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Background: Shoulder fractures (proximal humerus fractures) are common, painful, debilitating injuries. Recovery is a long process often hindered by complications such as mal-union and frozen shoulder. The purpose of this qualitative study was to explore the experiences and information needs of people at different time points after a shoulder fracture and how views on recovery change over time., Methods: This longitudinal telephone interview study used a semi-structured approach based on a pre-planned interview topic guide. Recruitment was from June to November 2023. Participants were interviewed approximately two months and five to six months after their injury. Interviews were audio-recorded and transcribed verbatim. Data were analysed using thematic analysis., Results: 14 participants were recruited (age range 44-80 years; three male). The themes identified were dependence, vulnerability, information needs, and recovery. Loss of function and identity were associated with dependence. Feelings of vulnerability were present for most participants at six months post-injury. Information needs evolved, with information about the extent of the injury and practical advice needed first, but later participants emphasized the importance of reassurance and expected timelines for recovery. Recovery meant regaining function and independence, and returning to meaningful activities, which was also not fully achieved for most participants by six months., Conclusions: This study is the first to explore information needs and experiences along the timeline of recovery from a shoulder fracture. What recovery means to individual patients, along with recognition of the extent to which feelings of vulnerability affect recovery are important factors to consider. Clinicians should be aware of the full impact of these injuries to guide patients on their recovery journey, including identifying feelings of vulnerability and regaining their identity. Adopting a person-centred care approach, and considering the changing priorities and information needs of patients throughout their recovery journey may lead to improved patient care., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 May et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The purpose of this study was to define the optimal combination of surgical technique and postoperative rehabilitation protocol for elderly patients undergoing either hemiarthroplasty (HA) or reverse total shoulder arthroplasty (rTSA) for acute proximal humerus fracture (PHF) by performing a network meta-analysis of the comparative studies in the literature., Methods: A systematic review of the literature using Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines of MEDLINE, EMBASE, and Cochrane Library was screened from 2007 to 2023. Inclusion criteria were level I-IV studies utilizing primary HA and/or rTSA published in a peer-reviewed journal, that specified whether humeral stems were cemented or noncemented, specified postoperative rehabilitation protocol, and reported results of HA and/or rTSA performed for PHF. Early range of motion (ROM) was defined as the initiation of active ROM at ≤3 weeks after surgery. Level of evidence was evaluated based on the criteria by the Oxford Centre for Evidence-Based Medicine. Clinical outcomes were compared using a frequentist approach to network meta-analysis with a random-effects model that was performed using the netmeta package version 0.9-6 in R., Results: A total of 28 studies (1119 patients) were included with an average age of 74 ± 3.7 and mean follow-up of 32 ± 11.1 months. In the early ROM cohort (Early), the mean time to active ROM was 2.4 ± 0.76 weeks compared to 5.9 ± 1.04 weeks in the delayed ROM cohort (Delayed). Overall, rTSA-Pressfit-Early resulted in statistically superior outcomes including postoperative forward elevation (126 ± 27.5), abduction (116 ± 30.6), internal rotation (5.27 ± 0.74, corresponding to L3-L1), American Shoulder and Elbow Surgeons score (71.8 ± 17), tuberosity union (89%), and lowest tuberosity nonunion rate (9.6%) in patients ≥65 year old with acute PHF undergoing shoulder arthroplasty (all P ≤ .05). In total there were 277 (14.5%) complications across the cohorts, of which 89/277 (34%) were in the HA-Cement-Delayed cohort. HA-Cement-Delayed resulted in 2-times higher odds of experiencing a complication when compared to rTSA-Cement-Delayed (P = .005). Conversely, rTSA-Cement-Early cohort followed by rTSA-Pressfit-Early resulted in a total complication rate of 4.7% and 5.4% (odds ratios, 0.30; P = .01 & odds ratios, 0.42; P = .05), respectively. The total rate of scapular notching was higher in the cemented rTSA subgroups (16.5%) vs. (8.91%) in the press fit rTSA subgroups (P = .02)., Conclusion: Our study demonstrates that patients ≥65 years of age, who sustain a 3-or 4-part PHF achieve the most benefit in terms of ROM, postoperative functional outcomes, tuberosity union, and overall complication rate when undergoing rTSA with a noncemented stem and early postoperative ROM when compared to the mainstream preference-rTSA-Cement-Delayed., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Objective: Fractures of the proximal humerus (PHF) are commonly treated conservatively. Evidence suggests that a period of immobilization of one week or less may lead to some advantages compared to a traditional 3-4 weeks of immobilization. The purpose of this systematic review was to assess the clinical and radiological results in the case of early rehabilitation vs. delayed rehabilitation after PHF., Materials and Methods: In July 2023, a literature search was carried out on the PubMed, MEDLINE, and Embase databases to identify all the randomized trials comparing early rehabilitation vs. delayed rehabilitation after PHF. The following data were extracted from each included study: patients' demographics, study design and level of evidence, follow-up times, treatment groups, evaluation scores adopted, and overall clinical and radiological findings. The quality of the trials was assessed using the Cochrane Risk of Bias Assessment., Results: A total of 5 studies, including 378 patients and dealing with early vs. delayed rehabilitation in case of conservative treatment of PHF, were included in this study. Early rehabilitation was started within 1 week and consisted mainly of pendulum exercise and progressive passive mobilization. Early rehabilitation was associated with better pain and functional scores within the first 3 months in 3 studies. No difference in pain or function was reported at 6 months or longer follow-up, and no differences in complications rate were observed between early vs. delayed rehabilitation groups., Conclusions: This systematic review suggests that early mobilization within one week in case of conservative treatment of PHF leads to improved function recovery and reduced pain, especially in the first months of rehabilitation, without differences at longer follow-up and without increasing complications rate. Reducing immobilization time could accelerate function recovery and regaining independence in daily life activities.

Background: The use of continuous passive motion therapy (CPM) has led to promising results in the early phase of rehabilitation after surgical treatment of rotator cuff tears and arthrolysis of the elbow. However, its use has not been proven in other pathologies of the upper extremity. Therefore, the aim of the underlying study was to evaluate the use of CPM therapy after plate osteosynthesis of proximal humeral fractures., Methods: 95 patients with isolated proximal humerus fractures were enrolled in a prospective, randomized study. Patients were assigned to a treatment group with (n = 48, CPM) or without CPM therapy (n = 47, CG). Four patients (2 of each cohort) violated the study protocol and were excluded. CPM therapy was used for 6 weeks after surgery 2-3 times daily. Functional (range of motion) and patient reported outcomes (PROM, Constant Score [CSS], QuickDASH, subjective shoulder value [SSV], pain on visual analogue scale [VAS]) were evaluated at 6 weeks, 3 and 12months. 60 patients completed the 1-year follow-up., Results: The average patient age was 65.3 years (min: 27, max: 88, SD: ± 14.7). Seventy-two patients were female (79%). There was no difference regarding injury severity (2/3/4 part-fracture: 6/32/7 vs. 9/26/11, p = 0.867) and sex (p = 0.08). However, patients in the CPM group were significantly younger (CPM: 67 [min: 34, max: 82], CG: 74 [min: 27, max: 88], p = 0.032). After 6 weeks we observed a better range of motion for forward flexion (CPM: 90° [min: 50°, max: 180°] vs. CG: 80° [min: 20°, max: 170°] p = 0.035) and abduction (CPM: 80° [min: 40°, max: 180°] vs. CG: 70° [min: 20°, max: 180°], p = 0.048) in the CPM group. There was no difference regarding the further planes of motion or the assessed PROMs at 6 weeks. At 3 and 12 months the results between the treatment groups equalized with no further significant differences., Conclusion: The treatment with CPM increases the range of motion after plate osteosynthesis of proximal humerus fractures in the first 6 weeks after surgery. This effect is not sustained after 3 and 12months. The evaluated PROMs are not being influenced by CPM therapy. Hence the results of this prospective randomized study suggest that CPM can be a beneficial asset in the early period of rehabilitation after proximal humerus plate osteosynthesis., Trial Registration: The study protocol was registered in the US National Institutes of Health's database ( http://www., Clinicaltrials: gov ) registry under NCT05952622., (© 2024. The Author(s).)

