Do shoulder fractures need surgery?

Fractures that occur at the upper end of the humerus near the shoulder (called humeral neck fractures) are common. They are often treated with surgery despite a lack of supporting evidence for this, particularly in older, osteoporotic patients. Now, thanks to a recent study from the UK, it is possible that most of these fractures don’t need surgery, even in young patients. This is big news, but will this research jump the gap from research into practice and influence the decision making of the end users – the patient and their surgeon?

Humeral neck fractures are one of the most common fractures in the elderly but they can occur from falls or accidents at any age. They come in many shapes and sizes. The ones that are not very displaced do not need surgery. The ones that are associated with dislocations of the shoulder joint are treated surgically. However, for all the ones in between – the displaced fractures – the decision making is not so clear.

Current decision making
Like a lot of other fractures, we know that we can make the X-ray look better if we operate to put the broken pieces back in alignment, or if we replace the broken bits with an artificial shoulder joint. This is what is commonly done for displaced fractures, but are we just treating the X-ray and not the patient?

Fractures in older patients
There has always been some debate about the advisability of surgery in this group of patients. The advantages of making the X-ray look better are balanced against the risk of failure due to the screws coming loose in the soft bone, infection, further fracturing, dislocation of the joint, and other general surgical complications, all of which are a little more common in frail patients.

The evidence up to now
There have been several randomised trials comparing surgery to non-operative treatment for displaced fractures, starting from the 80’s. In a review of these studies (here), it was shown that there is very little evidence that our attempts to fix things up with surgery make any difference to the patients in terms of their pain or shoulder function. In fact, the only difference is that surgery tends to lead to more complications and more secondary surgery than non-operative treatment.

The practice up until now
There has always been considerable practice variation, with some surgeons treating many of these with surgery, and other surgeons treating most of them without surgery. And the decision making for each type of surgeon was not based on solid science – more of a feel. Over the years I have seen young surgeons who were very keen to fix these, thinking that they will make the patient better by making the X-ray better, and then seen these surgeons reverse their practice after a few unfavourable cases and treat most of them non-operatively.

Despite evidence showing a lack of benefit with surgery, practice still varies between surgeons and as long as newer implants are being introduced, there is always someone that believes that the new implant will be the answer to this problem. The introduction of “fixed-angle” or “locking” screws in plates was an example of this. It was widely taken up but has failed to deliver benefits to patients. I must admit that the studies up until now (that show surgery to be of no benefit) have not been without flaws, but that shouldn’t allow us to assume that the results from these studies are all wrong. There are still no good studies supporting surgery.

The evidence now
A study released in 2015 in JAMA (here) has provided good evidence that surgery is not necessary for most of these displaced fractures. There are two things about this study that I would like to highlight. Firstly, it is a good study that is likely to be generalisable to practice in most developed countries. This is because it is a “pragmatic” study (my favourite type) because it took all comers and left it to the surgeons as to what operation they thought would be best (in the group that was randomised to surgery) therefore reflecting real life. Secondly, unlike the previous studies, it recruited all patients aged 16 and over, not just older patients. I thought this was a big call because the assumption has always been (admittedly in the absence of evidence) that surgery was beneficial for younger patients, in whom there was a lower likelihood of the implants coming loose.

They recruited 250 patients from 32 centres across the NHS with fractures that the surgeons thought would benefit from surgery, and then randomised them to having surgery or non-operative treatment. They had good follow up and measured the results up to two years. Other aspects of the study were very good and they only excluded very bad fractures (dislocations of the joint or cases where the bone was pushing under the skin). There was no meaningful differences between the groups in the outcomes measured (shoulder function, quality of life etc.), including in the younger patients where, if anything (and surprisingly), the non-operative group did slightly better.

The bottom line
The lure of newer implants, of making bones line up and of actively doing something has led doctors to treat many of these common fractures with surgery, despite a lack of evidence of any benefit, and some evidence of a lack of benefit. Now there is high quality evidence that surgery is of no benefit for most of these fractures. I am interested to see if this will change the way people treat these fractures. I think it will, but these things take time.