Interventions for treating proximal humeral fractures in adults

Helen HG Handoll; Benjamin J Ollivere; Katie E Rollins

doi:10.1002/14651858.CD000434.pub3

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Figure 1

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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Analysis 1.1

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 1 Shoulder disability: Croft Shoulder Disability Score.

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Analysis 1.2

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 2 Croft shoulder disability score: individual problems at 2 years.

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Analysis 1.3

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 3 Number of treatment sessions (until independent function achieved).

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Analysis 1.4

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 4 SF‐36 scores: pain & physical dimensions.

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Analysis 1.5

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 5 Adverse events.

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Analysis 1.6

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 6 Constant shoulder score (ratio of affected/unaffected arm).

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Analysis 1.7

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 7 Constant shoulder score (0 to 100: best).

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Analysis 1.8

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 8 Changes in pain intensity (mm) from baseline: 100 mm visual analogue scale (positive change = less pain).

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Analysis 1.9

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 9 Range of motion at 6 months (degrees): difference between two shoulders.

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Analysis 1.10

Comparison 1 Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks, Outcome 10 Patient dissatisfied with treatment.

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Analysis 2.1

Comparison 2 Gilchrist bandage versus 'Classic' Desault bandage, Outcome 1 Problems with bandages.

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Analysis 2.2

Comparison 2 Gilchrist bandage versus 'Classic' Desault bandage, Outcome 2 Fracture displacement by 3 weeks.

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$Comparison 2 Gilchrist bandage versus 'Classic' Desault bandage, Outcome 3 Poor or bad rating by patient at fracture consolidation.$

Analysis 2.3

Comparison 2 Gilchrist bandage versus 'Classic' Desault bandage, Outcome 3 Poor or bad rating by patient at fracture consolidation.

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Analysis 3.1

Comparison 3 Instructed self physiotherapy versus conventional physiotherapy, Outcome 1 Pain at one year (scale 0 to 8: maximum pain).

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Analysis 3.2

Comparison 3 Instructed self physiotherapy versus conventional physiotherapy, Outcome 2 Severe or moderate pain at 3 months.

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Analysis 3.3

Comparison 3 Instructed self physiotherapy versus conventional physiotherapy, Outcome 3 Requested change of therapy.

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Analysis 3.4

Comparison 3 Instructed self physiotherapy versus conventional physiotherapy, Outcome 4 Adverse events (frozen shoulder: 1 v 2; unexplained prolonged pain: 0 v 1).

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Analysis 3.5

Comparison 3 Instructed self physiotherapy versus conventional physiotherapy, Outcome 5 Neer's rating (0 to 100: best) at mean 16 months (exploratory analysis).

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Analysis 3.6

Comparison 3 Instructed self physiotherapy versus conventional physiotherapy, Outcome 6 Active gleno‐humeral elevation (degrees).

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Analysis 4.1

Comparison 4 Surgery versus conservative treatment, Outcome 1 Functional scores at 12 months (higher = worse).

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Analysis 4.2

Comparison 4 Surgery versus conservative treatment, Outcome 2 DASH (0 to 100: worst disability).

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Analysis 4.3

Comparison 4 Surgery versus conservative treatment, Outcome 3 American Shoulder and Elbow Surgeons score (0 to 24: best).

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Analysis 4.4

Comparison 4 Surgery versus conservative treatment, Outcome 4 Activities of daily living.

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Analysis 4.5

Comparison 4 Surgery versus conservative treatment, Outcome 5 Quality of life assessment: EuroQol (0: dead to 1: best health).

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Analysis 4.6

Comparison 4 Surgery versus conservative treatment, Outcome 6 Quality of life assessment (Fjalestad 2010 data).

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Analysis 4.7

Comparison 4 Surgery versus conservative treatment, Outcome 7 Mortality.

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Analysis 4.8

Comparison 4 Surgery versus conservative treatment, Outcome 8 Additional surgery (re‐operation or secondary surgery).

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Analysis 4.9

Comparison 4 Surgery versus conservative treatment, Outcome 9 Adverse events / complications.