Background: Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015., Objectives: To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults., Search Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results., Selection Criteria: We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults.  DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison., Main Results: We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence)., Authors' Conclusions: There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures., (Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objective: To examine whether robotic-assisted training as a supplement to usual therapy is safe, acceptable and improves function and patient reported outcome after proximal humeral fractures (PHF)., Design: Multicentre, assessor-blinded, randomised controlled prospective trial., Setting: Three different rehabilitation hospitals in Germany., Subjects: In total 928 PHF patients between 35 and 70 years were screened. Forty-eight participants were included in the study (intervention group n  = 23; control group n  = 25)., Intervention: The control group received usual occupational and physiotherapy over three weeks, and the intervention group received additional 12 robot-assisted training sessions at the ARMEO ® -Spring., Main Measures: Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH), the Wolf Motor Function Test-Orthopaedic, active range of motion and grip strength were determined before and after intervention period. The DASH was additionally obtained postal 6 and 13 months following surgery., Results: The mean age of participants was 55 ± 10 years and was similar in both groups ( p  > 0.05). The change in DASH as the primary endpoint in the intervention group after intervention was -15 (CI = 8-22), at follow-up six month -7 (CI = -2 to 16) at follow up 13 month -9 (CI = 1-16); in control group -14 (CI = 11-18), at follow-up six month -13 (CI = 7-19) at follow up 13 month -6 (CI = -3 to 14). No difference in the change was found between groups ( p  > 0.05). None of the follow-up time points demonstrated an additional benefit of the robotic therapy., Conclusion: The additional robot-assisted therapy was safe, acceptable but showed no improvement in functional shoulder outcome compared to usual therapy only.

BACKGROUND For proximal humeral fractures (PHFs), locking intramedullary nails and locking plates have been widely used. However, few reports have been published on the therapy of complex PHFs accompanying humeral shaft fractures. Therefore, we performed this research to analyze the effectiveness of locking intramedullary nails and locking plates in the management of proximal humeral fractures involving the humeral shaft. MATERIAL AND METHODS We retrospectively reviewed 40 cases diagnosed with proximal humeral fractures involving the humeral shaft fixed with either locking intramedullary nails or locking plates with at least of 2 years' follow-up. Clinical data were obtained from the medical records. Follow-up data included the Constant-Murley score, American Shoulder and Elbow Surgeons score (ASES), visual analog scale score (VAS), and the relative strength of the supraspinatus and deltoid muscles. RESULTS In total, 19 locking plate patients and 21 locking intramedullary nail patients were analyzed. The average follow-up period was 35 months in the locking plate group and 34 months in the locking intramedullary nail group. There were obvious differences in the intraoperative blood loss, time of operation, and the length of operative incision between the 2 groups (p<0.05). There were no significant differences between the groups in Constant-Murley score, ASES, VAS, or the relative strength of supraspinatus and deltoid muscles. CONCLUSIONS For PHFs involving the humeral shaft, both locking plates and locking intramedullary nails can achieve satisfactory functional results in the long-term follow-up assessment. The locking intramedullary nail group was superior with regards to intraoperative blood loss, time of operation, and length of incision.

Background: An early postoperative mobilization shows beneficial effects in terms of complications and long-term mobilization scores in elderly adult fracture patients. The primary objective of this study was to evaluate the overall mobilization of orthogeriatric patients during the postoperative hospital stay based on a continuous accelerometry measurement. Secondly, the collected data was analyzed to detect fracture related differences. We hypothesized that upper extremity fractures come along with higher levels of physical activity compared to fractures of the lower extremity., Methods: Thirty-one orthogeriatric patients with proximal femur fractures (PFF) and proximal humerus fractures (PHF) were enrolled consecutively in a maximum care hospital in a prospective study design (level of evidence 2). In the PFF study group 9 patients received hip arthroplasty and 11 patients intramedullary nailing (PFNA) and in the PHF group 10 patients received osteosynthesis of the proximal humerus. All patients worn a waist placed accelerometer during the length of hospitalization to quantify mobilization and physical activity., Results: The PFF group (n = 21) had a mean age of 80.86 years (SD ± 6.75), the PHF (n = 10) group had a mean age of 75.20 (SD ± 6.86). A significantly higher gait speed was observed in the PHF group of 0.52 m/s (SD ± 0.27) compared to the slower PFF group with 0.29 (SD ± 0.45); p = 0.0403. Quantitative mobility was measured by using the average number of daily steps. This showed a significantly lower number of steps in the PFF group (102.7; SD ± 188.1) compared to the PHF group (413.5; SD ± 287.7; p = 0.0002)., Conclusions: Our data demonstrates that it is feasible and accepted by the patient to continuously measure the mobility including gait speed and characteristics of orthogeriatric patients using waist worn accelerometry based wearables. Postoperative mobility and gait speed was generally low in both groups. Actions to improve postoperative mobility of orthogeriatric patients are urgently needed. Level Of Evidence Prospective cohort study, Level of Evidence 2., Competing Interests: Declaration of Competing Interest AMK, WB and JF revceived funding and research support from Novartis AG Basel, Switzerland for a previous study regarding the topic real world gait speed and mobiltiy. The study submitted was not funded by any company nor was it supported by any third party fund or grant. The other authors declare no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Case: We present the case of a 36-year-old patient with a 4-part proximal humerus fracture with subcoracoid dislocation and devascularization of the humeral head after a fall onto his right shoulder., Conclusion: The patient was successfully treated with open reduction and locking plate fixation to demonstrate that a successful postoperative functional outcome with humeral head survival can be achieved in these complex situations.

Background: Since the early 1990s, opioids have been used as a mainstay for pain management surrounding fracture injuries. As opioid dependence has become a major public health issue, it is important to understand what factors can leave patients vulnerable. The purpose of this study was to examine what risk factors, patient or injury severity, contribute most to postoperative opioid dependence following surgical treatment of proximal humerus fractures (PHFs)., Methods: A retrospective review of all patients who underwent an open reduction and internal fixation of PHF was performed within a large multisite hospital system. Recorded variables included age, gender, ASA class, BMI, fracture type, time to surgery, pre- and postoperative opioid prescriptions, physical and psychological comorbidities, smoking status, and complications. Pre- and postoperative opioid dependence was defined as prescription opioid use in the 3 months leading up to or following surgery. Odds ratio calculations were performed for each variable, and a multivariate logistic regression was used to compare all predictors., Results: A total of 198 surgically treated PHFs were included in the cohort with an average age of 59.9 years. Thirty-nine cases were determined to be preoperatively opioid dependent while 159 cases were preoperatively opioid naïve. Preoperative opioid dependence was found to be a significant risk factor for postoperative narcotic dependence, carrying a 2.42 times increased risk. (CI 1.07-5.48, p = 0.034). Fracture type was also found to be a risk factor for postoperative dependence, with complex 3- and 4-part fracture patients being 1.93 times more likely to be opioid dependent postoperatively compared to 2 part fractures (CI 1.010-3.764, p = 0.049). All other factors were not found to have any significant influence on postoperative opioid dependence., Conclusions: Our results demonstrate that the most important risk factors of postoperative opioid dependence following proximal humerus fractures are preoperative dependence and fracture complexity. It is important for orthopedic surgeons to ensure that patients who have more complex fractures or are preoperatively opioid dependent receive adequate education on their increased risk and support to wean off of opioids following surgery., Level of Evidence: III.

An 86-year-old female was operated on due to a comminuted fracture of the right proximal humerus whose configu-ration necessitated over-screwing of the humeral head to improve stability, with the screws directed divergently: anteriorly and poste-riorly, to minimize their conflict with the acetabulum. 3.5 years later she sustained a corresponding fracture of the left shoulder which was stabilized without over-screwing. On both occasions, the fractures were stabilized with titanium interlocking plates (ChM, Poland) and the limbs were immobilized in a shoulder brace for three weeks followed by in-tensive rehabilitation. The patient attended a follow-up visit at 12 months (i.e. 52 months post the right shoulder fracture) which included an assess-ment of radiographs, pain and limb function as well as tests of the range of movement of the shoulder and girdle. Assessments were repeated at 12 and 18 months afterwards. Patient denied limb pain and dysfunction. Abduction was reduced by 20°, which was compensated for by the scapulothoracic joint. Shoulder (girdle) abduction reached 50° (150°) for the right and 70° (170°) for the left extremity. Flexion was reduced by 20°, but extension and rotations were comparable. At 12 months post fracture, no improvement of limb mobility was noted despite continued intensive physiotherapy. X-rays showed satisfactory bone union. The patient scored 87 for the right and 89 for the left shoulder according to the Con-stant score and 6.8 points for each limb according to the QuickDash score. Overscrewing of the humeral head is not the most beneficial method for improving stability of comminuted proximal humeral fractures; however, it may be used when alternative and more suitable methods are unavailable. Moreover, directing screws divergently anteriorly and posteriorly to minimize their conflict with the scapular acetabulum does not interfere with joint function outcomes.

