Forces Using a Two-Part Fracture Model

OBJECTIVES

To compare a locking compression plate versus an intramedullary nail with an angular stable locking system (ASLS) using a 2-part fracture model in a shoulder test bench.

METHODS

Twelve fresh frozen humeri were used for biomechanical testing in a shoulder simulator. A 2-part fracture model, with and without medial cortical support, was used to compare the locking plate and a nail with an ASLS. The varus impaction, varus per cycle motion, tilt, and tilt per cycle were analyzed.

RESULTS

No significant differences for the resulting forces in the glenoid fossa were evaluated. The stable fracture model showed no significant differences for the 2 groups. The median varus impaction was -0.96 degrees (range -0.55 to -4.26 degrees) in the plate group and 0.5 degrees (range -3.06 to 0.98 degrees) in the nail group, after 500 cycles of cyclic loading in the unstable fracture model. The plate group showed a significantly higher median varus impaction per cycle motion and median varus impaction at the 200th, 300th, and 400th cycle of physiological loading.

CONCLUSIONS

The intramedullary nail with the ASLS could be an alternative for patients suffering from osteoporosis and comorbidities.

Surgical management of 2- or 3-part proximal humeral fractures: comparison of plate, nail and K-wires

Background

Proximal humeral fractures (PHFs) are fairly common injuries, and their treatment is a challenge. The aim of this study is to compare clinical and functional outcomes of different osteosynthesis techniques.

Materials and methods

We retrospectively reviewed patients’ files and the hospital’s digital database between March 2002 and April 2018. We treated surgically 148 patients with 2- and 3-part PHFs: 64 with plate and screws, 53 with intramedullary nailing and 31 with retrograde K-wires. We constituted three groups according to the type of treatment and two subgroups for each according to the number of fragments (Neer II or Neer III). Disabilities of the Arm, Shoulder and Hand (DASH) and Short Form-12 (SF-12) scores were recorded.

Results

Mean DASH and SF-12 scores both from the group treated with plate (Group I) and the one subjected to intramedullary nailing (Group II) were statistically superior to results from the patients treated by retrograde K-wires (Group III), while nails showed better functional results than the locking plates. In the first two groups, no difference was found between Neer II and III subgroups, while in Group III the DASH scores were significantly better in Neer II subgroup than those in Neer III subgroup. Avascular necrosis was the most frequent cause of revision surgery in Group I (4 cases) where we had 8 cases of reintervention (12.5%). In Group II, the subacromial impingement was the only cause for revision surgery with 3 cases (5.6%).

Conclusions

Intramedullary nails showed better functional results and a lower complication rate than the locking plates. Both techniques showed superior results compared to those available with retrograde K-wires. So the nail seems to be a more reliable and adequate method for treating 2- and 3-part proximal humeral fractures.

Finite element analyses for predicting anatomical neck fractures in the proximal humerus

BACKGROUND

Proximal humerus fractures which occur as a result of a fall on an outstretched arm are frequent among the elderly population. The necessity of stabilizing such fractures by surgical procedures is a controversial matter among surgeons. Validating a personalized FE analysis by ex-vivo experiments of humeri and mimicking such fractures by experiments is the first step along the path to determine the necessity of such surgeries.

METHODS

Four fresh frozen human humeri were loaded using a new simple experimental setting, so to fracture the humeri at the anatomical neck. Strains on humeri's surfaces predicted by the high order FE analyses (as in Dahan et al., 2016) were compared to the experimental observations to further enhance the validity of the FE analyses. A simplified yield criterion based on a linear elastic analysis and principal strains was used to predict the anatomical neck fracture as observed in the experiment.

FINDINGS

An excellent correlation between experimental measured and FE predicted strains was obtained (slope of 0.99 and R²=0.98). All humeri were fractured at the anatomical neck. The predicted yield load was within 10%-20% accuracy.

INTERPRETATION

High-order FE analyses reliably predict strains and yield loads in the humeri. Fractures induced by the experimental setting correspond to anatomical neck fractures noticed in practice and classified as AO C1.1-C1.3. Surgical neck fractures, which are most common in clinical practice, could not be realized in the proposed experiments, and a different experimental setting should be sought to obtain them ex-vivo.

