Management Of Proximal Humerus Fractures Research Articles

Trends in the surgical management of proximal humerus fractures in Ireland from 2009 to 2022: An increasing usage of reverse shoulder arthroplasty.

Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients. The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13years. A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes. Demographic details remained stable with females and those within the 55-69year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed. There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel.

MELD score predicts short-term outcomes after surgical management of proximal humerus fractures: a matched analysis.

We aimed to evaluate the difference in 30-day outcomes after surgical management of proximal humerus fractures (PHFs) between patients with and without chronic liver disease as defined by a MELD score greater than 10. This was a retrospective database review. All centers participating in the American College of Surgeons National Surgical Quality Improvement Program database were included. Patients with proximal humerus fractures who (1) underwent ORIF, HA, or SA and (2) had calculable MELD scores were included. Open reduction and internal fixation, hemiarthroplasty, or shoulder arthroplasty was used for treatment. Thirty-day complications, mortality, readmission, and reoperation rates were measured. Of the total 1732 PHF patients identified, 300 had a MELD score higher than 10. After propensity matching by significant covariates, MELD score higher than 10 was found to be significantly associated with higher rates of 30-day mortality, 30-day readmission, transfusion within 72 hours, and systemic complications. Among patients with a MELD score higher than 10, treatment with SA or HA instead of ORIF was associated with a higher rate of transfusion and longer operative time. There were no significant differences between treatment cohorts regarding mortality, reoperation, readmission, or complications. A MELD score higher than 10 is associated with higher risk of surgical complications, transfusion, and death in patients undergoing surgery for proximal humerus fractures. Among patients with a MELD score higher than 10, ORIF was associated with a lower transfusion rate and shorter operative time than arthroplasty or hemiarthroplasty. Prognostic Level III.

Arthroscopic Lysis of Adhesions for Stiffness After Surgical Management of Proximal Humerus Fractures Leads to Satisfactory Outcomes in Most Patients

To report patient-reported outcomes (PROs), range of motion (ROM), and satisfaction, in patients who underwent arthroscopic lysis of adhesions for stiffness after open reduction with internal fixation (ORIF) or reverse shoulder arthroplasty (RSA) for fracture. A retrospective review was performed to identify patients with stiffness who underwent arthroscopic lysis of adhesions following ORIF or RSA for proximal humerus fracture at a single institution between 2012 and 2021 with minimum 1-year follow-up. PROs including visual analog scale for pain (VAS), American Shoulder and Elbow Surgeons (ASES), and Subjective Shoulder Value (SSV), as well as active ROM including forward flexion (FF), external rotation (ER), internal rotation (IR), were collected pre- and postoperatively. Attempted nonoperative treatment before arthroscopic lysis of adhesions was documented. Complications and satisfaction were also recorded. A total of 21 patients met the study criteria (4 RSA, 17 ORIF), with an average age of 66.7 ± 8 years. The study sample comprised mostly of female patients (90%). The mean time from the index surgery to arthroscopy was 9 months, and mean follow-up post-lysis was 17 months. Patients with ORIF reported significant pain relief (VAS, Δ -3.2) and improvement in range of motion (FF, Δ 36°; ER, Δ 20°; IR Δ 3 spinal levels) and PROs (ASES, Δ 34.7; SSV Δ 44.8) (P < .01) after lysis. Patients with RSA had significant improvement in ASES (Δ 21.8; P= .04), SSV (Δ 8.8; P= .04), and FF (Δ38; P= .02) but did not have significant improvement in VAS (Δ -2; P= .2), ER (Δ 0°; P= 1.0), and IR (Δ 1 spinal level; P= .2). Satisfaction was 100% in the RSA cohort and 82% in the ORIF cohort. No complications were observed. Arthroscopic lysis of adhesions for stiffness after surgical management of proximal humerus fracture leads to satisfactory outcomes in most patients. Post-ORIF, patients may achieve improvement in PROs and global ROM, whereas post-RSA, patients may achieve improvement in PROs and FF but do not necessarily improve in rotational ROM. Level IV, therapeutic case series.