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Analysis 4.10

Comparison 4 Surgery versus conservative treatment, Outcome 10 Constant scores (overall: 0 to 100: best score).

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Analysis 4.11

Comparison 4 Surgery versus conservative treatment, Outcome 11 Constant scores (difference between injured and uninjured shoulder): Normal = 0..

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Analysis 4.12

Comparison 4 Surgery versus conservative treatment, Outcome 12 Poor or unsatisfactory function at 1 year (Neer rating).

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Analysis 4.13

Comparison 4 Surgery versus conservative treatment, Outcome 13 Dependent in activities of daily living (or dead) at 6 months.

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Analysis 4.14

Comparison 4 Surgery versus conservative treatment, Outcome 14 Pain at 2 years: VAS (0 to 100: worst pain).

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Analysis 4.15

Comparison 4 Surgery versus conservative treatment, Outcome 15 Constant score at 50 months: overall and components.

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Analysis 4.16

Comparison 4 Surgery versus conservative treatment, Outcome 16 Constant (often severe) pain at 6 months.

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Analysis 4.17

Comparison 4 Surgery versus conservative treatment, Outcome 17 Failure to recover 75% muscle power relative to other arm (survivors) at 6 months.

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Analysis 4.18

Comparison 4 Surgery versus conservative treatment, Outcome 18 Range of movement impairments in survivors at 6 months.

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Study	Measure	Surgery	Conservative treatment	Difference (conclusion)
Fjalestad 2010	Total health‐care costs	mean = 10,367	mean = 10,946	Abstract: "the mean difference in total health‐care costs was 597 Euros in favour of surgery (95% CI = ‐5291, 3777)". No significant difference.
Fjalestad 2010	Health‐care + indirect costs	mean = 23,953	mean = 21,878	Reformatted text: "Including indirect costs... the difference [was] 2,075 (95% CI = ‐15,949 to 20,100)". No significant difference, but favours the conservative group.

Analysis 4.19

Comparison 4 Surgery versus conservative treatment, Outcome 19 Costs at 1 year (Euros in 2005).

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Analysis 4.20

Comparison 4 Surgery versus conservative treatment, Outcome 20 Total costs including indirect costs (Euros) at 1 year.

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Analysis 5.1

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 1 American Shoulder and Elbow Surgeons (ASES) score (0 to 100: best).

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Analysis 5.2

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 2 Death, re‐operation and adverse events.

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Study	Measure	Locking plate	Locking nail	Reported significance
Zhu 2011	Pain at 1 year	median = 0.5 interquartile range: 1.8 n = 29	median = 1.0 interquartile range = 1.0 n = 26	P = 0.042
Zhu 2011	Pain at 3 years	median = 0 interquartile range = 0.8 n = 26	median = 0 interquartile range = 1.0 n = 25	P = 0.642

Analysis 5.3

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 3 Pain (VAS: 0 to 10: worst).

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Analysis 5.4

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 4 Constant score (0 to 100: best).

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Analysis 5.5

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 5 Active range of motion (at 3 years).

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Study	Measure	Locking plate	Locking nail	Reported significance
Zhu 2011	At 1 year	mean location = T8 range = T4 to L2 n = 29	mean location = T9 range = T2 to buttock n = 26	P = 0.443
Zhu 2011	At 3 years	mean location = T8 range = T2 to buttock n = 26	mean location = T8 range = T2 to buttock n = 25	P = 0.636

Analysis 5.6

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 6 Range of movement: internal rotation (level on spine).

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Analysis 5.7

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 7 Strength of suprapinatus (relative to opposite side) % ‐ at 3 years.

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Analysis 5.8

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 8 Operation times and blood loss.

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Analysis 5.9

Comparison 5 Locking plate versus locking intramedullary nail, Outcome 9 Intra‐operative complication.

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Analysis 6.1

Comparison 6 Locking plate versus intramedullary nails (Zifko method), Outcome 1 Complications and [slight] malunion.

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Analysis 6.2

Comparison 6 Locking plate versus intramedullary nails (Zifko method), Outcome 2 Constant score (% of healthy limb) at mean 2 years.

