Aims

A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults.

A new technique for the treatment of displaced fractures of the proximal humerus is described. Twelve fractures in 11 patients were managed by transcutaneous reduction using a Steinmann pin, and external fixation with a Hoffmann-type neutralising bar connected to two half-pins in the humeral head and three half-pins in the shaft. The pins were removed after four weeks. Two patients sustained redisplacement after a further injury, but in the others reduction was maintained. Two cases of pin-track infection resolved after antibiotics, but delayed union resulted. There were no neurovascular injuries and at follow-up of 6 to 12 months no refractures had been seen. The early functional results were excellent or satisfactory in nine cases

A consecutive series of 31 displaced fractures of the proximal humerus were randomly selected for treatment either by closed manipulation or by transcutaneous reduction and external fixation. Follow-up assessed the quality of reduction and healing as well as the functional outcome. The external fixation method gave better reduction, safer healing and superior function

Aims

The PROximal Fracture of the Humerus Evaluation by Randomisation (PROFHER) randomised clinical trial compared the operative and non-operative treatment of adults with a displaced fracture of the proximal humerus involving the surgical neck. The aim of this study was to determine the long-term treatment effects beyond the two-year follow-up.

Abstract. Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus. The main goal of the current study was to evaluate the functional and radiographic results after primary RSA of three or four-part fractures of the proximal humerus in elderly patients. Between 2012 and 2020, 70 consecutive patients with a recent three- or four-part fracture of the proximal humerus were treated with an RSA. There were 41 women and 29 men, with a mean age of 76 years. The dominant arm was involved in 42 patients (60%). All surgeries were carried out within 21 days. Displaced three-part fracture sustained in 16 patients, 24 had fracture dislocation and 30 sustained a four-part fracture of the proximal humerus. Patients were followed up for a mean of 26 months. The mean postoperative OSS at the end of the follow-up period was 32.4. The mean DASH score was 44.3. Tuberosity non-union occurred in 18 patients (12.6%), malunion in 7 patients (4.9%), heterotopic ossification in 4 patients (2.8%) and scapular notching in one patient. Anatomical reconstruction was achieved in 25 patients (17.5%), the influence of greater tuberosity healing on shoulder function could not be demonstrated. Heterotopic ossification seems to affect OSS and QDASH, we found statistically significant relation between HO and clinical outcomes. Patients with heterotopic ossification had significantly lower postoperative scores on DASH and OSS (P = .0527). Despite expecting good functional outcome with low complication rate after RSA, the functional outcome was irrespective of healing of the tuberosities

Fractures of the proximal humerus occur predominantly in the elderly patient population. There has been a tendency over the last 15 years to perform surgical procedures to reduce and hold these fractures while the bone and soft tissue heal. The osteoporotic nature of the bone does not allow adequate fixation of the bone and therefore fixation techniques are inadequate to allow optimal soft tissue rehabilitation. A study was performed to observe the results of non-surgically treated displaced fractures of the proximal humerus in the elderly. The encouraging results are presented and discussed. Non-surgical management of displaced fractures of the proximal humerus achieves a good functional shoulder although not normal in this predominantly sedentary population. The question arises as to quality of function after surgical management of these difficult fractures compared to non surgical management and if surgical management is indicated in these elderly usually frail patients with low demand from their shoulders

In 42 elderly patients, 33 women and nine men with a mean age of 72 years, we treated displaced fractures of the proximal humerus (34 three-part, 8 four-part) using a blade plate and a standard deltopectoral approach. Functional treatment was started immediately after surgery. We reviewed 41 patients at one year and 38 at final follow-up at 3.4 years (2.4 to 4.5). At the final review, all the fractures had healed. The clinical results were graded as excellent in 13 patients, good in 17, fair in seven, and poor in one. The median Constant score was 73 ± 18. Avascular necrosis of the humeral head occurred in two patients (5%). We conclude that rigid fixation of displaced fractures of the proximal humerus with a blade plate in the elderly patient provides sufficient primary stability to allow early functional treatment. The incidence of avascular necrosis and nonunion was low. Restoration of the anatomy and biomechanics may contribute to a good functional outcome when compared with alternative methods of fixation or conservative treatment. Regardless of the age of the patients, we advocate primary open reduction and rigid internal fixation of three- and four-part fractures of the proximal humerus