Geriatric proximal humerus fracture operative management: a Truven Health Analytics database study (2015-2020)

The purpose of this study is to assess the trends in operative management of geriatric (≥65 years) proximal humerus fractures during a six-year period (2015-2020) within an insurance claims database. This retrospective database cohort study utilized data gathered from the 2015-2020 IBM Truven MarketScan Commercial and IBM Truven MarketScan Medicare Supplemental databases. The ICD10 data was correlated to the CPT code for shoulder arthroplasty [proximal humeral prosthetic replacement (23616), shoulder hemiarthroplasty (HA)(23470), reverse total shoulder arthroplasty (rTSA)(23472)] or open reduction internal fixation (ORIF) [open treatment of proximal humerus fracture with internal fixation (23615), open treatment of proximal humerus fracture-dislocation with internal fixation (23680)] We investigated the number of proximal humerus fracture operative cases per year, percent arthroplasty used per year, rTSA and HA per year, hospital cost information as well as percent arthroplasty per US geographic region. A total of 8,057 operative proximal humerus fractures cases were identified in 7,697 patients over 65 years of age, with 0.45% (360/8,057) being bilateral. There was a 40.8 % decrease in the rate of operative management of proximal humerus fractures between the first half (2015-2017, 1687.3 +/- 146.6) and second half of the study period (2018-2020, 998.3 +/- 258.7). Arthroplasty accounted for 78.7% of all surgeries, and 91% of those being rTSA. The total number of cases, rTSA and ORIF performed decreased per year (p=.01). The downward trend of percent ORIF per year approached significance (p=.054). Arthroplasty was a more expensive payment for total case option by almost $850.00 (p=.001). There was a larger percentage of arthroplasty performed in the Northeast, and North central US geographic regions. Despite the rise of both the elderly population and related geriatric proximal humerus fractures, there were less operatively represented in this insurance claims database across the six-year period. There may be a trend to utilize less ORIF when addressing these fractures. Although it incurred a higher in-hospital cost, Arthroplasty was being performed at a higher percentage in the Northeast, and North central regions of the United States.

Evaluation of effectiveness of locking compression plates in internal fixation of proximal humerus fractures: a prospective study

Introduction: Locking compression plate (LCP) provides significant biological and biomechanical advantages in the management of proximal humerus fracture (PHF) by providing greater stability, vascular preservation, superior healing, and fewer complications. However, the translation of these properties to functional benefits for patients remains to be elucidated. The objective of the study was to evaluate the effectiveness of LCP in internal fixation of PHF in terms of rate of healing and functional outcomes. Method: This prospective study enrolled 30 Proximal Humerus Fracture patients aged &gt;18 years, from both genders, and treated them with LCP. They were followed up regularly for 1 year and assessed clinically and radiologically using Neer’s criteria and Constant-Murray score. Results were analysed using Chi-square test, p≤0.05 indicated statistical significance. Result: With a mean age of 45.20±15.02 y and M:F ratio of 2.3:1, most patients showed right-sided injuries 18(60%) and Neer 4-part injuries 13(43.33%), predominantly due to road traffic accidents 19(60%), with a satisfactory Neer’s score 26(86.67%) and a good Constant-Murray score 16(53.33%).  The mode of injury showed significant association with age (p=0.013) but not with gender (p=0.866). Over follow up, 27(90%) patients maintained humeral head height and 24(80%) patients showed good humeral neck-shaft angle. Radiological union of PHF took 12 weeks in 12(43.33%) of patients with no dislocation in 27(90%) of patients. However, 1(3.3%) patient showed no union. Conclusion: LCP is associated with favorable clinical, functional and radiological outcomes in PHF patients by providing rapid healing and good rigidity, angular stability, and torsional strength.

Plate Fixation of Proximal Humerus Fractures: How to Get It Right and Future Directions for Improvement.

