Interventions for treating proximal humeral fractures in adults
Abstract
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 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 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.
PICOs
Plain language summary
Interventions for treating proximal humeral (top end of upper arm bone) fractures in adults
Fracture of the top end of the upper arm bone is a common injury in older people. The bone typically fractures (breaks) just below the shoulder, usually after a fall. Most of these fractures occur without breaking of the skin. Often the injured arm can be supported in a sling until the fracture heals sufficiently to allow shoulder movement. More complex fractures may be treated surgically. This may involve fixing the fracture fragments together by various means. Alternatively, the top of the fractured bone may be replaced (half joint replacement: hemiarthroplasty), or sometimes together with the joint socket (total joint replacement). Physiotherapy is often used to help restore function.
This review includes evidence from 16 small randomised trials with a total of 801 participants. Several trials had weaknesses that could bias their results. No trials were similar enough to pool their results.
Eight trials evaluated conservative (non‐surgical) 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 physiotherapy delayed until after three weeks of immobilisation resulted in less pain and faster recovery in people with 'stable' 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 could generally achieve a satisfactory outcome when given sufficient instruction to pursue exercises on their own.
Evidence from two trials did not show that surgery resulted in improved function, but it was associated with more complications in one trial. Preliminary data from a third trial showed no differences in complications or quality of life between fixation with a bracket and screws and conservative treatment. In another trial, hemiarthroplasty resulted in better short‐term function and less pain when compared with conservative treatment for severe injuries. Another trial found that fixation of severe injuries by holding the broken fragments together with wires resulted in more reoperations than replacement with a hemiarthroplasty. One trial found better functional results for one of two types of hemiarthroplasty.
There was very limited evidence suggesting similar outcomes for early versus later mobilisation after either surgical fixation or hemiarthroplasty.
Overall, there is some evidence to support earlier arm movement for some types of fractures. Otherwise, there is not enough evidence to determine the best treatment, including surgery, for these fractures.
