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Background Four-part fractures of the proximal humerus account for 3% of all humeral fractures and are regarded as the most difficult fractures to treat in the elderly. Various authors recommend nonoperative treatment or hemiarthroplasty, but the literature is unclear regarding which provides better quality of life and function. Questions/purposes We therefore performed a randomized controlled trial to compare (1) function, (2) strength, and (3) pain and disability in patients 65 years and older with four-part humeral fractures treated either nonoperatively or with hemiarthroplasty. Methods We randomly allocated 50 patients to one of the two approaches. There were no differences in patient demographics between the two groups. The Constant-Murley score was the primary outcome measure. Secondary outcome measures were the Simple Shoulder Test, abduction strength test as measured by a myometer, and VAS scores for pain and disability. All patients were assessed at 12 months. Results We found no between-group differences in Constant-Murley and Simple Shoulder Test scores at 3- and 12-months followup. Abduction strength was better at 3 and 12 months in the nonoperatively treated group although the nonoperatively treated patients experienced more pain at 3 months; this difference could not be detected after 12 months. Conclusions We observed no clear benefits in treating patients 65 years or older with four-part fractures of the proximal humerus with either hemiarthroplasty or nonoperative treatment. Level of Evidence Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Background Proximal humeral fractures are mainly associated with osteoporosis and are becoming more common with the aging of our society. The best surgical approach for internal fixation of displaced proximal humeral fractures is still being debated. Questions/purposes In this prospective randomized study, we aimed to investigate whether the deltoid-split approach is superior to the deltopectoral approach with regard to (1) complication rate; (2) shoulder function (Constant score); and (3) pain (visual analog scale [VAS]) for internal fixation of displaced humeral fractures with a polyaxial locking plate. Methods We randomized 120 patients with proximal humeral fractures to receive one of these two approaches (60 patients for each approach). We prospectively documented demographic and perioperative data (sex, age, fracture type, hospital stay, operation time, and fluoroscopy time) as well as complications. Followup examinations were conducted at 6 weeks, 6 months, and 12 months postoperatively, including radiological and clinical evaluations (Constant score, activities of daily living, and pain [VAS]). Baseline and perioperative data were comparable for both approaches. The sample size was chosen to provide 80% power, but it reached only 68% as a result of the loss of followups to detect a 10-point difference on the Constant score, which we considered the minimum clinically important difference. Results Complications or reoperations between the approaches were not different. Eight patients in the deltoid-split group (14%) needed surgical revisions compared with seven patients in the deltopectoral group (13%; p = 1.00). Deltoid-split and deltopectoral approaches showed similar Constant scores 12 months postoperatively (Deltoid-split 81; 95% confidence interval [CI], 74–87 versus deltopectoral 73; 95% CI, 64–81; p = 0.13), and there were no differences between the groups in terms of pain at 1 year (deltoid-split 1.8; 95% CI, 1.2–1.4 versus deltopectoral 2.5; 95% CI, 1.7–3.2; p = 0.14). No learning-curve effects were noted; fluoroscopy use during surgery and function and pain scores during followups were similar among the first 30 patients and the next 30 patients treated in each group. Conclusions The treatment of proximal humeral fractures with a polyaxial locking plate is reliable using both approaches. For a definitive recommendation for one of these approaches, further studies with appropriate sample size are necessary. Level of Evidence Level II, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The purpose of this single-center, randomized, controlled trial was to report on the 2-year outcomes of proximal humerus fractures in elderly patients treated with open reduction and internal fixation (ORIF) with either a locking plate or shoulder hemiarthroplasty. Thirty-two patients (87% women) with a mean age of 71.9 years (range, 67–86 years) were treated with ORIF with either a locking plate or shoulder hemiarthroplasty after shoulder injury. The main outcome measures were the Constant score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and health-related quality of life (HRQoL) according to the EQ-5D (EuroQol Group, Rotterdam, The Netherlands). At final 2-year follow-up, DASH and pain scores favored the shoulder hemiarthroplasty group. Mean flexion was 129° in the shoulder hemiarthroplasty group and 117° in the ORIF group (Thirty-two patients (87% women) with a mean age of 71.9 years (range, 67–86 years) were treated with ORIF with either a locking plate or shoulder hemiarthroplasty after shoulder injury. The main outcome measures were the Constant score, Disabilities of the Arm, Shoulder and Hand (DASH) score, and health-related quality of life (HRQoL) according to the EQ-5D (EuroQol Group, Rotterdam, The Netherlands). At final 2-year follow-up, DASH and pain scores favored the shoulder hemiarthroplasty group. Mean flexion was 129° in the shoulder hemiarthroplasty group and 117° in the ORIF group ( P =.27), and mean abduction was 123° in the shoulder hemiarthroplasty group and 111° in the ORIF group ( P =.41). In the shoulder hemiarthroplasty group, the EQ-5D index score decreased from 0.85±0.21 before injury to 0.65±0.14 at 4 months postoperatively. The score was 0.79±0.24 at 12 months postoperatively and 0.81±0.17 at 24 months postoperatively. The results of this study indicate an advantage in functional outcomes and HRQoL favoring shoulder hemiarthroplasty compared with ORIF with a locking plate, although most outcomes were not significantly different.