Open reduction and internal fixation with locking plates (ORIF-LP) has been used for decades for the surgical management of proximal humerus fractures. Despite good outcomes have been widely published in the literature, unacceptably high rates of complications (up to 40%), many of them yielding poor outcomes and requiring reoperation (up to 25%), have also been reported, especially in elderly patients. Most common complications are related to implant failure, with intra-articular screw penetration as the most frequent and devastating. Advances in patient selection and surgical technique, and implementation of bone or cement augmentation, have been developed to hopefully decrease complication rates. Mayo-FJD Classification offers prognostic information that can aid in the decision-making process for proximal humeral fractures. Displaced valgus impacted fractures seem to be associated with well over a 10% rate of avascular necrosis after ORIF-LP. A principle-based and stepwise surgical technique combining anatomic reduction and a short screw configuration can provide good outcome in most patients, even the elderly, decreasing implant failures to less than 10%. Acrylic cement augmentation has the potential to further decrease implant failure rate to 1%. Reoperation rates are higher partly due to the need to remove hardware for painful subacromial conflict. However, no studies to date definitively demonstrated the superiority of ORIF-LP compared to non-operative treatment, intramedullary nailing, or reverse shoulder arthroplasty. ORIF-LP can provide good results for the surgical management of displaced proximal humerus fractures even in elderly patients provided adequate patient selection and a principle based and stepwise surgical technique, supplemented with bone graft or acrylic cement when needed. Poor outcomes and high complication and reoperation rates should be expected when these recommendations are not followed.

Surgeon-specific factors have a larger impact on decision-making for the management of proximal humerus fractures than patient-specific factors: a prospective cohort study.

There is significant variability both in how proximal humerus fractures (PHFs) are treated and the ensuing patient outcomes. The purpose of this study was to investigate which surgeon- and patient-specific factors contribute to decision-making in the treatment of adult PHFs. We hypothesized that orthopedic sub-specialty training creates inherent bias and plays an important role in management algorithms for PHFs. We performed a prospective cohort investigation in 2 groups of surgeons-traumatologists (N=25) and shoulder & elbow/sports surgeons (SES) (N=26)-and asked them to provide treatment recommendations for 30 distinct clinical cases with standardized radiographic and clinical data. This is a population-based sample of surgeons who take trauma call and treat PHFs with different sub-specializations and practice settings including academic, hospital-employed, and private. Surgeons characterized based on subspecialty (trauma vs. SES), experience level (>10 vs. ≤10-years), and employment type (hospital- vs. non-hospital-employed). Chi-square analyses, logistic mixed-effects modeling, and relative importance analysis were used to evaluate the data. Of the patient-specific factors, we found that the management of PHFs is largely dependent on initial radiographs obtained. Traumatologists were more likely to offer open reduction internal fixation (ORIF) and less likely to offer arthroplasty: 69% ORIF (traumatologists) vs. 51% ORIF (SES, P<.001), 8% arthroplasty (traumatologists) vs. 17% (SES, P<.001). Traumatologists were less likely to change from operative (either ORIF or arthroplasty) to non-operative management compared to SES surgeons when presented with additional patient demographic data. Surgeon-specific factors contributed to more than one-half of the variability in decision-making of PHF management while patient-specific factors contributed to about one-third of the variability in decision-making. As physicians strive to advance the treatment for PHFs and optimize patient outcomes, our findings highlight the complex overlap between surgeon-, fracture-, and patient-specific factors in the final decision-making process.

Comparing Race/Ethnicity and Zip Code Socioeconomic Status for Surgical versus Nonsurgical Management of Proximal Humerus Fractures in a Medicare Population.

This study evaluated the effect of race/ethnicity and socioeconomic status (SES) on surgical utilization after proximal humerus fractures in a large Medicare cohort. The PearlDiver Medicare claims database was used to identify patients aged 65years and older with isolated, closed proximal humerus fractures, for whom race/ethnicity data were available (65.5% of identified fractures). Patients with polytrauma or neoplasm were excluded. Patient demographic, race/ethnicity, comorbidity, and median household income were compared for surgical versus nonsurgical management. Univariate and multivariable logistic regressions were used to determine disparities of surgical utilization based on the abovementioned factors. Of 133,218 patients with proximal humerus fracture identified, surgery was conducted for 4446 (3.3%). Those less likely to receive surgery were older (incrementally by increasing age bracket up to 85 years and older odds ratio [OR], 0.16, P < 0.001), male (OR, 0.79, P < 0.001), Black (OR, 0.51, P < 0.001) or Hispanic (0.61, P = 0.005), higher Elixhauser Comorbidity Index (per 2 increase OR, 0.86, P < 0.001), and low median household income (OR, 0.79, P < 0.001). The independent significance of race/ethnicity and SES point to disparities in surgical decision making/access to care. These findings highlight the need for increased attention on initiatives and policies that seek to eliminate racial disparities and improve health equity independent of SES.