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Analysis 6.3

Comparison 6 Locking plate versus intramedullary nails (Zifko method), Outcome 3 Time to union and time to recover upper limb function (weeks).

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Analysis 6.4

Comparison 6 Locking plate versus intramedullary nails (Zifko method), Outcome 4 Operation and fluoroscopic times.

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Analysis 6.5

Comparison 6 Locking plate versus intramedullary nails (Zifko method), Outcome 5 Length of hospital stay (days).

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$Comparison 7 Hemi‐arthroplasty versus tension band wiring (4 part fractures), Outcome 1 Re‐operation at 1 year.$

Analysis 7.1

Comparison 7 Hemi‐arthroplasty versus tension band wiring (4 part fractures), Outcome 1 Re‐operation at 1 year.

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$Comparison 7 Hemi‐arthroplasty versus tension band wiring (4 part fractures), Outcome 2 Implant removal at 1 year.$

Analysis 7.2

Comparison 7 Hemi‐arthroplasty versus tension band wiring (4 part fractures), Outcome 2 Implant removal at 1 year.

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$Comparison 7 Hemi‐arthroplasty versus tension band wiring (4 part fractures), Outcome 3 Pain at 1 year.$

Analysis 7.3

Comparison 7 Hemi‐arthroplasty versus tension band wiring (4 part fractures), Outcome 3 Pain at 1 year.

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Analysis 8.1

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 1 DASH score at 12 months (0 to 100: greatest disability).

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Analysis 8.2

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 2 Simple shoulder test (0 to 12: best outcome).

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Analysis 8.3

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 3 Re‐operation.

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Analysis 8.4

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 4 Dead at 1 year.

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Analysis 8.5

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 5 Constant score at 12 months (% of contralateral limb).

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Analysis 8.6

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 6 Complications (radiological assessment).

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Analysis 8.7

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 7 Range of motion (degrees) at 12 months.

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Analysis 8.8

Comparison 8 Polyaxial versus monoaxial screw insertion in plate fixation, Outcome 8 Operation and fluoroscopic times.

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Analysis 9.1

Comparison 9 Medial support screws versus control for locking plate fixation, Outcome 1 Adverse events.

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Analysis 9.2

Comparison 9 Medial support screws versus control for locking plate fixation, Outcome 2 Constant score (0 to 100: best) at 2.5 years.

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Analysis 10.1

Comparison 10 Hemiarthoplasty: EPOCA prosthesis versus HAS prosthesis, Outcome 1 Adverse events.

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Analysis 10.2

Comparison 10 Hemiarthoplasty: EPOCA prosthesis versus HAS prosthesis, Outcome 2 Radiological assessment findings.

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Study	Measure	EPOCA prosthesis n = 18	HAS prosthesis n = 17	Reported significance
Fialka 2008	Active forward flexion	mean = 109° range = 30° to 150°	mean = 62° range = 20° to 110°	P < 0.001
Fialka 2008	Active abduction	mean = 101° range = 30° to 150°	mean = 62° range = 30° to 100°	P = 0.001
Fialka 2008	Active external rotation in 90° abduction	mean = 30° range = 0° to 60°	mean = 17° range = 0° to 40°	P = 0.01
Fialka 2008	Active external rotation in 90° abduction	mean = 45° range = 0° to 70°	mean = 13° range = 0° to 40°	P = 0.001

Analysis 10.3

Comparison 10 Hemiarthoplasty: EPOCA prosthesis versus HAS prosthesis, Outcome 3 Range of motion results at one year (degrees).

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Analysis 11.1

Comparison 11 Post‐operative (percutaneous fixation) immobilisation for 1 week versus 3 weeks, Outcome 1 Neer score ≤ 80 points (unsatisfactory or failure) at 6 months.

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Analysis 11.2

Comparison 11 Post‐operative (percutaneous fixation) immobilisation for 1 week versus 3 weeks, Outcome 2 Premature removal of Kirschner wires.

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Analysis 12.1

Comparison 12 Post‐operative (hemiarthroplasty) mobilisation: early (2 weeks immobilisation) versus late (6 weeks), Outcome 1 Oxford Shoulder Score at 1 year (adjusted: 0 to 100 best).

