Quadruple Disruption of Superior Shoulder Suspensory Complex With Proximal Humerus Open Fracture-Dislocation: A Case Report.

CASE: A 34-year-old man was a restrained passenger involved in a high-speed rollover motor vehicle crash. The patient sustained a type 5 AC joint separation, severely comminuted intra-articular glenoid fracture with extension to the coracoid process base, displaced open scapular body fracture, a posterior shoulder dislocation of the glenohumeral joint, and a 2-part proximal humerus fracture. CONCLUSION: To our knowledge, this is the first report describing this injury pattern involving the superior shoulder suspensory complex with an associated open proximal humerus fracture-dislocation.

Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis.

BACKGROUND: This systemic review and meta-analysis aimed to evaluate the clinical outcomes of proximal humeral fracture in elderly patient fixation using locked plate with or without cement augmentation. METHODS: The databases of PubMed, Embase, and Cochrane Library were searched in August 2023 for literature comparing the clinical outcomes of patients with PHFs treated with locked plate alone and locked plate augmented with cement. Data describing study design; level of evidence; inclusion criteria; demographic information; final follow-up; revision rate; implant failure rate; avascular necrosis rate; total complication rate; constant score; and disability of arm, shoulder, and hand (DASH) score were collected. RESULTS: Eight studies (one randomized-controlled trial and seven observational studies), involving 664 patients, were identified. Compared with locked plates alone, using cement-augmented locked plates reduced the implant failure rate (odds ratio (OR) = 0.19; 95% confidence interval (CI) 0.10-0.39; P < 0.0001) and total complication rate (OR = 0.45; 95% CI 0.29-0.69; P = 0.0002) and improved DASH scores (mean difference (MD) = 2.99; 95% CI 1.00-4.98; P = 0.003). However, there was no significant difference in clinical outcomes, including revision rate, avascular necrosis rate, and constant score. CONCLUSION: In this review and meta-analysis, fixation of the PHFs in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. Good results are expected for most patients treated with this technique. TRIAL REGISTRATION: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)21 guidelines were followed to conduct this systematic review and meta-analysis and was registered as a protocol in PROSPERO (CRD42022318798).

Early functional improvements using continuous passive motion therapy after angular-stable plate osteosynthesis of proximal humerus fractures - results of a prospective, randomized trial.

BACKGROUND: The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures. METHODS: 95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up. RESULTS: The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences. CONCLUSION: The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis. TRIAL REGISTRATION: The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS: gov ) registry under NCT05952622.

Factors influencing shoulder stiffness after open reduction and internal fixation of proximal humeral fractures.

OBJECTIVES: The study aimed to investigate the factors associated with shoulder stiffness following open reduction and internal fixation (ORIF) of proximal humeral fractures. PATIENTS AND METHODS: The retrospective study included a total of 151 patients who underwent ORIF of proximal humeral fractures between January 2016 and May 2021. Based on their shoulder joint motion at the latest follow-up, the patients were divided into two groups. The stiffness group (n=32; 8 males, 24 females; mean age: 62.4±9.3 years; range, 31 to 79 years), exhibited restricted shoulder forward flexion (<120°), limited arm lateral external rotation (<30°), and reduced back internal rotation below the L3 level. The remaining patients were included in the non-stiffness group (n=119; 52 males, 67 females; mean age: 56.4±13.4 years; range, 18 to 90 years). Various factors were examined to evaluate the association with shoulder stiffness following ORIF of proximal humeral fractures by multivariate unconditional logistic regression models. RESULTS: The mean follow-up duration was 31.8±12.6 (range, 12 to 68) months. Based on the results of the multivariate regression analysis, it was found that high-energy injuries [compared to low-energy injuries; adjusted odds ratio (aOR)=7.706, 95% confidence interval (CI): 3.564-15.579, p<0.001], a time from injury to surgery longer than one week (compared to a time from injury to surgery equal to or less than one week; aOR=5.275, 95% CI: 1.7321-9.472, p=0.031), and a body mass index (BMI) >24.0 kg/m2 (compared to a BMI between 18.5 and 24.0 kg/m2 ; aOR=4.427, 95% CI: 1.671-11.722, p=0.023) were identified as risk factors for shoulder stiffness following ORIF of proximal humeral fractures. CONCLUSION: High-energy injury, time from injury to surgery longer than one week, and BMI >24.0 kg/m2 were identified as independent risk factors for shoulder stiffness after proximal humeral fracture surgery, which should be treated with caution in clinical treatment.