A study on the functional and radiological outcome with complications in the management of proximal humerus fractures operated with proximal humerus internal locking osteosynthesis system

Background: A number of opinions exist regarding the management of proximal humerus fractures starting from conservative to tension band-wiring to internal fixation with plates. The aim of this study is to assess the functional outcome, the radiological outcome and the complications associated with the management of proximal humerus fractures treated with proximal humerus interlocking osteosynthesis system (PHILOS). Methods: A prospective descriptive study was undertaken comprising of 40 patients. Closed proximal humerus fractures meeting Neer’s criteria for operative displacement were enrolled. Patients underwent open reduction internal fixation with PHILOS plate. Post-operative radiological outcome was estimated with follow-up x-rays, functional outcome using the Constant and Murley score. Results: 60% patients were female, with the most common mode of injury being fall at a ground level. Late complications were noted in 25% of patients, which were malunion 5%, joint stiffness 10%, joint instability 5% and heterotopic ossification 5%. The mean Constant and Murley score was 79.5 and it was found to be statistically significant to the type of fracture according to the Neer’s classification (Kruskal Wallis test, p=0.005). Joint stiffness was also found to be statistically significantly correlated to the type of fracture pattern (Chi square test, p=0.016). The average time to union was 10 weeks. Conclusions: Thus, by this study it can be expressed due to appropriate articular reduction by open reduction and by the use of a fixed angle implant like the PHILOS plate, operative management of proximal humerus fractures by the said implant is a viable option to enable quick and early rehabilitation of patients.

A PROSPECTIVE OBSERVATIONAL STUDY ON FUNCTIONAL OUTCOME OF PROXIMAL HUMERUS FRACTURES FIXED SURGICALLY WITH PHILOS

Proximal humerus fractures are common injuries that can result in signicant functional disability. The use of the PHILOS plate in surgical management of these fractures has gained popularity due to its ease of use and favourable biomechanical properties. This paper aims to assess the functional outcomes of surgical management of proximal humerus fractures xed with the PHILOS plate. The methodology involved studying patient demographics, fracture classication, surgical technique, postoperative protocol, and complications. The study found that surgical management of proximal humerus fractures with the PHILOS plate results in good functional outcomes, with a low complication rate.

Early rehabilitation after reverse total shoulder prosthesis on fracture of proximal humerus in elderly patients provides better functional outcome.

Reverse total shoulder arthroplasty (RSA) has revolutionized the management of proximal humerus fractures (PHF) in the elderly patients. There is few or no consensus regarding to management of postoperative rehabilitation in elderly patients. An early rehabilitation from D1 allowed better functional results compared to rehabilitation started to D30 independently from tuberosities consolidation. 94 patients operated on for PHF were evaluated retrospectively, with a minimum radio-clinical follow-up of 2years. Clinical evaluation included mobilities and four functional scores: ASES, quick DASH, gross constant, weighted constant. Radiological evaluation was performed on a frontal shoulder X-ray with evaluation of tuberosities' consolidation. The mean follow-up was 45 ± 19months (24-88months). Early rehabilitation was significantly associated with a better Constant Score (71.1 ± 17.2 vs. 56.4 ± 15.8; p < 0.001), better adjusted Constant score (92.4 ± 14.2 vs. 80.3 ± 19.5; p < 0.001), better quick DASH (22.8 ± 19.8 vs. 36.7 ± 21.3; p < 0.01), better ASES (78.6 ± 20.2 vs. 63 ± 22; p < 0.001). In traumatology, functional result of RSA seems not related in tuberosities' union but in rehabilitation in order to limit postoperative stiffness of operated shoulder. An early rehabilitation is related with better clinical and functional results, independently of tuberosities' union. 3, control-case study.