Background: The incidence of proximal humeral fractures (PHF) increased by more than 30% over the last decade, which is accompanied by an increased number of operations. However, the evidence on operative vs. non-operative treatment and post-operative treatments is limited and mostly based on expert opinion. It is mandatory to objectively assess functional capacity to compare different treatments. Clinical tools should be valid, reliable and sensitive to change assessing functional capacity after PHFs. This study aimed to analyse inter-rater reliability of the videotaped Wolf-Motor-Function-Test-Orthopaedic (WMFT-O) and the association between the clinical WMFT-O and the Disability of the Arm, Shoulder and Hand (DASH) and to determine the sensitivity to change of the WMFT-O and the DASH to measure functional capacity before and after rehabilitation in PHF patients., Methods: Fifty-six patients (61.7 ± 14.7 years) after surgical treatment of PHF were assessed using the WMFT-O at two different time points. To determine inter-rater reliability, the videotaped WMFT-O was evaluated through three blinded raters. Inter-rater agreement was determined by Fleiss' Kappa statistics. Pearson correlation coefficients were calculated to assess the association between the clinical WMFT-O and the video rating as well as the DASH. Sensitivity to change and responsiveness were analysed for the WMFT-O and the DASH in a subsample of forty patients (53.8 ± 1.4 years) who were assessed before and after a three week robotic-assisted training intervention., Results: Inter-rater agreement was indicated by Fleiss' Kappa values ranging from 0.33-0.66 for functional capacity and from 0.27-0.54 for quality of movement. The correlation between the clinical WMFT-O and the video rating was higher than 0.77. The correlation between the clinical WMFT-O and the DASH was weak. Sensitivity to change was high for the WMFT-O and the DASH and responsiveness was given. In comparison to the DASH, the sensitivity to change of the WMFT-O was higher., Conclusion: The overall results indicate that the WMFT-O is a reliable, sensitive and responsive instrument to measure more objectively functional change over time in rehabilitation after PHF. Furthermore, it has been shown that video assessment is eligible for studies to ensure a full blinding of raters., Trial Registration: Clinicaltrials.gov, NCT03100201 . Registered on 28 March 2017. The trial was retrospectively registered.

Objectives: To summarize and appraise any patient-reported or clinician-measured outcome measures based on their measurement properties in proximal humerus fracture patients., Data Sources and Study Selection: MEDLINE, EMBASE, and CINAHL were searched from January 2000 to August 2018 to identify all studies of proximal humerus fracture patients that reported a measurement property evaluation of an outcome measure., Data Extraction and Synthesis: Quality appraisal of each measure was completed using the Evaluating the Measurement of Patient-Reported Outcomes (EMPRO) tool. The EMPRO takes into account all studies of each measure, and the overall score is transformed linearly to a range of 0 (lowest) to 100 (best)., Results: Eleven instruments were identified. Intended concepts of the instruments included clinician-measured shoulder function, patient-reported function or disability, and patient-reported general health state. Only the Disabilities of the Arm, Shoulder and Hand (DASH), Oxford Shoulder Score, Constant Score, University of California, Los Angeles Shoulder Score, and EuroQol 5 Dimension (EQ5D) were evaluated in more than 1 study. The Shoulder Function Index (SFINX), DASH, and EQ5D had the highest EMPRO scores (80, 66, and 58, respectively). The SFINX and DASH consistently scored among the top 3 instruments for each attribute., Conclusions: Evidence on the measurement properties of outcome measures for proximal humerus fracture patients is limited. With the available evidence, the SFINX is recommended as a clinician-measured functional outcome measure, the DASH as a patient-reported functional outcome measure, and the EQ5D as a general health status measure.

Introduction: Fractures of the proximal humerus (PHF) represent a common injury among orthopedic department; especially for three- and four-part fractures no consensus about the best treatment is still achieved. The aim of our study was to compare clinical and radiological outcomes in patients alternatively treated with plates and screws or external fixation system for a type III-IV proximal humerus fracture., Material and Methods: Sixty-nine patients went surgery for type III-IV PHF between January 2011 and January 2014. According to the Neer classification, fractures were classified as type III in 50 cases (72,46%) and type IV in 19 cases (24,56%). 45 patients were treated with plates (65%) and 24 external fixators (35%). The patients' mean age was 62 years (range, 31-87 y). At five years, 60 patients (86,9%) were assessed using the visual analog scale (VAS) pain score, Constant Score (CS), the range of motion, and radiological evaluation. The CS at five years was the primary outcome measure. Results were evaluated and compared with the contralateral unaffected side to avoid bias related to different ages., Results: At the final follow up, we found no clinical differences when comparing the two procedures. Moreover, when age was considered as a variable, a significative difference of the CS was observed in the group of patients younger than 65 years treated with a plate (Plate Group Mean: 79; SD: +/- 15. Ex Fi Mean: 58; SD:+/- 4. P = 0,008). In the group of patients older than 65 years, the two procedures did not show significative differences in outcomes (Plate Group Mean: 69; SD: +/- 15. Ex Fi Mean: 63; SD:+/- 7. P = 0,032). External fixation procedure was overall associated with a reduction in blood loss, surgical time, length of hospital stay., Conclusion: Percutaneous techniques have a long tradition in PHF treatment; the introduction of dedicated external fixation system has the advantage to improve the stability and allow early rehabilitation when compared to the classical pinning technique. In our experience, the indication elderly patients with osteoporosis and comorbidities may benefit by this type of mini-invasive surgery with low soft tissue damages., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Comminuted fractures of the proximal humerus impair shoulder function, resulting in more or less severe disability. They rank among the most frequent fractures in adults, with incidence increasing with age and the degree of bone loss (osteoporosis). Among all currently used methods of stabilization of proximal humeral fractures, the best outcomes are afforded by angularly-stable plate fixation and interlocking or reconstructive intramedullary nailing. Both methods produce comparable results enabling bone union and restoration of limb functionality. Nevertheless, in elderly patients with advanced bone loss, in whom anatomical reduction of bone fragments is difficult or impossible, stabilization questionable and patient cooperation in the postoperative rehabilitation impossible to enforce, arthroplasty should be considered. Non-displaced or minimally displaced fractures may be treated conservatively by immobilizing the limb in an orthosis for three weeks. Nevertheless, the recommendations for operative interventions are being broadened, as stabilization eliminates the need to immobilize the limb, thus not affecting the patient's professional and social activities, enabling immediate rehabilitation, reducing the risk of joint stiffness and shortening recovery time.

Background: Reverse shoulder arthroplasty (RSA) is being increasingly used for complex, displaced fractures of the proximal humerus in older patients. Anatomic tuberosity healing in RSA has been recognized to restore better shoulder function. We compared the reported clinical and functional outcomes of RSA in proximal humeral fractures with and without tuberosity healing., Methods: We performed a systematic review of literature based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched MEDLINE, CINAHL, Embase, and Cochrane Central Register of Controlled Trials. We included all studies with RSA for proximal humeral fractures in patients older than 60 years and compared outcomes based on tuberosity healing with minimum follow-up of 12 months., Results: Seven studies met the inclusion criteria. A total of 381 patients (382 shoulders) were identified. There were 53 men (18.3%) and 236 women (81.7%), with mean age of 76.83 years (range, 74-81 years). Mean follow-up duration was 29.84 months (range, 24-90 months), and the mean rate of greater tuberosity healing was 70.5%. Patients with healed tuberosity had significantly better active forward flexion (134.1° vs. 112.5°, P < .05), abduction (114.8° vs. 95.1°, P < .05), external rotation with elbow by the side (27.8° vs. 7.6°), and mean Constant score (63.5 vs. 56.6, P < .05) than with those with nonhealed tuberosity., Conclusion: The RSA group with healed greater tuberosity showed better range of motion, especially forward flexion and external rotation and Constant scores, compared with the nonhealed greater tuberosity group. Tuberosity healing may influence overall shoulder function after RSA for proximal humeral fractures in the elderly, and this needs verification with future prospective studies., (Copyright © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Introduction: While locking plates have markedly improved fixation of proximal humerus fractures, a cohort of fractures remains difficult to treat. This cohort has been identified as fractures with marked medial comminution and varus deformity. Loss of reduction and fixation failure are the most frequently reported complications for this cohort. We report the use of an orthogonal 1/3 tubular plate to augment the proximal humerus locking plate., Methods: The subject underwent osteosynthesis for a four-part proximal humerus fracture with medial comminution. Fixation was performed within 24 h of injury. Standard deltopectoral approach exposed the fracture. Sutures were sited to control the tuberosities and cuff. Initial reduction was held with a K-wire and augmented with a three-hole 1/3 tubular plate. Proximal humerus locking plate was sited in standard fashion including locked medial support screws. Reduction was confirmed both clinically and with intra-operative radiography., Results: The technique provided satisfactory results. At 6 months, the fracture had fully united with no loss of reduction. At 1 year, the patient had excellent range of motion., Conclusion: The use of a 1/3 tubular plate to augment fixation of proximal humerus fractures with medial comminution may provide a simple, reproducible, and cost-effective method to decrease loss of reduction and subsequent malunion.

