Elsevier

Journal of Shoulder and Elbow Surgery

Volume 17, Issue 1, January–February 2008, Pages 42-54
Journal of Shoulder and Elbow Surgery

Original article
Proximal humeral fractures: A systematic review of treatment modalities

https://doi.org/10.1016/j.jse.2007.03.016Get rights and content

A systematic review was conducted of primary intervention of proximal humeral fracture, which is a common injury with significant morbidity. Keywords of proximal humeral fracture were entered into PubMed and Embase databases. Two evaluators reviewed abstracts from 1985 to 2004 for inclusion and exclusion criteria yielding 66 articles. These articles were evaluated independently for outcomes and quality of evidence using the Structured Effectiveness Quality Evaluation Scale and Sackett's Levels of Evidence. Patient characteristics and outcomes were recorded. The 66 studies included 2155 patients grouped by fracture types according to the Neer classification system. Studies differed by intervention, methods, outcome measures and results. Quality scores averaged 15/48; only 2 articles included randomized groups. Current studies typically lack randomization, comparators, and independent evaluation, with a resultant inability to produce clinical conclusions. Further research comparing primary treatment methods in a properly designed and controlled fashion is required, ideally using randomized controlled trials.

Section snippets

Methods and materials

A literature search of bibliographic databases with limitations of English language and human subjects using key words “proximal humeral fracture” was conducted. The databases utilized were the PubMed database that produced 415 articles, of which 112 were not English, as well as the OVID Embase database. Two independent evaluators analyzed abstracts and titles to identify articles that dealt with the treatment of proximal humeral fractures and met the study inclusion criteria. All articles

Results

The systematic review included a total of 66 publications encompassing 2653 patients who entered the studies and 2155 patients who completed follow-up. The average age of the patients included was 62.8 years, with 70% of these fractures occurring due to a fall from a standing height. The type of fracture with the highest average age was the 2-part fracture group at 69.4 years old, with 83% occurring as a result of a fall from an upright position. The lowest average age was 62.2 years old for

Treatment modality

Nonoperative intervention included sling immobilization for 1-2 weeks followed by physiotherapy,13, 41, 46, 88 swathe immobilization for 30 days followed by physiotherapy,8 or was not clearly defined.86

The ORIF group was further categorized into the subgroups of percutaneous treatment, plating fixation, intramedullary fixation, and miscellaneous fixation. Percutaneous treatment groups did not always specify whether the percutaneous devices were subcutaneous or transcutaneous at the conclusion

Fracture types

While the results of each fracture group is discussed in detail in the following paragraphs, the number of patients in each treatment subset of each fracture type are examined in Appendix II.

Each fracture group was discussed individually to discriminate the unique characteristics of their treatment and outcomes where the outcome measures are comparable (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5). The Neer scores, pain values, subsequent complications, as well as the ROM values, were

Discussion

This study indicates that there is a wide variation in recommended treatments for fractures of the proximal humerus. The quality of the evidence is low and does not support any specific treatment choice. The treatment of a patient with a proximal humeral fracture represents a challenge to the orthopaedic surgeon for a number of reasons. Accurate assessment of fracture type can be difficult, as imaging assessment is imprecise.4, 43, 69, 71, 72 Obtaining and maintaining fracture reduction is

References (89)

  • M.A. Mighell et al.

    Outcomes of hemiarthroplasty for fractures of the proximal humerus

    J.Shoulder.Elbow.Surg

    (2003)
  • A. Misra et al.

    Complex proximal humeral fractures in adults–a systematic review of management

    Injury

    (2001)
  • M. Muller et al.

    Effectiveness of hand therapy interventions in primary management of carpal tunnel syndrome: a systematic review

    J Hand Ther

    (2004)
  • U. Prakash et al.

    Hemiarthroplasty for severe fractures of the proximal humerus

    J Shoulder Elbow Surg

    (2002)
  • C. Rajasekhar et al.

    Fixation of proximal humeral fractures with the Polarus nail

    J.Shoulder Elbow Surg

    (2001)
  • D. Ring et al.

    The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal humerus

    J Shoulder Elbow Surg

    (2001)
  • C.M. Robinson et al.

    The two-part proximal humeral fracture: a review of operative treatment using two techniques

    Injury

    (1993)
  • C. Sadowski et al.