Study of Functional Outcome of Surgical Management of Proximal Humerus Fractures in a Tertiary Care Hospital

Study of Functional Outcome of Surgical Management of Proximal Humerus Fractures in a Tertiary Care Hospital

PROXIMAL HUMERUS FRACTURE DISLOCATIONS: OUTCOMES OF MANAGEMENT

Proximal humerus fracture dislocations are amongst the most severe proximal humerus injuries, presenting a challenging management problem. The aim of this study was to report on the long-term outcomes of the management of proximal humerus fracture dislocations.Patients with a proximal humerus fracture dislocation managed at a Level 1 trauma centre from January 2010 to December 2018 were included. Patients with an isolated tuberosity fracture dislocation or a pathological fracture were excluded. Outcome measures were the Oxford Shoulder Score (OSS), EQ-5D-5L, return to work, and radiological outcomes. Complications recorded included further surgery, loss of position/fixation, non-union/malunion, and avascular necrosis.A total of 69 patients were included with a proximal humerus fracture dislocation in the study period; 48 underwent surgical management and 21 were managed with closed reduction alone. The mean (SD) age of the cohort was 59.7 (±20.4), and 54% were male. Overall patients reported a mean OSS of 39.8 (±10.3), a mean EQ-5D utility score of 0.73 (±0.20), and 78% were able to return to work at a median of 1.2 months. There was a high prevalence of complications in both patients managed operatively or with closed reduction (25% and 38% respectively). In patients undergoing surgical management, 21% required subsequent surgery.Patient reported outcome measures post proximal humerus fracture dislocations do not return to normal population levels. These injuries are associated with a high prevalence of complications regardless of management. Appropriate patient counselling should be undertaken before embarking on definitive management.

The Utility of Routine Follow-up Radiographs in the Nonoperative Management of Proximal Humerus Fractures in Patients 65 Years and Older.

Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or peri-prosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [Orthopedics. 2023;46(4):e244-e248.].

Trends in the treatment of proximal humerus fractures in the United States Medicare population

BackgroundMany factors influence the decision-making in the treatment of proximal humerus fractures. With the increasing popularity of reverse shoulder arthroplasty (RSA), treatment strategies for proximal humerus fractures are evolving. The extent to which expanding indications for RSA has impacted the way surgeons treat these fractures is still under question. The purpose of the current study was to determine trends in the treatment of proximal humerus fractures in the United States Medicare population from 2010 to 2019. Materials and methodsThe Mariner subset of the PearlDiver database, a Health Insurance Portability and Accountability Act compliant national insurance database, was queried for Medicare patients who sustained a proximal humerus fracture from 2010 to 2019. Current Procedural Terminology and International Classification of Diseases codes were used to determine which patients were treated nonoperatively vs. operatively in the acute setting. Operative interventions included RSA, hemiarthroplasty, or open reduction internal fixation (ORIF). Poisson regression was used to detect the prevalence trends. Chi-square test was used to detect differences in operative treatment between 2010 and 2019. Descriptive statistics were calculated. Statistical significance was set at <0.05. ResultsIn the Medicare population queried, the prevalence of operative management of proximal humerus fractures remained largely unchanged (6.5% of all fractures treated operatively in 2010, compared to 6.3% of all fractures treated operatively in 2019; P = .64). The utilization of RSA for proximal humerus fractures increased substantially during the last decade (8.9% of operations in 2010, compared to 50.9% of operations in 2019; P ≤ .001). The utilization of hemiarthroplasty has continuously decreased (24.6% of operations in 2010, compared to 5.2% of operations in 2019; P ≤ .001). The utilization of ORIF for these fractures has also decreased during the last decade (69.2% of operations in 2010, compared to 47.7% of operations in 2019; P ≤ .001). ConclusionIn the Medicare population, there was no difference in the proportion of proximal humerus fractures treated operatively over the decade. The use of ORIF and hemiarthroplasty for proximal humerus fractures has declined significantly. More surgeons are utilizing RSA as a treatment for proximal humerus fractures in this patient population.