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Analysis 12.2

Comparison 12 Post‐operative (hemiarthroplasty) mobilisation: early (2 weeks immobilisation) versus late (6 weeks), Outcome 2 Constant shoulder score (at 1 year).

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Analysis 12.3

Comparison 12 Post‐operative (hemiarthroplasty) mobilisation: early (2 weeks immobilisation) versus late (6 weeks), Outcome 3 Radiological assessment findings.

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Analysis 12.4

Comparison 12 Post‐operative (hemiarthroplasty) mobilisation: early (2 weeks immobilisation) versus late (6 weeks), Outcome 4 Range of motion at 1 year.

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Table 1. Surgical versus conservative treatment trials: brief characteristics

Study	Participants (Neer classification)	Surgery	Conservative (starting with)	Follow‐up
Fjalestad 2010	50 patients with 3‐ or 4‐part fractures (Norway)	Open reduction and fixation with an interlocking plate device and metal cerclages	Immobilisation of the injured arm in a modified Velpeau bandage. Closed reduction in 8 patients.	1 year so far (2 years in all)
Kristiansen 1988	30 patients with 31 with 2‐, 3‐ or 4‐part fractures (Denmark)	Percutaneous reduction and external fixation	Closed manipulation and sling immobilisation	2 years
Olerud 2011a	60 patients with 3‐part fractures (all had displaced surgical neck fracture) (Sweden)	Open reduction and fixation with a PHILOS plate and non‐absorbable sutures	Sling immobilisation	2 years
Olerud 2011b	55 participants with 4‐part fractures (Sweden)	Humeral head replacement with the Global Fx prosthesis	Sling immobilisation	2 years
Stableforth 1984	32 participants with 4‐part fracture (UK)	Hemi‐arthroplasty	Closed manipulation and sling	6 months
Zyto 1997	40 patients with 3‐ or 4‐part fractures (3 others excluded) (Sweden)	Internal fixation using surgical tension band or cerclage wiring	Sling immobilisation	50 months

Table 1. Surgical versus conservative treatment trials: brief characteristics

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Table 2. Assessment of items relating to applicability of trial findings

	Clearly defined study population?	Interventions sufficiently described?	Main outcomes sufficiently described?	Appropriate timing of outcome measurement? (Yes = ≥ 1 year)
Agorastides 2007	Partial: exclusions not specified upfront	Yes	Yes	Yes: 1 year
Bertoft 1984	Partial: no exclusion criteria given (e.g. ability to understand instructions for exercises)	Yes	Yes	Yes: 1 year
Fialka 2008	Yes	Yes	Yes	Yes: 1 year
Fjalestad 2010	Yes	Yes	Yes	Yes: 2 years
Hoellen 1997	Yes: but some question over fracture type in that the Holbein 1999 report included 3‐part fractures too	Yes	Yes	Yes: 1 year
Hodgson 2003	Yes	Yes	Yes	Yes: 2 years
Kristiansen 1988	Partial: no exclusion criteria given	Partial: incomplete description of timing of sling use and care of external fixator pin sites	Partial: no description of measurement procedures	Yes: 1 year
Kristiansen 1989	Partial: no exclusion criteria given	Partial: although sling and body bandage are common expressions, some variation possible	Partial: no description of measurement procedures	Yes: 2 years
Lefevre‐Colau 2007	Yes	Yes	Yes	Partial: 6 months
Livesley 1992	Yes: although this included 4 patients under 20 years with epiphyseal fractures	Yes	Yes	Partial: 6 months
Lundberg 1979	Partial: no exclusion criteria given (e.g. ability to understand instructions for exercises)	Yes	Yes	Yes: 1 year or above (mean: 16 months)
Ockert 2010	Partial: exclusion criteria described in context of post‐randomisation exclusions.	Yes	Yes	Partial: 6 months
Olerud 2011a	Yes	Yes	Yes	Yes: 2 years
Olerud 2011b	Yes	Yes	Yes	Yes: 2 years
Revay 1992	Yes	Partial: frequency of swimming sessions not stated	Yes	Yes: 1 year
Rommens 1993	Yes: but to note that other fractures including rib (3 participants) were included	Yes	Partial: functional outcome assessment not described (sufficiently)	No: only until fracture consolidation
Smejkal 2011	Yes	Partial: Only minimal intra‐operative details given and nothing regarding post‐operative management including rehabilitation	Partial: this may have been ‘lost in translation’ (Czech article)	Yes: mean 2 years but range not stated (probably most / all > 1 year as recruitment had finished January 2010).
Stableforth 1984	Yes	Yes	Partial: no description of measurement procedures, incomplete description of pain categories	Partial: up to 6 months, then between 18 months to 12 years. This is too spread out. Most results applied to the 6 month follow‐up.
Voigt 2011	Yes	Yes	Yes	Yes: 1 year
Wirbel 1999	Yes	Yes	Partial: no description of measurement procedures	Partial: between 9 and 36 months; < 1 year in 10 participants. Main results applied to 6 months.
Zhang 2011	Yes	Yes	Partial: Insufficient information on measurement of complications and timing of their measurement.	Yes: All over 25 months (mean 30.8 months)
Zhu 2011	Yes	Yes	Yes	Yes: 1 and 3 years
Zyto 1997	Yes	Yes	Yes	Yes: 1 year, and 3 to 5 years

