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Proximal humerus fractures are a common fragility fracture that significantly affects the independence of older adults. The outcomes of these fractures are frequently disappointing and previous systematic reviews are unable to guide clinical practice. Through an integrated knowledge user collaboration, we sought to map the breadth of literature ava...
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... group of diverse participants is collectively described as the project's Knowledge Users because they are "individuals likely able to use the know- ledge generated through [this] research to make informed decisions about health policies, programs, and/or prac- tices" [11]. Using the scoping review framework pro- posed by Arksey and O'Malley [10], we adopted an integrated research process that ensured the knowledge users input throughout all six stages of the review's methodology (Figure 1). Understanding the current state of the proximal humerus fracture literature, in particular, areas for potential evidence-based recommendations and future research priorities, was defined as the primary purpose of the review. ...
Citations
... The acute treatment options for PHF are numerous and are typically guided by the fracture pattern and functional demands of the patients. The most commonly used methods are non-operative management with a sling or surgical fixation 3 . Although non-surgical treatment is a reasonable treatment option for the majority of humerus fractures, there is an increasing interest in surgical intervention 4 . ...
Fear of movement, pain, and loss of shoulder function are the most common problems irrespective of their approach to management after proximal humeral fracture (PHF). However, it has been unclear whether there could be differences between both treatments in early clinical outcomes. It can help physiotherapists to guide in choosing treatment approaches. This study aimed to compare kinesiophobia, pain, range of motion (ROM), shoulder function, and Quality of life (QoL) in patients treated with either conservative (CT) versus surgical (ST) after PHF. In addition, it aimed to determine correlations between fear of movement and seconder outcome measures. This cross-sectional study enrolled the patients having 5-6 weeks (being permitted active movement) after being treated either CT or ST and receiving no physical therapy. Pain, passive and active ROMs, shoulder function, fear of movement, and QoL were evaluated. 42 patients were recruited. Kinesiophobia scores were similar (p=0.55) and moderate in both groups. There was a significant difference in degrees of shoulder active flexion, active and passive abduction in favor of the CT group (p=0.05, p=0.02, p=0.04, respectively). However, there was no difference between groups regarding the remaining clinical outcomes. Furthermore, kinesiophobia showed a moderate negative correlation with energy/fatigue, social functioning, and general health. These findings showed that patients treated surgically did not have more kinesiophobia, less function, and QoL before starting physiotherapy, despite having soft tissue damage and different types of fractures. However, surgically treated patients had significantly less range of motion.
... 9,17,26 Nevertheless, the most beneficial nonsurgical treatment has yet to be thoroughly investigated 9,24 as only about 5% of the current literature regarding treatment after PHF investigates the nonsurgical treatment approach. 33 Thus, there is an urgent need for more high-quality evidence to support the planning of nonsurgical treatment strategies. ...
Background: Proximal humerus fracture (PHF) is a common fragility fracture in older adults and can have a substantial impact on upper limb function. Although most patients with PHF can be treated non-surgically, it is unknown whether older adults benefit from supervised exercise therapy after PHF. Therefore, the objective of this trial was to investigate whether 10 weeks of physiotherapist-supervised exercises once a week was superior to 10 weeks of non-supervised home-based exercises in older adults with a non-surgically treated displaced 2-part PHF.
Methods: This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in three Nordic countries. In total, 72 patients (≥60 years) with non-surgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks combined with daily home-based exercises were compared to 10 weeks of daily non-supervised home-based exercises. The primary outcome measure was the Disability of the Arm, Shoulder, and Hand (DASH) with a primary endpoint at 3 months. Secondary outcomes were DASH (at 12 months), Constant-Murley Score, the 15D-instrument, Visual Analog Scale, General Self-Efficacy Scale, and Pain Catastrophizing Scale, with follow-up visits after 3 and 12 months. Non-union and patient death within 3 months were counted as complications.
