***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Background Fractures of the proximal humerus are associated with a profound temporary and sometimes permanent , impairment of function and quality of life . The treatment of comminuted fractures of the proximal humerus like selected three-or four-part fractures and split fractures of the humeral head is a dem and ing and unresolved problem , especially in the elderly . Locking plates appear to offer improved fixation ; however , screw cut-out rates ranges due to fracture collapse are high . As this may lead to higher rates of revision surgery , it may be preferable to treat comminuted fractures in the elderly primarily with a prosthesis or non-operatively . Results from case series and a small- sample r and omized controlled trial ( RCT ) suggest improved function and less pain after primary hemiarthroplasty ( HA ) ; however these studies had some limitations and a RCT is needed . The primary aim of this study is to compare the Constant scores ( reflecting functional outcome and pain ) at one year after primary HA versus non-operative treatment in elderly patients who sustained a comminuted proximal humeral fracture . Secondary aims include effects on functional outcome , pain , complications , quality of life , and cost-effectiveness . Methods / Design A prospect i ve , multi-center RCT will be conducted in nine centers in the Netherl and s and Belgium . Eighty patients over 65 years of age , who have sustained a three-or four part , or split head proximal humeral fracture will be r and omized between primary hemiarthroplasty and conservative treatment . The primary outcome is the Constant score , which indicates pain and function . Secondary outcomes include the Disability of the Arm and Shoulder ( DASH ) score , Visual Analogue Scale ( VAS ) for pain , radiographic healing , health-related quality of life ( Short-form-36 , EuroQol-5D ) and healthcare consumption . Cost-effectiveness ratios will be determined for both trial arms . Outcome will be monitored at regular intervals over the subsequent 24 months ( 1 , 3 and 6 weeks , and 3 , 6 , 12 , 18 , and 24 months ) . Data will be analyzed on an intention to treat basis , using univariate and multivariable analyses . Discussion This trial will provide level-1 evidence on the effectiveness of the two mostly applied treatment options for three-or four part and split head proximal humeral fractures in the elderly . These data may support the development of a clinical guideline for treatment of these traumatic injuries . Trial registration Netherl and s Trial Register ( NTR ) : Abstract Background Surgical treatment for displaced proximal humeral fractures is widely used . However , there are very few r and omized controlled studies comparing surgical treatment to conservative treatment , and the evidence is debated . The aim of this study was to describe patients with displaced proximal humeral fractures in a 2-years extension of a r and omized controlled trial , their functional outcome and quality of life .  Material s and methods Patients from a single-center r and omized controlled study of fifty patients aged 60 or above with displaced proximal humeral fracture ( AO/OTA group B2 or C2 ) were r and omized to surgical or conservative treatment . Surgery was performed with an angular stable implant . The main outcome was Constant score at 2-year follow-up . Secondary outcomes were an ASES self- assessment form , the 15D quality of life assessment and radiographs at 2 years . Results A marked improvement of shoulder function and health-related quality of life for both surgically and conservatively treated patients occurs between 6 and 12 months . Almost no change was observed between 1 and 2 year . There were no significant differences between the two treatments at 2-year follow-up . Conclusions In this r and omized controlled trial , surgical treatment proved no better results than conservative treatment for patients with displaced proximal humeral fracture at 2-year follow-up The purpose of this single-center , r and omized , controlled trial was to report on the 2-year outcomes of proximal humerus fractures in elderly patients treated with open reduction and internal fixation ( ORIF ) with either a locking plate or shoulder hemiarthroplasty .  