Clinical outcomes of conservative versus surgical treatment for patients with proximal humeral fracture before physiotherapy.

Fear of movement, pain, and loss of shoulder function are the most common problems irrespective of their approach to management after proximal humeral fracture (PHF). However, it has been unclear whether there could be differences between both treatments in early clinical outcomes. It can help physiotherapists to guide in choosing treatment approaches. This study aimed to compare kinesiophobia, pain, range of motion (ROM), shoulder function, and Quality of life (QoL) in patients treated with either conservative (CT) versus surgical (ST) after PHF. In addition, it aimed to determine correlations between fear of movement and seconder outcome measures. This cross-sectional study enrolled the patients having 5-6 weeks (being permitted active movement) after being treated either CT or ST and receiving no physical therapy. Pain, passive and active ROMs, shoulder function, fear of movement, and QoL were evaluated. 42 patients were recruited. Kinesiophobia scores were similar (p=0.55) and moderate in both groups. There was a significant difference in degrees of shoulder active flexion, active and passive abduction in favor of the CT group (p=0.05, p=0.02, p=0.04, respectively). However, there was no difference between groups regarding the remaining clinical outcomes. Furthermore, kinesiophobia showed a moderate negative correlation with energy/fatigue, social functioning, and general health. These findings showed that patients treated surgically did not have more kinesiophobia, less function, and QoL before starting physiotherapy, despite having soft tissue damage and different types of fractures. However, surgically treated patients had significantly less range of motion.

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients-which scores can be evaluated by a telephone-based assessment?

BACKGROUND: The aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders. METHODS: Ninety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score. RESULTS: In the first and second interview, we could state fair outcomes: CS 91 (range 40-100) and 65.5 (23-86), DASH 12.5 (0-64.2) and 18.3 (0-66.7), and OSS 58 (33-60) and 55 (25-60) points. The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of - 22.3, 4.9, and - 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74). CONCLUSION: Patients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients. TRIAL REGISTRATION: (250/2011BO2).

Underlying Mental Illness and Psychosocial Factors Are Predictors of Poor Outcomes After Proximal Humerus Repair.

OBJECTIVES: (1) To assess the correlation of psychosocial factors and long-term outcomes of proximal humerus fractures all in surgical repair; (2) to identify specific psychosocial factors with favorable and unfavorable outcomes; and (3) to assess the correlation between DSM-V mental health diagnoses and long-term Disabilities of Arm, Shoulder, and Hand (DASH) scores. DESIGN: Prospective cohort study. SETTING: Academic medical center. PATIENTS: Patients were screened and identified on presentation to the emergency department or in the clinical office for inclusion in an institutional review board-approved registry. One hundred eighty-five proximal humerus fractures of 247 met inclusion criteria. INTERVENTION: Surgical repair of proximal humerus fractures. MAIN OUTCOME MEASURE: All patients were prospectively followed up and assessed for clinical and functional outcomes at latest follow-up visit (mean = 24.8 months) using the DASH questionnaires along with ranges of motion and pain level. Psychosocial factors at 3 months were obtained from the DASH survey. RESULTS: Concomitant diagnosis of depressed mood (P = 0.001), anxiety (P < 0.0005), low energy level (P = 0.003), and fatigue (P = 0.001) correlated significantly with poorer outcome. All 6 psychosocial factors correlated directly and significantly with pain at latest follow-up (P < 0.0005). Multiple regression analysis revealed that the strongest predictor of the overall DASH score was the extent of interference with social life (P = 0.001). CONCLUSION: Analysis demonstrated that psychological and social factors at 3 months postoperatively have a strong correlation with negative long-term (>1 year) outcomes after proximal humerus fixation. Clinicians may offer psychological support and encourage social support to these patients postoperatively to improve pain and treatment outcomes. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results.

