Early active motion may be noninferior to immobilization for proximal humeral fractures
Key takeaways:
- For patients with humeral fractures, early active motion yielded similar postoperative outcomes to conventional sling immobilization.
- Both cohorts had similar functional and quality of life scores at 2 years.
Published results showed early functional rehabilitation with no range of motion or force restrictions yielded similar outcomes as sling immobilization after surgical fixation of a proximal humerus fracture.
“We could demonstrate, that early active motion rehabilitation for postoperative treatment after locking plate fixation of proximal humerus fractures was not inferior to a restrictive treatment protocol after a follow-up period of 24 months, even in a slightly older and more comorbid patient population,” Ulrich Crepaz-Eger, MD, from the department of orthopedics and traumatology at the Medical University of Innsbruck in Austria, and colleagues wrote in the study. “A nonsignificant trend towards higher patient satisfaction was observed in the [early functional group].”
Crepaz-Eger and colleagues performed a prospective randomized controlled trial of 41 patients who underwent open reduction and internal fixation with a locking plate for a proximal humerus fracture between March 2016 and February 2023. Patients had 2 years of follow-up.
Crepaz-Eger and colleagues randomly assigned 21 patients (mean age, 65 years) to undergo an early active motion rehabilitation protocol with no range of motion or force restrictions starting on postoperative day 1 and 20 patients (mean age, 58 years) to undergo conventional rehabilitation with sling immobilization for 4 weeks.
Outcomes were assessed at 6-month, 1-year and 2-year follow-ups and included Constant scores, DASH scores, EuroQol-5D scores, VAS pain scores and patient satisfaction.
Overall, three complications were found in the early active motion cohort, while six complications were found in the immobilization cohort.
At 2 years, mean Constant score was 77.6 in the early active motion cohort and 81.3 in the immobilization cohort, while mean DASH score was 13.8 in the early active motion cohort and 15.9 in the immobilization cohort. Crepaz-Eger and colleagues noted both cohorts reached 89.8% of mean Constant scores compared with the uninjured limb.
In addition, Crepaz-Eger and colleagues found no significant differences in EQ-5D scores, VAS pain score or patient satisfaction between the groups. However, they found a statistically nonsignificant trend toward increased patient satisfaction in the early active motion cohort.
Perspective
Back to Top
This study by Ulrich Crepaz-Eger, MD, and colleagues mirrors what I have subjectively seen in my practice over the years. Early on, I held ROM exercises for patients with proximal humerus fractures for 4 to 6 weeks to reduce the potential for fracture displacement and to make sure the fracture was fully healed, mirroring how I was trained. However, the concern for postoperative stiffness is valid.
The AO Principles of Fracture Management speak to rigid fixation and early ROM. It seems logical that if we are fixing these fractures solidly then early ROM shouldn’t risk the construct. This study does support that logic, as there was not an increased rate of fixation failure. The study, in fact, found a higher complication rate in the conservative group, but this was mainly avascular necrosis and not fracture displacement or loss of fixation. I have also been advocating for early ROM with my own patients and have not seen any increased failures. Many patients are happy to not be as constricted.
While the study does not show that early ROM is better than conservative treatment, it supports that we can give patients an option to start early ROM without increased risk and possibly some benefits.
Reference:
Buckley RE, et al. AO Principles of Fracture Management. AO Foundation; 2017. Accessed March 10, 2025.
Perspective
Back to Top
This is a small (41 patients), but interesting, randomized trial that examines outcomes following open reduction and internal fixation of complex proximal humeral fractures. Patients were randomized to strict sling use for 4 weeks postoperatively (conventional group [CG]) vs. essentially unrestricted early use (early functional group [EFG]).
The investigators found no significant difference in any of the standard outcome measures at any time point, up to 2 years postoperatively. Importantly, there was no increase in the complication rate in the EFG group. In fact, the complication rate was lower in the EFG group (14%) vs. the CG group (30%). Although underpowered, in my opinion, this study clearly supports a more liberal postoperative regimen than what has traditionally been recommended in this setting, without fear of a catastrophically high failure rate.
I am surprised that allowing early functional activity in the EFG group did not result in better early (3-week and 6-week) outcome scores for these patients. This is certainly in contrast to my own clinical experience where, in general, patients allowed early activity logically return to everyday life quicker and seem happier. Perhaps our outcome measures are not sensitive enough to pick up these improvements or, pragmatically, our carefully prescribed postoperative regimens or randomization groups matter little to the patient. If it hurts too much, they will not move their arm; and if it does not, they will.
Collapse
Read more about