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Background Proximal humerus fractures (PHFs) are relatively common, although optimal rehabilitation is unknown. This review aims to characterize the published rehabilitation regimens utilized for PHFs. Methods A systematic review was performed per PRISMA guidelines, utilizing PubMed/MEDLINE, Embase, and Cochrane. All studies reporting PHF rehabilitation protocols after nonoperative management, open reduction internal fixation with a plate, or intramedullary nailing were included. Results Forty articles comprising 3507 patients (66% female, weighted mean age 63.5 years) were included. Substantial variability was present regardless of management. Rehabilitation modalities reported were: sling use in 34 cohorts, most commonly for three weeks; pendulum exercises in 21 cohorts, most commonly starting at post-intervention day 1; post-intervention passive range of motion (ROM) for 30 cohorts, most commonly starting at two days; active-ROM in eight cohorts, most commonly starting at three weeks; active-assisted ROM for 21 cohorts, most commonly starting at three weeks; unlimited ROM for 20 cohorts, most commonly at 4 or 6 weeks; non-weight-bearing for six cohorts, most commonly for six weeks; strengthening for 16 cohorts, most commonly at six weeks; removal of all restrictions for nine cohorts, most commonly starting at six weeks. Conclusions Published rehabilitation protocols for PHFs vary considerably regardless of management. Future studies comparing methods of management need to consider the influence of postoperative rehabilitation protocol heterogeneity when aggregating data from multiple sites. Level of Evidence IV

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BACKGROUND: After severe trauma, the older host experiences more dysfunctional hematopoiesis of bone marrow (BM) hematopoietic stem and progenitor cells (HSPCs), and dysfunctional differentiation of circulating myeloid cells into effective innate immune cells. Our main objective was to compare BM HSPC microRNA (miR) responses of old and young mice in a clinically relevant model of severe trauma and shock. METHODS:C57BL/6 adult male mice aged 8 to 12 weeks (young) and 18 to 24 months (old) underwent multiple injuries and hemorrhagic shock (polytrauma [PT]) that engenders the equivalent of major trauma (Injury Severity Score, >15). Pseudomonas pneumonia (PNA) was induced in some young and old adult mice 24 hours after PT. MicroRNA expression patterns were determined from lineage-negative enriched BM HSPCs isolated from PT and PT-PNA mice at 24 and 48 hours postinjury, respectively. Genome-wide expression and pathway analyses were also performed on bronchoalveolar lavage (BAL) leukocytes from both mouse cohorts. RESULTS:MicroRNA expression significantly differed among all experimental conditions (p < 0.05), except for old-naive versus old-injured (PT or PT-PNA) mice, suggesting an inability of old mice to mount a robust early miR response to severe shock and injury. In addition, young adult mice had significantly more leukocytes obtained from their BAL, and there were greater numbers of polymorphonuclear cells compared with old mice (59.8% vs. 2.2%, p = 0.0069). Despite increased gene expression changes, BAL leukocytes from old mice demonstrated a more dysfunctional transcriptomic response to PT-PNA than young adult murine BAL leukocytes, as reflected in predicted upstream functional pathway analysis. CONCLUSION: The miR expression pattern in BM HSPCs after PT (+/−PNA) is dissimilar in old versus young adult mice. In the acute postinjury phase, old adult mice are unable to mount a robust miR HSPC response. Hematopoietic stem and progenitor cell miR expression in old PT mice reflects a diminished functional status and a blunted capacity for terminal differentiation of myeloid cells.