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Nonsurgical treatment is recommended for proximal humeral fractures in elderly patients

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Nonsurgical treatment is recommended for proximal humeral fractures in elderly patients

Vol: 3| Issue: 1| Number:14| ISSN#: 2564-2537
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:2
Journal Level of Evidence:N/A

Internal fixation versus nonoperative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients: a meta-analysis of randomized controlled trials

PLoS One. 2013 Sep 16;8(9):e75464

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Three randomized control trials with a total of 130 patients were pooled in this meta-analysis to compare non-operative treatment methods versus open reduction and internal fixation for proximal humerus fractures in the elderly. No differences were found in Constant Scores, nonunion rate, risk of avascular necrosis of the humeral head or osteoarthritis. The results of this study do not encourage the surgical treatment for older patients with fractures of the proximal humerus.

Publication Funding Details +
Non-Industry funded
National Natural Science Foundation of China
None disclosed

Risk of Bias


Reporting Criteria


Fragility Index


Were the search methods used to find evidence (original research) on the primary question or questions stated?

Was the search for evidence reasonably comprehensive?

Were the criteria used for deciding which studies to include in the overview reported?

Was the bias in the selection of studies avoided?

Were the criteria used for assessing the validity of the included studies reported?

Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?

Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?

Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?

Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?

How would you rate the scientific quality of this evidence?

Yes = 1

Uncertain = 0.5

Not Relevant = 0

No = 0

The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.




Accessing Data


Analysing Data





Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65

The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.

Why was this study needed now?

Six percent of all fractures treated in the emergency department are proximal humeral fractures and the majority can be successfully treated without surgery. These fractures are the most common type of fracture occurring in elderly patients and 13 to 16% are comminuted, displaced and categorized as 3- and 4-part fractures according to the Neer Classification. Controversy lies in the whether comminuted displaced fractures in elderly patients with osteoporosis who experienced low energy trauma should be treated with surgery or not. A select number of randomized control studies compare open reduction and internal fixation to conservative methods and this meta-analysis was brought forward to pool the data from the trials available to re-evaluate the use of both treatments.

What was the principal research question?

Are comminuted displaced humeral fractures in elderly patients best treated with open reduction and internal fixation or non-operative treatments?

Study Characteristics -
Data Source:
The online data bases PubMed and Cochrane Central Registered of Controlled Trials were searched for relevant articles published between 1996 to October 2012. Reference lists and conference proceedings were manually scanned to identify additional articles.
Index Terms:
Proximal humeral fracture, internal fixation, treatment outcome, surgery and comparative study were used in different combinations as MeSH terms and as text words.
Study Selection:
The three included randomized control trials that compared open reduction and internal fixation and nonoperative treatment of displaced 3- and 4-part proximal distal fractures in elderly patients and had a primary outcome measure of Constant Scores. Secondary measures included nonunion, avascular necrosis of humeral head and osteoarthritis. Methodological procedure was not included.
Data Extraction:
Patient characteristics, inclusion criteria, treatment protocols, constant scores and complications were extracted by two independent authors and discrepancies were resolved by a third reviewer.
Data Synthesis:
Data from three studies was analysed using Review Manager Version 5.0. Constant score was represented as a continuous variable using weighted mean differences (WMD). The remaining outcomes were dichotomous and analyzed using risk ratios (RR). Heterogeneity was evaluated using I squared and defined as I^2 > 50%. A random effects model was used for heterogeneous data and a fixed effect model was used when I squared was less than 50%.

What were the important findings?

  • All three studies (n=130) examined Constant score and the outcomes were similar between surgical and nonsurgical treatment groups (WMD 20.51, 95% CI: 27.25 to 6.22, P= 0.88, I squared = 0%).
  • The 3 studies found nonunion was uncommon in both groups and that the difference between the two was insignificant (RR =0.78; 95% CI: 0.18–3.41, P= 0.74, I squared = 0%).
  • In the 3 RCT's examined, no difference was found in the risk of avascular necrosis of humeral head (RR = 0.86; 95% CI: 0.46–1.58, P= 0.62, I squared =0%).
  • 2 of the studies (82 patients) reported data on osteoarthritis and neither treatment arm provided additional benefits (RR = 1.34; 95% CI: 0.37–4.82, P= 0.66, I squared =0%).

What should I remember most?

No benefits were found regarding constant score, nonunion rate, risk of avascular necrosis of the humeral head or osteoarthritis with open reduction and internal fixation over nonsurgical methods. Both nonunion rates and risk of avascular necrosis were low in each group.

How will this affect the care of my patients?

This meta-analysis of 3 randomized control studies suggests non-operative treatment should be used for 3- and 4-part proximal humeral fractures in elderly patients over open reduction and internal fixation, as there is no additional benefit of the operative treatment. This study was limited by the modest quantity of studies and few clinical outcomes observed.

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