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The Bone & Joint Journal
Vol. 98-B, Issue 2 | Pages 152 - 159
1 Feb 2016
Corbacho B Duarte A Keding A Handoll H Chuang LH Torgerson D Brealey S Jefferson L Hewitt C Rangan A

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.

Methods

A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods.


The Journal of Bone & Joint Surgery British Volume
Vol. 69-B, Issue 4 | Pages 643 - 646
1 Aug 1987
Kristiansen B Kofoed H

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


The Journal of Bone & Joint Surgery British Volume
Vol. 70-B, Issue 5 | Pages 821 - 824
1 Nov 1988
Kristiansen B Kofoed H

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


The Bone & Joint Journal
Vol. 99-B, Issue 3 | Pages 383 - 392
1 Mar 2017
Handoll HH Keding A Corbacho B Brealey SD Hewitt C Rangan A

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.

Patients and Methods

Of the original 250 trial participants, 176 consented to extended follow-up and were sent postal questionnaires at three, four and five years after recruitment to the trial. The Oxford Shoulder Score (OSS; the primary outcome), EuroQol 5D-3L (EQ-5D-3L), and any recent shoulder operations and fracture data were collected. Statistical and economic analyses, consistent with those of the main trial were applied.


The Journal of Bone & Joint Surgery British Volume
Vol. 82-B, Issue 8 | Pages 1107 - 1112
1 Nov 2000
Hintermann B Trouillier HH Schäfer D

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


The Journal of Bone & Joint Surgery British Volume
Vol. 73-B, Issue 2 | Pages 295 - 298
1 Mar 1991
Jakob R Miniaci A Anson P Jaberg H Osterwalder A Ganz R

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


The Journal of Bone & Joint Surgery British Volume
Vol. 79-B, Issue 3 | Pages 412 - 417
1 May 1997
Zyto K Ahrengart L Sperber A Törnkvist H

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


The Bone & Joint Journal
Vol. 102-B, Issue 1 | Pages 33 - 41
1 Jan 2020
Norman JG Brealey S Keding A Torgerson D Rangan A

Aims

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

Methods

A total of 250 patients presenting within three weeks of sustaining a displaced proximal humeral fracture involving the surgical neck were recruited at 32 acute NHS hospitals in the United Kingdom between September 2008 and April 2011. Of the 125 participants, 109 received surgery (fracture fixation or humeral head replacement) as per randomization. Data were included for 101 and 67 participants at six-month and five-year follow-up, respectively. Oxford Shoulder Scores (OSS) collected at six, 12, and 24 months and at three, four, and five years following randomization was plotted against time to surgery. Long-term recovery was explored by plotting six-month scores against five-year scores and agreement was illustrated with a Bland-Altman plot.


The Journal of Bone & Joint Surgery British Volume
Vol. 94-B, Issue 6 | Pages 799 - 804
1 Jun 2012
Hems TEJ Mahmood F

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 Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 6 | Pages 720 - 721
1 Jun 2011
Rangan A Maffulli N

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 Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 12 | Pages 1602 - 1607
1 Dec 2008
Bogner R Hübner C Matis N Auffarth A Lederer S Resch H

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 1 | Pages 1 - 11
1 Jan 2011
Murray IR Amin AK White TO Robinson CM

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 91-B, Issue 10 | Pages 1335 - 1340
1 Oct 2009
Kontakis GM Tosounidis TI Christoforakis Z Hadjipavlou AG

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.


The Journal of Bone & Joint Surgery British Volume
Vol. 87-B, Issue 2 | Pages 151 - 154
1 Feb 2005
Harvie P Pollard TCB Chennagiri RJ Carr AJ


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 3 | Pages 345 - 350
1 Mar 2006
Loew M Heitkemper S Parsch D Schneider S Rickert M

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.