Aim: To report our experience and early results with flexible nailing for unstable or irreducible displaced proximal humeral fractures in children. Material & methods: Between 1997 & 2004, 15 children with unstable or irreducible displaced fractures of the proximal humerus were treated with closed/open reduction and flexible IM nailing. There were 10 boys and 5 girls. The median age of the patients was 12.5 years (9–15). Thirteen children had a Salter – Harris II, Neer grade III/IV fracture and 2 children had metaphyseal fractures. The outcome assessment was performed using the shoulder score, clinical and radiological parameters. Results: All fractures united. None of the patients had a clinically significant malunion/shortening. Three patients had irritation at the nail insertion site. One patient had a transient radial nerve neurapraxia. There were no other operative or postoperative complications. The flexible nails were removed at a median time of 6 months (1.5–10) in 12 patients and 3 patients are awaiting removal. At a median follow-up of 30 months (4–66) all patients had a normal or near normal glenohumeral motion, full strength and all reported regaining full pre-injury functional use of the involved extremity. Conclusion: Flexible nailing can be used safely to maintain reduction in unstable or irreducible displaced fractures of the proximal humerus and allows early return to normal activities and function with minimal complications. This treatment is also useful in older children who have minimal remodelling potential

Objectives. Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. Methods. The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons. Results. Two or more baseline radiographic views were obtained for each participant. The independent raters confirmed that all fractures would have been considered for surgery in contemporaneous practice. A full description of the fracture population based on the Neer classification was obtained. The agreement between the categorisation at baseline (tuberosity involvement) and Neer classification as assessed by the two raters was only fair (kappa 0.29). However, this disparity did not appear to affect trial findings, specifically in terms of influencing the effect of treatment on the primary outcome of the trial. Conclusions. A key reporting requirement, namely the description of the fracture population, was achieved within the context of a pragmatic multicentre randomised clinical trial. This article provides important guidance for researchers designing similar trials on fracture management. Cite this article: H. H. G. Handoll, S. D. Brealey, L. Jefferson, A. Keding, A. J. Brooksbank, A. J. Johnstone, J. J. Candal-Couto, A. Rangan. Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures.Bone Joint Res 2016;5:481–489. DOI: 10.1302/2046-3758.510.BJR-2016-0132.R1

Purpose: The purpose of this study is to analyze the anatomo-radiological results, the clinical results, and complications of minimally displaced fractures of the proximal humerus, treated by immediate, ambulatory self-passive mobilization, followed by a strengthening and propioceptive training program. Materials and Methods: 12 patients, 7 females and 5 males, mean age 56.91 (SD: 15.76) were reviewed retrospectively at a mean of 28.33 months follow-up. All the patients were mobilized the day after the first visit, i.e. the day after the fracture in 7 patients (58.3%), up to 7 days after the fracture in 4 patients and 3 weeks after the fracture in one late referral. Over an average period of 5.8 months, an average 45.41 (SD: 20.83) sessions of rehabilitation, with a therapist, for each patient, were recorded. The patients were recommended to perform four sessions of self rehabilitation a day. Clinical evaluation included a questionnaire covering subjective evaluation, Activities of Daily Living (ADL) by means of the ASA index and the Constant’s score, and type and duration of rehabilitation. The radiological evaluation included review of the X-rays, from the initial traumatic event to the last follow up X-ray. An AP view with three rotations, outlet view and axillary view were performed for each patient. The fracture type, displacement, interval for union, glenohumeral osteoarthritis (according to the Samilson classification), type of acromion and osteoporosis, were recorded. Special attention was paid in detecting joint stiffness, algodystrophy, neurological impairment, malunion, further displacement, signs of avascular necrosis and post-traumatic osteoarthritis. Results: The mean non adjusted Constant’s score at last follow up was 88.33 over 100 (SD: 11.45) an average of 96.01% compared to the contralateral side. 83% of patients were pain free, and 17% reported mild pain. Active motion was very satisfactory averaging 96.23% in forward flexion, 89.86% in external rotation with the hand at the side, and 90.22% in external rotation at 90° abduction, and a difference of 1.46 vertebral levels in active internal rotation, as compared to the contralateral shoulder. Passive motion was also analyzed in the same way. Power of the affected shoulder in forward elevation was on average 90.19% of the contralateral side. Impingement was tested by the Neer, Hawkins and Yocum signs: 4 patients (33.3%) reported at least one positive sign of impingement. The Jobe and Palm up tests were negative in 100% of patients. 11 patients were very satisfied and 1 patient satisfied. Joint stiffness developed in one case (8.3%), with 100° of forward elevation, 50° external rotation with the hand at the side, 50° external rotation at 90° abduction. No algodystrophy, no neurological impairment, no further displacement, no signs of avascular necrosis, no post-traumatic progression of osteoarthritis, were observed in any case. Union was achieved in all the 12 patients, in 2 cases with some degree of angulation. Conclusions: Very good functional and radiological results were obtained with immediate passive mobilization of minimally displaced fractures of the proximal humerus. It is a safe method as all the fractures united and the rate of complication was very low especially without joint stiffness or RSD and with very good patient satisfaction