Short-Term Outcomes and Long-Term Implant Survival After Inpatient Surgical Management of Geriatric Proximal Humerus Fractures.

The most common surgical options for geriatric proximal humerus fractures are open reduction and internal fixation (ORIF), hemiarthroplasty (HA), and reverse total shoulder arthroplasty. We used a longitudinal inpatient discharge database to determine the cumulative incidence of conversion to arthroplasty after ORIF of geriatric proximal humerus fractures. The rates of short-term complications and all-cause reoperation were also compared. All patients 65 or older who sustained a proximal humerus fracture and underwent either ORIF, HA, or shoulder arthroplasty (SA) as an inpatient from 2000 through 2017 were identified. Survival analysis was performed with ORIF conversion to arthroplasty and all-cause reoperation as the endpoints of interest. Rates of 30-day readmission and short-term complications were compared. Trends in procedure choice and outcomes over the study period were analyzed. A total of 27 102 geriatric patients that underwent inpatient surgical management of proximal humerus fractures were identified. Among geriatric patients undergoing ORIF, the cumulative incidence of conversion to arthroplasty within 10 years was 8.2%. The 10-year cumulative incidence of all-cause reoperation was 12.1% for ORIF patients and less than 4% for both HA and SA patients. Female sex was associated with increased risk of ORIF conversion and younger age was associated with higher all-cause reoperation. ORIF was associated with higher 30-day readmission and short-term complication rates. Over the study period, the proportion of patients treated with ORIF or SA increased while the proportion of patients treated with HA decreased. Short-term complication rates were similar between arthroplasty and ORIF patients in the later cohort (2015-2017). The 10-year cumulative incidence of conversion to arthroplasty for geriatric patients undergoing proximal humerus ORIF as an inpatient was found to be 8.2%. All-cause reoperations, short-term complications, and 30-day readmissions were all significantly lower among patients undergoing arthroplasty, but the difference in complication rate between arthroplasty and ORIF was attenuated in more recent years. Younger age was a risk factor for reoperation and female sex was associated with increased risk of requiring conversion to arthroplasty after ORIF.

Has the ProFHER Trial Changed the Orthopaedic Surgeons' Decision Making and Treatment of Proximal Humeral Fractures?

To explore the impact of the ProFHER trial on initial decision making in the management of proximal humerus fractures at a district general hospital (DGH). Retrospective review of all proximal humerus fractures at a single DGH during 1 year before ProFHER (2014) and 1 year following publication (2018). Data related to demographics, fracture pattern, and management was collected from electronic patient records and analysed. 52 patients in 2014 and 70 patients in 2018 met the inclusion criteria. There was no significant difference in demographics or fracture classification. Fewer patients were admitted from Accident and Emergency in 2018 (44% vs 55%). Of patients admitted, there was no significant difference between the proportion referred to a shoulder surgeon (SS) (27.5% vs 30%). In patients seen initially in fracture clinic by a non-shoulder surgeon (NSS), significantly fewer were referred for a SS opinion in 2018 (6.7%) vs 2014 (50%). Computed tomography was requested in 5/52 cases (9.6%) in 2014 and 8/70 cases (11.4%) in 2018, all cases involved an SS. Significantly more patients (14/52, 27%) were managed surgically in 2014 compared to 2018 (10/70, 14%). All patients were discharged with the exception of 1 patient in each group who required later surgical intervention. 1. The widely disseminated ProFHER trial is likely to have influenced contemporary clinical practice. 2. This study shows non-shoulder specialists are more likely to manage these patients conservatively and without the involvement of shoulder surgeons post ProFHER. 3. This impact on clinical outcomes requires further research.

The N-brace trial: Does arm position during immobilisation of proximal humerus fractures influence outcome - A preliminary study.