    Fixation of fractures of the proximal humerus with the PlantTan Humerus Fixator Plate: early experience with a new implant

    J Shoulder Elbow Surg

    (2003)
  • P.I. Sallay et al.

    Reliability and reproducibility of radiographic interpretation of proximal humeral fracture pathoanatomy

    J Shoulder Elbow Surg

    (1997)
  • P.J. Soete et al.

    Transitory percutaneous pinning in fractures of the proximal humerus

    J Shoulder Elbow Surg

    (1999)
  • J. Wessel

    The effectiveness of hand exercises for persons with rheumatoid arthritis: a systematic review

    J Hand Ther

    (2004)
  • G.R. Williams et al.

    Two-part and three-part fractures: open reduction and internal fixation versus closed reduction and percutaneous pinning

    Orthop Clin North Am

    (2000)
  • K. Zyto

    Non-operative treatment of comminuted fractures of the proximal humerus in elderly patients

    Injury

    (1998)
  • K. Zyto et al.

    Shoulder function after displaced fractures of the proximal humerus

    J Shoulder Elbow Surg

    (1995)
  • K. Zyto et al.

    Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus

    J Shoulder Elbow Surg

    (1998)
  • J.A. Baron et al.

    Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age

    Epidemiology

    (1996)
  • R. Becker et al.

    Strength and motion after hemiarthroplasty in displaced four-fragment fracture of the proximal humerus: 27 patients followed for 1-6 years

    Acta Orthop Scand

    (2002)
  • J. Bernstein et al.

    Evaluation of the Neer system of classification of proximal humeral fractures with computerized tomographic scans and plain radiographs

    J Bone Joint Surg Am

    (1996)
  • P. Bungaro et al.

    Osteosynthesis with percutaneous wiring in fractures of the proximal humerus

    Chir Organi Mov

    (1998)
  • V. Calvisi et al.

    Current trends in conservative treatment of fractures of the proximal humerus

    Ital J Orthop Traumatol

    (1991)
  • C.Y. Chen et al.

    Closed management and percutaneous fixation of unstable proximal humerus fractures

    J Trauma

    (1998)
  • E.A. Codman

    Rupture of the supraspinatus tendon. 1911

    Clin Orthop Relat Res

    (1990)
  • C.N. Cornell

    Tension-band wiring supplemented by lag-screw fixation of proximal humerus fractures: a modified technique

    Orthop Rev

    (1994)
  • C.N. Cornell et al.

    Internal fixation of proximal humerus fractures using the screw-tension band technique

    J Orthop Trauma

    (1994)
  • C.M. Court-Brown et al.

    Impacted valgus fractures (B1.1) of the proximal humerus. The results of non-operative treatment

    J Bone Joint Surg Br

    (2002)
  • C.M. Court-Brown et al.

    The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient

    J.Bone Joint Surg Br

    (2001)
  • A. Darder et al.

    Four-part displaced proximal humeral fractures: operative treatment using Kirschner wires and a tension band

    J Orthop Trauma

    (1993)
  • M.J. De la Hoz et al.

    Surgical treatment of three-part proximal humeral fractures

    Acta Orthop Belg

    (2001)
  • M. Demirhan et al.

    Prognostic factors in prosthetic replacement for acute proximal humerus fractures

    J Orthop Trauma

    (2003)
  • P. Dimakopoulos et al.

    Hemiarthroplasty in the treatment of comminuted intraarticular fractures of the proximal humerus

    Clin Orthop

    (1997)
  • R.D. Esser

    Treatment of three- and four-part fractures of the proximal humerus with a modified cloverleaf plate

    J Orthop Trauma

    (1994)
  • R.D. Esser

    Open reduction and internal fixation of three- and four-part fractures of the proximal humerus

    Clin Orthop

    (1994)
  • E.L. Flatow et al.

    Open reduction and internal fixation of two-part displaced fractures of the greater tuberosity of the proximal part of the humerus

    J Bone Joint Surg Am

    (1991)
  • Handoll HHG., Gibson JNA., and Madhok R. Interventions for treating proximal humeral fractures in adults. The Cochrane...
  • Cited by (211)

    View all citing articles on Scopus

    Supported by Summer Research Training Program, Faculty of Medicine, University of Western Ontario, London, Ontario, Canada, and New Investigator Award, Canadian Institutes of Health Research.

    View full text