Introduction. There is considerable uncertainty about the optimal treatment of displaced four-part fractures of the proximal humerus. Within the last decade locking plate technology has been considered a breakthrough in the treatment of these complex injuries. Methods. We systematically identified and reviewed clinical studies of the benefits and harms after osteosynthesis with locking plates in displaced four-part fractures. Results. We included fourteen studies with 374 four-part fractures. There were no randomised trials, one prospective observational comparative study, three retrospective observational comparative studies, and ten case series. Small studies with a high risk of bias precluded reliable estimates of functional outcome. Unexpected high rates of complications (range 16% to 64%) and re-operations (range 11% to 27%) were reported. Conclusion. The empirical foundation for the clinical value of locking plates in displaced four-part fractures of the proximal humerus is very sketchy. We emphasise the need for well conducted randomised trials and observational studies

Introduction. A review of the literature showed a discrepancy between biomechanical and clinical studies on fracture fixation failure in patients with poor bone quality. The objective of the present study is to assess the influence of local bone status on complications after surgical treatment of proximal humerus fractures. Methods. A prospective cohort study was initiated in 2007. The inclusion criteria were closed displaced fractures of the proximal humerus, primary fracture treatment with a Philos plate, patients aged 50 to 90, normal pre-trauma function of both shoulders in accordance to age, and monotrauma. There was active follow-up for one year with radiological assessment at clinical centers from four countries. Bone quality at the proximal humerus was determined preoperatively for the contralateral side of the fracture by CT scan, and at the contralateral radius within six weeks post-surgery by DXA. The occurrence of complications was monitored up to one year post-surgery. Independent x-ray evaluation and final classification of all complications will be performed at the end by a study review board using anonymous data and x-rays. Preliminary Results. 157 patients, 127 female (79%) met the inclusion criteria. Their mean age at time of surgery is 69 (range 50–89). 119 patients (100%) attended the 1-year follow-up assessment, 64 (96%) the one at 3 months, and 148 (99%) the 6 week follow-up examination. According to the WHO criteria, 107 patients (71%) suffered from either osteopenia or osteoporosis, while 43 patients (29%) had a normal T-score. The overall reported complication rate was 39%. However, the number of intraoperative complications was 0.6%, bone/fracture complications 19.1%, implant complications 15.3%, and general complications 14.6%. Discussion. Fixation of proximal humerus fractures with Philos plates in elderly people with osteoporotic bone is associated with a high rate of fixation failure. Final results will be reported after x-rays, local BMD (CT- based) and complications assessment have been conducted

Purpose of the study: The reversed total shoulder prosthesis is one of the treatments currently proposed for excentered glenoid osteoarthritic degeneration with massive rotator cuff tears. In light of the mediocre or at best highly variable results obtained with osteosynthesis or humeral arthroplasty for four-fragment fractures of the proximal humerus, indications for the reversed total shoulder prosthesis have been widened to include this category of traumatology patients. The purpose of this prospective study was to report outcome with the reversed prosthesis used for complex fracture of the proximal humerus in subjects aged over 70 years. Material and methods: Ten patients, mean age 76 years, underwent surgery performed by the same surgeon to insert a Delta (DePuy) reversed prosthesis for four-fragment complex displaced fracture of the proximal humerus. The deltopectoral approach was used for all patients. The rotator cuff status was assessed intraoperatively. Clinical (Constant score) and radiological assessment were noted at 24 months. Results: During the operation, only three of the ten shoulders presented a full thickness rotator cuff tear. One patients developed a complication requiring revision: early dislocation revised with a retaining polyethylene insert without recurrent dislocation. There were no cases of glenoid loosening at last follow-up. The weighted Constant score was 65/100. A pain-free shoulder was achieved in all ten patients. Anterior elevation was 130° on average, internal rotation reached hand to buttocks and active external rotation 20°. Discussion: In patients aged over 70 years presenting a complex four-fragment fracture of the proximal humerus, the reversed prosthesis enables improved function and restoration of satisfactory joint movement. Early postoperative recovery and the gain in pain relief are encouraging factors. There was however unsatisfactory restoration of active rotation. For the elderly subject, free of a massive rotator cuff tear, rapid recovery after insertion of an reversed prosthesis should be balanced against the possible preservation of active rotations with an anatomic prosthesis

