Interventions for treating proximal humeral fractures in adults (Review)

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[Intervention Review] Interventions for treating proximal humeral fractures in adults Helen HG Handoll 1 , Rajan Madhok 2 1 Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, Middlesborough, UK. 2 Cochrane Bone, Joint and Muscle Trauma Group, University of Manchester, Manchester, UK Contact address: Helen HG Handoll, Centre for Rehabilitation Sciences (CRS), Research Institute for Health Sciences and Social Care, University of Teesside, School of Health and Social Care, Middlesborough, Tees Valley, TS1 3BA, UK. h.handoll@tees.ac.uk. H.Handoll@ed.ac.uk. Editorial group: Cochrane Bone, Joint and Muscle Trauma Group. Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008. Review content assessed as up-to-date: 28 September 2006. Citation: Handoll HHG, Madhok R. Interventions for treating proximal humeral fractures in adults. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD000434. DOI: 10.1002/14651858.CD000434. Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Background A B S T R A C T Proximal humeral fractures are common. The management, including surgical intervention, of these injuries varies widely. Objectives To review the evidence supporting the various interventions for treating proximal humeral fractures. Search strategy We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (September 2006), the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The search ended in September 2006. Selection criteria All randomised controlled trials pertinent to the management of proximal humeral fractures were selected. Data collection and analysis Two people performed independent quality assessment and data extraction. Trial heterogeneity prevented meta-analysis. Main results Twelve small randomised trials with 578 participants were included. Bias in these trials could not be ruled out. Seven trials evaluated conservative treatment. There was very limited evidence that the type of bandage used had any influence on the 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 compared with that delayed until after three weeks immobilisation resulted in less pain and faster and potentially better recovery in people with undisplaced two-part 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 to pursue an adequate physiotherapy programme. Interventions for treating proximal humeral fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 1
Operative reduction compared with conservative treatment improved fracture alignment in two trials. However, in one trial, surgery was associated with more complications, and did not result in improved shoulder function. In one trial, hemi-arthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries. Compared with hemi-arthroplasty, tension-band wiring fixation of severe injuries was associated with a high rate of re-operation in one trial. One trial provided very limited evidence of similar outcomes resulting from mobilisation at one week instead of three weeks after surgical fixation. Authors’ conclusions Only tentative conclusions can be drawn from the available evidence, which is insufficient to inform many of the decisions required 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. P L A I N L A N G U A G E S U M M A R Y Interventions for treating proximal humeral (upper arm bone) fractures in adults Fracture of the proximal humerus (top end of the upper arm bone) is a common injury in older people. The bone typically breaks just below the shoulder, after a person puts out an arm to support their body during a fall. Most of these fractures occur without breaking of the skin. For treatment, the injured arm can often be simply supported in a sling until the fracture joins sufficiently to allow movement. More complex fractures may be treated surgically. This may involve fixing the fracture fragments together by various means. Alternatively, various devices are used to replace the top of the fractured bone (hemi-arthroplasty), or sometimes together with the surrounding joint (arthroplasty). This review includes evidence from 12 randomised controlled trials with a total of 578 participants. As well as being small, several trials had methodological weaknesses that could have resulted in serious bias. No trials were similar enough to pool their results. Seven trials evaluated conservative treatment. There was very limited evidence that the type of bandage used to support the injured arm had any influence on outcome. However, an arm sling was generally more comfortable than a body bandage. There was some evidence that ’immediate’ physiotherapy compared with that delayed until after three weeks immobilisation resulted in less pain and faster recovery in people with simple undisplaced 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. While surgery restored anatomy better in two trials, this did not appear to result in improved function. However, surgery was associated more complications in one of these trials. In another trial, hemi-arthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries. One further trial found fracture fixation of severe injuries with tension-band wiring was associated with a high rate of re-operation when compared with hemi-arthroplasty. One trial provided very limited evidence of similar outcomes resulting from mobilisation at one week instead of three weeks after surgical fixation. Overall, there is some evidence to support earlier arm movement for some types of fractures. Otherwise, there is not enough evidence from presently available trials to determine the best treatment, including surgery, for these fractures. Interventions for treating proximal humeral fractures in adults (Review) Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 2
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