Operative versus nonoperative treatment of proximal humeral fractures: a systematic review, meta-analysis, and comparison of observational studies and randomized controlled trials

BACKGROUND

There is no consensus on the choice of treatment for displaced proximal humeral fractures in older patients (aged > 65 years). The aims of this systematic review and meta-analysis were (1) to compare operative with nonoperative management of displaced proximal humeral fractures and (2) to compare effect estimates obtained from randomized controlled trials (RCTs) and observational studies.

METHODS

The databases of MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) were searched on September 5, 2017, for studies comparing operative versus nonoperative treatment of proximal humeral fractures; both RCTs and observational studies were included. The criteria of the Methodological Index for Non-Randomized Studies, a validated instrument for methodologic quality assessment, were used to assess study quality. The primary outcome measure was physical function as measured by the absolute Constant-Murley score after operative or nonoperative treatment. Secondary outcome measures were major reinterventions, nonunion, and avascular necrosis.

RESULTS

We included 22 studies, comprising 7 RCTs and 15 observational studies, resulting in 1743 patients in total: 910 treated operatively and 833 nonoperatively. The average age was 68.3 years, and 75% of patients were women. There was no difference in functional outcome between operative and nonoperative treatment, with a mean difference of -0.87 (95% confidence interval, -5.13 to 3.38; P = .69; I² = 69%). Major reinterventions occurred more often in the operative group. Pooled effects of RCTs were similar to pooled effects of observational studies for all outcome measures.

CONCLUSIONS

We recommend nonoperative treatment for the average elderly patient (aged > 65 years) with a displaced proximal humeral fracture. Pooled effects of observational studies were similar to those of RCTs, and including observational studies led to more generalizable conclusions.

Functional and quality of life outcome after non-operatively managed proximal humeral fractures

BACKGROUND

Fractures of the proximal humerus are common and most often treated non-operatively. However, long-term follow-up studies focusing on functional results and quality of life in patients after this type of fracture are scarce. The primary aim of this study is to report the long-term functional and quality of life outcome in patients with a proximal humeral fracture.

MATERIALS AND METHODS

A retrospective analysis of all consecutive patients undergoing non-operative treatment for a proximal humeral fracture in a level 2 trauma centre between January 2000 and December 2013 was performed. A database consisting of all relevant demographic, patient and fracture characteristics was created. Subsequently, a questionnaire containing the DASH (Disabilities of the Arm, Shoulder and Hand) score, EuroQol-5D (EQ-5D), VAS (visual analogue scale) score, and subjective questions was sent to all patients.

RESULTS

A total of 410 patients (65 male, 345 female) were included for analyses. Average follow-up was 90 ± 48 months. DASH-scores <15 were considered as good. A median DASH-score of 6.67 [0.83-22.50] was found. A significant lower DASH-score was seen in patients under the age of 65 compared to older patients (p < 0.001). In comparison to an age-matched general Dutch population, Health related Quality of Life (HrQoL) on the EQ-us was not significantly worse in our study population (difference 0.02). Strong (negative) correlation was found between DASH-score and VAS-score, and DASH-score and HrQoL, respectively ρ = -0.534 and ρ = -0.787.

CONCLUSION

Long-term functional and quality of life outcomes are good in most patients after proximal humeral fractures, but negatively correlated to each other.

LEVEL OF EVIDENCE

Level III.

Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial

PURPOSE

To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program.

METHODS

In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up.

RESULTS

In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037).

CONCLUSIONS

This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program.

LEVEL OF EVIDENCE

Level 1, randomized controlled double-blinded trial.

[The role of short Telegraph nail in the treatment of fractures of the upper end of the humerus: about 19 cases]

La fracture de l'extrémité supérieure de l'humérus est la troisième fracture en fréquence chez les sujets âgés et leur répartition est bimodale touchant préférentiellement le sujet âgé ostéoporotique après un traumatisme à faible énergie ou plus rarement le sujet jeune par mécanisme à forte cinétique. Le traitement des fractures complexes de l'humérus proximal est le sujet de nombreuses controverses Le clou Telegraph constitue une approche thérapeutique très efficace pour les fractures déplacées de l'extrémité supérieure de l'humérus, de technique chirurgicale facile mais avec une courbe d'apprentissage et permettant un protocole de rééducation dans l'immédiat de l'intervention. C'est un matériel d'enclouage antérograde de 15 cm de long, plein verrouillé en proximal et en distal, le verrouillage proximal est assuré par 4 vis spongieuses, de filetage long, stables dans le clou et cela confère une solidité tout-à-fait remarquable à ce montage alors que le verrouillage distal est assuré au niveau du V deltoïdien en zone avasculaire et là où il n'y a pas de passage nerveux. L’étude présentée concerne 19 patients traités par un clou Telegraph court dans le traitement des fractures de l'extrémité supérieure de l'humérus entre 2013 et 2015 et elle a pour but d'analyser les résultats radio-cliniques et d’évaluer la répercussion de cette technique sur la fonction de l’épaule. Le clou Telegraph proposé depuis plus de 12 ans à peu près, a rencontré et continue de rencontrer un réel succès. Il permet de traiter très efficacement les fractures simples type 2 et 3, mais aussi les fractures impactées en valgus à 4 fragments. L'ostéosynthèse par clou Telegraph est une solution efficace, rapide et reproductible dans le traitement chirurgical des fractures de l'extrémité supérieur de l'humérus même en cas des fractures complexes et permet une reprise rapide de la mobilité de l’épaule.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012.