Results: The mean age of the patients in both groups was 73 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (18.9) in the non-supervised group. The mean between-group difference (3.5, 95% CI -5.0 to 12.5) was not clinically relevant. None of the secondary outcome measures presented any clinically relevant or statistically significant between-group differences at 3 or 12 months follow-up. One patient in the supervised group and three in the non-supervised group were diagnosed with non-union. One patient from each group died before 3 months follow-up.
Conclusions: This trial provides no evidence that supervised exercises are superior to non-supervised home-based exercises in improving functional outcome or quality of life in older patients with a non-surgically treated 2-part PHF. Further, our results suggest that most older adults with a non-surgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.
Keywords: Non-surgical; Proximal humerus fracture; Quality of life; Supervised exercise; Upper limb function.
... Ultimately, whichever management modality is chosen, treatment aims to facilitate return of upper limb function. This traditionally involves a comprehensive rehabilitation regime [7], beginning with immobilisation followed by exercises to maximise passive range of motion (PROM), active range of motion (AROM) and eventually progressive resistive/strengthening exercises [8][9][10]. Progression of therapy is prescribed by therapists in collaboration with surgeons, accounting for fracture healing/stability. ...
Introduction:
Proximal humeral fractures (PHFs) are 3rd commonest fragility fractures and cause significant functional impairment. This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance.
Methods:
Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported (Sport Injury Rehabilitation Adherence Scale [SIRAS]) and patient-reported (subjective compliance, frequency of exercise) rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables.
Results:
107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score (p = 0.023; 95%CI = 0.265,3.423), OSS (p = 0.038; 95%CI = 0.049,1.634), flexion ROM (p < 0.001; 95%CI = 2.872,8.982), extension ROM (p = 0.035; 95%CI = 0.097,2.614), abduction ROM (p = 0.002;95%CI = 1.995,8.466) and achievement of functional active ROM at 3-months (p = 0.049; 95%CI = 1.001,1.638). Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective (33.6% at 6-weeks, 24.3% at 3-months). Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001).
Conclusion:
Rehabilitation compliance predicts short-term clinical outcomes up to 3-months and potentially 1-year outcomes. Pain control should be optimised to maximise rehabilitation compliance and improve PHF outcomes. There is lack of consensus definition for rehabilitation compliance measures; patient-reported measures used have good correlation to existing validated measures and could serve as a steppingstone for further research.
Level of evidence:
II, cohort study.
... PHF account for approximately 5% of all fractures and occur most commonly in women [1]. Fractures are often caused by minimal trauma, such as a fall from standing height or less [2,3]. PHF can be divided into fractures through the tuberosities, metaphysis, surgical, and anatomical neck, in combination with a myriad of fragments. ...
In this study, we present a deep learning model for fracture classification on shoulder radiographs using a convolutional neural network (CNN). The primary aim was to evaluate the classification performance of the CNN for proximal humeral fractures (PHF) based on the AO/OTA classification system. Secondary objectives included evaluating the model's performance for diaphyseal humerus, clavicle, and scapula fractures. The training dataset consisted of 6,172 examinations, including 2-7 radiographs per examination. The overall area under the curve (AUC) for fracture classification was 0.89, indicating good performance. For PHF classification, 12 out of 16 classes achieved an AUC of 0.90 or greater. Additionally, the CNN model had excellent overall AUC for diaphyseal humerus fractures (0.97), clavicle fractures (0.96), and good AUC for scapula fractures (0.87). Despite the limitations of the study, such as the reliance on ground truth labels provided by students with limited radiographic assessment experience, our findings are in concordance with previous studies, further consolidating CNN as potent fracture classifiers in plain radiographs. The inclusion of multiple radiographs with different views from each examination, as well as the generally unselected nature of the sample, contributed to the overall generalizability of the study. This is the fifth study published by our group on AI in orthopaedic radiographs, which has consistently shown promising results. The next challenge for the orthopaedic research community will be to transfer these results from the research setting into clinical practice. External validation of the CNN model should be conducted in the future before it is considered for use in a clinical setting.
