This 2022 Cochrane review pooled 47 RCTs (3,179 adults) to determine whether surgery, specific surgical techniques, or rehabilitation timing produces better outcomes than non-surgical care for proximal humeral fractures. The population is predominantly older women with low-energy displaced fractures. It is the highest-certainty evidence synthesis available on this common injury.
An older woman with a displaced 3-part proximal humeral fracture after a ground-level fall arrives in your clinic. The instinct to operate is strong, but high-certainty evidence from 10 RCTs says surgery will not improve her shoulder function at 1 or 2 years compared to sling immobilization and rehabilitation.
Surgery doubles her risk of needing a second operation (RR 2.06). This is the number to communicate during consent — not as a reason to never operate, but as a concrete, evidence-backed risk that must be weighed against realistic functional benefit.
Reserve surgery for populations where this evidence does not apply: patients under 60, high-energy trauma, fracture-dislocations, and two-part tuberosity fractures. For those groups, no RCT data exists to guide the decision either way.
If arthroplasty is chosen for a complex fracture in an elderly patient, hemiarthroplasty carries a practical warning: every hemiarthroplasty failure in this review required RTSA salvage. Primary RTSA deserves serious consideration when arthroplasty is indicated.
This 2022 Cochrane review pooled 47 RCTs (3,179 adults) to determine whether surgery, specific surgical techniques, or rehabilitation timing produces better outcomes than non-surgical care for proximal humeral fractures. The population is predominantly older women with low-energy displaced fractures. It is the highest-certainty evidence synthesis available on this common injury.
An older woman with a displaced 3-part proximal humeral fracture after a ground-level fall arrives in your clinic. The instinct to operate is strong, but high-certainty evidence from 10 RCTs says surgery will not improve her shoulder function at 1 or 2 years compared to sling immobilization and rehabilitation.
Surgery doubles her risk of needing a second operation (RR 2.06). This is the number to communicate during consent — not as a reason to never operate, but as a concrete, evidence-backed risk that must be weighed against realistic functional benefit.
Reserve surgery for populations where this evidence does not apply: patients under 60, high-energy trauma, fracture-dislocations, and two-part tuberosity fractures. For those groups, no RCT data exists to guide the decision either way.
If arthroplasty is chosen for a complex fracture in an elderly patient, hemiarthroplasty carries a practical warning: every hemiarthroplasty failure in this review required RTSA salvage. Primary RTSA deserves serious consideration when arthroplasty is indicated.