Table 2. Assessment of items relating to applicability of trial findings

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Comparison 1. Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Shoulder disability: Croft Shoulder Disability Score Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Disability (1 or more problems) at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Severe disability (5 or more problems) at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Disability (1 or more problems) at 2 years	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.4 Severe disability (5 or more problems) at 2 years	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Croft shoulder disability score: individual problems at 2 years Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Pain on movement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Bathing difficulties	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Change position at night more often	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.4 Disturbed sleep	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.5 No active pastimes or usual physical recreation	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.6 Lifting problems	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.7 Help needed	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.8 More accidents (e.g. dropping things)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Number of treatment sessions (until independent function achieved) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 SF‐36 scores: pain & physical dimensions Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 Physical functioning (0‐100: excellent) at 16 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 Physical functioning (0‐100: excellent) at 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 Role limitation physical (0‐100: none) at 16 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.4 Role limitation physical (0‐100: none) at 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.5 Pain (0‐100: none) at 16 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.6 Pain (0‐100: none) at 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Adverse events Show forest plot	3		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5.1 Frozen shoulder	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 Fracture displacement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 Non‐union	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.4 Reflex sympathetic dystrophy	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.5 Treated (injection) subacromial impingement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Constant shoulder score (ratio of affected/unaffected arm) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 8 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 16 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Constant shoulder score (0 to 100: best) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.1 6 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 3 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.4 6 months: subjective assessment (0 to 35: best)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.5 6 months: objective assessment range of motion and strength (0 to 65: best)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Changes in pain intensity (mm) from baseline: 100 mm visual analogue scale (positive change = less pain) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8.1 At 6 weeks	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 At 3 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.3 At 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Range of motion at 6 months (degrees): difference between two shoulders Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

9.1 Abduction	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Anterior elevation	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.3 Lateral rotation	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
10 Patient dissatisfied with treatment Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 1. Early mobilisation (within or up to 1 week) versus immobilisation for 3 weeks

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Comparison 2. Gilchrist bandage versus 'Classic' Desault bandage

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Problems with bandages Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Application of bandage was uncomfortable	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Premature bandage removal	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Fracture displacement by 3 weeks Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 Poor or bad rating by patient at fracture consolidation Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 2. Gilchrist bandage versus 'Classic' Desault bandage

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Comparison 3. Instructed self physiotherapy versus conventional physiotherapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Pain at one year (scale 0 to 8: maximum pain) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Severe or moderate pain at 3 months Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 Requested change of therapy Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Adverse events (frozen shoulder: 1 v 2; unexplained prolonged pain: 0 v 1) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 Neer's rating (0 to 100: best) at mean 16 months (exploratory analysis) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6 Active gleno‐humeral elevation (degrees) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 3. Instructed self physiotherapy versus conventional physiotherapy

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Comparison 4. Surgery versus conservative treatment