Aim: To assess the functional outcome following internal fixation with the PHILOS® plating system for displaced proximal humeral fractures by using the ASES and Constant scoring system. Background: Controversy exists with regards to the management of displaced proximal humeral fractures and many methods of treatment have been proposed over the years. In particular, the role of surgery has not been clearly defined. The current trend is toward limited dissection of the soft tissues with the use of minimal amounts of hardware to gain stability. Methods: We performed a retrospective analysis of 30 consecutive patients treated surgically with the PHILOS ® plate for a displaced proximal humeral fracture between February 2002 and October 2003. Patients were assessed clinically and radio graphically at an average follow-up time of 9 months. Functional outcome was determined utilising the American Shoulder and Elbow Society score (ASES) and Constant Murley score. The injury was classified using Neer’s 4 part classification. Results: Average age of the patients was 58 years (19 to 92). There were 6 two part, 14 three part and 10 four part fractures. All the fractures were radio graphically united by 10 weeks. The average overall ASES score is 66.5%. The average overall Constant score is 55%. The average external rotation at 90 of abduction for the ages 15–55 was 55°–64° and the ages 56–95 was 25°–34°. The average forward elevation for the ages 15–55 was 85°–95° and the ages 76–95 was 55°–64°. The most difficult movement for the older subgroup of patients was internal rotation which was up to the sacrum. Conclusion: Our results show that good fracture stability and functional outcome can be obtained from the use of the PHILOS® plate. Early mobilisation of the shoulder can be achieved without compromising fracture union. We would recommend the use of the PHILOS® plate for the management of displaced fractures of the proximal humerus

Displaced proximal humeral fractures remain a difficult management problem. There are many treatment methods described in the literature but there is no universally accepted technique. Materials and Methods We treated 25 patients with displaced fractures of the proximal humerus by internal fixation with a locked Polarus nail at our hospital over a period of 4 years. The male: female ratio was 13:12. The average age was 63 yrs and the average follow-up in the series was 24 months. Fracture union was evaluated by regular clinical and radio graphic examination. The functional outcome was assessed by Constant’s score. Results In 23 patients, the fracture united while one patient had failure of the proximal fixation due to collapse of the head requiring a shoulder replacement. One patient died post-operatively due to medical conditions. There were no wound infections in our series; two patients had temporary radial nerve palsy. There were three patients in which one of the proximal locking screws was missing the nail. There was backing out of proximal locking screws in four patients which required removal. One patient required removal of the nail due to impingement symptoms. There was no difference in the Constant’s score in the young and the elderly population. 75% of the patient’s were satisfied with their functional outcome. Discussion In our limited experience, Polarus nail is an effective mechanical device for the treatment of unstable proximal humeral fractures. The proximal locking screws are often seen to back out in elderly population and they may require removal if symptomatic. This appears to be due to poor grip of screws in osteoporotic bone. In order to minimise the risk of proximal screws missing the nail we recommend the nail insertion device should be assembled by the surgeon himself before insertion into the patient and check to make sure the holes in the jig match those in the nail. In our hands we found that the entry point is very critical and we feel that it should be as medial as possible to preserve the lateral metaphysis. Our study shows that Polarus nail is an effective device to treat displaced proximal humeral fractures but the fracture communition and bone quality also plays a role in the outcome of such fractures

Purpose of the study: Hemi-arthroplasty, osteosynthesis, and ball-and-socket implants provide well-known results for the management of displaced joint fractures of the proximal humerus in elderly subjects. The purpose of this work was to assess the reversed Grammont prosthesis for these indications. Material and methods: From 1993 to 1999, eighteen Delta III prostheses were implanted by the same operator in recent trauma victims. The patients, 17 women and one man, mean age 75 years, presented four-fragment fractures (n=15) or fracture dislocation (n=3). The dominant side was involved in nine cases. These patients presented infiltrative rotator cuff tendinopathy (n=4), type 1 diabetes mellitus (n=2), exogenosis (n=2), morbid obestity (n=2), homelessness (n=2), and dementia (n=2). Surgery was performed under general anesthesia in the semi-sitting position via a trapezodeltoid approach without acromion osteotomy and with 20° humeral implant retroversion in all cases except one, cemented in 17 cases. The tubercles could be reinserted in four patients. Rehabilitation was not always possible. The Constant score and the anteroposterior and Lamy lateral views were used to assess clinical and radiographic outcome. Results: There were two deaths, so the analysis included 16 shoulders. Complications were: shoulder-hand syndrome (n=1), early deep Acinetobacter infection with revision and preservation of the arthroplasty (n=1), anterior dislocation at one month due to voluntary 10° anterotation of the humeral stem requiring reorientation (n=1). At mean follow-up of 85 months, the Constant score was 60, with a weighted score of 83%. The results were not influenced by reinsertion of the tubercles and were considered good for pain and activity, fair for strength, and disappointing for rotations. The x-rays did not reveal any sign of humeral loosening. There was one lucent line between the glenoid and the metaglenoid, four cases with pillar notches, and nine infraglenoid ossifications. Discussion and conclusion: For displaced joint fractures of the proximal humerus, endomedullary osteosynthesis and the ball-and-socket implant have shown their efficacy as an alternative to hemiarthroplasty. The reverted prosthesis also appears to be a valid therapeutic option for elderly persons with osteoporotic bone compromising the reinsertion of the tubercules. This option enables good results for pain, activity, strenth and active mobility except for rotation, with only five signs of gravity for the glenoid with one involving the glenoid and none the humerus at 85 months follow-up. These results should be further confirmed with a larger series and longer follow-up