Background Proximal humeral fractures are common in older patients. The majority are minimally displaced and are associated with good outcomes after nonoperative treatment. Poorer outcomes are associated with displaced, multipart fractures. There is no clear benefit from surgical fracture fixation compared to nonoperative treatment. Replacement of the fractured humeral head with a hemiarthroplasty is another treatment option, but has not been shown to be clearly superior to nonoperative treatment or internal fixation. Recently, reverse total shoulder arthroplasty has been used to treat these fractures, particularly in the older population with several case series demonstrating good outcomes. No comparative trial has been performed to test the effectiveness of reverse total shoulder arthroplasty against nonoperative treatment. Methods/design ReShAPE (Reverse Shoulder Arthroplasty for the treatment of Proximal humeral fractures in the Elderly) is a multicenter combined randomized and observational study. The primary objective is to compare pain and function 12 months post fracture using the American Shoulder and Elbow Society (ASES) score in patients aged 70 years or older with three- and four-part proximal humeral fractures treated by either reverse shoulder arthroplasty or nonoperative treatment. Secondary outcome measures will include the DASH (Disability of the Arm, Shoulder and Hand) score, the EQ-5D (EuroQol Health Survey), the EQ-VAS, pain, radiological parameters and complications. Discussion The study will assess the effectiveness of reverse shoulder arthroplasty for complex proximal humeral fractures and thereby guide treatment of a common injury in the older population. Trial registration World Health Organization Universal Trial Number (WHO UTN): U1111-1180-5452 . Registered on 10 March 2016. Australian and New Zealand Clinical Trials Registry (ANZCTR): 12616000345482 . Registered on 16 March 2016.

Background Surgeon and patient treatment preferences are important threats to the internal and external validity of surgical trials such as PROFHER, which compared surgical versus non-surgical treatment for displaced fractures of the proximal humerus in adults. We explored the treatment preferences expressed by surgeons and patients in the trial and how these impacted on patient selection, trial conduct and patient outcome. Methods A series of exploratory secondary analyses of the PROFHER trial data were undertaken. We reviewed the extent of surgeon and patient treatment preferences (surgery or not surgery) at screening ( n  = 1250) as well as prior preference (including no preference) of randomised patients ( n  = 250), and assessed their impact on recruitment and adherence to follow-up and rehabilitation. Changes in treatment after 2 years’ follow-up were explored. Patient preference and characteristics associated with trial inclusion or treatment preference ( t test, chi-squared test, Wilcoxon rank-sum test) were included as treatment interaction terms in the primary trial analysis of shoulder functioning (Oxford Shoulder Score, OSS). Results Surgeons excluded 17% of otherwise eligible patients based on lack of equipoise; these patients had less complex fractures ( p  < 0.001) and tended to be older ( p  = 0.062). Surgeons were more likely to recommend surgery for patients under 65 years of age ( p  = 0.059) and who had injured their right shoulder ( p  = 0.052). Over half of eligible patients (56%) did not consent to take part in the trial; these patients tended to be older ( p  = 0.022), with a preference for not surgery (74%; which was associated with older age, p  = 0.039). There were no differential treatment effects ( p value of interaction) for shoulder functioning (OSS) based on subgroups of patient preference ( p  = 0.751), age group ( p  = 0.264), fracture type ( p  = 0.954) and shoulder dominance ( p  = 0.850). Patients who were randomised to their preferred treatment had better follow-up rates (94 vs 84% at 2 years) and treatment adherence (90 vs 83% reported completing home exercises). Patients who were not randomised to their preferred treatment were more likely to change their treatment preference at 24 months (60 vs 26%). Conclusions The robustness of the PROFHER trial findings was confirmed against possible bias introduced by surgeon and patient preferences. The importance of collecting preference data is highlighted. Trial registration ISRCTN50850043 . Registered on 25 March 2008.