[Bilateral Dorsal Fracture-Dislocation of the Proximal Humerus]. / Bilaterálna dorzálna luxacná zlomenina proximálneho humeru.

Fractures of the proximal humerus constitute approximately 5% of all fractures. Shoulder joint injuries without any external mechanical impact during seizures with the occurrence of spasms occur only sporadically. The occurrence rate is reported in approximately 0.4% of patients. Very rarely they occur in the form of epileptic seizure-induced dorsal fracturedislocation impacting both sides. The case report describes a case of a 48-year-old woman with no treatment for epileptic seizures in her medical history. During the first seizure she sustained a bilateral dorsal fracture-dislocation caused by a muscle spasm, without any other mechanical impact. The fractures were classified as a 3-fragment fracture on the right side and a 4-fragment fracture on the left side. After the patient's admission to the inpatient emergency department, reduction under anaesthesia was attempted. Subsequently, after preparation, open reduction and osteosynthesis using an angularly stable plate were performed as a two-stage surgery. No complications were observed postoperatively Currently, at 3 years after surgeries, the female patient has full mobility of her shoulder joints with no subjective difficulties. Key words: epilepsy, seizure, dorsal fracture-dislocation of the proximal humerus.

Acute-on-Chronic Axillary Artery Thrombus After Reverse Total Shoulder Arthroplasty for Failed Proximal Humerus Open Reduction and Internal Fixation: A Case Report.

CASE: A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus. CONCLUSION: Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.

Scapula fractures: functional anatomy, clinical assessment and management.

Fractures of the scapula are rare injuries, accounting for 3-5% of all shoulder girdle fractures. They are frequently the result of high energy trauma and often present with concurrent and life-threatening injuries to adjacent structures, leading to significant morbidity and mortality. Patients presenting with scapula fractures must receive a thorough and systematic clinical assessment as directed by national trauma guidelines. Appropriate imaging is essential in delineating fracture morphology and should at the very least include anteroposterior, anteroposterior oblique (Grashey) and axillary or scapula 'Y' view of the shoulder. Computed tomography imaging with three-dimensional reconstruction allows better delineation of the fracture morphology and helps with surgical planning. A lack of randomised controlled trials comparing the efficacy of conservative and operative management of scapula fractures has resulted in limited consensus for surgical indications. Nevertheless, most extra-articular fractures can be managed conservatively while intra-articular fractures of the glenoid frequently require surgical fixation.

Factors affecting hospital admission, hospital length of stay and new discharge destination post proximal humeral fracture: a retrospective audit.

BACKGROUND: Outcomes following proximal humeral fracture (PHF) may be impacted by a range of clinical, fracture and premorbid factors. The aim of this study was to examine factors impacting hospital admission; length of stay (LOS) and new discharge destination for patients presenting to hospital with PHF. METHODS: Retrospective audit conducted at a tertiary health service. Data was collected from adult patients presenting to hospital with a PHF over a 54-month period. Fractures that were pathological or sustained during admission were excluded. Univariable and multivariable logistic and negative binomial regression were used to explore factors associated with hospital admission, LOS and new discharge destination. RESULTS: Data were analyzed from 701 participants (age 70 years (IQR 60, 81); 72.8% female); 276 (39.4%) participants required a hospital admission. New discharge destination was required for 109 (15.5%) participants, of whom 49 (45%) changed from home alone to home with family/friend(s). Greater comorbidities, as indicated by the Charlson Comorbidity Index score, were associated with hospital admission, longer LOS and new discharge destination. Premorbid living situations of home with family/friend(s) or from an external care facility were associated with a decreased likelihood of hospital admission, shorter LOS and reduced risk of a new discharge destination. Surgical treatment was associated with shorter LOS. Older age and dementia diagnosis were associated with a new discharge destination. CONCLUSIONS: Many factors potentially impact on the likelihood or risk of hospitalization, LOS and new discharge destination post PHF. Patients with greater comorbidities are more likely to have negative outcomes, while patients who had premorbid living situations of home with family/friend(s) or from an external care facility are more likely to have positive outcomes. Early identification of factors that may impact patient outcomes may assist timely decision making in hospital settings. Further research should focus on developing tools to predict hospital outcomes in the PHF population.

Clinical outcomes of conservative versus surgical treatment for patients with proximal humeral fracture before physiotherapy.

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.

Converting to reverse shoulder arthroplasty from primary anatomic shoulder arthroplasty and fracture hemiarthroplasty: a radiographic and clinical outcome analysis at 8-years.