BACKGROUND: On the basis of patients' demands, bone quality, and fracture type, we developed an evidence-based treatment algorithm for proximal humerus fractures (PHF) that includes all treatment modalities from open reduction and internal fixation, hemiprosthesis, to reverse total shoulder arthroplasty. This study was done to assess its feasibility and early clinical outcome. MATERIALS AND METHODS: Patients with isolated PHF in 2014 and 2015 were included in this prospective study. The quality of life (EQ-5D) and the level of autonomy before injury were recorded. The fractures were classified and local bone quality was measured. When possible, patients were treated according to the algorithm. Radiographic and clinical follow-up-Constant score, subjective shoulder value, and EQ-5D-took place after 3 months and 1 year. The rate of unplanned surgery was analyzed. RESULTS: A total of 192 patients (mean age 66 years; 58 male, 134 female) were included. Of these, 160 (83%) were treated according to the algorithm. In total, 132 patients were treated conservatively, 36 with open reduction and internal fixation and 24 with reverse total shoulder arthroplasty or hemiarthroplasty. Generally, the mean EQ-5D before trauma and 1 year after treatment was equal to 0.88 to 0.9 points. After 1 year, the overall mean relative Constant score was 95% and mean subjective shoulder value 84%. Unplanned surgery was necessary in 21 patients. CONCLUSION: This comprehensive algorithm is designed as a noncompulsory treatment guideline for PHF, which prioritize the patient's demands and biology. The high adherence proves that it is a helpful tool for decision making. Furthermore, this algorithm leads to very satisfying overall results with low complication and revision rates.

Outcome after operative treatment of proximal humeral fractures in elderly patients.

BACKGROUND: The proximal humeral fracture (PHF) (5 %) of the elderly is the third most common fracture after proximal femoral and distal radius fractures. Proximal femoral fractures often lead to a loss of autonomy. OBJECTIVES: The aim of this study is to show how PHF changes the patient's autonomy and the coping with everyday life as well as which factors influence the outcome 1 year (y) after surgery. MATERIALS AND METHODS: Data of 62 patients with surgical treatment of a PHF ≥ 60 y was prospectively collected. With a telephone interview Short Form (SF) 12 (physical and mental health; PH, MH), Barthel Index (BI), range of motion, pain, and satisfaction was observed after 3 and 12 months. The dependence of outcome on different factors was investigated. RESULTS: The mean age was 73.3 y (median 73, 60-94). Mortality after 3 months was 3 % and after 1 y 11 %. The PH before the injury (47.9) was significantly better than after 3 months (37.1) and after 1 y (42.6). The MH showed no difference. The BI before the injury (92) was significantly better than after 3 months (86), but the same after 1 y (91). After 1 y > 50 % were able to abduct and flex the arm > 90°. More than two-thirds were able to perform everyday life activities for body care and nutrition after 1 y. Approximately, 73 % of the patients had little or no pain, and 84 % were satisfied with the result after 1 y. Good score values before the fracture resulted in better outcome. Higher severity in fracture led to a higher level of pain. DISCUSSION: A surgically treated PHF in the elderly does not lead to a relevant impairment in quality of life. Despite the lack of complete retrieval of range of motion patients achieve a good to very good result in coping with everyday life.

[Proximal humeral fractures in the elderly : Quality of life, clinical results and institutionalization following primary reverse fracture arthroplasty]. / Proximale Humerusfraktur im fortgeschrittenen Lebensalter : Lebensqualität, klinische Ergebnisse und Institutionalisierung nach primärer inverser Frakturprothesenimplantation.

BACKGROUND: Treatment of humeral head fractures in the elderly remains a challenge. Within the framework of demographic change the incidence as well as the direct and indirect consequences of injuries will rise. The analysis of an optimal treatment should include functional parameters as well as global health parameters, e.g. quality of life. OBJECTIVE: The aim of this study was the evaluation of functional outcome, institutionalization (necessity of placement in a residential care home for the elderly, even if temporary), the influence of cognitive deficits, quality of life and the pattern of complications after primary reverse shoulder arthroplasty. MATERIAL AND METHODS: The study included a total of 34 patients (mean age 79.8 ± 6.7 years, 29 female) after implantation of a reversed modular fracture arthroplasty. The mean follow-up was 23 ± 10.6 months). The functional Constant-Murley score (CS), radiology results as well as the extent of institutionalization and quality of life as measured by the EQ-5D questionnaire were collated. RESULTS: The clinical examination showed good results in the CS (54 points, SD ± 9). In comparison to the age and gender-related CS according to Gerber the patient scores amounted to 78.9 %. The comparison of patients with and without cognitive deficits did not show any differences (53 vs. 54 points, p = 0.6525). The rate of institutionalization after treatment of humeral head fractures by reversed fracture arthroplasty was 2.94 %. The quality of life measured with EQ-5D showed a health-related quality of life (HRQoL) of 0.801. The rate of complications was 2.94 % involving an incomplete lesion of the radial nerve which was in regression. CONCLUSION: The results of this study showed good to moderate functional results, very low rates of complications and institutionalization and very good results according to the HRQoL. In comparison to conservative treatment or plate osteosynthesis, better results were achieved in this study with respect to HRQoL.