Background Proximal humerus fracture is the third most common fracture type after hip and distal radius fracture in elderly patients. A comprehensive study by Palvanen et al . demonstrated an increase in the annual fracture rate of 13.7% per year over the past 33 years. Should this trend continue, the fracture rate would triple over the next three decades. The increasing incidence of low-energy fractures raises questions about the optimal treatment in terms of functional outcome, pain, and rehabilitation time, as well as the economical impact. Despite the high incidence and costs of proximal humerus fractures, there is currently no valid scientific evidence for the best treatment method. Several publications, including a Cochrane review outline the need for high-quality, well-designed randomized controlled trials. Methods/Design The study is a prospective, randomized, national multi-center trial. The hypothesis of the trial is that surgical treatment of displaced proximal humerus fractures achieves better functional outcome, pain relief, and patient satisfaction compared to conservative treatment. The trial is designed to compare conservative and surgical treatment of proximal humerus fractures in patients 60 years and older. The trial includes two strata. Stratum I compares surgical treatment with locking plates to conservative treatment for two-part fractures. Stratum II compares multi-fragmented fractures, including three- and four-part fractures. The aim of Stratum II is to compare conservative treatment, surgical treatment with the Philos locking plate, and hemiarthroplasty with an Epoca prosthesis. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score and the secondary outcome measures will be the EuroQol-5D (EQ-5D) value, OSS, Constant-Murley Score, VAS, and 15D. Recruiting time will be 3 years. The results will be analyzed after the 2-year follow-up period. Discussion This publication presents a prospective, randomized, national multi-center trial. It gives details of patient flow, randomization, aftercare and also ways of analysis of the material and ways to present and publish the results. Trial registration ClinicalTrials.gov identifier: NCT01246167

Background Proximal humeral fractures, which occur mainly in older adults, account for approximately 4 to 5% of all fractures. Approximately 40% of these fractures are displaced fractures involving the surgical neck. Management of this group of fractures is often challenging and the outcome is frequently unsatisfactory. In particular it is not clear whether surgery gives better outcomes than non-surgical management. Currently there is much variation in the use of surgery and a lack of good quality evidence to inform this decision. Methods/Design We aim to undertake a pragmatic UK-based multi-centre randomised controlled trial evaluating the effectiveness and cost-effectiveness of surgical versus standard non-surgical treatment for adults with an acute closed displaced fracture of the proximal humerus with involvement of the surgical neck. The choice of surgical intervention is left to the surgeon, who must use techniques that they are fully experienced with. This will avoid 'learning curve' problems. We will promote good standards of non-surgical care, similarly insisting on care-provider competence, and emphasize the need for comparable provision of rehabilitation for both groups of patients. We aim to recruit 250 patients from a minimum of 18 NHS trauma centres throughout the UK. These patients will be followed-up for 2 years. The primary outcome is the Oxford Shoulder Score, which will be collected via questionnaires completed by the trial participants at 6, 12 and 24 months. This is a 12-item condition-specific questionnaire providing a total score based on the person's subjective assessment of pain and activities of daily living impairment. We will also collect data for other outcomes, including general health measures and complications, and for an economic evaluation. Additionally, we plan a systematic collection of reasons for non-inclusion of eligible patients who were not recruited into the trial, and their baseline characteristics, treatment preferences and intended treatment. Discussion This article presents the protocol for a multi-centre randomised controlled trial. It gives extensive details of, and the basis for, the chosen methods, and describes the key measures taken to avoid bias and to ensure validity. Trial Registration Current Controlled Trials ISRCTN50850043