Introduction: Fractures of the proximal humerus account for 4–5% of all fractures. The number one cause of this type of fracture is age related osteoporosis associated with minimal trauma. Approximately 80% of these fractures are non or minimally-displaced, and can be treated conservatively with good results. However, treatment of displaced complex fractures is still controversial. The disadvantage of open procedures is the risk of damaging the blood supply to the humeral head, leading to a higher incidence of avascular necrosis. Closed Reduction and Percutaneous Fixation (CRPF) is a minimal invasive procedure with a lower risk of damaging the blood supply. The main complication of this technique is loosening of the guide wires and displacement of the fragments requiring a second operation. Purpose: The guide wire loosening leads us to improve the technique by adding an external fixator to stabilize the guide wires and secure fragment positioning. We report our experience of treating displaced fractures of the proximal humerus with Closed Reduction and External Fixation (CREF). Materials and methods: Between the years 1996–2001 we operated on 37 patients for 38 complex fractures and fracture dislocations of the proximal humerus. We had 16 two part fractures, 13 three part fractures, 3 four part fractures, 5 two part fracture dislocation and 1 four part fracture dislocation according to the Neer’s classification. The mean age was 60 years old ranging from 16–90 with a male to female ratio of 1:1. The patients were placed in a beach chair position using an image intensifier for AP and axillary views. Because the closed reduction was unsatisfactory, six patients underwent open reduction and external fixation. The remaining 32 shoulders underwent CREF. Passive motion exercises were initiated on the first postoperative day. The external fixator was removed after four to six weeks (mean time for external fixator – 5.3 weeks). After removing the external fixator the patients began with active assisted mobilization of the shoulder and isometric strengthening exercises. Results: The average follow up was 31.6 months (range 6–60 months). No loosening was observed upon removal of the external fixator, however the following complications were encountered: 5 patients had superficial pin tract infections, 1 patients developed an avascular necrosis of the humeral head, 1 patient had a non union of the fracture. Of the remaining patients, 13 patients had an excellent result, 15 patients had a good result and 5 patients had a fair result. Conclusions: CREF is a minimal invasive technique for complex fractures of the proximal humerus, greatly reducing the damage to the blood supply when compared to open surgical procedures. It offers a better stabilization than CRPF, thus reducing the complication rate. The percutaneous technique causes less scaring and therefore a shorter rehabilitation program. Consequently, this procedure is recommended for complex fractures of the proximal humerus

The June 2023 Shoulder & Elbow Roundup³⁶⁰ looks at: Proximal humerus fractures: what does the literature say now?; Infection risk of steroid injections and subsequent reverse shoulder arthroplasty; Surgical versus non-surgical management of humeral shaft fractures; Core outcome set needed for elbow arthroplasty; Minimally invasive approaches to locating radial nerve in the posterior humeral approach; Predictors of bone loss in anterior glenohumeral instability; Does the addition of motor control or strengthening exercises improve rotator cuff-related shoulder pain?; Terminology and diagnostic criteria used in patients with subacromial pain syndrome.

Aims

Early large treatment effects can arise in small studies, which lessen as more data accumulate. This study aimed to retrospectively examine whether early treatment effects occurred for two multicentre orthopaedic randomized controlled trials (RCTs) and explore biases related to this.