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Functional scores at 12 months (higher = worse) Show forest plot	3	153	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.10 [‐0.42, 0.22]

1.1 DASH (0 to 100: worst disability) (reversed)	2	105	Std. Mean Difference (IV, Fixed, 95% CI)	‐0.19 [‐0.57, 0.19]
1.2 ASES (0 to 24: best)	1	48	Std. Mean Difference (IV, Fixed, 95% CI)	0.10 [‐0.46, 0.67]
2 DASH (0 to 100: worst disability) Show forest plot	2		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

2.1 at 4 months	2	106	Mean Difference (IV, Fixed, 95% CI)	0.91 [‐7.00, 8.83]
2.2 at 12 months	2	105	Mean Difference (IV, Fixed, 95% CI)	‐4.51 [‐13.50, 4.48]
2.3 at 24 months	2	99	Mean Difference (IV, Fixed, 95% CI)	‐7.43 [‐16.26, 1.41]
3 American Shoulder and Elbow Surgeons score (0 to 24: best) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Activities of daily living Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4.1 Unable to manage personal hygiene at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 Unable to comb hair at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.3 Unable to sleep on fractured side at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.4 Unable to carry 5 kg at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.5 Unable to manage personal hygiene at 50 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.6 Unable to comb hair at 50 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.7 Unable to sleep on fractured side at 50 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.8 Unable to carry 5 kg at 50 months	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Quality of life assessment: EuroQol (0: dead to 1: best health) Show forest plot	3		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

5.1 at 3 to 4 months	3	156	Mean Difference (IV, Fixed, 95% CI)	0.01 [‐0.02, 0.05]
5.2 at 6 months	3	156	Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.01, 0.08]
5.3 at 12 months	3	153	Mean Difference (IV, Fixed, 95% CI)	0.04 [‐0.01, 0.08]
5.4 at 24 months	2	101	Mean Difference (IV, Fixed, 95% CI)	0.15 [0.05, 0.25]
6 Quality of life assessment (Fjalestad 2010 data) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6.1 15D at 3 months (0: death; 1: perfect health)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 15D at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 15D at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 number of QALYs at 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.5 numbers of QALYs at 1 year (‐ deaths)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Mortality Show forest plot	4	196	Risk Ratio (M‐H, Fixed, 95% CI)	1.55 [0.55, 4.36]

8 Additional surgery (re‐operation or secondary surgery) Show forest plot	5	223	Risk Ratio (M‐H, Fixed, 95% CI)	3.36 [1.33, 8.49]

8.1 at 6 to 12 months	3	113	Risk Ratio (M‐H, Fixed, 95% CI)	1.90 [0.54, 6.73]
8.2 at 2 years	2	110	Risk Ratio (M‐H, Fixed, 95% CI)	5.83 [1.38, 24.70]
9 Adverse events / complications Show forest plot	6		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only

9.1 Infection	6	259	Risk Ratio (M‐H, Fixed, 95% CI)	4.13 [0.91, 18.87]
9.2 Nerve injury / palsy	3	146	Risk Ratio (M‐H, Fixed, 95% CI)	0.74 [0.20, 2.76]
9.3 Non union	5	223	Risk Ratio (M‐H, Fixed, 95% CI)	0.48 [0.16, 1.40]
9.4 Avascular necrosis	5	213	Risk Ratio (M‐H, Fixed, 95% CI)	0.65 [0.37, 1.16]
9.5 Post‐traumatic osteoarthritis (signs of)	3	133	Risk Ratio (M‐H, Fixed, 95% CI)	0.56 [0.21, 1.51]
9.6 Screw penetration into joint	3	160	Risk Ratio (M‐H, Fixed, 95% CI)	11.49 [2.25, 58.76]
9.7 Impingement	1	58	Risk Ratio (M‐H, Fixed, 95% CI)	2.0 [0.19, 20.86]
9.8 Redisplacement resulting in an operation	2	81	Risk Ratio (M‐H, Fixed, 95% CI)	0.26 [0.03, 2.22]
9.9 Secondary dislocation or resorption of the greater tuberosity	1	51	Risk Ratio (M‐H, Fixed, 95% CI)	15.18 [0.92, 249.78]
9.10 Tuberosity displacement at 50 months	1	29	Risk Ratio (M‐H, Fixed, 95% CI)	0.15 [0.01, 2.71]
9.11 Wire penetration at 1 year	1	38	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 69.31]
9.12 Fixation failure resulting in an operation	1	50	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 70.30]
9.13 Refracture	1	22	Risk Ratio (M‐H, Fixed, 95% CI)	1.0 [0.07, 14.05]
10 Constant scores (overall: 0 to 100: best score) Show forest plot	4		Mean Difference (IV, Fixed, 95% CI)	Subtotals only