INTRODUCTION: Revision shoulder arthroplasty can be challenging. One of the main considerations for surgeons is the type of implant that was placed in the initial surgery. Anatomic shoulder arthroplasty (ASA) is used for cases of osteoarthritis as well as for fractures of the humeral head. Hemiarthroplasty can be used for complex proximal humerus fractures. The purpose of this study is to determine whether there is a difference in clinical and radiographic outcomes between patients that failed primary fracture hemiarthroplasty (FHA), or ASA for osteoarthritis and then required reoperation with a conversion to reverse shoulder arthroplasty (RSA). METHODS: Patients with failed anatomic shoulder replacement, who had undergone conversion to RSA, were enrolled after a mean follow-up of 107 (85-157) months. Two different groups, one with failed ASA implanted for osteoarthritis and one with failed FHA, were created. At follow-up patients were assessed with standard radiographs and clinical outcome scores. RESULTS: Twenty-nine patients (f = 17, m = 12; 51%) suffered from a failed ASA (Group A), while the remaining 28 patients (f = 21, m = 74; 49%) had been revised due to a failed FHA (Group B). Patients of Group B had a poorer Constant score (Group A: 60 vs. Group B: 46; p = 0.02). Abduction (Group A: 115° vs. Group B: 89°; p = 0.02) was worse after conversion of a failed FHA to RSA in comparison to conversions of failed ASA. The mean bone loss of the lateral metaphysis was higher in patients with failed FHA (Group A: 5 mm vs. Group B: 20 mm; p = 0.0). CONCLUSION: The initial indication for anatomic shoulder arthroplasty influences the clinical and radiological outcome after conversion to RSA. Conversion of failed FHA to RSA is related to an increased metaphyseal bone loss, decreased range of motion and poorer clinical outcomes when compared to conversions of failed ASA implanted for osteoarthritis. LEVEL OF EVIDENCE: III Retrospective Cohort Comparison Study.

[Reverse Shoulder Arthroplasty - Current Concepts]. / Inverse Schulterendoprothetik ­ aktueller Stand.

Due to first promising long term outcome data, reverse shoulder arthroplasty experienced an immense increase of usage during the past decade. Moreover, the initial Grammont concept has constantly been refined and adapted to current scientific findings. Therefore, clinical and radiological problems like scapular notching and postoperative instability were constantly addressed but do still remain an area of concern.This article summarises current concepts in reverse shoulder arthroplasty and gives an overview of actual indications like cuff tear arthropathy, severe osteoarthritis, proximal humerus fractures, tumours, fracture sequelae as well as revision surgery and their corresponding clinical and radiological results.

Primary stability in locking plate fixation for proximal humeral fractures may be increased by using an additional nail osteosynthesis in combination with locking plate osteosynthesis-A biomechanical comparison.

BACKGROUND: Stability is regarded as an important factor for proper healing and avoiding secondary dislocation in osteoporotic fractures of the proximal humerus. Several surgical techniques have been proposed for treatment, including intramedullary nail osteosynthesis and locking plate fixation. This study introduces a novel approach that combines both techniques and compares its primary stability with conventional methods. METHODS: The study involved 25 osteoporotic humeri with two-part fracture models, which were randomly assigned to locking-plate fixation, intramedullary nailing, or a combination of both techniques. The specimens were subjected to sinusoidal loading at 250 N in 20° abduction for 5000 cycles and then to quasi-static loading until failure. Fracture movement, failure mode, and failure load were measured and compared among the groups. FINDINGS: The groups fixated with intramedullary nailing and the groups fixated with intramedullary nailing and locking plate fixation showed significantly lower fracture motion than the group using locking plate fixation only (p < 0.005) and significantly higher load to failure (p = 0.007 and p = 0.0062, respectively). There was no significant difference between the group using intramedullary nailing and the group using locking-plate fixation and intramedullary nailing in fracture movement or load-to-failure (p > 0.005). INTERPRETATION: The results indicate that locking plate fixation provides less primary stability than intramedullary nailing or the combined of both techniques. This combined approach may offer advantages as a treatment for complex proximal humeral fractures in osteoporotic bone, and specific implants should be developed to ensure optimal treatment.

[Clinical effect of allogeneic peroneal bone marrow support combined with plate fixation for the treatment of Neer type â £ proximal humeral fractures].