OBJECTIVES

To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014.

SELECTION CRITERIA

We considered all randomised controlled trials (RCTs) and quasi-randomised controlled trials pertinent to the management of proximal humeral fractures in adults.

DATA COLLECTION AND ANALYSIS

Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed.

MAIN RESULTS

We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single-centre trials. The main exception was the surgical versus non-surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison.Nine trials evaluated non-surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non-union (2/52 versus 1/54; 2 trials).One quasi-randomised trial (28 participants) found the Gilchrist-type sling was generally more comfortable than the Desault-type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high-frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long-term results than supervised exercise in a swimming pool plus home exercise.Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient-reported shoulder and upper-limb function at one- or two-year follow-up between surgical (primarily locking plate fixation or hemiarthroplasty) and non-surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow-ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non-surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a greater risk of adverse events after non-surgical treatment.Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically-related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K-wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re-operation rates, whereas another trial (30 participants) reported all five re-operations occurred in the tension-band fixation group. One trial (62 participants) found better patient-rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow-up and a lower incidence of re-operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty.No important between-group differences were found in one trial (120 participants) comparing the deltoid-split approach versus deltopectoral approach for non-contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re-operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants).

AUTHORS' CONCLUSIONS

There is high or moderate quality evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two-part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures.There is insufficient evidence from RCTs to inform the choices between different non-surgical, surgical, or rehabilitation interventions for these fractures.

Proximal fractures of the humerus in patients older than 75 years of age: should we consider operative treatment?

Background

Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly.

Materials and methods

In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations.

Results

Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction).

Conclusion

This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.

Level of evidence

According to OCEBM Working Group, Level IV.

A review of management options for proximal humeral fractures

Proximal humeral fractures are common and although the majority can be managed non-operatively, the optimal treatment of displaced or complex fractures remains controversial. Non-operative treatment is typically selected for minimally displaced fractures where union rates are high and good or excellent outcomes can be expected in approximately 80% of cases. The aims of surgical fixation are to restore articular surface congruency, alignment and the relationship between the tuberosities and the humeral head. Hemiarthroplasty provides patients with reliable pain relief and its indications include fracture dislocations, humeral head splitting fractures and some three- and four- part fractures. The key areas of surgical technique that influence functional outcome include correctly restoring the humeral height, humeral version and tuberosity position. Function, however, is poor if the tuberosities either fail to unite or mal-unite. The interest in reverse shoulder arthroplasty as an alternative option has therefore recently increased, particularly in older patients with poor bone quality and tuberosity comminution. The evidence supporting this, however, is currently limited to multiple case series with higher level studies currently underway.

Avascular necrosis in proximal humeral fractures in patients treated with operative fixation: a meta-analysis

BACKGROUND

Proximal humeral fractures are common lesions of the elderly, but there are no established treatment guidelines. A surgical treatment for comminuted and displaced fractures of the proximal humerus was developed and is still evolving. The aim of this study was to perform a quantitative review to evaluate the risk of avascular necrosis (AVN) in patients with proximal humeral fractures who were treated by operative fixation compared with conservative treatment.

METHODS

We searched the PubMed, MEDLINE, Springer, Elsevier Science Direct, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (in Chinese), and Wanfang database (in Chinese) up to December 2013 to identify studies related to operative fixation and AVN in patients with proximal humeral fractures.