Background Proximal humeral fractures are common in older people, often resulting in pain and reduced shoulder range of motion, which impacts daily activities. Although early exercises are recommended to improve function, reliable methods for assessing shoulder range of motion in the early post-fracture phase are lacking. This study aimed to develop a method for measuring shoulder flexion early after non-surgically treated proximal humeral fractures and to assess its test-retest reliability. Methods The novel Table Slide Shoulder Flexion test was piloted on 17 individuals, among them physiotherapists providing feedback. Within-day test-retest reliability was assessed by a single tester using an electronic goniometer. Shoulder flexion was measured in 37 patients (mean age 62 years, 86% women) with non-surgically treated proximal humeral fractures, 1–9 weeks post-injury. The goniometer was placed both in high-thoracic and mid-thoracic positions for reliability comparisons. Intraclass correlation coefficients (ICC) and Minimal Detectable Change (MDC) were calculated. Results The method was deemed unsuitable for two patients, and one dropped out. In the remaining 34, ICC (2,1) reached 0.932 for the high-thoracic goniometer position and 0.926 for the mid-thoracic position when performing two table slides, with both values increasing further when three repetitions were performed. High-thoracic measurements slightly outperformed mid-thoracic measurements, achieving a MDC of 19° at the third repetition, compared to 20° for the third mid-thoracic repetition. Measured high-thoracic shoulder flexion ranged from 58–178°. Conclusion The novel Table Slide Shoulder Flexion test is a reliable tool for measuring shoulder flexion in the early phase after proximal humeral fractures. It may be useful for tracking individual changes over time and as an outcome measure in group comparisons research. Further studies are needed to investigate its intertester reliability, responsiveness, and validity.

Background The demographic change in Germany leads to an increased number of centenarians. Within this population fragility fractures, such as the proximal humeral fracture (PHF), are not well investigated. This study aims to evaluate the epidemiology, treatment and outcome after a PHF in patients ≥ 100 years of age in Germany. Methods Retrospective claims data of the BARMER health insurance were analyzed. All in- and outpatient cases of insurance holders ≥ 65 years from 01/2011 to 09/2022, with coded diagnosis of PHF were analyzed. The patients aged 65–99 years were used as a comparison group for the centenarians. Primary endpoints were overall survival, major adverse events (MAEs) and thrombo-embolic events. Results In total, 100,482 patients with PHF were included in the study, with 230 aged 100 years and older. Centenarians with a PHF were more often female with several age-associated comorbidities, but less life-style associated risk factors. Centenarians were less often treated surgically. The outcome after PHF was worse with increasing age, 59.2% of the centenarians died one year after the PHF. Conclusion The majority of centenarians sustaining a proximal humeral fracture was female. The most common treatment was the non-operative therapy. Nevertheless, also the operative therapy is associated with a low complication rate. As expected, the mortality rate is high, with almost 60% of deceased patients after one year. It remains unclear, if the mortality was related to proximal humeral fractures. Level of evidence Level III, retrospective comparative study.

Posterior shoulder fracture–dislocation is a rare injury accounting for approximately 0.9 % of shoulder fracture–dislocations. Impression fractures of the articular surface of the humeral head, followed by humeral neck fractures and fractures of the lesser and grater tuberosity, are the more common associated fractures. Multiple mechanisms have been implicated in the etiology of this traumatic entity most commonly resulting from forced muscle contraction as in epileptic seizures, electric shock or electroconvulsive therapy, major trauma such as motor vehicle accidents or other injuries involving axial loading of the arm, in an adducted, flexed and internally rotated position. Despite its’ scarce appearance in daily clinical practice, posterior shoulder dislocation is of significant diagnostic and therapeutic interest because of its predilection for age groups of high functional demands (35–55 years old), in addition to high incidence of missed initial diagnosis ranging up to 79 % in some studies. Several treatment options have also been proposed to address this type of injury, ranging from non-surgical methods to humeral head reconstruction procedures or arthroplasty with no clear consensus over definitive treatment guidelines, reflecting the complexity of this injury in addition to the limited evidence provided by the literature. To enhance the literature, this article aims to present the current concepts for the diagnosis, evaluation and treatment of the patients with posterior fracture–dislocation shoulder, and to present a treatment algorithm based on the literature review and our own experience.