... Proximal humerus fracture (PHF) is ranked in the top three frequent upper extremity injuries. [1][2][3][4] PHF often causes prolonged disability and interferes with the capacity to do daily tasks and perform social roles independently. 4 PHF is highly prevalent in the 60+ years old population, with a woman-to-man ratio of 70:30. 5 Higher susceptibility of PHF in women may be attributed to the prevalence of osteoporosis. ...
Background:
Proximal humerus fracture (PHF) is a common upper extremity injury. PHF often causes prolonged disability and interferes with independent function.
Purpose:
This study reviewed and summarized prognostic factors of recovery following PHF and classified them within the International Classification of Functioning, Disability and Health (ICF) with each domain sub-categorized by modifiability.
Study design:
Systematic review.
Methods:
We searched MEDLINE, CINAHL, EMBASE, and PsychINFO from the date of database inception to March 2019 and updated searches in December 2021. Studies included examining an association between prognostic factors and recovery with at least a 6-month follow-up. Two independent reviewers used the Quality in Prognosis Studies tool for methodological bias and levels of evidence. Designs showed wide variability in terms of characteristics of the included population, definition of recovery, assessment of prognostic factors, and outcome measures used. This prevented pooled estimates from being produced. Prognostic factors linked to ICF domains were possible.
Results:
Twenty-three studies including 4323 participants aged ≥18 met inclusion criteria. The risk of bias was low (35%), moderate (30%), and high (35%) across the included studies. Moderate evidence showed a significant association between pre-fracture functional independence and post-fracture complications with recovery. Fracture type, structural deformity, medication use, age, and gender were prognostic factors with inconclusive evidence. We assigned a weak level of evidence to the remaining 20 factors due to limited data. Immediate rehabilitation, compliance to post-fracture rehabilitation exercise, task-oriented exercise, and pain self-efficacy (i.e., coping behavior) are modifiable and are tapped into the ICF contextual factors.
Conclusions:
An array of factors that fit within an ICF biopsychosocial framework have been investigated as potential mediators of outcomes after PHF. The evidence is incomplete conceptually and in terms of research design quality. Preoperative functional status is predictive of functional recovery emphasizing the importance of healthy aging.
... Proximale Humerusfrakturen gehören zu den dritthäufigsten osteoporotischen Verletzungen in Deutschland und stellen die zweithäufigste osteoporotische Verletzung der oberen Extremität dar [1][2][3]. ...
Background
Proximal humeral fractures are one of the three most common osteoporotic injuries with an increasing incidence. Treatment options are still controversially discussed. The aim of the study was to evaluate whether the trend towards nonoperative treatment is justified, and whether comparable, reproducible results can be achieved, especially for geriatric patients.Materials and methodsA retrospective single-center study included 128 patients with nonoperative and head-preserving surgery between 2012 and 2015 and 91 patients were available for follow-up. Demographic data, treatment protocol, and complications were investigated. Follow-up comprised the following: Subjective Shoulder Value (SSV), Visual Analog Scale (VAS), Disability of Arm, Shoulder and Hand Questionnaire (DASH), Constant Murley Score (CMS), and range of motion. A radiological analysis was also performed.ResultsThe following scores were obtained for nonoperative (VAS pain 8.9 points, CMS abs. 70.7 points, DASH: 16.5 points) and surgical treatment (VAS pain 1.7 points, CMS abs. 63.5 points, DASH: 24.2 points). There was no significant difference between nail or plate osteosynthesis. The overall complication rate was 20%. The nonoperative treatment group achieved a better range of motion. Dislocated fractures were worse, although not statistically different compared to Neer 1 fractures and only slightly worse than patients undergoing surgery.Conclusion
Individualized treatment of proximal humerus fractures must be made based on functional demand, age, and comorbidities. Despite clear indications for surgery, nonoperative treatment (especially for 2‑ and 3‑part fractures) can be at least considered an option, since comparable results with high patient satisfaction with reduced (perioperative) risks can be achieved.