RESULTS

Seven studies with a total of 291 patients (142 operative fixation cases and 149 conservative treatment cases) with proximal humeral fractures were considered in the meta-analysis. The overall meta-analysis showed no significant difference in the incidence of AVN between the two groups [odds ratio (OR) 1.42, 95% confidence interval (CI) 0.33-6.11, p = 0.64]. The subgroup meta-analysis by study design (retrospective/prospective), sample size (≤40/>40), and ethnicity (European/Asian) demonstrated similar results. However, the subgroup analysis by specific operative approach (plate fixation/tension band wiring fixation/others) indicated that plate fixation was associated with a higher rate of AVN than conservative treatment (OR 0.20, 95% CI 0.05-0.76, p = 0.019).

CONCLUSIONS

Plate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures.

The treatment of proximal humeral fracture in adults

BACKGROUND

The incidence of proximal humeral fractures lies between 105 and 342 per 100 000 persons per year. Around the world, this type of fracture remains a major challenge for treating surgeons. While non-displaced fractures can be managed conservatively, displaced ones are often treated surgically.

METHODS

Selective literature review.

RESULTS

There are still no evidence-based schemes or guidelines for the treatment of proximal humeral fractures, and very few prospective randomized trials are available. The few that have been published recently show a trend in favor of conservative treatment, but they were carried out on small groups of patients and their findings are not directly generalizable. For younger patients, the goal of treatment is generally anatomical repositioning and osteosynthetic stabilization; for older patients, primary treatment with a prosthesis is a further option. Depending on the mode of treatment, complications can arise such as shoulder stiffness, necrosis of the humeral head, pain, infection, loss of reposition, and "cutting out."

CONCLUSION

Current evidence supports the individualized treatment of proximal humeral fractures. Treatment decisions must always be made jointly with the patient in consideration of his or her individual needs and characteristics. Particularly for elderly patients, the possibility of conservative treatment should be carefully considered. If conservative treatment is not possible, then the type of operation performed should also be a function of the surgeon's individual skills and experience with particular types of implant.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Fractures of the proximal humerus are common injuries. The management, including surgical intervention, of these fractures varies widely. This is an update of a Cochrane review first published in 2001 and last updated in 2010.

OBJECTIVES

To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in January 2012.

SELECTION CRITERIA

All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected.

DATA COLLECTION AND ANALYSIS

Two people performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed.

MAIN RESULTS

Twenty-three small randomised trials with a total of 1238 participants were included. Bias in these trials could not be ruled out. Additionally there is a need for caution in interpreting the results of these small trials, which generally do not provide sufficient evidence to conclude that any non-statistically significant finding is 'evidence of no effect'.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate self-directed exercise programme.Six heterogeneous trials, involving a total of 270 participants with displaced and/or complex fractures, compared surgical versus conservative treatment. Pooled results of patient-reported functional scores at one year from three trials (153 participants) showed no statistically significant difference between the two groups (standardised mean difference -0.10, 95% CI -0.42 to 0.22; negative results favour surgery). Quality of life based on the EuroQol results scores from three trials (153 participants) showed non-statistically significant differences between the two groups at three time points up to 12 months. However, the pooled EuroQol results at two years (101 participants) from two trials run concurrently from the same centre were significantly in favour of the surgical group. There was no significant difference between the two groups in mortality (8/98 versus 5/98; RR 1.55, 95% CI 0.55 to 4.36; 4 trials). Significantly more surgical group patients had additional or secondary surgery (18/112 versus 5/111; RR 3.36, 95% CI 1.33 to 8.49; 5 trials). This is equivalent to an extra operation in one of every nine surgically treated patients.Different methods of surgical management were tested in seven small trials. One trial comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of better function after plate fixation but also of a higher rate of surgically-related complications. One trial comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary nails found some evidence of a short-term benefit for the nailing group. Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a higher re-operation rate in one trial. Two trials found no important differences between 'polyaxial' and 'monaxial' screws combined with locking plate fixation. One trial produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial found better functional results for one of two types of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It remains unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes but it is likely to be associated with a higher risk of surgery-related complications and requirement for further surgery.There is insufficient evidence to establish what is the best method of surgical treatment, either in terms of the use of different categories of surgical intervention (such as plate versus nail fixation, or hemiarthroplasty versus tension-wire fixation) or different methods of performing an intervention in the same category (such as different methods of plate fixation). There is insufficient evidence to say when to start mobilisation after either surgical fixation or hemiarthroplasty.

