Cochrane in CORR ®: Interventions for Treating Proximal Humeral Fractures in Adults (Review)

Importance of the Topic Proximal humeral fractures are common fractures that account for 6% of all adult fractures [4] with an overall incidence of 19 per 100,000 [8]. Neer estimated that approximately 85% of all proximal humeral fractures were undisplaced, [10] but others have found proportions to be much lower [12]. Proximal humeral fractures are typical osteoporotic fractures, with women about three to four times more often affected than men, and older patients some 16 times more likely to experience this injury than younger patients [8]. They are the third most common fracture in elderly patients after hip and wrist fractures [4]. There is a rise in the incidence of proximal humeral fractures during the last 40 years [8, 11]. The introduction of locking-plate technology in 2002 and reverse shoulder arthroplasty in 2006 for proximal humeral fractures led to a relative increase of surgical treatment of up to 40% [1, 8], but this trend in practice was not supported by high quality evidence. The number of displaced fracture fragments and patient age are the most important factors that influence decision-making and long-term clinical outcomes, but there is considerable variation in current clinical practice. This systematic review and meta-analysis compared surgical versus conservative treatment, different methods of surgical treatment, different methods of conservative treatment (including rehabilitation), and different methods of rehabilitation after surgical treatment for proximal humeral fractures in adults. Upon Closer Inspection This meta-analysis is a comprehensive update of a prior Cochrane review that was conducted in 2001. Although seven higher quality trials were added, the major limitation of this review is still the size of the trials included, each varying from only 20 patients to 86 patients. Small clinical trials are at risk of producing misleading or erroneous findings due to low numbers of outcome events and consequent statistical fragility. Likewise, each of the included trials was a single-center study, which may pose problems for generalizability across varying populations. There was also limited or incomplete blinding in all included studies. Although patients undergoing some surgical interventions cannot always be blinded, it is often still possible to blind independent outcome assessors, healthcare providers, and data analysts. The authors pooled the functional outcomes scores across six trials (n = 270) that compared surgical treatment versus conservative treatment, but the trials used several different functional outcome instruments. In order to combine the data, all of the scores were converted to a standardized measure of effect called the standardized mean difference (SMD). SMDs are calculated by dividing the mean difference in scores between the two treatment groups on a particular scale by the estimated between-participants standard deviation (SD) for each trial. Unfortunately, most clinicians are not familiar with interpreting results presented in SD units, and the SDs can be under or overestimated in the presence of substantial between-study heterogeneity [7]. Authors of meta-analyses can aid the interpretation of SMD treatment effects by converting SMD scores back to a familiar scale or comparing them to a known Minimally Important Difference [7], but neither approach was incorporated in this meta-analysis. Take-Home Messages This Cochrane study showed no difference between surgical and conservative treatment of complex and/or proximal humeral fractures. Neither one specific method of surgical management is clearly superior to another. There is insufficient high-quality evidence to guide the management of patients with proximal humeral fractures. Three additional small randomized controlled trials have been published since this review was updated [2, 3, 13], and recent meta-analyses suggest no benefit of surgical management in displaced three- and four-part proximal humeral fractures in elderly [6, 9]. However, there are currently at least 14 ongoing trials, of which five are large (up to 290 patients) multicenter trials and one is a single-center trial [5] comparing surgical versus conservative treatment in displaced proximal humeral fractures. The other ongoing trials are investigating a variety of surgical approaches, implant choices, and rehabilitation regimes. These randomized controlled trials may help us arrive at stronger recommendations to help guide the management of this challenging fracture type. In anticipation of these results, broad variation in treatment preference is still justified.

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