Economic and social impact of upper extremity fragility fractures in elderly patients.

BACKGROUND: Fragility fractures of the proximal humerus and distal radius can have a significant impact on the elderly population, both economically and physically. Limited data are available to demonstrate the functional and economic impact of upper extremity fragility fractures. AIMS: To investigate the economic and social impact that proximal humerus fragility fractures may have on an older population. METHODS: A retrospective chart review for patients ≥50 years old treated as an inpatient at a local hospital between 2006 and 2012 for a proximal humerus or a distal radius fracture was done. Patients were divided into two groups to show age impact; Group 1 = 50-79 years old and Group 2 = 80 years and older. Eighty-six charts were reviewed, 38 for Group 1 and 48 for Group 2. Demographic, admission, inpatient, and discharge data were compared between groups. RESULTS: A third of patients in each group had a previous fragility fracture. Inpatient length of stay was comparable between groups. Surgical treatment was used at a higher rate in the younger cohort (p = 0.06). Approximate average hospital charges for an inpatient surgical treatment were about twice those of the non-surgically treated patients. DISCUSSION: Our results illustrate the significant burden of upper extremity fractures in terms of loss of independence, inpatient hospitalizations and prolonged nursing home or rehabilitation needs, which account for considerable health care costs. CONCLUSION: Fractures of the humerus, forearm and wrist account for one-third of the total incidence of fractures and can be a significant burden to individuals and the community.

Treatment of proximal humerus fractures in the elderly: a systemic review of 409 patients.

BACKGROUND AND PURPOSE: There is no consensus on the treatment of proximal humerus fractures in the elderly. PATIENTS AND METHODS: We conducted a systematic search of the medical literature for randomized controlled trials and controlled clinical trials from 1946 to Apr 30, 2014. Predefined PICOS criteria were used to search relevant publications. We included randomized controlled trials involving 2- to 4-part proximal humerus fractures in patients over 60 years of age that compared operative treatment to any operative or nonoperative treatment, with a minimum of 20 patients in each group and a minimum follow-up of 1 year. Outcomes had to be assessed with functional or disability measures, or a quality-of-life score. RESULTS: After 2 independent researchers had read 777 abstracts, 9 publications with 409 patients were accepted for the final analysis. No statistically significant differences were found between nonoperative treatment and operative treatment with a locking plate for any disability, for quality-of-life score, or for pain, in patients with 3- or 4-part fractures. In 4-part fractures, 2 trials found similar shoulder function between hemiarthroplasty and nonoperative treatment. 1 trial found slightly better health-related quality of life (higher EQ-5D scores) at 2-year follow-up after hemiarthroplasty. Complications were common in the operative treatment groups (10-29%). INTERPRETATION: Nonoperative treatment over locking plate systems and tension banding is weakly supported. 2 trials provided weak to moderate evidence that for 4-part fractures, shoulder function is not better with hemiarthroplasty than with nonoperative treatment. 1 of the trials provided limited evidence that health-related quality of life may be better at 2-year follow-up after hemiarthroplasty. There is a high risk of complications after operative treatment.

Responsiveness of the EQ-5D in patients with proximal humeral fractures.

BACKGROUND: This study evaluated the internal and external responsiveness of the EuroQol EQ-5D (EuroQol Group, Rotterdam, The Netherlands) health status component, defined as the instrument's ability to capture clinically important changes in patients with a proximal humeral fracture within the context of a prospective study. MATERIALS AND METHODS: To evaluate the internal responsiveness of the EQ-5D, the observed change and the standardized response mean (SRM) in relation to the change in the EQ-5D(index) score were calculated. To calculate external responsiveness, an external criterion (EC) was constructed by using the Disabilities of the Arm, Shoulder and Hand (DASH) score. Receiver operating characteristic (ROC) curves and logistic regression analysis were used in the evaluation. RESULTS: The mean change score from prefracture status to the 4-month follow-up for the EQ-5D was -20.9 and the corresponding SRM was 0.90, indicating good internal responsiveness. The clearly improved or clearly deteriorated patients according to the EC (DASH) reported change scores of approximately 12 points in the EQ-5D, corresponding to moderately strong SRMs, which, together with the results of the ROC analyses and logistic regression, indicated a good external responsiveness. CONCLUSION: The EQ-5D displayed good internal and external responsiveness in patients with proximal humeral fractures and can be recommended for use as a quality of life measure in patients with this particular injury.