Thirty-two patients ( 87 % women ) with a mean age of 71.9 years ( range , 67 - 86 years ) were treated with ORIF with either a locking plate or shoulder hemiarthroplasty after shoulder injury . The main outcome measures were the Constant score , Disabilities of the Arm , Shoulder and H and ( DASH ) score , and health-related quality of life ( HRQoL ) according to the EQ-5D ( EuroQol Group , Rotterdam , The Netherl and s ) . At final 2-year follow-up , DASH and pain scores favored the shoulder hemiarthroplasty group . Mean flexion was 129 ° in the shoulder hemiarthroplasty group and 117 ° in the ORIF group ( P=.27 ) , and mean abduction was 123 ° in the shoulder hemiarthroplasty group and 111 ° in the ORIF group ( P=.41 ) . In the shoulder hemiarthroplasty group , the EQ-5D index score decreased from 0.85±0.21 before injury to 0.65±0.14 at 4 months postoperatively . The score was 0.79±0.24 at 12 months postoperatively and 0.81±0.17 at 24 months postoperatively . The results of this study indicate an advantage in functional outcomes and HRQoL favoring shoulder hemiarthroplasty compared with ORIF with a locking plate , although most outcomes were not significantly different Background Fractures of the proximal humerus are common injuries and account for 4–5 percent of all fractures , second only to hip and wrist fractures . The incidence is positively correlated with age and osteoporosis , and is likely to increase . Displaced four-part fractures are among the most severe injuries , accounting for 2–10 percent of proximal humeral fractures . The optimal intervention is disputed . Two previous r and omised trials were very small and involved a noticeable risk of bias , and systematic review s consequently conclude that there is inadequate basis for evidence -based treatment decisions . We aim to compare the effect of osteo synthesis with angle-stable plate with non-surgical management , and the effect of  primary hemiarthroplasty  with both osteo synthesis and non-surgical management . Methods / Design We will conduct a r and omised , multi-centre , clinical trial including patients from ten national shoulder units within a two-year period . We plan to include 162 patients . A central r and omisation unit will allocate patients . All patients will receive a st and ardised three-month rehabilitation program of supervised physiotherapy regardless of treatment allocation . Patients will be followed at least one year . The primary outcomes will be the overall score on the Constant Disability Scale , and its pain subscale , measured at 12 months . A blinded physiotherapist will carry out the assessment s. Other secondary outcomes are Oxford Shoulder Score , and general health status ( Short Form-36 ) BACKGROUND Monoaxial and polyaxial screw insertion are used in angular stable plating of displaced proximal humeral fractures . Aim of the study was to compare both fixation techniques by radiographic evaluation . METHODS Prospect i ve r and omized treatment with monoaxial or polyaxial screw insertion in angular stable anatomic preshaped plates of displaced proximal humeral fractures . Analysis of st and ardized true anterior-posterior ( true a.p . ) and outlet-view radiographs at 1 day , 6 weeks , 3 months , and 6 months after surgery by two radiologists with respect to radiographic evidence of secondary varus displacement , cut out of screws , osteonecrosis , and hardware failure . Secondary varus displacement was defined as a varus decrease of the humeral head-shaft angle of > 10 degree in true a.p . radiographs . RESULTS Sixty-six consecutive patients ( 48 women , [ 72.7 % ] ; 18 men , [ 27.3 % ] ; mean age 67.7 years [ 95 % CI , 63.9 - 71.6 ] ) with displaced proximal humeral fractures were evaluated in this study . Nineteen patients ( 29 % ) showed secondary varus displacement of > 10-degree angle . In 6 cases ( 9 % ) , intra-articular cut out of screws was found . Furthermore , 1 case ( 2 % ) of nonunion was observed . No relationship between monoaxial and polyaxial screw insertion was found regarding occurrence of secondary varus displacement ( monoaxial , 11/polyaxial , 8 ; p = 0.91 ) or screw cut out ( monoaxial , 4/polyaxial , 2 ; p = 0.64 ) . Prevalence of secondary varus displacement and hardware cut out was related to patients age ( p = 0.02 ) and fracture pattern , according to Neer- and AO/OTA-classification ( p < 0.001 ) . The average immediate postoperative head-shaft angle was 135.2 degrees ( CI , 132.3 - 138.1 ) in the group without radiographic complication , compared with 126.7-degree angle ( CI , 123.6 - 129.7 ) among those with secondary varus displacement of > 10-degree angle and screw cut out ( p < 0.001 ) . Furthermore , in cases of an immediate postoperative head-shaft angle of < 130 degrees , there was a 48 % incidence of secondary varus dislocation ( n = 13 ) versus 15 % in cases with a head-shaft angle > 130 degrees ( n = 6 , p = 0.004 ) . CONCLUSION Monoaxial and polyaxial screw insertion allow for mechanical stabilization in angular stable plating of unstable proximal humerus fractures . Radiographic evidence of secondary varus displacement of > 10-degree angle and screw cut out was seen similarly often in both fixation techniques . To avoid secondary varus displacement and screw cut out , restoration of a humeral head-shaft angle of > 130 degrees seems to be important in monoaxial and polyaxial fixation of proximal humeral fractures Background The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear . Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteo synthesis . In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteo synthesis in terms of speed of recovery , pain , patient satisfaction , functional outcome , quality of life or complications . Methods / Design A r and omized controlled multicenter trial will be conducted . Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included . Exclusion criteria are a fracture older than 14 days , multiple comorbidity , multitrauma , a pathological fracture , previous surgery on the injured shoulder , severely deranged function caused by a previous disease , " head-split " proximal humerus fracture and unwillingness or inability to follow instructions . Participants will be r and omized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteo synthesis . Measurements will take place preoperatively and 3 months , 6 months , 9 months , 12 months and 24 months postoperatively . Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm , Shoulder and H and score ( DASH ) . Secondary outcome measures are pain , patient satisfaction , shoulder function , quality of life , radiological evaluation and complications . Data will be analyzed on an intention-to-treat basis , using univariate and multivariate analyses . Discussion Both hemiarthroplasty and angle-stable locking compression plate osteo synthesis are used in the current treatment of dislocated three- and four-part fractures of the proximal humerus . There is a lack of level-1 studies comparing these two most-used surgical treatment options . This r and omized controlled multicenter trial has been design ed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb , and will provide better outcomes in pain , satisfaction , shoulder function , quality of life , radiological evaluation and complications . Trial registration numberThe trial is registered in the Netherl and s Trial Registry ( NTR2461 Purpose The purpose of this study was to evaluate the clinical benefit of medial support screws for locking plating of proximal humerus fractures . Methods Seventy-two consecutive patients underwent prospect i ve treatment for proximal humerus fractures with locking plates between October 2007 and September 2008 . Sixty-eight patients accomplished a mean 30.8-month follow-up and were r and omized into two groups : 39 patients were treated with only a locking plate and were classified in the –MSS ( medial support screw ) group , and 29 patients were included in the + MSS group , which were fixed with additional medial support screws .  Clinical and radiological investigations were performed in both groups . Results The fractures united at an average of 13.6 weeks after final surgery . Comparably better shoulder function recovery was achieved in the + MSS group with regard to the Constant shoulder score ( P = 0.01 ) , with the respective excellent and good rates of 79 % and 62 % . Eleven patients developed various complications . A statistical difference ( P = 0.036 ) was observed regarding the failure rate ( 23.1 % in the −MSS group vs. 3.4 % in the + MSS group ) . The early loss of fixation was related to higher age ( P < 0.001 ) and less initial neck-shaft angle ( NSA ) ( P = 0.011 ) of the patients 
    Output:
    
This found some evidence that early mobilisation result ed in better recovery and less pain in people with mainly minimally displaced fractures .
One trial ( 68 participants ) produced some preliminary evidence that tended to support the use of medial support locking screws in locking plate fixation .
There is high or moderate quality 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 involving the humeral neck and is likely to result in a greater need for subsequent surgery .
The evidence does not cover the treatment of two-part tuberosity fractures , fractures in young people , high energy trauma , nor the less common fractures such as fracture dislocations and head splitting fractures .
There is insufficient evidence from RCTs to inform the choices between different non-surgical , surgical , or rehabilitation interventions for these fractures