There is a specific type of displaced four-part fracture of the proximal humerus which consists of valgus impaction of the head fragment; this deserves special consideration because the rate of avascular necrosis is lower than that of other displaced four-part fractures. Using either closed reduction or limited open reduction and minimal internal fixation, 74% satisfactory results can be achieved in this injury

We randomised 40 elderly patients of mean age 74 years with displaced three- or four-part fractures of the humerus to either conservative treatment or tension-band osteosynthesis. At one year and after three to five years, clinical follow-up showed no functional differences between the two groups of patients, with optimal function achieved within one year. There were major complications only in the surgically-treated group. Radiological review showed that surgery had improved the position of the fractured humeral head, but this was not reflected in improved function. Semi-rigid fixation with tension-band wiring of displaced multifragment fractures of the proximal humerus in the elderly did not improve the functional outcome when compared with conservative treatment

Introduction: Management of displaced comminuted fractures of the proximal humerus in the elderly is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Rigid fixation of these fractures by plates may offer stability in anatomic position, but requires in most cases extensive soft tissue exposure and may result in a relatively high incidence of avascular necrosis of the humeral head. Therefore, many authors are today of the opinion that hemiarthroplasty of the shoulder joint in such fractures is preferable to rigid fixation. This study reviews our experience with hemiartroplasty of the shouldere in elderly patients with comminuted fractures of the proximal humerus. Material & Methods: This study consists of 39 Pts. (27F, 12M; 72–89 year old, mean 76.5Y; 12 with 3 parts fractures and 27 with 4 parts fracture) treated by hemiarthroplasty of the proximal humerus. Patients were followed for 2–8 years (mean 4Y), and evaluated by the Neer‘s shoulder grading score and radiographs. Results: 74% of the patients treated by hemiarthroplasty had satisfactory results. They were almost free of pain, but most of them had only a moderate improvement in shoulder motion (active abduction or flexion of 110–130 degrees were observed in 4/39, of 90–110 degrees in 7/39, of 50–90 degrees in 17/39 and of 30–50 degrees in 11/29). Conclusions: Based on this study it seems that pain relief by hemiarthroplasty may be achieved in most older patients with comminuted fractures of the proximal humerus, but the gain in shoulder function is relatively limited

Introduction- Proximal humeral fractures remain a challenging problem. Most authors agree that anatomical reduction and stable fixation are essential to allow early range of motion. A variety of techniques have been described such as threaded pins, tension band wiring, screws, nails, plates and primary prosthesis. Locking plates score over other implants by the virtue of providing greater angular stability and better biomechanical properties. The Aim of the Study is to evaluate the functional outcome of PHILOS plate Osteosynthesis of displaced proximal humeral fractures. Materials and Methods- A retrospective study of 50 patients treated with PHILOS plating for the 2 part, 3part and 4 part proximal humeral fractures with a minimum follow up of 1 year. All the patients were assessed in clinic by Constant Murley and ASES scoring systems. X-ray evaluation was done for fracture healing, AVN, mal-union, non-union, collapse of head, screw penetration and impingement of plate. Results- Total of 50 acute displaced fractures of proximal humerus treated with PHILOS plating between 2003–2005 were assessed. Mean age was 64 years (15–86) Male to female ratio was 12:38, dominant to non-dominant ratio was 32:18. According to Neer’s classification 16 fractures were 2 part, 24 fractures were 3 part and 10fractures were 4 part. The overall mean Constant score was 73.4(range20–100) and ASES score was 71.7(range 25–98). Under 60 years of age the mean Constant and ASES scores were 83.5 and 83, over 60 years of age scores were 63.1 and 60.4 respectively. The complications include two deep infections which needed excision arthroplasty, one malunion, one subacromial impingement which needed plate removal after fracture healing. No mechanical failure, no non-union, no ANV was noted. Conclusions- PHILOS plate Osteosynthesis is a reliable method of treating complex proximal humeral fractures. It provides good mechanical stability and allows rapid mobilization with out compromising fracture healing

The purpose of this study is to evaluate the results of the treatment of displaced greater-tuberosity fractures by open reduction and stable fixation with heavy non absorbable sutures and early passive motion. Thirty-six patients, 21 male (average age 50 years) and 15 female (average age 62 years) underwent open reduction and internal fixation for a displaced greater-tuberosity fracture of the proximal humerus, between 1992–2000. Main indication for operative treatment was at least 1 cm displacement of the tuberosity. Reduction and stable fixation of the greater tuberosity with its rotator-cuff attachments, was performed by a lateral approach using heavy transosseous nonabsorbable sutures. Passive motion was started at the second postoperative day followed by active range of motion after the fifth postoperative week. All patients were examined periodically using clinical and radiological criteria. All fractures were healed without any displacement within 3 months. Final assessment was performed according to Neer’s criteria for pain, motion, function, strength and patient’s satisfaction, in a mean follow-up period of 4 years. Twenty seven patients (75%) rated excellent, without pain, showing active forward elevation at 160 to 180°, external rotation at 60 to 80° and internal rotation up to tiq level. Nine patients (25%) rated very good, had only minor pain problems. We conclude that, if displaced fractures of the greater tuberosity are not diagnosed and treated promptly, may result in limitation of motion and functional disability. To our experience open reduction and stable fixation with transosteal suturing, allowing early passive motion of the joint, gives excellent to very good final results