Measuring shoulder injury function: common scales and checklists.

The increasing shift towards patient-centred healthcare has lead to an emergence of patient-reported outcome instruments to quantify functional outcomes in orthopaedic patients. Unfortunately, selecting an instrument for use in a shoulder trauma population is often problematic because most shoulder instruments were initially designed for use with chronic shoulder pathology patients. To ensure an instrument is valid, reliable, and sensitive to clinical changes, it is important to obtain psychometric evidence of its use in the target population. Four commonly used shoulder outcome instruments are reviewed in this paper: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES); Constant-Murley shoulder score (CMS); Disabilities of Arm, Shoulder, and Hand (DASH); Oxford Shoulder Score (OSS). Each instrument was reviewed for floor or ceiling effects, validity, reliability, responsiveness, and interpretability. Additionally, evidence of each instrument's psychometric properties was sought in shoulder fracture populations. Based on the current literature, each instrument has limited amounts of evidence to support their use in shoulder trauma populations. Overall, psychometric evaluations in isolated shoulder fracture populations remain scarce, and clinicians must remember that an instrument's properties are defined for the population tested and not the instrument. Therefore, caution must always be exercised when using an instrument that has not been fully evaluated in trauma populations.

Quality of life and functional outcome after a 2-part proximal humeral fracture: a prospective cohort study on 50 patients treated with a locking plate.

BACKGROUND: The aim of the study was to report the 2-year outcome after a displaced 2-part fracture of the proximal humerus in elderly patients treated with a locking plate, including an assessment of the health-related quality of life (HRQoL). MATERIAL AND METHODS: We included 50 patients, mean age 75 (range, 55-93) years with 80% women. The fracture inclusion criteria were a displacement of the shaft of >50% of its width and/or >45 degrees of angulation. Follow-up examinations were performed at 4, 12, and 24 months. The main outcome measures were the Constant and DASH scores and HRQoL according to the EQ-5D. RESULTS: Eight patients (16%) were re-operated upon during the study period. At the final follow-up the mean Constant score was 61 and the mean DASH score 32. The EQ-5D (index) score decreased from 0.86 before the fracture to 0.62 at 4 months. At 12 months the EQ-5D (index) score was 0.65 and at 24 months 0.68. The values at all follow-ups were significantly lower than before the fracture (P < .001 in all 3 comparisons). CONCLUSION: Locking plates appear to be a good treatment alternative in elderly patients with a displaced 2-part fracture of the surgical neck of the proximal humerus with an acceptable complication rate and an acceptable functional outcome; however, rigorous attention has to be paid to avoid screw penetration. Despite the overall acceptable functional outcome, the patients reported a substantial negative effect upon their HRQoL.

[Central-medullary nailing of proximal humerus fractures using T2 nails. A retrospective study of 38 cases]. / Enclouage centromédullaire des fractures de l'extrémité proximale de l'humérus par clou T2. Etude rétrospective de 38 cas.

The intramedullary nailing of humerus has emerged as one of the treatments of reference for proximal fractures. We have reviewed 38 patients aged 64.2 on average with a mean follow of 18 months. The functional scores used were the Constant and Murley's score as well as the DASH self-administered quality of life questionnaire. Radiological criteria have been analyzed, namely the cephalic angle noted alphaF and the presence of any osteolysis of the major tuberosity. Patients were grouped by type of fracture, according to Neer's classification, with nine cases in Neer 2 group, 19 in Neer 3 group, and ten in Neer 4 group. The unrefined Constant score was 53.4 points on average, balanced to 71.6%. The joint mobilities were an average forward elevation of 108 degrees, an average abduction of 100 degrees and an external rotation of 27 degrees. These scores were even worse than the fracture was comminuted. It was not found a radioclinical correlation between value of the angle alphaF and clinical outcome, but the presence of osteolysis of the major tuberosity was significantly associated with poor late functional results. Five cases of osteonecrosis have been counted, divided with 10.5% in the Neer stage 3, and 30% in the Neer stage 4. The average unrefined Constant score from these patients was 38.5 points on average, balanced to 57.7%. Intramedullary nailing allows fixation of comminuted fractures with three or four fragments, but control of fixing and strength of assembly were not always practiced. In young patients, where tuberosities consolidation is essential, screwed plates seem to be a favorable alternative. Moreover, total reverse prosthesis seems to have more and more arguments to impose itself like the preferred treatment towards fractures in four fragments in people aged over 75 years.