Interventions for treating proximal humeral fractures in adults (Review)

B A C K G R O U N D
Proximal humeral fractures account for four to five per cent of
all fractures and are about half as common as hip fractures. The
incidence rapidly increases with age, and women are affected over
twice as often as men (Horak 1975; Kristiansen 1987). Many patients
who sustain a proximal humeral fracture are elderly and
their bones are osteoporotic. A recently published study found
that 87% of these fractures in adults resulted from falls from a
standing height (Court-Brown 2001). Bone quality also influences
the appropriateness of any intervention and hence long term clinical
outcome. Furthermore, the patient’s frailty may lead to a low
rehabilitation drive and delay any recovery from both the initial
trauma and any subsequent management.
The majority of proximal humeral fractures are not displaced or
only minimally displaced. Neer’s estimate (Neer 1970) that approximately
85% of all proximal humeral fractures are “undisplaced”,
in that no bone fragment is displaced by more than one
centimetre, or angulated more than 45 degrees is often cited (Koval
1997). A lower figure of 49% is reported in a prospective study of
over 1000 proximal humeral fractures (Court-Brown 2001). For
these fractures, conservative treatment is generally the preferred
option. The arm is immobilised to maintain fracture stability and
to provide pain relief during healing. This is usually followed by
physiotherapy and exercises aimed at restoring the function and
mobility of the injured arm. Surgery is usually reserved for displaced
and unstable fractures and those with more complicated
fracture patterns. Surgical stabilisation of the fracture may also allow
earlier movement of the shoulder and elbow, preventing stiffness.
The most commonly used classification of shoulder fractures is
that of Neer (Neer 1970). He considered four segments of the
proximal humerus - the articular part, the greater tuberosity, the
lesser tuberosity and the humeral shaft - that might be fractured
off and displaced from each other. All fractures, regardless of the
number of fracture lines present, which did not meet the criteria for
displacement (stated above) of any one segment with respect to the
others were considered “undisplaced” and categorised as one-part
fractures. Neer’s other categories, two-part, three-part and fourpart
fractures all involved the displacement of some or all of the
above four segments. Each of these may be potentially associated
with an anterior or posterior humeral head dislocation. At initial
presentation, it may be difficult to delineate the exact pattern of
the fracture even with sophisticated imaging. In any event, this
may not correlate with the degree to which avascularity (loss of
blood supply) may develop within the humeral head. Surgeons
have often followed Neer’s premise (Neer 1975) that in a four-part
fracture head necrosis is virtually guaranteed and have offered their
patients a replacement arthroplasty, where the humeral head or all
of the shoulder joint is replaced by artificial parts. An exception is
made for a specific type of four-part fracture, the valgus impacted
four-part fracture, not mentioned in Neer’s classification. This
fracture is less likely to lead to avascular necrosis of the humeral
head, provided lateral displacement of the head fragment is not
excessive (Jakob 1991; Resch 1997).
Aside from conservative treatment, generally involving immobilisation
of the injured arm, surgical interventions considered include:
• Closed reduction and stabilisation with percutaneous
Kirschner wires
• External fixation
Interventions for treating proximal humeral fractures in adults (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
• Open reduction and plating (AO humeral buttress plate,
angle blade plates)
• Open reduction and wiring using a tension-band principle
• Intramedullary nailing either antegrade or retrograde: for
example, Rush pins, Seidel, AO, Richards, Marchietti and
Halder nails
• Hemi-arthroplasty (replacement of the humeral head) or
total shoulder replacement
O B J E C T I V E S
This review aims to determine the most appropriate treatment
for fractures of the proximal humerus in skeletally mature people
(adults).
We aimed to examine the evidence from randomised and quasirandomised
controlled trials for the effects (benefits and harms)
of different treatment, including rehabilitation, interventions in
adults with fractures of the proximal humerus. We defined a priori
the following broad objectives:
• To compare different methods of conservative treatment
(including rehabilitation)
• To compare surgical versus conservative treatment
• To compare different methods of surgical treatment
• To compare different methods of rehabilitation after
surgical treatment
We planned to study the outcomes in different age groups (initially,
under versus over 65 years) and for different types of fractures.
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