Luxatio erecta humeri is the rarest type of glenohumeral dislocation, which has been reported to be associated with humeral fracture, rotator cuff tear and neurovascular injury. To our knowledge, a single-sided acute inferior glenohumeral dislocation associated with humeral greater tuberosity fracture and axillary nerve injury has not yet been reported. Here, we reported a traumatic first-time inferior shoulder dislocation from a construction worker who got hyperflexion of the left shoulder when fell and grasped the railing causing. The patient underwent traction counter-traction closed reduction followed by proper immobilization, and rehabilitation therapy. At thirteen months follow-up, the patient had returned to the workload that required high stress on shoulder joint with an excellent outcome., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The incidence of proximal humeral fractures increases with age. The functional recovery of the upper arm after such fractures is slow, and results are often disappointing. Treatment is associated with long immobilisation periods. Evidence-based exercise guidelines are missing. Loss of muscle mass as well as reduced range of motion and motor performance are common consequences. These losses could be partly counteracted by training interventions using robot-assisted arm support of the affected arm derived from neurorehabilitation. Thus, shorter immobilisation could be reached. Thus far, this approach has been tested in only a few small studies. The aim of the present study is to examine whether assistive robotic training augmenting conventional occupational and physical therapy can improve functional shoulder outcomes., Methods/design: Patients aged between 35 and 66 years with proximal humeral fracture and surgical treatment will be recruited at three different clinics in Germany and randomised into an intervention group and a control group. Participants will be assessed before randomisation and followed after completing an intervention period of 3 weeks and additionally after 3, 6 and 12 months. The baseline assessment will include cognition (Short Orientation-Memory-Concentration Test); level of pain in the affected arm; ability to work; gait speed (10-m walk); disability of the arm, shoulder and hand (Disabilities of the Arm, Shoulder and Hand Outcome Measure [DASH]); range of motion of the affected arm (goniometer measurement); visual acuity; and motor function of orthopaedic patients (Wolf Motor Function Test-Orthopaedic version [WMFT-O]). Clinical follow-up directly after the intervention will include assessment of disability of the arm, shoulder and hand (DASH) as well as range of motion and motor function (WMFT-O). The primary outcome parameter will be the DASH, and the secondary outcome parameter will be the WMFT-O. The long-term results will be assessed prospectively by postal follow-up. All patients will receive conventional occupational and physical therapy. The intervention group will receive additional robot-assisted training using the Armeo®Spring robot for 3 weeks., Discussion: This study protocol describes a phase II, randomised, controlled, single-blind, multicentre intervention study. The results will guide and possibly improve methods of rehabilitation after proximal humeral fracture., Trial Registration: Clinicaltrials.gov, NCT03100201 . Registered on 28 March 2017.

Purpose: To select in a 2-year survey of proximal humerus fractures accessing the emergency department, a population of osteoporotic stable impacted fractures and to randomize them into two groups, one with an immediate intensive mobilization program and the other with an immediate conventional mobilization program., Methods: In emergency department, patients with clinical signs of shoulder girdle fracture were submitted to standard X-ray examination and CT scan. Patients with stable (absence of metaphyseal comminution or fifth fragment) osteoporotic (cortical bone thickness lower than 6 mm) impacted (Is any part of metaphysis or head impacted into the shaft? YES/NO) proximal humerus fractures were selected for randomization in one of the two groups. Group 1: early intensive mobilization; Group 2: early conventional mobilization. Functional and radiographic assessment was recorded at 3, 6 and 12 months of follow-up., Results: In the considered period, 120 patients were affected by a stable impacted osteoporotic proximal humerus fracture. At the final follow-up, 36 patients in group 1 and 39 patients in group 2 were available for statistical analysis. Functional and radiographic scores were comparable, with a trend of significance in favor of group 2. No fracture in any of the group showed significant loss of reduction respect to 6 months of follow-up. 4 (10%) and 1 (2.5%) patients in groups 1 and 2 were not compliant with the rehabilitation program (p = 0.037)., Conclusions: This randomized controlled trial showed that impacted osteoporotic proximal humerus fractures can be managed non-operatively with an early conventional rehabilitation program composed by 10 sessions of passive motion twice a week, followed by recovery of active range of motion for further 10 sessions thrice a week, while no advantage is given by a more aggressive rehabilitation regimen. Self-assisted exercises should be explained to patients to maximize the effects of the assisted program., Level of Evidence: Level 1, randomized controlled double-blinded trial.

Background: The aim of the surgical treatment in proximal humeral fractures is to maintain bone alignment facilitating an early shoulder mobilization. This can be obtained with the use of an endomedullary nail with specific characteristics: a proximal angular multiplanar stability and the possibility to place proximal screws in the calcar region. The objective of this randomized controlled trial is to investigate the effects of an early rehabilitation program in 3-part proximal humeral fractures treated with endomedullary nailing., Materials and Methods: 126 patients treated with the Diphos Proximal Humeral Nail (PHN), followed with an Intensive Rehabilitation Program (IRP) started in the second postoperative day, were compared to 62 patients with a Standard Rehabilitation Program (SRP) where shoulder mobilization started after 3 weeks. The age of patients was under 65 years. Main Outcome measures were improvement of shoulder function based on Constant Score and quality of life on DASH questionnaire at 1, 3, 6 and 12 months after surgery. Safety outcome was no loss of radiological reduction at any follow-up control., Results: A difference considered statistically significant (95% confidence interval) was demonstrated by Constant scores at 3 and 6 months and by DASH questionnaire scores at 1 month after surgery between IRP and SRP groups, however without loss of radiological reduction and maintaining the full fracture healing at the same mean period of 1,8 ± 0,7 months., Discussion: This experience allows to highlight essential features of this new kind of endomedullary humeral nail, by its mechanical properties, in proximal humeral fractures in order to permit an early rehabilitation without creating displaced or consolidation delay., Level of Evidence: III, randomized clinical-case-control study.

Complex proximal humerus fractures are often difficult to treat. Their frequency is high, especially in the elderly, and their treatment is still controversial. The aim of this study was to analyze the clinical and radiological results achieved by patients with complex proximal humerus fractures, treated with PHILOS plate only. A cohort of 55 patients was selected. The mean age was 63.4 (range 33-89), while the mean follow-up time was 21.5 months (range 6-75). Clinical outcome was evaluated with the "Constant-Murley shoulder score." All the informations about the presence of complications were gathered, and radiological images were used to calculate the head-shaft angle. The overall mean Constant score was 61.93 ± 18.59, the Individual CS was 70 ± 20 % and the Relative CS was 83 ± 23 %. No significant differences were found between fractures Neer 3 and Neer 4 and between the surgical approaches (delta-split vs. delto-pectoral). Six patients had a fracture with dislocation, seven patients (12.7 %) had complications while in four patients a head-shaft angle beyond the normal range was found. Osteosynthesis with PHILOS plate is stable in the greater part of the cases, and it allows an earlier rehabilitation and so a good functional result, which could be compromised by a prolonged immobilization. Therefore, PHILOS plate is a good option for the treatment of complex proximal humerus fractures.

Background: Concerns about test administration, reliability estimations, content and internal structure (dimensionality) of available shoulder measures for people with proximal humeral facture led to the development of a new clinician-observed outcome measure: the Shoulder Function Index (SFInX). The SFInX measures shoulder function by judgement of actual ability to perform daily tasks in which the shoulder is involved. Patients and health professionals had input into the instrument development, and Rasch analysis was used to create a unidimensional, interval-level scale. This study comprehensively evaluated the measurement properties of the SFInX in people recovering from a proximal humeral fracture., Methods: Data were collected on 92 people [79 women, mean age 63.5 years (SD13.9)] who sustained a proximal humeral fracture within the previous year on three occasions to allow for evaluation of the following measurement properties: construct validity (convergent, discriminant and known-groups validity), longitudinal validity (responsiveness), intra-rater reliability (one week retest interval), and inter-rater reliability (n = 20 subgroup; two independent raters). Comparative measures were Constant Score and Disabilities of the Arm Shoulder and Hand (DASH) and discriminative measure was a mental status questionnaire. Minimal clinically important difference, floor and ceiling effects and feasibility of the SFInX were also evaluated. A priori hypotheses were formulated where applicable., Results: Results for construct validity testing supported hypothesised relationships (convergent validity r = 0.75-0.89 (Constant Score and DASH); discriminant validity r = -0.08 (mental status); known-groups validity r = 0.50). For longitudinal validity, lower correlations (r = 0.40-0.49) than hypothesised (r = 0.50-0.70) were found. The SFInX scores changed more (10.3 points) than other scales, which could indicate that the SFInX is more responsive than the comparative measures. Intra-rater and inter-rater reliability found ICCs of 0.96 (95 % CI 0.94-0.97) and 0.91 (95 % CI 0.63-0.97) respectively, with low measurement error (SEM = 3.9-5.8/100). A change of 11-12 points (out of 100) was indicative of a clinically important difference., Conclusions: The SFInX is a feasible outcome measure which clinicians can use to reliably measure and detect clinically important changes in the construct of 'shoulder function', the ability to perform activities in which the shoulder is involved, in people recovering from a proximal humeral fracture.