Purpose of the study: Functional recovery afte displaced cephalotuberosity fracture of the proximal humerus in pateints aged over 70 years is a major surgical challenge. Reconstuction with an inversed prosthesis avoids the problems of tuberosity fixation. We report a prospective consecutive series of reversed prostheses used of 3 and 4 fragment displaced and non-displace fractures in patients aged over 70 years. Material and methods: Between January 2001 and June 2004, 19 patients aged over 70 years were included in this study, 16 women and 3 men, mean age 74.9 years (range 58–94 years, median 76 years). All presented 3- or 4-fragment fractures. An independent operator established the Constant and Dash scores. The position of the implants, loosening, presence of a glenoid notch (Nerot) were noted on plain x-rays. Results: Sixteen of the 19 patients (13 women, 3 men), mean age 73.9 years (range 58–94 years) were reviewed at mean 12.6 months follow-up (range 6–18 months). There were no cases of dislocation. Hematogenous sepsis occurred at 16 months in one patient and led to implant removal. The raw Constant score was 53 (34–76) and the weighted Constant score 76.1 (41–110.1). The Dash score was 37.4 (34–76). Active abduction reached 91.2° (10–150°), active elevation 97.5° (20–150°), active RE1 6.6° (0–50°), active RE2 9.4° (0–90°) and active internal rotation 31.2° (0–60°). There was a humeral lucent line in five cases and a grade 0 glenoid line in one, grade 1 and 2 in six, and grade 3 in three. Discussion: The only series of fracture of the proximal humerus in patients aged over 70 years was a retrospective study of prosthesis patients reported by Wretenberg in 1997. To date, there has not been a published series on use of the reversed prosthesis for fracture. For the short term in a population with frail bone and minimal functional requirements, reversed implants provide the best subjective and objective functional results. The absence of postoperative immobilization and independence from the rotator cuff enables rapid recovery of useful motion. Range of motion is reduced only to a small extent for rotation. Thus when possible, we reinsert the tuberosities with the reversed implant. Even if the tuberosity assembly dismounts (agitation in a context of temporospatail disorientation), there is no consequence on the reversed prosthesis. The large number of lucent lines with no clinical impact is a point to be examined carefully, showing that further improvement can be achieved with the existing implants

Aims

The aim of this study was to explore whether time to surgery affects functional outcome in displaced proximal humeral fractures

Objectives

The objective of this study was to perform a meta-analysis of all randomised controlled trials (RCTs) comparing surgical and non-surgical management of fractures of the proximal humerus, and to determine whether further analyses based on complexity of fracture, or the type of surgical intervention, produced disparate findings on patient outcomes.

Objectives

To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice.

Objectives

The PROximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial has recently demonstrated that surgery is non-superior to non-operative treatment in the management of displaced proximal humeral fractures. The objective of this study was to assess current surgical practice in the context of the PROFHER trial in terms of patient demographics, injury characteristics and the nature of the surgical treatment.

We reviewed 101 patients with injuries of the terminal branches of the infraclavicular brachial plexus sustained between 1997 and 2009. Four patterns of injury were identified: 1) anterior glenohumeral dislocation (n = 55), in which the axillary and ulnar nerves were most commonly injured, but the axillary nerve was ruptured in only two patients (3.6%); 2) axillary nerve injury, with or without injury to other nerves, in the absence of dislocation of the shoulder (n = 20): these had a similar pattern of nerve involvement to those with a known dislocation, but the axillary nerve was ruptured in 14 patients (70%); 3) displaced proximal humeral fracture (n = 15), in which nerve injury resulted from medial displacement of the humeral shaft: the fracture was surgically reduced in 13 patients; and 4) hyperextension of the arm (n = 11): these were characterised by disruption of the musculocutaneous nerve. There was variable involvement of the median and radial nerves with the ulnar nerve being least affected.

Surgical intervention is not needed in most cases of infraclavicular injury associated with dislocation of the shoulder. Early exploration of the nerves should be considered in patients with an axillary nerve palsy without dislocation of the shoulder and for musculocutaneous nerve palsy with median and/or radial nerve palsy. Urgent operation is needed in cases of nerve injury resulting from fracture of the humeral neck to relieve pressure on nerves.

