Handoll Helen Hg, Ollivere Benjamin J
Health and Social Care Institute, Teesside University, Middlesborough, Tees Valley, UK, TS1 3BA.
Cochrane Database Syst Rev. 2010 Dec 8(12):CD000434. doi: 10.1002/14651858.CD000434.pub2.
Proximal humeral fractures are common injuries. The management, including surgical intervention, of these fractures varies widely.
To review the evidence supporting the various treatment and rehabilitation interventions for proximal humeral fractures.
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and other databases, and bibliographies of trial reports. The full search ended in March 2010.
All randomised controlled trials pertinent to the management of proximal humeral fractures in adults were selected.
Two people performed independent study selection, risk of bias assessment and data extraction. Trial heterogeneity prevented meta-analysis.
Sixteen small randomised trials with 801 participants were included. Bias in these trials could not be ruled out.Eight trials evaluated conservative treatment. One trial found an arm sling was generally more comfortable than a less commonly used body bandage. There was some evidence that 'immediate' physiotherapy compared with that delayed until after three weeks of immobilisation resulted in less pain and potentially better recovery in people with undisplaced or other stable fractures. Similarly, there was evidence that mobilisation at one week instead of three weeks alleviated short term pain without compromising long term outcome. Two trials provided some evidence that unsupervised patients could generally achieve a satisfactory outcome when given sufficient instruction for an adequate physiotherapy programme.Surgery improved fracture alignment in two trials but was associated with more complications in one trial, and did not result in improved shoulder function. Preliminary data from another trial showed no significant difference in complications, quality of life or costs between plate fixation and conservative treatment. In one trial, hemiarthroplasty resulted in better short-term function with less pain and disability when compared with conservative treatment for severe injuries.Compared with hemiarthroplasty, tension-band fixation of severe injuries using wires was associated with a high re-operation rate in one trial. One trial found better functional results for one type of hemiarthroplasty.Very limited evidence suggested similar outcomes from early versus later mobilisation after either surgical fixation (one trial) or hemiarthroplasty (one trial).
AUTHORS' CONCLUSIONS: There is insufficient evidence to inform the management of these fractures. Early physiotherapy, without immobilisation, may be sufficient for some types of undisplaced fractures. It is unclear whether surgery, even for specific fracture types, will produce consistently better long term outcomes.
肱骨近端骨折是常见损伤。这些骨折的治疗方法，包括手术干预，差异很大。
综述支持肱骨近端骨折各种治疗和康复干预措施的证据。
我们检索了Cochrane骨、关节与肌肉创伤小组专业注册库、Cochrane对照试验中央注册库、MEDLINE、EMBASE及其他数据库，以及试验报告的参考文献。全面检索于2010年3月结束。
选择所有与成人肱骨近端骨折治疗相关的随机对照试验。
两人独立进行研究选择、偏倚风险评估和数据提取。试验异质性妨碍了荟萃分析。
纳入了16项有801名参与者的小型随机试验。这些试验中的偏倚无法排除。八项试验评估了保守治疗。一项试验发现，手臂吊带通常比较少使用的身体绷带更舒适。有一些证据表明，对于无移位或其他稳定骨折的患者，与固定三周后延迟进行的物理治疗相比，“立即”进行物理治疗导致的疼痛更少，恢复可能更好。同样，有证据表明，一周而不是三周进行活动可减轻短期疼痛，且不影响长期结果。两项试验提供了一些证据，表明在给予足够的指导以进行适当的物理治疗方案时，无人监督的患者通常可以取得满意的结果。两项试验显示手术改善了骨折对位，但一项试验显示手术并发症更多，且未改善肩部功能。另一项试验的初步数据显示，钢板固定与保守治疗在并发症、生活质量或费用方面无显著差异。在一项试验中，与严重损伤的保守治疗相比，半关节置换术在短期功能方面更好，疼痛和残疾更少。在一项试验中，与半关节置换术相比，使用钢丝对严重损伤进行张力带固定的再次手术率较高。一项试验发现一种半关节置换术的功能结果更好。非常有限的证据表明，手术固定（一项试验）或半关节置换术（一项试验）后早期与晚期活动的结果相似。
没有足够的证据为这些骨折的治疗提供依据。对于某些类型的无移位骨折，早期不固定的物理治疗可能就足够了。尚不清楚手术，即使是针对特定骨折类型，是否会始终产生更好的长期结果。