Robotics is an emerging field in rehabilitation medicine. Robots have the potential to complement traditional clinical assessments because they can measure functions more precisely and quantitatively than current clinical assessments. We present a patient with a proximal humeral fracture whose recovery process was evaluated with an exoskeleton robotic device. The patient, a 34-year-old woman, suffered a left proximal humeral fracture while snowboarding. She is an occupational therapist and is the first author of this study. With conservative therapy, fracture union was seen on X-ray at 6 weeks post-injury. At that time, the patient was permitted to move her left upper limb actively within the tolerance of pain. We assessed the function of the injured upper limb at 6, 7, and 12 weeks post-injury with the KINARM exoskeleton robotic device and with conventional clinical measures. The active range of motion and the muscle strength of the left shoulder improved over time. Using robotic assessment, the precise movement profiles, position sense, and functional ability of both arms were quantified and also showed progressive improvement over time. Assessment with a robotic device of the recovery process after proximal humeral fracture allowed quantification of functional impairments that could not be felt subjectively nor identified with conventional clinical assessments.

Purpose: The aim of this study is to report the clinical and radiological results of reverse total shoulder arthroplasty (rTSA) in elderly patients who have been treated for complex humeral fractures., Materials and Methods: From January 2005 to December 2014, we have implanted rTSA for proximal humeral fractures in 95 patients (80 women, 15 men) about 75 years old on average (range 62-95 years). All rates and results on intraoperative and postoperative complications have been collected in a specific database. In all cases we have used a modular implant prosthesis (Lima Corporate, San Daniele del Friuli, Italy). The prosthesis was implanted cementless in 92 cases. Because of the presence of a high percentage of comorbidities in the elderly patients, we have retrospectively analyzed the necessity of a secondary hospitalization, from a week to a 6-month time after the discharge, due to general health problems and specific postoperative shoulder complications. The mean follow-up was 5 years (range 1-9 years) for 70 of 95 patients, 50 of whom had adequate radiographic controls., Results: None of 95 patients has required a reoperation or a hospitalization for general health problems from 1 week to 6 months postoperative. No early or late infection of prosthesis has been observed. There were seven cases of perioperative complications, three humeral vertical bone fissuring, two glenoid fractures and two cases of deltoid muscle damage. We have had three cases of postoperative hematoma and one case of ulnar nerve neuropathy. The mean constant score was 85.4, and the mean simple shoulder test was 7.4. We have observed a grade 1 scapular notching in 15 cases (30 %). In the remaining 35 reviewed cases, there was no notching. Peri-articular heterotopic ossifications were found in 11 cases (22 %)., Conclusion: Reverse shoulder prosthesis in complex humeral fractures in the elderly can be considered as a reliable surgical procedure, which leads to very good clinical and radiological results in case of cementless prosthesis, as well.

Background: Bilateral posterior dislocation of the shoulders is rare and may result from a seizure. A 48 year-old HIV-positive man who presented eight weeks after bilateral posterior shoulder dislocation and bilateral fractures of the surgical necks of both humeri is reviewed. He was treated with an algesics and physiotherapy and was able to return to work after 9 months., Conclusion: The rarity of this lesion, its late presentation, the importance of a high index of suspicion in making the diagnosis and the fair outcome of non-operative treatment informed this report.

Objective: The aim of this study was to evaluate functional recovery in a subgroup of hip fracture patients who sustained a simultaneous fracture at the upper limb, taking into account the site of upper limb injury., Design: Of 760 patients admitted consecutively to the authors' rehabilitation hospital because of a fall-related hip fracture, 700 were retrospectively investigated. Functional outcome was assessed using Barthel Index scores., Results: In 49 of the 700 patients, a single fall resulted in both a hip fracture and a fracture of either wrist (n = 34) or proximal humerus (n = 15). The patients with concomitant shoulder fractures had lower median Barthel Index scores after rehabilitation (70 vs. 90, P = 0.003), lower median Barthel Index effectiveness (57.1 vs. 76.9, P = 0.018), and prolonged median length of stay (42 vs. 36 days, P = 0.011) than did the patients with isolated hip fractures. Significant differences persisted after adjustment for six potential confounders. The adjusted odds ratio for achieving a Barthel Index score lower than 85 was 6.71 (95% confidence interval, 1.68-26.81; P = 0.007) for the patients with concomitant shoulder fractures. Conversely, no prognostic disadvantages were associated with concomitant wrist fractures., Conclusions: Data show a worse functional recovery and a prolonged length of stay in the subgroup of hip fracture patients who sustained a concomitant fracture at the proximal humerus, but not at the wrist.

Objectives: Determine the relative position of the main fractured fragments of proximal humerus fractures treated conservatively to compare displacement at 2 time points: injury (0), and 1 year later (1)., Design: Prospective, comparative cohort study., Setting: Level I trauma center., Patients: Eighty-nine prospectively enrolled adults., Intervention: Six weeks of sling immobilization and a home-based program rehabilitation protocol started 2 weeks after injury., Main Outcome Measurements: Standardized radiographs of injured shoulders were obtained in all patients at times 0 and 1. Computed tomography scans were also obtained at these times in 73 cases. Forty-two computer-assisted measurements of displacement were performed at times 0 and 1 and then compared. Factors related to progression of displacement were analyzed., Results: Ninety percent of fractures were classified into 1 of 4 patterns: posteromedial (varus) impaction (46), lateral (valgus) impaction (13), isolated greater tuberosity (15), and anteromedial impaction (6). Head-shaft displacement increased over time. In posteromedial impaction fractures, average fracture settling included 9 degrees in varus, 7 degrees in retroversion, and 3.2 mm in posterior shortening. In valgus-impacted fractures, a decrease in valgus tilt and a tendency toward a more anterior orientation of the articular surface was observed. Greater tuberosity displacement increased more than 5 mm in less than 20% of cases. Age and initial displacement were related to progression of displacement., Conclusions: Proximal humerus fractures treated conservatively settle at the head-shaft junction during healing. Substantial additional displacement of tuberosities was seldom observed., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: The purpose of this study was to analyze functional and radiologic results of a consecutive series of elderly patients who underwent uncemented hemiarthroplasty as primary treatment of complex proximal humeral fractures., Methods: Twenty-one patients with severe proximal humerus fracture (three or four fragments and three- or four-fragment fracture dislocations) were treated with uncemented proximal humerus hemiarthroplasty. Patients were evaluated using the Constant-Murley Score, the Quick scale Disabilities of Arm, Shoulder and Hand (Quick-DASH) Score, range of motion, residual pain, radiographic parameters, and complications including clinical and radiologic data of mobilization., Results: After a mean postoperative period of 20.57 months (range 12-42 months), the mean Constant-Murley Score was 44 points (20-57), the mean Quick-DASH score was 24 points (16-39), postoperative pain according to a mean visual analogue scale was 1 (0-8), active abduction was 50° (30-135), and active flexion 70° (20-120). There were no cases of infection, deep vein thrombosis, dislocation, blood transfusions, or reoperation because of prosthetic loosening. Bivariate analysis of demographic data, radiologic findings, and other variables showed associations between duration of surgery and a higher Quick-DASH score (0.606; p = 0.037), and the number of sessions of rehabilitation with a higher Quick-DASH score (0.708; p = 0.015)., Conclusions: The results of treatment of severe proximal humerus fractures in the elderly with an uncemented hemiarthroplasty are safe and promising; however, a comparative cohort study (cemented vs. uncemented) and long-term follow-up are still needed.