The April 2012 Shoulder & Elbow Roundup³⁶⁰ looks at katakori in Japan, frozen shoulder, if shoulder impingement actually exists, shoulder arthroscopy and suprascapular nerve blocks, why shoulder replacements fail, the infected elbow replacement, the four-part fracture, the acromion index, and arm transplantation

Multicentre clinical trials in trauma care are gaining prominence as a means of generating good-quality evidence to inform and influence clinical practice. We believe multicentre trials have an important role to play in supporting evidence-based practice, and further investment in such trials is justified.

The surgical treatment of three- and four-part fractures of the proximal humerus in osteoporotic bone is difficult and there is no consensus as to which technique leads to the best outcome in elderly patients. Between 1998 and 2004 we treated 76 patients aged over 70 years with three- or four-part fractures by percutaneous reduction and internal fixation using the Humerusblock.

A displacement of the tuberosity of > 5 mm and an angulation of > 30° of the head fragment were the indications for surgery.

Of the patients 50 (51 fractures) were available for follow-up after a mean of 33.8 months (5.8 to 81). The absolute, age-related and side-related Constant scores were recorded. Of the 51 fractures, 46 (90.2%) healed primarily. Re-displacement of fragments or migration of Kirschner wires was seen in five cases. Necrosis of the humeral head developed in four patients. In three patients a secondary arthroplasty had to be performed, in two because of re-displacement and in one for necrosis of the head. There was one case of deep infection which required a further operation and one of delayed healing.

The mean Constant score of the patients with a three-part fracture was 61.2 points (35 to 87) which was 84.9% of the score for the non-injured arm. In four-part fractures it was 49.5 points (18 to 87) or 68.5% of the score for the non-injured arm.

The Humerusblock technique can provide a comfortable and mobile shoulder in elderly patients and is a satisfactory alternative to replacement and traditional techniques of internal fixation.

Most proximal humeral fractures are stable injuries of the ageing population, and can be successfully treated non-operatively. The management of the smaller number of more complex displaced fractures is more controversial and new fixation techniques have greatly increased the range of fractures that may benefit from surgery.

This article explores current concepts in the classification and clinical aspects of these injuries, reviewing the indications, innovations and outcomes for the most common methods of treatment.

We reviewed the outcome of 28 patients who had been treated using the Aequalis fracture prosthesis for an acute fracture of the proximal humerus at a mean follow-up of 39.3 months (24 to 63). The mean age of the patients at the time of the fracture was 66.3 years (38 to 80). The mean Constant score was 68.2 (37 to 84) for the operated shoulder, which represented 89.5% of the mean score for the uninjured side (p < 0.001). The quality of the reconstruction as shown on the immediate post-operative radiographs was categorised into three types, anatomical, acceptable, and unacceptable, depending on the position of the tuberosities relative to the prosthetic head and the humeral shaft. Anatomical reconstruction was associated with a higher mean Constant score as well as higher mean values of anterior forward elevation, abduction and external rotation than the other types, but the differences were not statistically significant (p > 0.231).

A total of 18 patients had active anterior elevation ≥150°. Their mean active abduction and external rotation were 163.6° and 31.3°, respectively. In seven of the 28 patients, the mean active anterior elevation, abduction and external rotation were 130.7°, 129.2° and 22.8°, respectively. In all, 12 patients were very satisfied with the results, 12 were satisfied, two were dissatisfied and two were disappointed; 26 reported no or only mild pain while only two had moderate pain. In five patients proximal migration of the humeral head was shown on the anteroposterior radiographs of the shoulder. No evidence of loosening was found in any prosthesis.

We reviewed 39 patients with displaced three- and four-part fractures of the humerus. In 21 patients (group A) we had used an anatomical prosthesis for the humeral head and in 18 (group B) an implant designed for fractures.

When followed up at a mean of 29.3 months after surgery the overall Constant score was 51.9 points; in group A it was 51.5 and in group B 52.4 points. The subjective satisfaction of the patients was assessed using a numerical rating scale and was similar in both groups. In group A complete healing of the tuberosities was found in 29% and 50% in group B. Partial integration was seen in 29% of group A and in only one patient in group B, while resorption was noted in 43% of group A and 44% of group B. The functional outcome was significantly better in patients with complete or partial healing of the tuberosities (p = 0.022). The specific trauma prosthesis did not lead to better healing of the tuberosities. The difference in clinical outcome obtained by the two designs did not reach statistical significance.