Traditional initial management of proximal humerus fractures (PHF) involves arm immobilisation in a simple sling (SS) in an internally rotated position. We believe this risks fracture displacement and imbalance of soft tissues, encouraging malunion and stiffness. A neutral-rotation brace (NRB) maintains an arm position which may prevent this, leading to quicker and superior recovery. We randomised patients with two- to four-part PHF into 4 weeks of immobilisation with either a SS or NRB, independent of surgery. Range of motion (ROM), subjective shoulder value (SSV), DASH, Constant-Murley (CMS) and Oxford Shoulder (OSS) scores were assessed at 6-weeks, 3-months and 1-year post-injury. The SS group included 11 patients vs 9 in the NRB group. At final follow-up, the SS and NRB groups had mean DASH scores of 42 vs 35, OSS 42 vs 46, CMS 71 vs 86, SSV 84% vs 92%, respectively. ROM was superior with the NRB (elevation 159°, ER 47° and IR score 8 vs 140°, 37° and 7 with SS). Despite being a small series, our results demonstrate a trend towards NRB providing better outcomes. This feasibility study supports the need for a larger multi-centre randomised controlled trial comparing these immobilisation methods for PHF.

Hemiarthroplasty for proximal humerus fractures and for fracture sequelae: did not differ in their outcomes

The role of hemiarthroplasty (HA) in the management of proximal humerus fractures (PHFs) and their sequalae has evolved with the development of contemporary internal fixation techniques and the widespread use of the reverse total shoulder arthroplasty. However, HA may still have a role in certain acute PHFs as well as select fracture sequalae. The aim of this investigation was to evaluate the outcomes of HA when used in acute fractures and fracture sequelae. Over a 16-year period (2000 - 2016), 122 primary HA performed for either acute PHFs or fracture sequelae were identified. Of these, 70 (57.4%) HA were performed within 4 weeks of the injury, whereas 52 (42.6%) underwent HA for fracture nonunion, malunion, or avascular necrosis. The minimum follow-up period was 2 years. Outcomes included the visual analog scale for pain, range of motion, American Shoulder and Elbow Surgeons (ASES) score, complications, and reoperations inclusive of revision surgery. Cumulative incidence analysis was used to report implant survivorship with death as a competing risk. The mean follow-up time after HA was 4.8 years (range, 2-15 years) with no differences between groups (P=.102). Cohort comparisons demonstrated an older age (67.8 vs. 60.1; P=.004), lower rate of previous procedure (4.3% vs. 51.9%; P<.001), lower bone graft use (28.6% vs. 59.6%; P<.001), and a longer length of stay (5.9 vs. 3.0 days; P<.001) in the acute HA group. Additionally, no differences were observed between the acute and sequalae cohort in pain (2.0 vs. 2.5; P=.523), forward elevation (98° vs. 93°; P=.627), external rotation (30° vs. 23°; P=.215), internal rotation score (4.0 vs. 4.5; P=.589), satisfaction (P=.592), ASES scores (64.4 vs. 57.1; P=.168), complications (27.1% vs. 28.8%; P=.836), or reoperations (11.4% vs. 19.2%; P=.229). When comparing acute fractures and sequalae, the 15-year complication rates were 32.4% and 43.3%, respectively (P=.172), with 15-year reoperation rates of 13.7% and 24%, respectively (P=.098). HA, whether performed acutely for a PHF or in a delayed fashion for fracture sequalae, demonstrated no statistically significant differences in outcomes for all examined parameters. HA in this setting may provide reasonable pain relief. However, limited motion, marginal ASES scores, and elevated rates of complications and reoperations can be expected up to 15 years postoperatively.

Management of Proximal Humerus Fractures in Adults-A Scoping Review.

Proximal humerus fractures are the third most common fracture type in adults, with their incidence increasing over time. There are varied approaches to both the classification and treatment of proximal humerus fractures. Optimal treatments for this fracture type are still widely open to debate. This review summarizes the current and historical treatment modalities for proximal humerus fractures. In this paper, we provide updates on the advances and trends in the epidemiology, classification, and operative and nonoperative treatments of proximal humerus fractures.