Purpose/aim: This meta-analysis compares the clinical outcomes of surgical versus conservative treatment of displaced, 3- or 4-part, proximal humeral fractures., Materials and Methods:  Medline, Cochrane, EMBASE, and Google Scholar were searched for studies published until October 2013, reporting functional outcomes of 3- or 4-part fractures of the proximal humerus in skeletally mature patients. Only randomized controlled trials were included. The treatments that were evaluated included non-surgical, open surgery, intramedullary pin, locking plate, arthroplasty, and minimally invasive surgical treatments. A meta-analysis was performed on the difference in functional outcomes and quality of life (QoL) between participants undergoing surgical versus non-surgical treatment., Results: Out of 254 participants in the studies who were analyzed, 127 were treated surgically. The difference in mean values of functional score showed similar results between surgical and non-surgical treatments (difference in mean values = 0.015, 95% CI = -0.232 to 0.261, p = .908).The difference in mean values of QoL showed that surgical treatment provided better post-operative QoL than non-surgical treatment (difference in mean values = 0.146, 95% CI = 0.052 to 0.240, p = .002)., Conclusions: Surgical treatment of displaced, multi-fragment fractures of the proximal humerus did not improve shoulder functional outcome, based on the Constant-Murley Score, when compared with conservative and non-surgical treatments. However, health-related QoL was significantly improved with surgical treatment compared with conservative treatment.

Objective: To describe the characteristics of patients hospitalized for osteoporotic proximal humerus fracture in 2009 in France, in-patient mortality, and further hospitalizations for hip fracture., Methods: Data were extracted from the French Hospital National Database. We selected patients aged 40 years and over hospitalized for proximal humerus fracture in 2009, without cancer. Based on their unique identification number, we described the next hospitalizations occurring in 2009-2011 whatever the causes. Incidence, in-patient mortality, and hospital costs were calculated., Results: We numbered 10,874 patients (77% of women, mean age 72.5 years). The incidence per million was 477 and 163 in women and men, respectively. This incidence increased with age and was higher in women (i.e. 1374 and 320 in women and men aged over 74 years, respectively). Surgical treatment was applied in 56% of patients; median hospital stay was 5 days. Rehabilitation unit was necessary in 26% of cases. In-patient mortality was 1.1%. The overall hospital costs was €34 millions. Rehospitalizations occurred for 61% of the patients and had more co-morbidities than others. Near 8% of the rehospitalized patients were for hip fractures occurring in a median of 353 days after hospitalization for proximal humerus fracture. The hospital costs for these rehospitalizations was €52 millions., Conclusion: Proximal humerus fractures incidence increases with aging, especially in women. These fractures are associated with a significant in-patient mortality and health care resources utilization. Patients with such fracture must receive high priority for optimal post fracture treatment., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

The incidence of fractures of the humerus has increased exponentially in recent years. The most used classifications for humerus fracture are morphological (Neer), biological (AO/ASIF) and descriptive (Hertel). The types of surgical treatment for humerus fracture include prosthetic replacement and synthesis using different devices, including the Tension Guide Fixator (TGF), Gex-Fix. External fixation for displaced proximal humeral fractures avoids dissection and soft tissue stripping and has been reported by some authors to be associated with higher union rates, a lower incidence of avascular necrosis, less scarring of the scapulohumeral interface, and faster rehabilitation compared with open reduction and internal fixation. Other authors have reported that external fixation does not ensure acceptable reduction and fracture stability, particularly in patients with osteoporosis. The external fixation technique involves the introduction of Steinmann's pin to keep manual reduction, the introduction of two K-wires in the humeral head, the removal of the Steinmann's pin, and the introduction of two fiches on the humeral shaft. Hub connectors are mounted on the wires and on the chips to connect the outer bar and tensioning system. A total of 84 patients aged 42-84 years with proximal end humeral fractures (66% had two-part fractures) were treated with Fixator TGF in this study from December 2007 to June 2012. The postoperative recovery was earlier and the active-assisted motion was less painful than has been reported with other surgical techniques. The TGF was removed without anaesthesia at the outpatient clinic at a mean of 7 weeks (range 5-8 weeks) after surgery, and there was no loss of reduction or secondary displacement after removal. These results, after five years of experience, confirm that the best indication for this fixator is two- or three-part fractures because the device enables early active mobilisation. The limitations of this fixator are evident in fractures in which closed reduction is not possible and in three-part fractures with varus displacement because the TGF has less stability than other systems, such as the plate or cage. The short learning curve, reduced surgical time and risk, and low cost encourage the use of this technique., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Background: Treatment for displaced proximal humeral fractures is still under debate. Few studies exist at the highest level of evidence. Although reversed total shoulder prosthesis has gained popularity and showed promising results in the treatment for proximal humeral fractures in the elderly patients, no randomized controlled trials exist to the authors' knowledge., Methods/design: This study is a randomized semi-blinded controlled multicenter trial designed according to the Consort statement and the recommendations given by the Cochrane reviewers for proximal humeral fractures. The study will investigate whether a reversed total shoulder prosthetic replacement gain better functional outcome compared to open reduction and internal fixation using an angular stable plate in displaced three- and four parts proximal humeral fractures after two and five years follow-up.Participants are aged 65-85 admitted in seven different hospitals with a displaced proximal humeral fracture according to AO-OTA type 11-B2 or 11-C2. The intervention group is surgical treatment using a reversed total shoulder prosthesis (Delta X-tend) compared to open reduction and internal fixation with an angular stable plate (Philos) and thread cerclage in the control group. 60 patients will be randomized to each group.The primary outcome is shoulder function (Constant score). Secondary outcomes will be patient self-assessment form (Oxford shoulder score), a quality of life questionnaire (15D score) and resource implications (cost-effectiveness). Follow-ups take place at 3, 6, 12 and 24 months, and five years. The trial design is semi-blinded with blinded physiotherapists performing the functional testing of patients at all follow-ups.Randomization to treatment groups is electronic online, by independent supervisor (web-CRF). The recruitment of patients started at January 1.st 2013. Inclusion of 120 patients during three years is expected., Discussion: This semiblinded trial include a high number of patients compared to existing randomized trials in this field. To our knowledge and according to ClinicalTrials.gov, this is the first study that compare these two treatments for a displaced proximal humeral fracture in elderly patients. This may provide important information to help the surgeon to decide the best treatment in the future., Trial Registration Number: ClinicalTrials.gov Identifier: NCT01737060.

Proximal humerus fractures are commonly encountered in elderly patients. Surgical treatment demonstrates high complication rates, including varus construct collapse and screw cutout. In this study, the authors evaluate the clinical outcome of locking plate fixation with intramedullary fibular strut graft augmentation as a primary surgical treatment in the prevention of early collapse and screw cutout. A total of 9 patients were evaluated. Surgery was performed for displaced proximal humerus fractures between April and December 2011. Patients were either class 2, 3, or 4, according to Neer classification. Mean patient age was 75.4 years. Preoperative and immediate, 6-week, and 3-month postoperative radiographs were evaluated. Head-shaft angles were measured to assess for varus collapse and displacement. Range of motion, complication rates, and functional recovery were also evaluated. Patients underwent open reduction and internal fixation with placement of an intramedullary fibular strut graft. Fixation was achieved with a Philos plate (Synthes, Oberdorf, Switzerland). Reduction and fixation were evaluated with radiographs. Passive exercises and range of motion were allowed immediately postoperatively, and all patients achieved active abduction and forward flexion 6 weeks postoperatively. Shoulder radiographs taken 12 weeks postoperatively revealed no loss of reduction or screw cutout. The introduction of the locking plate has improved outcomes. The addition of an intramedullary strut graft has shown improved preliminary results. Maintained reduction was observed in all 9 patients in the early postoperative period, and good functional motion was achieved. No incidence of screw cutout was recorded., (Copyright 2014, SLACK Incorporated.)

Reverse shoulder prosthesis has become one of the most often used prosthetic implants in shoulder replacement surgery. It has a wide spectrum of indications, starting from comminuted humeral fractures and posttraumatic arthritis to arthritis caused by the rotator cuff loss. Its application at our hospital began in 2004, at first in few specific cases and with time in ever growing number of patients. Over 8 years, more than 250 reverse shoulder prostheses were implanted at our institution. In addition, our surgeons supervised its application in other hospitals all over Croatia. In the postoperative course, the shoulder was immobilized for 4-6 weeks with a thoracobrachial cast. After removal of the cast, physical therapy was initiated. The length of physical therapy program depended upon many factors. As a rule, immobilization lasted longer in patients that were operated on due to posttraumatic arthritis and those that suffered from deltoid muscle atrophy and shoulder contracture before surgery. Complications included dislocation of the prosthesis shortly after surgery (in the first four weeks) and infection. Infection was a special problem and treatment included even explantation of the prosthesis.