... This is likely due to significant heterogeneity among studies of PHF patient cohorts (including patient age, fracture patterns, and fracture displacement) and treatment options making it difficult to transfer into clinical practice. Additionally, there is a disproportionate amount of literature focusing on surgical PHF management (85%) compared to the less than 5% on non-surgical PHF management [27]. Limited high-quality evidence is available, but there are several studies that demonstrate acceptable results with nonoperative management [28][29][30][31]. ...
PurposeThe objective of this study was to determine the underlying factors that drive the decision for surgeons to pursue operative versus nonoperative management for proximal humerus fractures (PHF) and if fellowship training had an impact on these decisions.Methods
An electronic survey was distributed to members of the Orthopaedic Trauma Association and the American Shoulder and Elbow Surgeons Society to assess differences in patient selection for operative versus nonoperative management of PHF. Descriptive statistics were reported for all respondents.ResultsA total of 250 fellowship trained Orthopaedic Surgeons responded to the online survey. A greater proportion of trauma surgeons preferred nonoperative management for displaced PHF fractures in patients over the age of 70. Operative management was preferred for older patients with fracture dislocations (98%), limited humeral head bone subchondral bone (78%), and intraarticular head split (79%). Similar proportions of trauma surgeons and shoulder surgeons cited that acquiring a CT was crucial to distinguish between operative and nonoperative management.Conclusion
We found that surgeons base their decisions on when to operate primarily on patient’s comorbidities, age, and the amount of fracture displacement when treating younger patients. Further, we found a greater proportion of trauma surgeons elected to proceed with nonoperative management in patients older than the age of 70 years old as compared to shoulder surgeons.
... Capability and comfort do not correspond with alignment of a healed, nonoperatively treated PHF. 24 Instead, the evidence points to variation in mindset, such feelings of worry or despair, and unhelpful thoughts such as worst case thinking and fear of painful movement. 4,10, 13 We were interested in the association of social factors such as in-home caregivers and assisted living with capability and comfort, based on the rationale that an association could inform the development of care strategies. ...
Background
Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year.
Methods
One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index.
Results
Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: −5.02 [95% CI: −9.96 to −0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: −4.07 [95% CI: −6.62 to −1.53]; P = .002 and coef: −0.18 [95% CI: −0.29 to −0.07]; P = .001 respectively) or living in an assisted care facility (coef: −14.82 [95% CI: −22.24 to −7.39]; P < .001 and coef: −0.59 [95% CI: −0.90 to −0.29] P < .001).
Conclusions
The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.
... Further, patients were significantly more likely to undergo a reverse total shoulder arthroplasty (OR = 22.65) compared to total shoulder arthroplasty, ORIF, closed reduction percutaneous pinning, hemiarthroplasty, and intramedullary nailing in 2019 compared to 2010 [14]. However, these trends are not reflected in the literature as more than 70% of publications on PHF deal with surgical treatment modalities (out of which only approximately 3% constitute randomised clinical trials), whereas less than 5% consider non-surgical management [15]. ...
