Restricted accessReview articleFirst published online 2024-10
How long is the arm immobilised after a conservatively managed displaced proximal humerus fracture and does early mobilisation effect complication rates: A systematic review
Conservative management of displaced proximal humerus fractures involves a period of rest in a sling followed by physiotherapy. The aim of this review is to provide a narrative synthesis of how long immobilisation is used, types of slings, when and how exercises are introduced, and if complications may be associated with these components.
Method
A systematic search of the literature was undertaken. Two researchers screened relevant articles using Covidence software, with a third reviewer consulted for consensus. Data was extracted and a narrative synthesis is presented.
Results
Thirty-nine studies were included (3059 studies screened, 159 full-text reviews). This included a cohort of 2664 patients with a mean age of 70.9. Time immobilised in sling ranged from 1 to 6 weeks. Sling types were variable and were grouped into low, medium and higher levels of support. Exercises were introduced at variable timescales tending to introduce passive and pendular exercises first. Complications were reported in 243 incidences (9.1%).
Discussion
There was vast variation in how long patients were immobilised for, types of slings used and when and how exercises were introduced and progressed. No relationship was found between complications and these components. Research to identify the most effective approach is required.
Court-BrownCMCaesarB. Epidemiology of adult fractures: a review. Injury2006; 37: 691–697.
2.
JohnellOKanisJA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int2006; 17: 1726–1733.
3.
NeerCS2. Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am1970; 52: 1077–1089.
4.
OstergaardHKMechlenburgILaunonenAP, et al.The benefits and harms of early mobilization and supervised exercise therapy after non-surgically treated proximal humerus or distal radius fracture: a systematic review and meta-analysis. Curr Rev Musculoskelet Med2021; 14: 107–129.
5.
AguadoHJArinoBMoreno-MateoF, et al.Does an early mobilization and immediate home-based self-therapy exercise program displace proximal humeral fractures in conservative treatment? Observational study. J Shoulder Elbow Surg2018; 27: 2021–2029.
6.
HandollHBrealeySRanganA, et al.The ProPHER (Proximal fracture of the humerus: evaluation by randomization) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess2015; 19: 1–280.
7.
Soler-PeiroMGarcia-MartinezLAguilellaL,et al.Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review. J Orthop Surg Res2020; 15: 347–347.
8.
GibsonJNHandollHHMadhokR. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev2002; 2: CD000434.
9.
HandollHHElliottJThillemannTM, et al.Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev2022; 2: CD000434.
10.
HandollHHGOllivereBJRollinsKE. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev2012; 12: CD000434.
11.
HandollHHKedingACorbachoB, et al.Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J2017; 99-B: 383–392.
12.
LiberatiAAltmanDGTetzlaffJ, et al.The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. Br Med J2009; 339: b2700.
13.
RethlefsenMLKirtleySWaffenschmidtS, et al.PRISMA-S: an extension to the PRISMA statement for reporting literature searches in systematic reviews. J Med Libr Assoc2021; 109: 174–200.
14.
Lefevre-ColauMMBabinetAFayadF, et al.Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. J Bone Joint Surg Am2007; 89: 2582–2590.
15.
MartínezRSantanaFPardoA,et al.One versus 3-week immobilization period for nonoperatively treated proximal humeral fractures: a prospective randomized trial. J Bone Joint Surg Am2021; 103: 1491–1498.
16.
ZytoKAhrengartLSperberA,et al.Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br1997; 79: 412–417.
17.
RanganAHandollHBrealeyS, et al.Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA2015; 313: 1037–1047.
18.
HandollHBrealeySRanganA, et al.The ProFHer (PROximal fracture of the humerus: evaluation by randomisation) trial - A pragmatic multicentre randomized controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adult. Health Technol Assess2015; 19: 1–280.
19.
FjalestadTHoleMHovdenIA, et al.Surgical treatment with an angular stable plate for complex displaced proximal humeral fractures in elderly patients: a randomized controlled trial. J Orthop Trauma2012; 26: 98–106.
20.
FjalestadTHoleMØ. Displaced proximal humeral fractures: operative versus non-operative treatment–a 2-year extension of a randomized controlled trial. Eur J Orthop Surg, Traumatol2014; 24: 1067–1073.
21.
BoonsHWGoosenJHvan GrinsvenS, et al.Hemiarthroplasty for humeral four-part fractures for patients 65 years and older: a randomized controlled trial. Clin Orthop Relat Res2012; 470: 3483–3491.
22.
GuzziniMLanzettiRMPrinciG, et al.Comparison between conservative and surgical treatment in proximal humeral fractures. A prospective randomized study with 5-years follow-up. Muscles, Ligaments Tendons J2021; 11: 240–245.
23.
LaunonenAPSumreinBOReitoA, et al.Operative versus non-operative treatment for 2-part proximal humerus fracture: a multicenter randomized controlled trial. Plos Med2019; 16: e1002855.
24.
LopizYAlcobía-DíazBGalán-OllerosM, et al.Reverse shoulder arthroplasty versus nonoperative treatment for 3- or 4-part proximal humeral fractures in elderly patients: a prospective randomized controlled trial. J Shoulder Elbow Surg2019; 28: 2259–2271.
25.
OlerudPAhrengartLPonzerS, et al.Hemiarthroplasty versus nonoperative treatment of displaced 4-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg2011; 20: 1025–1033.
26.
TorrensCCorralesMVilaG, et al.Functional and quality-of-life results of displaced and nondisplaced proximal humeral fractures treated conservatively. J Orthop Trauma2011; 25: 581–587.
27.
CanboraMKKoseOPolatA, et al.Relationship between the functional outcomes and radiological results of conservatively treated displaced proximal humerus fractures in the elderly: a prospective study. Int J Shoulder Surg2013; 7: 105–109.