Objective: Primary endoprosthetic joint replacement in non-reconstructable proximal humeral fracture in the elderly. Alternative to fracture hemi-endoprosthesis with resorption of tuberosities and secondary rotator cuff insuffiency which leads to unsatisfying functional results., Indications: Non-reconstructable proximal humeral fracture in mainly old patients with osteoporotic bone, multifragment tuberosity fracture and degenerative rotator cuff lesion., Contraindications: Patient not fit for surgery, pre-existing shoulder infection or sepsis, severe general medical condition, nerve damage (axillay nerve, Plexus), Surgical Technique: Deltopectoral or delta-split approach. Removal of head fragments. Reinforcement of tuberosities and exposure of glenoid. Implantation of the metaglene and fixation of glenosphere after removal of labrum and capsule. Reaming of humeral shaft and cementing of the prosthesis stem. The retroversion and height of the reverse central part then can be adjusted freely. The tuberosities can be fixed with suture at the middle part. With a titanium cable an additional compression osteosynthesis of the tuberosities can be done by direct pressing on the osseoinductive coated central part., Postoperative Management: Positioning of the arm on an abduction pillow for 4 weeks, then active exercise treatment until week 6. Free movement exercise under guidance for 6 months., Results: Multicentre study with 43 patients (40 women, 3 men), average age 79.8 years (range 66.9-95.8 years), 36 patients with 4-part-fracture according to Neer classification. To date, follow-up of 24 patients after at least 24 months, 9 patients lost to follow-up. Mean Constant Score 65.5 points, age and gender corrected Constant Score 96.7 %. Visual Analog Scale (VAS) for pain 1.9. VAS for subjective satisfaction 7.5. Mean American Shoulder and Elbow Surgeons Shoulder Score (ASES) 72.8 points. Mean active range of motion: flexion 142.3°, abduction 135.9°, external rotation 18.6°, internal rotation 47°, the radiological evaluation so far did not show any signs of scapular notching., Complications: One dislocated acromion fracture.

Proximal humeral fractures in the pediatric population are commonly treated conservatively. When there is an indication for surgery, percutaneous pinning is considered to be the elective choice. We report our experience with a new external fixator that reduces the risk of pin migration and permits an early rehabilitation. The range of motion was completely restored in all patients and no pain or discomfort was detected at follow-up. According to the literature, a small varus malunion at the first x-ray control can be tolerated in the pediatric population because of the remodeling ability of the bone. We conclude that this system provides a good stability and healing of Salter-Harris type II proximal humerus injuries.

Background: In the management of displaced proximal humerus fractures in the elderly, wide variation has been documented. However, no prior study has investigated the factors that currently lead surgeons to treat patients with surgical fixation, arthroplasty or non-operative management. The purpose of this study was to identify the factors associated with treatment selection in the management of displaced proximal humerus fractures in individuals over the age of 60 years. To this end, we conducted a retrospective review of all such injuries that presented to our two level-I trauma centres between 2006 and 2009., Patients and Methods: From our prospectively collected trauma database, we identified 229 displaced proximal humerus fractures that met all inclusion and exclusion criteria. Data were collected on patient-, fracture- and surgeon-related characteristics that were plausibly related to the decision for treatment. The choice of management was recorded, and logistic regression was used to identify factors associated with the decision for treatment., Results: In the multivariate analysis, the predictors of operative intervention as opposed to non-operative treatment were younger patient age (p = 0.038), associated orthopaedic injuries requiring surgery (p = 0.012), higher Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification (p = 0.012), translation-type displacement (p = 0.0012) and associated glenohumeral dislocation (p = 0.0006). In addition, shoulder and upper extremity specialists were found to choose operative intervention significantly more frequently than orthopaedic trauma specialists (49.1% vs. 26.1%, adjusted relative risk (RR) 1.96, p = 0.012). Factors associated with the decision for arthroplasty as opposed to fixation were higher Charlson score (p = 0.045), higher Neer classification (p = 0.012), and higher AO classification (p = 0.0097)., Conclusions: In this study of displaced proximal humerus fractures in the elderly, the decision for surgery was influenced by the patient's age, the presence of associated orthopaedic injuries, the severity of the fracture and the presence of an associated glenohumeral dislocation. In addition, treatment by a shoulder or upper extremity specialist (as opposed to an orthopaedic trauma specialist) was associated with a higher likelihood of operative intervention. Further investigation into the resultant clinical outcomes is required to determine whether the use of these characteristics to select operative candidates is appropriate and beneficial for patients., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Objective: Most clinical evaluations after fracture treatment focus on pure functional and radiological outcome. However, this may not appreciate the impact on quality of life (QoL). The aim of this study was to assess QoL and its improvement during the first year of postoperative recovery after fracture treatment., Design: Prospective single-centre observational study., Setting: Trauma unit. City hospital., Patients: From March 2003 to June 2008 inclusion of 269 consecutive patients (72 years, 77% female) was possible. All were treated by open reduction and internal fixation (ORIF) with PHILOS because of isolated traumatic fractures of the proximal humerus., Intervention: Clinical follow-up examinations were performed at 6 weeks and 3, 6, and 12 months, postoperatively., Main Outcome Measurements: Constant-Murley score (CMS) and the QoL (SF-36 questionnaire) were used to assess outcome. All results were stratified according to length of follow-up, age, and fracture type., Results: CMS and SF-36, including the corresponding subgroups Physical Component Summary and Mental Component Summary, demonstrated continuing improvement during the period of observation. US norm values for the SF-36 were achieved after 6 months. However, speed of progress varied greatly between the scores and age groups. The fracture type significantly impacted CMS. Increasing age and complexity of fracture influenced the results negatively and cumulatively., Conclusion: This study highlights and defines subjective improvements and changes of QoL up to 1 year after ORIF of these fractures. Increasing age and a more complex fracture type is correlated with a deceleration of functional improvement. The CMS shows a definite positive correlation with the unassisted self-evaluation of SF-36, but exchangeability could not be demonstrated.

We report an unusual case of clinical improvement after 2 years from one stage bilateral open reduction of chronic anterior shoulder dislocations with internal fixation of greater tuberosity fractures. The chronic bilateral anterior shoulder dislocations with greater tuberosity fractures were caused by electric shock. After the injury the patient was hospitalized on a medical ward and the dislocations were not diagnosed. Four weeks later the diagnosis of both anterior shoulders dislocations with greater tuberosity fractures was confirmed by X-ray. The patient was treated with one stage bilateral open reduction of chronic shoulder dislocations with internal fixation of greater tuberosity fractures by means of a deltopectoral approach. The shoulders were kept immobilized for six week, next the patient was rehabilitated. He underwent a thorough first evaluation 1 year after the procedure and second ewaluation after 2 years. He had a very good and comfortable range of motion in both shoulders at a follow-up. The modified Constant score was very good in both shoulders (95 points). To the best of our knowledge, such a case has not yet been described in the literature. Our case proved the chronic anterior bilateral humeral head dislocation may be successfully treated in one stage procedure provided the patient is carefully selected and his consent obtained. Moreover, the clinical improvement may be expected even two years after the surgery.

Introduction: Experience with treating proximal humeral nonunions with reverse total shoulder arthroplasty is limited. We report our results., Patients: Eighteen patients with proximal humeral atrophic nonunion were treated with reverse total shoulder prosthesis. There were 12 women and 6 men, with a mean age of 78.8 years (range, 75-84 years). The mean follow up after reverse arthroplasty was 28 months (range, 24-32 months). Extensive proximal humeral bone loss that was found in six cases was treated adding a proximal humeral allograft. A long humeral stem was always used., Results: The mean Constant score increased from 26% preoperatively to 55% postoperatively (p <0.0001). The average anterior elevation increased from 35° to 90° (p<0.0001), abduction from 35° to 85° (p<0.0001), external rotation from 15° to 30° (p <0.0001) and internal rotation from 25° to 55° (p <0.0001). The average subjective shoulder score increased from 10% preoperatively to 50% postoperatively (p <0.0001). All but 4 patients would undergo the same procedure again if faced with the same problem. Eight patients were very satisfied, 6 satisfied and 4 unhappy with the operation. We had one case of transitory axillary nerve palsy and two cases of infection. Two prosthetic dislocations occurred; they were successfully treated by revision with a larger polyethylene glenosphere of 44 mm., Conclusions: Reverse total shoulder arthroplasty improves function and motion in patients with proximal humeral fracture sequelae. However, the rate of dislocation is high., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Fixation of proximal humerus fractures with precontoured, fixed angle devices has improved operative management of these difficult injuries, particularly in patients with osteoporosis. However, recent data has revealed that fixation with these constructs is not without complications, particularly screw cut-out and loss of reduction. Multiple strategies have been developed to decrease the number of complications. We offer a surgical technique combining suture augmentation of the proximal humerus with locked plate fixation utilizing short screws.

