Conservative treatment of nondisplaced fractures offers increased function, pain relief

Torrens, C. J Orthop Trauma. 2011. doi:10.1097/BOT.0b013e318210ed2f.

Surgeons who conservatively treat older patients with proximal humeral fractures should find a limited functional outcome but good pain relief and a higher quality of life, according to a recent prospective study.

Carlos Torrens, MD, and his colleagues catergorized 70 patients between the ages of 60 years and 85 years with two, three, and four-part fractures into two groups based on whether they had displaced or nondisplaced fractures. Researchers used the Constant score to measure functionality, as well as X-rays and CT scans to measure the fracture pattern. EuroQol-5D was also used as an outcome measure in the study.

The results showed significant differences in all Constant scores for displaced and nondisplaced fractures except for external rotation. The investigators found that nondisplaced fractures had a final Constant score of 73.58, where displaced fractures scored 59.41. Despite age differences, patients older than 75 years scored a Constant score of 54.63 but reported no additional quality of life issues when compared with the 75 years of age and under cohort, which scored 70.83.

Patients with two-part fractures achieved near complete pain relief with function, as indicated by a Constant score, of 65.88 and 71. Three-part fractures scored 54.64, while four-part fractures displayed the lowest results at 33.66.

William N. Levine

This is an important paper in that it asks the important question, “What proximal humeral fractures can be treated non-operatively?” While it does not completely answer that question it does show that elderly patients with minimally displaced fractures can do reasonably well with respect to pain relief. It is important to note, however, that function will be impaired with more severe fractures as indicated by the decreasing constant scores in this series.

While there is great enthusiasm recently for operative intervention with proximal humeral locking plates, arthroplasty, and reverse shoulder arthroplasty it is important to keep in mind that all of these interventions are also associated with significant complications. Ultimately, we are left trying to decide whether decreased function and little to no pain is better off than improved function and the potential for post-op complications.

The current study gives us some insight into this and future studies will be necessary to ultimately answer the question of who is the best patient on whom to recommend non-operative or operative intervention for proximal humeral fractures.

— William N. Levine, MD
Columbia University Medical Center
New York, NY

Disclosure: Levine has no relevant financial disclosures.

Proximal humeral fractures are common injuries and rank third in fractures of elderly patients, with over 90% of the patients being 60 years and older. The increased incidence in the older population is thought to be related to osteoporosis. The question remains, “Who will benefit from surgical treatment?”

According to current literature up to 80% of the proximal humeral fractures are non-displaced fractures or fractures with minimal displacement and adequate stability that can successfully be treated non-operatively. The recent study by Torrens et al. provides an interesting view on the conservative treatment of proximal humerus fractures in elderly patients. The results clearly demonstrate that outcomes decrease with increasing age and the severity of the fracture. Despite this demonstrable limitation of function, particularly in patients older than 75 years, the patients in this group seemed to be satisfied with their treatment. The study underlines the fact that non-displaced proximal humerus fractures can successfully be treated non-operatively.

For displaced fractures, a myriad of operative options now exist. We can achieve stable internal fixation, even in osteoporotic bone, using modern implants, such as locking plates. Techniques for percutanous fixation, although not always ideal for osteoporotic bone, do offer minimally invasive options which may decrease perioperative morbitidy. New prosthesis designs, both hemiarthroplasty and reverse arthroplasty, have been designed specifically for the treatment of proximal humerus fractures. While we hope that these treatments may offer improved outcomes for our patients, it is important to have studies such as the one from Torrens et al. to serve as a benchmark. The treatment options of displaced and multifragmentary fractures need to be discussed with the patient. Ultimately the individual treatment decision should be made based on a variety of factors that include the patient’s respective biological age, comorbidities, fracture pattern, and expectations and perhaps most importantly the surgeon’s skill.

— Peter J. Millett, MD, MSc
Frank Martetschläger, MD
Vail, CO

Disclosure: Millett is a consultant for and receives royalties from Arthrex.

In this interesting study of non-operatively treated proximal humerus fractures, there is decreased function with increased fracture displacement and patient age. Of note with higher grade fractures, the un-injured arm’s function in many categories was worse than the injured arm of lower grade fractures. This might indicate that there is an overall lower pre-injury functional level in patients who sustain more severe fractures.

Despite the decrease in functional outcomes with worse fractures and increased age, there was no such correlation noted in patient reported quality of life. This is in line with recently published data by Slobogean et al.1 that found objective measures comprise only a fraction of patient reported outcomes. To further complicate matters, despite improvement in objective outcomes with surgical management of proximal humerus fractures, it is unclear how much subjective improvement can be expected when compared to non-operative treatment.

In conclusion, exact indications for who should undergo surgical treatment is unclear. Further studies are clearly needed. When deciding between non-operative and surgical treatment options, a patient’s overall functional demands and expectations must be taken into account. Based on this study, lower demand older patients even with displaced fractures may be considered for treatment with a short period of sling wear and early rehab.

— Scott G. Kaar, MD
Department of Orthopaedic Surgery
Saint Louis University
Saint Louis, MO

Disclosure: Kaar has no relevant financial disclosures.

Reference:
1. Does objective shoulder impairment explain patient-reported functional outcome? A study of proximal humerus fractures. Slobogean GP, Noonan VK, Famuyide A, O'Brien PJ. J Shoulder Elbow Surg. 2011 Mar;20(2):267-72.