The displaced proximal humeral fracture: Is there evidence for therapeuticconcepts?

Introduction: There is no general agreement on the operative treatment of d isplaced proximal humeral fractures. While T-plate fixation was the method of choice until the end of the 1980s, minimally invasive techniques have be en favoured during the past decade. The indication for primary shoulder pro sthesis is controversial. The purpose of this report was to evaluate the sc ientific evidence of current treatment recommendations. Methods: Relevant a rticles were retrieved from "Medline" and "Knowledge-Finder" using the comb ined search strategy for the keywords "proximal humerus" and "fracture". Re trieved articles were evaluated according to the criteria of evidence-based medicine. Results: The analysis retrieved 3 randomized, 4 prospective, and 26 retrospective studies and a number of review articles relevant to the s ubject. Limitations of most publications were due to small study population s, differences in patient selection and fracture classification as well as measurements of outcome. According to these studies good functional results can be achieved in dislocated two-part fractures treated with minimal oste osynthesis in the elderly and T-plate fixation in younger patients. For thr ee- and four-part fractures minimally invasive techniques seem to be more f avourable in the elderly. However, there is some evidence that alternative therapies such as conservative treatment and plating can be successful in d efined populations. A general indication for primary implantation of a pros thesis in four-part fractures in the elderly is not supported by the litera ture. Conclusion: We conclude from our analysis that the scientific evidenc e for treatment recommendations of displaced proximal humeral fractures is still limited.