OBJECTIVE: To explore clinical effect of allogeneic peroneal bone marrow support combined with plate internal fixation in treating Neer type Ⅳproximal humeral fractures. METHODS: From December 2017 to December 2020,12 patients with Neer type Ⅳ proximal humeral fractures were treated with allogeneic peroneal bone marrow support combined with plate internal fixation,including 7 males and 5 females,aged from 56 to 78 years old;the time from injury to operation ranged from 1 to7 days. Operative time,fracture healing time and complications during follow-up were observed,and clinical efficacy was evaluated by Constant-Murley score at the latest follow-up. RESULTS: All patients were obtained follow up for 20 to 29 months. All patients got bone healing and incisicons were healed at stageⅠ,operative time ranged from 95 to 138 min,blood loss ranged from 210 to 275 ml,fracture healing time ranged from 14 to 18 weeks. Two patients occurred postoperative shoulder stiffness and recovered after 2 weeks of passive exercise. There were no complications such as infection,poor wound healing,and failure (fracture and loosening) of internal fixators occurred. Constant-Murley shoulder function score ranged from 69 to 89 at the latest follow up,2 patients got excellent results,9 good and 1 fair. CONCLUSION: The application of allogeneic fibular bone marrow placement could provide effective support for medial humerus,which is conducive to assisting reduction of fracture end,reducing occurrence of internal fixation failure caused by collapse of humerus head and screw perforation,and significantly improving function of shoulder joint.

Conservative treatment of 3- and 4-part proximal humeral fractures: Can poor outcomes be predicted?

PURPOSE: 3- and 4-part proximal humeral fractures are frequently treated conservatively. This study aims to combine radiographic, and patient reported outcome data to identify factors leading to poor outcomes following conservative treatment. METHODS: A retrospective local database analysis identified 3- and 4-part fractures. Radiographic and functional outcomes including Oxford Shoulder Score (OSS), QuickDash (QD), Subjective Shoulder Score (SSV) and VAS pain scores were collected. RESULTS: 104 patients were included at mean follow-up of 55 months. Analysis highlighted significant OSS differences in 3- versus 4-part (p = 0.027), dominant arm injury (p = 0.046), age > 65 (p = 0.006), varus coronal neck-shaft angle < 115 versus 115-155 degrees (p = 0.008), posterior head tilt > 155 degrees (p = 0.005), greater tuberosity (GT) displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.032). According to QD scores; age > 65 (p = 0.012), varus neck-shaft angle (p = 0.01), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.01), medial calcar hinge displacement > 2 mm (p = 0.006). SSV varied significantly with 3- versus 4-part fractures (p = 0.005), age > 65 (p = 0.04), varus neck-shaft angle (p = 0.001), posterior head tilt (p = 0.005), GT displacement > 5 mm (p = 0.001), GT comminution (p = 0.003), and medial calcar hinge displacement > 2 mm (p = 0.001). CONCLUSION: We highlight risk factors for unfavourable outcomes following conservative management, aiding surgeons in shared decision-making and patient expectation management.

Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients.

INTRODUCTION: The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. MATERIALS AND METHODS: We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. RESULTS: Mean follow-up time was 17.3 months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. CONCLUSIONS: Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Three-dimensional printed models can reduce costs and surgical time for complex proximal humeral fractures: preoperative planning, patient satisfaction, and improved resident skills.

BACKGROUND: Proximal humeral fractures (PHFs) are still controversial with regards to treatment and are difficult to classify. The study's objective is to show that preoperative planning performed while handling a three-dimensional (3D) printed anatomical model of the fracture can ensure a better understanding of trauma for both surgeons and patients. MATERIALS AND METHODS: Twenty patients (group A, cases) with complex PHF were evaluated preoperatively by reproducing life-size, full-touch 3D anatomical models. Intraoperative blood loss, radiographic controls, duration of surgery, and clinical outcomes of patients in group A were compared with 20 patients (group B, controls) who underwent standard preoperative evaluation. Additionally, senior surgeons and residents, as well as group A patients, answered a questionnaire to evaluate innovative preoperative planning and patient compliance. Cost analysis was evaluated. RESULTS: Intraoperative radiography controls and length of operation were significantly shorter in group A. There were no differences in clinical outcomes or blood loss. Patients claim a better understanding of the trauma suffered and the proposed treatment. Surgeons assert that the planning of the definitive operation with 3D models has had a good impact. The development of this tool has been well received by the residents. The surgery was reduced in length by 15%, resulting in savings of about EUR 400 for each intervention. CONCLUSIONS: Fewer intraoperative radiography checks, shorter surgeries, and better patient compliance reduce radiation exposure for patients and healthcare staff, enhance surgical outcomes while reducing expenses, and lower the risk of medicolegal claims. LEVEL OF EVIDENCE: Level I, prospective randomized case-control study.