10.1 at 4 months	2	107	Mean Difference (IV, Fixed, 95% CI)	‐1.33 [‐6.80, 4.14]
10.2 at 12 months	3	152	Mean Difference (IV, Fixed, 95% CI)	2.36 [‐3.52, 8.24]
10.3 at 24 months	2	101	Mean Difference (IV, Fixed, 95% CI)	0.48 [‐7.26, 8.22]
10.4 at 50 months	1	29	Mean Difference (IV, Fixed, 95% CI)	‐5.0 [‐17.52, 7.52]
11 Constant scores (difference between injured and uninjured shoulder): Normal = 0. Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

11.1 at 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
11.2 at 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
12 Poor or unsatisfactory function at 1 year (Neer rating) Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

13 Dependent in activities of daily living (or dead) at 6 months Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

14 Pain at 2 years: VAS (0 to 100: worst pain) Show forest plot	2	101	Mean Difference (IV, Fixed, 95% CI)	‐6.38 [‐14.18, 1.41]

15 Constant score at 50 months: overall and components Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

15.1 Overall score (0‐100: best score)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.2 Pain (maximum score 15)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.3 Range of motion (maximum score 40)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.4 Power (maximum score 25)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
15.5 Activities of daily living (maximum score 20)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
16 Constant (often severe) pain at 6 months Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

17 Failure to recover 75% muscle power relative to other arm (survivors) at 6 months Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

17.1 Flexion	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17.2 Abduction	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
17.3 Lateral rotation	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18 Range of movement impairments in survivors at 6 months Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

18.1 Flexion < 45 degrees	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.2 Unable to place thumb on mid spine (T12)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
18.3 Lateral rotation < 5 degrees	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
19 Costs at 1 year (Euros in 2005) Show forest plot			Other data	No numeric data

20 Total costs including indirect costs (Euros) at 1 year Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 4. Surgery versus conservative treatment

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Comparison 5. Locking plate versus locking intramedullary nail

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 American Shoulder and Elbow Surgeons (ASES) score (0 to 100: best) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 At 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 At 3 years	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Death, re‐operation and adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Death	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Any complication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Screw penetration into humeral head (all had re‐operation)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.4 Heterotopic ossification	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.5 Infection	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.6 Osteonecrosis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.7 Degenerative change of glenohumeral joint	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.8 Secondary varus collapse	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.9 Non‐union	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Pain (VAS: 0 to 10: worst) Show forest plot			Other data	No numeric data

4 Constant score (0 to 100: best) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 At 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 At 3 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Active range of motion (at 3 years) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 Forward elevation (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 External rotation	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Range of movement: internal rotation (level on spine) Show forest plot			Other data	No numeric data

7 Strength of suprapinatus (relative to opposite side) % ‐ at 3 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.1 At 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 At 3 years	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Operation times and blood loss Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8.1 Duration of surgery (minutes)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Blood loss (ml)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
9 Intra‐operative complication Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9.1 Pneumothorax	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
9.2 Blood transfusion	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 5. Locking plate versus locking intramedullary nail

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Comparison 6. Locking plate versus intramedullary nails (Zifko method)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Complications and [slight] malunion Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Any complication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Malunion (usually slight)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Constant score (% of healthy limb) at mean 2 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Time to union and time to recover upper limb function (weeks) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3.1 Time to radiographic union	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Time to recover normal upper limb function	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Operation and fluoroscopic times Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 Duration of operation (minutes)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 X‐ray exposure (minutes)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5 Length of hospital stay (days) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 6. Locking plate versus intramedullary nails (Zifko method)

