Fracture of the top end of the upper arm bone (proximal humerus) is a common injury in older people. It is often called a shoulder fracture. The bone typically fractures (breaks) just below the shoulder, usually after a fall. Most of these fractures occur without breaking the skin lying over the fracture. The injured arm is often supported in a sling until the fracture heals sufficiently to allow shoulder movement. More severe (displaced) fractures may be treated surgically. This may involve fixing the fracture fragments together by various means. Alternatively, the top of the fractured bone may be replaced (half 'shoulder' replacement: hemiarthroplasty). More rarely, the whole joint, thus including the joint socket, is replaced (total 'shoulder' replacement). Physiotherapy is often used to help restore function.
Results of the search
We searched medical databases up to November 2014 and included 31 randomised studies with a total of 1941 participants. Most of the 18 treatment comparisons were tested by one study only. The best evidence was from eight studies, one of which was a relatively large multicentre study; these investigated whether surgery gave a better result than non-surgical treatment for displaced fractures.
Nine trials evaluated non-surgical treatment in usually less severe fractures. One trial found a type of arm sling was generally more comfortable than a type of body bandage. There was some evidence that early mobilisation (within one week), compared with delayed mobilisation (after three weeks), resulted in less pain and faster recovery in people with 'stable' fractures. Two studies provided weak evidence that many patients could generally achieve a satisfactory outcome when given sufficient instruction to pursue exercises on their own.
Eight studies, involving 567 participants with displaced fractures, compared surgical versus non-surgical treatment. Pooled results from the five most recent trials showed that there were no important differences between the two approaches for patient-reported measures of function and quality of life at 6, 12 and 24 months. There was little difference between the two groups in mortality. Twice as many surgical group patients had additional or secondary surgery. More surgical group patients had adverse events.
Twelve trials (744 participants) tested different methods of surgical treatment. There was weak evidence of some differences (e.g. in complications) between some interventions (e.g. different devices or different ways of using devices).
There was very limited evidence suggesting similar outcomes for early versus delayed mobilisation after either surgical fixation or hemiarthroplasty.
Quality of the evidence
Most of the 31 studies had weaknesses that could affect the reliability of their results. We considered that the evidence was either of high or moderate quality for the results of the surgical versus non-surgical treatment comparison, which means that we are pretty certain these results are reliable. We considered that the evidence for other comparisons was of low or very low quality, which means we are unsure of these results.
Surgery does not result in a better outcome for the majority of people with displaced proximal humeral fractures and is likely to result in a greater need for subsequent surgery. Otherwise, there is not enough evidence to determine the best non-surgical or, when selected, surgical treatment for these fractures.
There is high or moderate quality evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures involving the humeral neck and is likely to result in a greater need for subsequent surgery. The evidence does not cover the treatment of two-part tuberosity fractures, fractures in young people, high energy trauma, nor the less common fractures such as fracture dislocations and head splitting fractures.
There is insufficient evidence from RCTs to inform the choices between different non-surgical, surgical, or rehabilitation interventions for these fractures.
Fracture of the proximal humerus, often termed shoulder fracture, is a common injury in older people. The management of these fractures varies widely. This is an update of a Cochrane Review first published in 2001 and last updated in 2012.
To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and other databases, conference proceedings and bibliographies of trial reports. The full search ended in November 2014.
We considered all randomised controlled trials (RCTs) and quasi-randomised controlled trials pertinent to the management of proximal humeral fractures in adults.
Both review authors performed independent study selection, risk of bias assessment and data extraction. Only limited meta-analysis was performed.
We included 31 heterogeneous RCTs (1941 participants). Most of the 18 separate treatment comparisons were tested by small single-centre trials. The main exception was the surgical versus non-surgical treatment comparison tested by eight trials. Except for a large multicentre trial, bias in these trials could not be ruled out. The quality of the evidence was either low or very low for all comparisons except the largest comparison.
Nine trials evaluated non-surgical treatment in mainly minimally displaced fractures. Four trials compared early (usually one week) versus delayed (three or four weeks) mobilisation after fracture but only limited pooling was possible and most of the data were from one trial (86 participants). This found some evidence that early mobilisation resulted in better recovery and less pain in people with mainly minimally displaced fractures. There was evidence of little difference between the two groups in shoulder complications (2/127 early mobilisation versus 3/132 delayed mobilisation; 4 trials) and fracture displacement and non-union (2/52 versus 1/54; 2 trials).
One quasi-randomised trial (28 participants) found the Gilchrist-type sling was generally more comfortable than the Desault-type sling (body bandage). One trial (48 participants) testing pulsed electromagnetic high-frequency energy provided no evidence. Two trials (62 participants) provided evidence indicating little difference in outcome between instruction for home exercises versus supervised physiotherapy. One trial (48 participants) reported, without presentable data, that home exercise alone gave better early and comparable long-term results than supervised exercise in a swimming pool plus home exercise.
Eight trials, involving 567 older participants, evaluated surgical intervention for displaced fractures. There was high quality evidence of no clinically important difference in patient-reported shoulder and upper-limb function at one- or two-year follow-up between surgical (primarily locking plate fixation or hemiarthroplasty) and non-surgical treatment (sling immobilisation) for the majority of displaced proximal humeral fractures; and moderate quality evidence of no clinically important difference between the two groups in quality of life at two years (and at interim follow-ups at six and 12 months). There was moderate quality evidence of little difference between groups in mortality in the surgery group (17/248 versus 12/248; risk ratio (RR) 1.40 favouring non-surgical treatment, 95% confidence interval (CI) 0.69 to 2.83; P = 0.35; 6 trials); only one death was explicitly linked with the treatment. There was moderate quality evidence of a higher risk of additional surgery in the surgery group (34/262 versus 16/261; RR 2.06, 95% CI 1.18 to 3.60; P = 0.01; 7 trials). Although there was moderate evidence of a higher risk of adverse events after surgery, the 95% confidence intervals for adverse events also included the potential for a greater risk of adverse events after non-surgical treatment.
Different methods of surgical management were tested in 12 trials. One trial (57 participants) comparing two types of locking plate versus a locking nail for treating two-part surgical neck fractures found some evidence of slightly better function after plate fixation but also of a higher rate of surgically-related complications. One trial (61 participants) comparing a locking plate versus minimally invasive fixation with distally inserted intramedullary K-wires found little difference between the two implants at two years. Compared with hemiarthroplasty, one trial (32 participants) found similar results with locking plate fixation in function and re-operation rates, whereas another trial (30 participants) reported all five re-operations occurred in the tension-band fixation group. One trial (62 participants) found better patient-rated (Quick DASH) and composite shoulder function scores at a minimum of two years follow-up and a lower incidence of re-operation and complications after reverse shoulder arthroplasty (RSA) compared with hemiarthroplasty.
No important between-group differences were found in one trial (120 participants) comparing the deltoid-split approach versus deltopectoral approach for non-contact bridging plate fixation, and two trials (180 participants) comparing 'polyaxial' and 'monaxial' screws in locking plate fixation. One trial (68 participants) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation. One trial (54 participants) found fewer adverse events, including re-operations, for the newer of two types of intramedullary nail. One trial (35 participants) found better functional results for one of two types of hemiarthroplasty. One trial (45 participants) found no important effects of tenodesis of the long head of the biceps for people undergoing hemiarthroplasty.
Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial: 64 participants) or hemiarthroplasty (one trial: 49 participants).