Predictive factors for functional outcome and failure in angular stable osteosynthesis of the proximal humerus

INTRODUCTION

Angular stable osteosynthesis has become the gold standard in the operative treatment of proximal humeral fractures. The aim of this article is to determine the indications for osteosynthesis versus primary arthroplasty based on clinical and radiological parameters.

METHODS

A total of 368 surgically treated proximal humeral fractures were reviewed. Preoperative X-rays were used to evaluate the displacement and vascularity of the humeral head (according to the Hertel criteria) and the AO (Arbeitsgemeinschaft für Osteosynthesefragen) fracture type. Postoperative X-rays were analysed to assess the quality of the reduction, the reconstruction of the medial hinge and the displacement of the tuberosities. Follow-up X-rays were used to evaluate healing progress, the occurrence of avascular necrosis, loss of reduction and implant related failures. The American Shoulder and Elbow Surgeons score (ASES score) was used to evaluate the functional outcome. Correlations between a set of variables, type of treatment and eventual outcome were verified in both univariate and multivariate settings, with the significance rate set at p<0.05.

RESULTS

In total, 307 shoulders were evaluated. Mean follow-up was 4.3 years and showed a 15.3% failure rate, a 23.8% re-operation rate and a mean ASES score of 75.3. Better results were noted in patients who were younger at the time of surgery. More displaced fractures, AO type C fractures, varus fracture configuration and reduced head vascularity all led to a worse outcome. Anatomical reduction correlated with better results. Articular fractures had better results when treated with a plate.

CONCLUSION

Surgical treatment of proximal humeral fractures remains difficult, with a failure rate of 15.3% and a re-operation rate of 23.8% at 4.3 years. A significantly displaced varus articular fracture in the older patient results in the worst outcome.

Locking plate versus nonsurgical treatment for proximal humeral fractures: better midterm outcome with nonsurgical treatment

BACKGROUND

Since its introduction, there has been controversy about the use of locking plates in the treatment of proximal humeral fractures. Have they really improved the functional outcome after a proximal humeral fracture or should nonsurgical treatment have a more prominent role? In order to evaluate our hypothesis that nonsurgical treatment for proximal humerus fractures should be the first choice of treatment, a matched controlled cohort study was conducted to compare the midterm (>1 year) functional and radiologic outcome of a group of patients treated with a locking plate and a matched group of patients treated nonsurgically. Complications in each group of patients were evaluated.

MATERIALS AND METHODS

Through direct matching, 17 patients (1 bilateral fracture) treated with a locking plate were matched to 18 patients treated nonsurgically. Medical records and radiographs were reviewed retrospectively to obtain relevant patient related data and fracture type according to Neer classification (i.e. 2-, 3- and 4-part fractures). At the time of clinical follow-up, EQ-5D, American Shoulder and Elbow Surgeons (ASES) score, visual analog pain (VAS) pain and VAS satisfaction scores were completed. Active range of motion was tested. New radiographs were made to evaluate fracture healing, complications and, in the locking plate group, the position of the plate and screws.

RESULTS

No significant differences were found in the characteristics of the patient groups. A significant difference in range of motion was found in favor of the nonsurgically treated patients. Results of ASES and patient satisfaction scores were also tending toward nonsurgical treatment. Furthermore, the complication rate was higher with locking plate treatment. Patients treated with a locking plate needed significantly more additional treatment on their injured shoulder (P = 0.005).

DISCUSSION

This study's main limitation was the fact that the choice of initial fracture management was based on clinical judgement, as well as patient's fitness for surgery and therefore not randomized. By matching for fracture type this bias was largely overcome. Surgical treatment had a higher complication rate, requiring more additional treatment, which was often related to the initial surgery. Improving surgical technique could possibly lead to better outcomes for the surgically treated patients. In addition to the more favorable outcomes, nonsurgical treatment is also a more cost effective treatment.

CONCLUSION

Nonsurgical treatment should have a more prominent role in the treatment of proximal humeral fractures.

The results of nonoperative treatment for three- and four-part fractures of the proximal humerus in low-demand patients

OBJECTIVE

To evaluate the results of nonoperative treatment of three- and four-part fractures of the proximal humerus in patients who refused surgery or could not undergo surgery because of medical conditions.

DESIGN

Retrospective evaluation of prospective collected data.

SETTING

Educational and research hospital. Level IV, therapeutic case series.

PATIENTS

Eighteen patients (eight three- and 10 four-part fractures) were included. The mean age was 68.2 ± 13.8 years (range, 39-90 years). The mean follow-up was 39.1 ± 12.4 months (range, 24-60 months). Patients were grouped into two: Group A being younger than 65 years and Group B 65 years or older.