Outcomes of proximal humerus fractures in children: a retrospective cohort study.

OBJECTIVE: Paediatric proximal humerus fractures (PHFs) have historically been treated non-operatively. However, the management of severely displaced PHFs in older children has been debated over the years, with contemporary studies advocating for surgery. The purpose of this study was to review the outcomes of a cohort of paediatric patients treated for a PHF to guide management of future paediatric PHFs. METHODS: The records of the Women's and Children's Hospital in South Australia were reviewed to identify paediatric PHFs occurring between 1 January 2010 and 1 June 2020. Participants completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), the Shoulder Pain and Disability Index, and the Paediatric Outcomes Data Collection Instrument via phone interview. Participants' shoulder range-of-motion was assessed via telehealth using Zoom. Multivariable logistic regression was used to identify patient and clinical variables that were associated with a poorer outcome. RESULTS: Of 307 patients contacted, 125 participated. Forty-six patients met the definition of a poorer clinical outcome, defined as a QuickDASH score of ≥2. Fractures of greater severity were predictive of a poorer outcome, and patients aged ≥12 years old at the time of injury had higher total QuickDASH scores. The findings did not suggest that these subgroups of patients have superior outcomes if treated surgically. CONCLUSION: The majority of paediatric PHFs have an acceptable clinical outcome, irrespective of treatment methodology. Multicentre prospective studies are required to establish the indications for surgery for adolescent patients with severely displaced PHFs.

Physiotherapist-supervised exercises versus unsupervised home-based exercises after nonsurgically treated proximal humerus fracture: a multicenter randomized controlled trial.

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 nonsurgically, 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 were superior to 10 weeks of unsupervised home-based exercises in older adults with a nonsurgically treated displaced 2-part PHF. METHODS: This was designed as an assessor-blinded, prospective, randomized controlled trial and took place in 3 Nordic countries. In total, 72 patients (≥60 years) with nonsurgically treated displaced 2-part PHF were randomized to either physiotherapist-supervised exercises once a week for 10 weeks, combined with daily home-based exercises, or to 10 weeks of daily unsupervised 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 72 years. At 3 months follow-up, the mean DASH score in the supervised group was 25.9 (SD 16.0) compared to 22.4 (SD 18.9) in the unsupervised 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 3 in the unsupervised 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 unsupervised home-based exercises in improving functional outcome or health-related quality of life in older patients with a nonsurgically treated 2-part PHF. Further, our results suggest that most older adults with a nonsurgically treated 2-part PHF can perform home-based exercises without the supervision of a physiotherapist.

Does interferential current provide additional benefit to orthopedic rehabilitation for the patients with proximal humeral fractures? A randomized controlled study.

BACKGROUND: Approximately 80% of all proximal humeral fractures (PHFs) are non-displaced or minimally displaced fractures, which can be treated with conservative treatment. This study investigated the effect of interferential current (IFC) added to orthopedic rehabilitation on shoulder function, pain, and disability in patients with PHF. METHODS: This study was a prospective, double-blind, randomized, placebo-controlled conducted in physical medicine and rehabilitation outpatient clinic. Thirty-five patients were randomly separated into the IFC group (n = 18) and the sham group (n = 17). The orthopedic rehabilitation program was applied to all patients by the same physiotherapist three times a week for four weeks. Patients in the IFC group received the intervention for 20 minutes 3 times a week before the exercise. The same pads were performed for the sham group, but no electrical stimulation was applied. Constant-Murley score (CMS) for shoulder function, visual analog scale (VAS) activity pain, disabilities of the arm, shoulder, and hand (DASH) score, and paracetamol intake were recorded post-treatment, at 6 weeks and 18 weeks post-treatment. RESULTS: The demographic and fracture characteristics were not different between the groups. Significant differences were observed in the IFC and sham group in intragroup comparisons of total CMS, VAS activity pain, DASH score, and paracetamol intake over time (p < 0.001). Significant improvement over time was valid for all pairwise comparisons in both groups. However, no significant differences were detected between the IFC and sham group. CONCLUSION: IFC added to orthopedic rehabilitation could not appear to be an electrotherapy modality that could potentially benefit shoulder function and disability in patients with PHF.