This document is part of the "Care Pathways in Physical and Rehabilitation Medicine" series developed by the French Physical and Rehabilitation Medicine Society (Sofmer) and the French Physical and Rehabilitation Medicine Federation (Fedmer). For a given patient profile, each concise document describes the patient's needs, the care objectives in physical and rehabilitation medicine, the required human and material resources, the time course and the expected outcomes. The document is intended to enable physicians, decision-makers, administrators and legal and financial specialists to rapidly understand patient needs and the available care facilities, with a view to organizing and pricing these activities appropriately. Here, patients with acute proximal humeral fracture requiring shoulder hemi-arthroplasty are classified into four care sequences and two clinical categories, both of which are treated according to the same six parameters and by taking account of personal and environmental factors (according to the WHO's International Classification of Functioning, Disability and Health) that may influence patient needs., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Study Design: Case report., Background: Scapular fractures are uncommon, and displaced glenoid fractures are even rarer. Surgery is usually performed for severely displaced fractures and positive outcomes have been reported, although some patients have residual limitations. Published rehabilitation guidelines are limited. The purpose of this case report is to describe the physical therapy (PT) rehabilitation of a patient with a complicated scapular fracture, and to describe factors influencing his outcome., Case Description: Exercise, manual therapy, and modalities were used in the rehabilitation process. Outcome measures included manual muscle testing for strength, goniometry for range of motion (ROM), and the shoulder pain and disability index (SPADI) for function., Outcomes: Improvements in strength, ROM, and function were noted. The patient had full ROM, 4+ /5 to 5/5 strength, and a SPADI score of 3/100 at discharge from PT., Discussion: The patient achieved a favorable outcome, in spite of having a long-duration wound infection and a second surgery for hardware removal. Further research should identify the optimal rehabilitation progression for patients with this type of surgery.

Background: The treatment of unstable displaced proximal humeral fractures remains challenging and controversial. Reports about the application of a mini-external fixator in the treatment of proximal humeral fractures are rare. The objective of this retrospective study was to evaluate the efficacy and complications of surgical treatment of proximal humeral fractures by closed reduction and external fixation with application of a mini-external fixator., Methods: Thirty-two patients with displaced proximal humeral fractures were surgically treated by closed reduction and external fixation with mini-external fixators at our institute between March 2007 and June 2009. There were 22 men and 10 women who had a mean age of 56 years (range, 23-81 years). The Neer scoring system related to pain, function, and range of motion was used to assess the outcome., Results: All the patients were followed up at an mean of 18 months (range, 13-27 months). The duration of surgery was 29 ± 12 minutes. The accumulative fluoroscopy time was 12 ± 3.5 exposures. The mean time of fracture union was 13 ± 3.6 weeks. The mean Neer score was 83.2 ± 12.5 points at final follow-up. The incidence of excellent and good results was 81%. Two patients had loosening of the pins. One patient had a collapsed humeral head. There was no infection and impingement., Conclusion: The surgical treatment of displaced proximal humeral fractures with a mini-external fixator is characterized by minimal invasion, a shorter duration of surgery, and easy manipulation, making application of the mini-external fixator a good option for some selected patients., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.)

Purpose: Elderly subjects often have fractures of the proximal humerus, which may be difficult to manage in patients in poor general condition. The MIROS is a new percutaneous pinning device allowing correction of angular displacement and stable fixation of fracture fragments. We evaluated the results of percutaneous fixation of three- or four-part fractures of the proximal humerus of patients in the American Society of Anesthesiologists physical status three or four treated either with MIROS or traditional percutaneous pinning (TPP)., Methods: A total of 31 patients treated with MIROS and 27 undergoing TPP were enrolled in the study. Pre-operatively anteroposterior and transthoracic or axillary radiographs were obtained in all cases and computed tomography scans in patients with the most complex fractures. Follow-up evaluations were carried out at three, six, 12 and 16 weeks, and six months, one year and two years postoperatively, using the Constant Score (CS) and subjective shoulder value (SSV) methods., Results: Of the 58 patients, 52 could be evaluated at all follow-ups. In both three- or four-part fractures there were significantly higher CS and SSV scores in the MIROS compared to the TPP group at all the late follow-ups. Lower rates of deep infection, pin tract infection and pin mobilisation were found in the MIROS group (p < 0.001). In both groups there was a significant association between the final result (CS) and either the type of fracture or complications (p < 0.001)., Conclusions: The MIROS resulted in better clinical results and less complications than TPP in elderly patients. This method, however, may not be indicated for younger patients in good general condition.

Proximal humerus fractures are the third most common fracture in elderly patients. Hemiarthroplasty has been the treatment of choice in patients with bone quality and fracture patterns not amenable to open reduction and internal fixation. Reverse total shoulder arthroplasty is a newer option that appears to be less dependent on tuberosity healing than hemiarthroplasty. The authors hypothesized that reverse total shoulder arthroplasty provides improved functional outcomes compared with hemiarthroplasty for fractures in elderly patients.A retrospective review was performed of all patients treated with arthroplasty for acute proximal humerus fractures in an orthopedic practice using a Current Procedural Terminology code search, patient charts, and radiographs. Validated outcome scores were used to assess satisfaction, function, and general well-being. Twenty-three patients were treated for acute proximal humerus fractures (11 reverse total shoulder arthroplasties and 12 hemiarthroplasties). Three patients were lost to follow-up, and 6 patients were deceased. Mean follow-up was 3.6 years (range, 1.3-8 years). Reverse total shoulder arthroplasty outperformed hemiarthroplasty with regard to forward flexion, American Shoulder and Elbow Society score, University of Pennsylvania shoulder score, and Single Assessment Numerical Evaluation score.Reverse total shoulder arthroplasty is a reliable option for acute, proximal humerus fractures that are not amenable to closed treatment or reconstruction in elderly patients. Improved functional outcomes when compared with hemiarthroplasty must be balanced against the increased cost and limited life expectancy of patients with this injury., (Copyright 2012, SLACK Incorporated.)

Purpose: The follow-up results of bony union after an arthroscopic bony Bankart repair have not been reported. We studied follow-up computed tomography (CT) arthrograms to evaluate radiographic healing of bony Bankart fragments., Methods: Among 41 patients who underwent arthroscopy for a bony Bankart lesion between July 2006 and May 2009, 31 cases in 30 patients who had undergone sequential follow-up CT arthrography preoperatively, at 3 months postoperatively, and at 1 year postoperatively were enrolled. Radiologic patterns of fracture healing were classified into bony healing and fibrous healing. The mean age was 23.4 years, and the mean follow-up was 30.5 months. The mean interval from the first trauma to surgery was 32.5 months, and the mean preoperative dislocation number was 12.1., Results: The mean preoperative glenoid defect was 14.1%. The fracture healing patterns included 26 bony and 5 fibrous unions. There was a significant positive relation between the total dislocation number and the preoperative glenoid defect (P = .003). The proportion of the mean fragment dimension to a circle drawn through the outer cortex of the inferior glenoid was 8.4% preoperatively, 6.6% at 3 months postoperatively, and 6.2% at 1 year postoperatively. The fragment size decreased from that measured preoperatively to the size measured 3 months after surgery (P < .05). However, the fragment size was maintained between 3 months and 1 year postoperatively (P > .05). The mean Rowe score at 1 year postoperatively was 97.2., Conclusions: Follow-up CT arthrographic evaluation showed that small bony Bankart fragments survived without resorption until 1 year postoperatively, even with fibrous union, and that reattached bone fragment fixation to the anatomic position with the labrum could survive., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2012 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Evaluate the functional outcome of a specific program of rehabilitation during conservative treatment of fracture of the greater tuberosity., Methods: We retrospectively studied the records of 22 patients, with minimally displaced greater tuberosity fracture, according to inclusion criteria. All patients have received an early (one week after the injury) rehabilitation program based on physical analgesic therapy means, techniques for recovering range of motion, strengthening exercises, proprioceptive stabilization exercises and usability advices. The evaluation was done at baseline, one, two and three months of the end of physical treatment., Results: Pain, perceived disability and range of motion were improved significantly since the end of rehabilitation. The improvement of function (Constant score) was significant at different evaluation times. The functional result seems to be poor when patients are aged and pain is severe at baseline., Conclusion: During conservative treatment of fracture of the greater tuberosity, earlier rehabilitation allows rapid range of motion and functional recovery limiting care duration. After fracture healing, the rehabilitation program becomes similar to that advocated in rotator cuff disease. Whatever the initial treatment choice, rehabilitation must be considered at the waning of the first week., (Copyright © 2011 Elsevier Masson SAS. All rights reserved.)