28.
Vrancken PeetersMJTFDKasteleinGWBreslauPJ. Proximal humerus fractures: a prospective study of the functional outcome after conservative treatment. Eur J Trauma Emerg Surg2001; 27: 133–136.
29.
GoudieEBMacdonaldDJRobinsonCM. Functional outcome after nonoperative treatment of a proximal humeral fracture in adults. J Bone Joint Surg Am2022; 104: 123–138.
30.
SysonPABBonifacioLRLlanesJJD. Revisiting the outcome of displaced two-part fractures of the humeral neck in elderly patients after conservative treatment. Osteoporosis Int2013; 24: S608.
31.
ForuriaAMde GraciaMMLarsonDR, et al.The pattern of the fracture and displacement of the fragments predict the outcome in proximal humeral fractures. J Bone Joint Surg Br2011; 93: 378–386.
32.
Court-BrownCMGargAMcQueenMM. The translated two-part fracture of the proximal humerus. Epidemiology and outcome in the older patient. J Bone Joint Surg Br2001; 83: 799–804.
33.
EdelsonGSafuriHSalamiJ, et al.Natural history of complex fractures of the proximal humerus using a three-dimensional classification system. J Shoulder Elbow Surg2008; 17: 399–409.
34.
GeWSunQLiG, et al.Efficacy comparison of intramedullary nails, locking plates and conservative treatment for displaced proximal humeral fractures in the elderly. Clin Interv Aging2017; 12: 2047–2054.
35.
HansonBNeidenbachPde BoerP,et al.Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg2009; 18: 612–621.
36.
ShahaniMA. Functional outcomes of non-operative treatment in proximal humeral fracture of adults. Pak J Med Health Sci2022; 16: 360–362.
37.
LeyshonRL. Closed treatment of fractures of the proximal humerus. Acta Orthop Scand1984; 55: 48–51.
38.
CaliskanEDoganO. PHILOS plate versus nonoperative treatment in 2-, 3-, and 4-part proximal humeral fractures: comparison with healthy control subjects. J Orthop Surg (Hong Kong)2019; 27: 2309499019875169.
39.
Court-BrownCMCattermoleHMcQueenMM. Impacted valgus fractures (B1.1) of the proximal humerus. J Bone Joint Surg Br2002; 84: 504–508.
40.
LangeMBrandtDMittlmeierT,et al.Proximal humeral fractures: non-operative treatment versus intramedullary nailing in 2-, 3- and 4-part fractures. Injury2016; 47: S14–S19.
41.
PaceGZaleCChanJ, et al.Clinical results of conservative treatment of severe proximal humerus fractures requiring surgical treatment in old patients. Tech Shoulder Elb Surg2019; 20: 80–87.
42.
RobersonTAGranadeCMHuntQ, et al.Nonoperative management versus reverse shoulder arthroplasty for treatment of 3- and 4-part proximal humeral fractures in older adults. J Shoulder Elbow Surg2017; 26: 1017–1022.
43.
YukselHYYimazSAksahinE, et al.The results of nonoperative treatment for three- and four-part fractures of the proximal humerus in low-demand patients. J Orthop Trauma2011; 25: 588–595.
44.
TamimiIMontesaGColladoF, et al.Displaced proximal humeral fractures: when is surgery necessary?Injury2015; 46: 1921–1929.
45.
van den BroekCMvan den BesselaarMCoenenJMF,et al.Displaced proximal humeral fractures: intramedullary nailing versus conservative treatment. Arch Orthop Trauma Surg2007; 127: 459–463.
HauschildOKonradGAudigeL, et al.Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus. Arch Orthop Trauma Surg2013; 133: 1385–1393.
48.
InnocentiMCarulliCCivininiR, et al.Displaced fragility fractures of proximal humerus in elderly patients affected by severe comorbidities: percutaneous fixation and conservative treatment. Aging Clin Exp Res2013; 25: 447–452.
49.
UrgelliSCrainzEManiscalcoP. Conservative treatment vs prosthetic replacement surgery to treat 3- and 4-fragment fractures of the proximal epiphysis of humerus in the elderly patient. Chir Organi Mov2005; 90: 345–351.
50.
FjalestadTStromsoeKBlucherJ,et al.Fractures in the proximal humerus: functional outcome and evaluation of 70 patients treated in hospital. Arch Orthop Trauma Surg2005; 125: 310–316.
51.
ChivotMLamiDBizzozeroP, et al.Three- and four-part displaced proximal humeral fractures in patients older than 70 years: reverse shoulder arthroplasty or nonsurgical treatment?J Shoulder Elbow Surg2019; 28: 252–259.
52.
MarmorMTAgelJDumpeJ, et al.Comparison of the Neer classification to the 2018 update of the Orthopedic Trauma Association/AO fracture classification for classifying proximal humerus fractures. OTA Int2022; 5: e200.
53.
TejwaniNCLiporaceFWalshM, et al.Functional outcome following one-part proximal humeral fractures: a prospective study. J Shoulder Elbow Surg2008; 17: 216–219.
54.
BudharajuAHonesKMHaoKA, et al.Rehabilitation protocols in proximal humerus fracture management: a systematic review. Shoulder Elbow2023; 0(0).
55.
XuBAndersonDBEun-SunPA, et al.The influence of smoking and alcohol on bone healing: systematic review and meta-analysis of non-pathological fractures. EClinicalMedicine2021; 42: 101179.
56.
ChuaSKSohQYLimCJ, et al.Social determinants of outcomes in non-operatively treated proximal humerus fractures. JSES Int2023; 7: 743–750.
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