Conservative treatment of 3-part and 4-part proximal humeral fractures: a systematic review

Abstract

Background Although there are numerous publications about surgical treatment of proximal humeral fractures (PHFs), few assess conservative treatment, which is the most common approach. The aim of this systematic literature review was to assess criteria for indications, treatment protocols, and outcomes obtained with the conservative treatment of 3-part and 4-part PHF. Methods We searched the PubMed and Cochrane databases for clinical studies published between 2000 and 2019 on conservative treatment for 3-part and 4-part PHF that included patients older than 18 years, a minimum follow-up of 1 year, fracture classification, and description of outcomes with assessment scales. Results The search yielded 26,660 records. We reviewed 44 of them in full, and finally 6 studies were included. We obtained a population of 133 patients (79% women), with a mean age of 74.3 years (range 25 to 98) and mean follow-up of 32 months (range 12 to 68.8). According to the Neer classification system, there were 41% (55) three-part fractures and 59% (78) four-part fractures; 5.81% of the patients were lost to follow-up. The mean Constant score was 64.5 for three-part fractures and 54.9 patients with four-part fractures. Consolidation was achieved in 95% of the three-part fractures and 91% of the four-part fractures. Loss of mobility varied according to the type of fracture. Regarding complications, the most frequent was malunion (21%), followed by avascular necrosis (9%). Conclusions Our data show that most three-part PHFs treated conservatively achieve fracture consolidation even noting a negligible rate of malunion got fair–good functional results with few complications, while the orthopedic four-part PHF treatment presents high rate of consolidation with less rate of malunion than the three-part PHF but achieve poor functional results with few complications. Level of evidence Level IV, Systematic Review

Clinico-radiological and functional outcome of Neer’s 2 part, 3 part and 4 part proximal humeral fractures in elderly treated by conservative management in a tertiary care centre of North India

“…In the present study, 14 (40%) were males and 21(60%) were females. In females, the incidence of trauma was also reported higher than males in the previous studies Rangan et al, Oleurd et al, Stableforth et al, Soler-Peiro et al 10,11,23,24 Fractures were more common on the left side than on the right side which were in agreement with previous studies Yuksel et al, Rahul et al, Zyto et al, Torrens et al 20,22,25,26 Figure 5: Showing forward flexion at final follow up.…”

“…In three part fractures, the mean score was 59.5 graded as moderate, and in four part fractures it was 51.2 which was graded as poor. Similar results were given by previous studies; Zyto et al (for 3 part fractures=59, for 4 part fractures=47), Soler-Peiro et al (for 3 part fractures=64.5, for 4 part fractures=54.9) and Launonen AP et al24,31 for 2 part fractures (Mean CS=66). The Constant score was higher in relatively less elderly patients and patients with two part fractures as compared to the complex fractures in the present study, overall range of CS was 35 to 91.…”

Projections of Primary and Revision Shoulder Arthroplasty until 2040: Facing a Massive Rise in Fracture-Related Procedures

“…Although we documented a massive increase in fracture-related rTSA in our study, current scientific evidence contrarily suggests, that non-operative treatment may be favorable in the elderly compared to surgical treatment in certain fracture patterns [37,38]. However, based on the increasing demand for self-independency in the elderly, there is still a controversial debate, on which patients may be better treated by surgical intervention.…”

“…However, it is possible, that after the world has overcome all issues regarding the pandemic, new technologies, surgical innovations, or disruptive innovation techniques, such as cartilage regeneration, tissue engineering, or drug therapies that limit the progression of osteoarthritis or enhance fracture recovery or joint-preserving surgery [41]; as well as health-care reforms or reimbursement changes, will meaningfully affect the relationship between supply and demand for shoulder arthroplasty. Especially, it remains to be seen, if the demand of rTSA for proximal humerus fracture will actually see the projected rise in the future, as more and more studies suggest that non-operative treatment may be more favorable in the elderly compared to a surgical approach [37,38,42].…”

Functional outcome of operative vs conservative management of 4 part proximal humerus fracture: A prospective comparative study

“…It is a customary practice to consider conservative treatment for minimally displaced fractures according to the Neer criteria (< 1 cm displacement or < 45° angulation) [12] . One of the review studies done by Soler -Piero et al Discussed about which type of displaced fractures are considered for surgical treatment and which fracture types benefit more from conservative approach [13] which has comparatively low inherent complications and risks [14] . They conclude in this review study that a significative difference between the outcomes for the three-part fractures compared with the fourpart fractures seen with operative management.…”