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Comparison 7. Hemi‐arthroplasty versus tension band wiring (4 part fractures)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Re‐operation at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Implant removal at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 Pain at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 7. Hemi‐arthroplasty versus tension band wiring (4 part fractures)

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Comparison 8. Polyaxial versus monoaxial screw insertion in plate fixation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 DASH score at 12 months (0 to 100: greatest disability) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Simple shoulder test (0 to 12: best outcome) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 At 3 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 At 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 At 12 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Re‐operation Show forest plot	2	122	Risk Ratio (M‐H, Fixed, 95% CI)	1.43 [0.56, 3.67]

3.1 By 6 months	1	66	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.15, 4.76]
3.2 By 1 year	1	56	Risk Ratio (M‐H, Fixed, 95% CI)	1.86 [0.59, 5.88]
4 Dead at 1 year Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

5 Constant score at 12 months (% of contralateral limb) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6 Complications (radiological assessment) Show forest plot	2		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6.1 Any complication	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.2 Primary implant malposition	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.3 Secondary loss of reduction and screw perforation	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.4 Non‐union / delayed union due to osteonecrosis (6 months)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.5 Avascular necrosis at 1 year	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.6 Varus deformity (> 10 / ≥20 degrees)	2		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.7 Greater tuberosity displacement	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
6.8 Screw cut‐out (intra‐articular)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
7 Range of motion (degrees) at 12 months Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

7.1 Flexion	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.2 Abduction	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.3 External rotation	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
7.4 Internal rotation	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8 Operation and fluoroscopic times Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

8.1 Duration of operation (minutes)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
8.2 Fluoroscopic time (minutes)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 8. Polyaxial versus monoaxial screw insertion in plate fixation

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Comparison 9. Medial support screws versus control for locking plate fixation

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Early loss of fixation	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Re‐operation for early failure	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 Osteonecrosis (asymptomatic)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Constant score (0 to 100: best) at 2.5 years Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 9. Medial support screws versus control for locking plate fixation

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Comparison 10. Hemiarthoplasty: EPOCA prosthesis versus HAS prosthesis

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Adverse events Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

1.1 Deep infection	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 Persistent pain ‐ scheduled for reoperation	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Radiological assessment findings Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2.1 Resorption of tuberosities	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Secondary dislocation of tuberosities	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Superior migration of prosthesis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.4 Anterior subluxations	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.5 Glenoid erosion	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.6 Aseptic loosening of stem	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Range of motion results at one year (degrees) Show forest plot			Other data	No numeric data

Comparison 10. Hemiarthoplasty: EPOCA prosthesis versus HAS prosthesis

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Comparison 11. Post‐operative (percutaneous fixation) immobilisation for 1 week versus 3 weeks

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Neer score ≤ 80 points (unsatisfactory or failure) at 6 months Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Premature removal of Kirschner wires Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 11. Post‐operative (percutaneous fixation) immobilisation for 1 week versus 3 weeks

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Comparison 12. Post‐operative (hemiarthroplasty) mobilisation: early (2 weeks immobilisation) versus late (6 weeks)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Oxford Shoulder Score at 1 year (adjusted: 0 to 100 best) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Constant shoulder score (at 1 year) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2.1 Overall score (0 to 100: best)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.2 Pain component (0 to 15: best))	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.3 Activities of daily living component (0 to 25: best)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.4 Mobility component (0 to 40: best)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2.5 Strength component (0 to 25: best)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
3 Radiological assessment findings Show forest plot	1		Risk Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3.1 Nonunion (with bone resorption)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.2 Malunion	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.3 Greater tuberosity migration (all had severe pain at 6 & 12 months)	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
3.4 Superior luxation of prosthesis	1		Risk Ratio (M‐H, Fixed, 95% CI)	0.0 [0.0, 0.0]
4 Range of motion at 1 year Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4.1 Elevation (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
4.2 External rotation (degrees)	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]

Comparison 12. Post‐operative (hemiarthroplasty) mobilisation: early (2 weeks immobilisation) versus late (6 weeks)

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