INTERVENTION

Standardized nonoperative treatment and follow-up protocols were used.

MAIN OUTCOME MEASUREMENTS

Functional and radiographic assessments were performed in posttreatment first year and at latest follow-up. Constant-Murley scores were also obtained for both shoulders.

RESULTS

The mean Constant-Murley score was 61.3 ± 13.5 (range, 40-85) at latest follow-up. Osteonecrosis was detected in five patients. All patients had significantly lower SF-36 scores for all subscales except mental health than the normal Turkish population. There was no significant difference between three- and four-part fractures regarding age and Constant-Murley scores. The mean Constant-Murley score of the Group A patients with three-part fractures was significantly higher when compared with the Group A patients with four-part fractures. There was no significant difference between patients with and without osteonecrosis regarding fracture types or the Constant-Murley scores at the latest follow-up.

CONCLUSIONS

Although the individual fracture type does not have an influence on functional results, these results are better in patients younger than 65 years with three-part fractures. The results of the nonoperative treatment of these fractures are satisfactory even in elderly patients. The radiographic appearances did not correspond with the functional results.

The clinical benefit of medial support screws in locking plating of proximal humerus fractures: a prospective randomized study

PURPOSE

The purpose of this study was to evaluate the clinical benefit of medial support screws for locking plating of proximal humerus fractures.

METHODS

Seventy-two consecutive patients underwent prospective treatment for proximal humerus fractures with locking plates between October 2007 and September 2008. Sixty-eight patients accomplished a mean 30.8-month follow-up and were randomized into two groups: 39 patients were treated with only a locking plate and were classified in the -MSS (medial support screw) group, and 29 patients were included in the + MSS group, which were fixed with additional medial support screws. Clinical and radiological investigations were performed in both groups.

RESULTS

The fractures united at an average of 13.6 weeks after final surgery. Comparably better shoulder function recovery was achieved in the +MSS group with regard to the Constant shoulder score (P = 0.01), with the respective excellent and good rates of 79% and 62%. Eleven patients developed various complications. A statistical difference (P = 0.036) was observed regarding the failure rate (23.1% in the -MSS group vs. 3.4% in the +MSS group). The early loss of fixation was related to higher age (P < 0.001) and less initial neck-shaft angle (NSA) (P = 0.011) of the patients. However, bone mineral density was not significantly associated with loss of fixation (P = 0.076). Although no difference was found in all types of the fractures between the +MSS and -MSS groups regarding immediate postoperative NSA, we observed a significantly lower final NSA in the -MSS group and greater secondary angle loss in the subgroup of Neer three-part (P = 0.033 and 0.015, respectively) and four-part fractures (P = 0.043 and 0.027).

CONCLUSIONS

Anatomical reduction can substantially decrease the risk of postoperative failure in locking plating of proximal humerus fractures. Medial support for proximal humerus fractures seems to have no benefits in Neer two-part fractures. However, the additional medial support screws inserted into the medio-inferior region of the humeral head may help to enhance mechanical stability in complex fractures and allow for better maintenance of reduction.

Trends and variation in incidence, surgical treatment, and repeat surgery of proximal humeral fractures in the elderly

BACKGROUND

the treatment of proximal humeral fractures in the elderly remains controversial. Options include nonoperative treatment, open reduction with internal fixation (ORIF), and hemiarthroplasty. Locking plate technology has expanded the indications for ORIF for certain fracture types in osteoporotic bone. This study was performed to characterize the incidence, treatment, and revision surgery of proximal humeral fractures according to geographic region both before (1999 to 2000) and after (2004 to 2005) the introduction of locking plates.

METHODS

we used a 20% sample of Medicare Part-B data and the Medicare denominator file for the years 1998 to 2006. Proximal humeral fractures were identified by Common Procedural Terminology codes for treatment, categorized as nonoperative, ORIF, or hemiarthroplasty. Geographic variation in treatment type was determined with use of 306 hospital referral regions. Odds ratios for revision surgery were calculated by the need for repeat surgery within one year of the index procedure. Rates were adjusted for age, sex, race, and comorbidities.