Proximal humerus fracture (PHF) treatment remains challenging. Multiple therapy options exist, and the optimal choice of management has been increasingly discussed in the literature. The aim of this study was to (1) analyze trends in the propensity of proximal humerus fracture treatments and (2) compare complication rates after joint replacement, surgical repair, and non-surgical treatment in terms of mechanical complications, union failure, and infection rates. In this cross-sectional study, patients aged 65 years or older with proximal humerus fractures occurring between 1 January 2009 and 31 December 2019 were identified from Medicare physician service claims records. The Kaplan-Meier method with the Fine and Gray adjustment was used to calculate the cumulative incidence rates for malunion/nonunion, infection, and mechanical complications for the following treatment categories: shoulder arthroplasty, open reduction and internal fixation (ORIF), and non-surgical treatment, respectively. Semiparametric Cox regression was performed incorporating 23 demographic, clinical, and socioeconomic covariates to determine risk factors. Between 2009 through 2019, conservative procedures decreased by 0.9%. ORIF procedures decreased from 9.51% (95% CI: 8.7-10.4) to 6.95% (95% CI: 6.2-7.7), whereas shoulder arthroplasties rose from 1.99% (95% CI: 1.6-2.4), to 5.45% (95% CI: 4.8-6.2). PHFs managed through ORIF were associated with higher union failure rates compared to conservatively treated fractures (HR = 1.31, 95% CI: 1.15-1.5, p < 0.001). The risk of developing an infection was increased after joint replacement compared to ORIF (2.66% vs. 1.09%, HR = 2.09, 95% CI: 1.46-2.98, p < 0.001). Mechanical complications were more common after joint replacement (6.37% vs. 4.85%, HR = 1.66, 95% CI: 1.32-2.09, p < 0.001). Complication rates differed significantly across treatment modalities. This should be considered when choosing a management procedure. Vulnerable elderly patient cohorts could be identified, and the optimization of modifiable risk factors might lead to a decrease of complication rates in both surgically and non-surgically treated patients.
... трАВмАтОЛОгИЯ И ОртОпЕДИЯ рОССИИ / TrAUmAToLogy AND orThopEDICS of rUSSIA ВВеДение Переломы проксимального отдела плечевой кости (ПОПК) составляют около 6% всех переломов, а пик заболеваемости приходится на возрастную группу от 60 до 90 лет [1]. У пациентов старше 65 лет они находятся на третьем месте по частоте после повреждений критических зон остеопороза [2]. ...
... Рассматриваются современные способы стимуляции репаративных процессов, которые наиболее доступны для реализации в многопрофильном стационаре. Использование свободных губчатых костных аутотрансплантатов из крыла подвздошной кости рассматривается исключительно для замещения дефектов ПОПК, возникающих вследствие смятия остеопорозной кости в момент травмы [1]. Данный вариант костной пластики является оптимальным по многим параметрам, включающим отсутствие иммунного ответа, наличие живых остеогенных клеток. ...
Introduction. To date, the proposed directions of osteosynthesis of intra-articular fractures of the butt (bone osteosynthesis with LCP plates, intramedullary osteosynthesis PHN) do not reduce the risk of ANGPC and do not reduce the number of non-joints; with the accumulation of information on the results of hemi- and total endoprosthetics of the shoulder joint, an increasing number of complications specific to this method and a small patient satisfaction are revealed. In this regard, there is a need to use the method of osteosynthesis with an element of stimulation of reparative osteogenesis for the prevention of ischemic changes in the head of the humerus. Goal. To improve the results of surgical treatment of intra-articular fractures of the proximal humerus on the basis of the development of a new technique of osteosynthesis using reparative stimulation with a non-free musculoskeletal graft from the cranial process of the scapula.Material and methods. The material for the study was the analysis of the results of treatment of 67 cases of patients with intra-articular fractures of the proximal humerus of categories 11-C1 and 11-C2. In the databases of electronic information resources PubMed, eLibrary, the analysis of literary data on search words was carried out. Results. According to the data obtained during the study, the functional results of the group of patients operated using the method of reparative stimulation with a non-free musculoskeletal graft from the cranial process of the scapula are statistically higher than the results of the control group. Taking into account the peculiarities of the blood supply of the POPC, indications for the types of osteosynthesis of intra-articular fractures (bone osteosynthesis or bone osteosynthesis with transplantation of NCMT from the cranial process of the scapula) were established. Conclusion. In the treatment of intra-articular fractures of the proximal humerus, the operative method of bone osteosynthesis is preferred. The use of autoplasty with a non-free musculoskeletal graft from the cranial process of the scapula reduces the risk of developing post-traumatic aseptic necrosis of the head.