RESULTS

there were 14,774 proximal humeral fractures in the 20% sample from 1999 to 2000 (an estimated total of 73,870 fractures) and 16,138 fractures in the sample from 2004 to 2005 (an estimated total of 80,690 fractures). The overall age, sex, and race-adjusted incidence of proximal humeral fractures was unchanged from 1999 to 2005 (2.47 vs. 2.48 per 1000 Medicare beneficiaries; p = 0.992). However, the absolute rate of surgically managed proximal humeral fractures rose 3.2 percentage points from 12.5% to 15.7%, a relative increase of 25.6% (p < 0.0001). The relative increase in the percentage of fractures treated with ORIF was 28.5% (p < 0.0001), while the percentage of fractures treated with hemiarthroplasty increased 19.6% (p < 0.0001). There were large regional variations in the proportion treated surgically (range, 0% to 68.18%). The rates of repeat surgery were significantly higher in 2004 to 2005 compared with 1999 to 2000 (odds ratio = 1.47, p = 0.043).

CONCLUSIONS

although the incidence of proximal humeral fractures in the elderly did not change from 1999 to 2005, the rate of surgical treatment increased significantly. The marked regional variation in the rates of surgical treatment highlights the need for better consensus regarding optimal treatment of proximal humeral fractures. Additional research is needed to help to determine which fractures are best treated operatively in order to maximize outcome and minimize the need for revision surgery.

LEVEL OF EVIDENCE

therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

Interventions for treating proximal humeral fractures in adults

BACKGROUND

Proximal humeral fractures are common injuries. The management, including surgical intervention, of these fractures varies widely.

OBJECTIVES

To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.

SEARCH STRATEGY

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in March 2010.

SELECTION CRITERIA

All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected.

DATA COLLECTION AND ANALYSIS

Two people performed independent study selection, risk of bias assessment and data extraction. Trial heterogeneity prevented meta-analysis.

MAIN RESULTS

Sixteen small randomised trials with 801 participants were included. Bias in these trials could not be ruled out.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate physiotherapy programme.Surgery improved fracture alignment in two trials but was associated with more complications in one trial, and did not result in improved shoulder function. Preliminary data from another trial showed no significant difference in complications, quality of life or costs between plate fixation and conservative treatment. In one trial, hemiarthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries.Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a high re-operation rate in one trial. One trial found better functional results for one type of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes.

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients

OBJECTIVE

This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.

DESIGN

This study is a randomised controlled trial.

PARTICIPANTS

This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.

INTERVENTIONS

The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).

MAIN OUTCOME MEASURE

The outcomes measured included quality-adjusted life years (QALYs) and societal costs.

RESULTS

At 12 months' follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI)=-0.025, 0.078) while the mean difference in total health-care costs was 597 euro in favour of surgery (95% CI=-5291, 3777).

CONCLUSION

There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.

Fraturas da extremidade proximal do úmero: estudo comparativo entre dois métodos de fixação

OBJETIVO: Comparar o resultado do tratamento das fraturas da extremidade proximal do úmero. osteossíntese com a placa em t de pequenos fragmentos (grupo a), promovendo uma estabilização relativa, em contraposição à placa com parafusos bloqueados (grupo b). MÉTODOS: São alocados de forma aleatória 18 pacientes e avaliados prospectivamente, segundo critérios clínicos, escala funcional e parâmetros radiográficos da redução obtida. RESULTADOS: Pela escala analógica de dor a média aos seis meses de evolução foi 2,1 para o grupo a e 2,2 para o grupo b, a amplitude de elevação no grupo a foi de 140ºe de 143ºno grupo b e a pontuação na escala funcional da ucla foi respectivamente 30 e 31. Nas radiografias avaliadas; no grupo a, três pacientes obtiveram ângulos medidos após a estabilização entre 0º e 10º de desvio em relação à anatomia normal e seis entre 11º e 40º, no grupo b sete pacientes com ângulos entre 0º e 10º e dois entre 11º e 20º. CONCLUSÕES: Nos resultados precoces e tardios não ocorreram diferenças clínicas e funcionais nos dois grupos, prevalecendo uma alta incidência de bons resultados. as medidas radiográficas das reduções obtidas ficaram mais próximas do anatômico no grupo tratado com placas bloqueadas.

Functional outcomes after nonoperative management of fractures of the proximal humerus

BACKGROUND

Prospective follow-up data after nonoperative treatment for fractures of the proximal humerus are scarce. We studied functional outcomes and rates of complication and failure after conservative management of these common injuries.

MATERIALS AND METHODS

Consecutive patients aged older than 18 years presenting to the emergency department of a large district hospital with an isolated, closed proximal humeral fracture considered suitable for functional treatment by the surgeon on charge were enrolled in a prospective, externally monitored observational study. Surgeons were free to reduce the fracture and to prescribe any type of sling or brace. Active follow-up after 12 weeks, 6, and 12 months included plain radiographs, Constant score, and Disabilities of Arm, Shoulder and Hand (DASH) score.

RESULTS

We enrolled 160 patients (118 women; mean age, 63.3 +/- 14.8 years), and 124 completed 1-year follow-up. There were 85, 71, and 4 AO 11 A, B, and C fractures, and 75 one-part, 60 two-part, 23 three-part, and 2 four-part and head-splitting fractures. After 1 year, the mean difference in Constant scores between the injured and contralateral shoulder was 8.2 (95% confidence interval [CI], 6.0-10.4). The mean difference in 1-year DASH scores to baseline assessment was 10.2 points (95% CI 7.3-13.1 points). The risk of delayed and nonunion was 7.0% (95% CI, 3.6%-12.3%). Four patients subsequently underwent surgical fixation, and 5 had arthroscopic subacromial decompression.

CONCLUSION

This study may provide reference values for future investigations and stresses ceiling effects that will make it difficult to demonstrate a significant advantage of surgical over nonoperative treatment in patients with proximal humeral fractures.

LEVEL OF EVIDENCE

Level 4; Prospective case series without a control group.

The impacted varus (A2.2) proximal humeral fracture in elderly patients: is minimal fixation justified? A case control study

BACKGROUND

The purpose of this retrospective case control study was to assess the outcome of K-wire osteosynthesis of a varus displaced proximal humeral fracture in patients over 65 years old, compared to a control group treated nonoperatively.

METHODS

The patient cohort was taken from our database in the period 2003-2007. After data extraction, the patients were re-examined and scored by the Constant score (CS), modified Constant score (MCS), and the QuickDASH score. The control group was carefully selected and matched to the surgical one for age, type of fracture, and degree of displacement. Minimum follow-up was 12 months, with a mean of 30 months in the surgery group, and 27 months in the nonoperative group.

RESULTS

K-wire osteosynthesis in our series yielded consistently good results in older patients who sustained an A2.2 proximal humeral fracture, with an average MCS of 88 points and a QuickDASH score of 15. The surgery group had a statistically significant higher CS and modified Constant score at follow-up than did the conservatively treated group (p = .03).

CONCLUSION

Operative treatment of varus displaced proximal humerus fractures treated with K-wire osteosynthesis yields good results that are superior to those treated nonoperatively.

LEVEL OF EVIDENCE

Level 3; Case control study, treatment study.

Open reduction and internal fixation of proximal humerus fractures

Open reduction of proximal humeral fractures has the advantage of providing direct control over each fracture fragment and permitting anatomic reduction and fixation with advanced devices. Modern fixed-angle locking plates designed specifically for proximal humerus fractures have allowed the expansion of surgical indications permitting surgeons to address more complicated fractures. Advanced preoperative imaging and fluoroscopy allow a better understanding of fracture patterns and permit the surgeon to use this knowledge intraoperatively. Research is required to further validate fracture classification systems, to develop surgical guidelines for decision making, and to compare the outcomes of the various treatments options for proximal humerus fractures.

Avaliação funcional retrospectiva de pacientes com fratura proximal de úmero fixada com placa com parafusos de ângulo fixo para região proximal no úmero

As fraturas do úmero proximal são lesões comuns, levando seus pacientes a importantes limitações funcionais além de algumas complicações. Atualmente existem algumas opções de tratamentos cirúrgicos visando à melhor estabilização da lesão através de técnicas de ostessíntese, dependendo do grau de gravidade da lesão. Dentre eles, tem-se utilizado a placa com parafusos de ângulo fixo para região proximal do úmero, a qual possui o intuito de preservar a integridade biológica da cabeça umeral associada à redução anatômica segura utilizando múltiplos parafusos de fixação com estabilidade angular, permitindo assim a mobilização precoce do membro fraturado. Foram estudados retrospectivamente 11 pacientes com fratura proximal do úmero, tratados com esse modelo de placa entre os anos de 2004 e 2005. Na avaliação funcional foram utilizados o questionário de Constant e o índice DASH. Os resultados sugerem o aparecimento de perda funcional residual no membro superior após esse tipo de trauma, apesar da fixação estável e o tratamento fisioterapêutico.

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.

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.

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.

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.