Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Michael D. McKee, MD, FRCS(C)*,
University of Toronto and St. Michael's Hospital, Toronto, Canada
Posted December 2007
This randomized clinical trial comparing early postoperative passive mobilization
of the extremity with conventional (three-week) immobilization for impacted proximal
humeral fractures was performed in France by Lefevre-Colau and colleagues. They
concluded that immediate mobilization for appropriately selected impacted proximal
humeral fractures provided more rapid improvement in objective shoulder scores,
without increasing the risk of fracture complications such as delayed union or
nonunion. This conclusion seems intuitive and supports findings of previous studies
that showed that immediate mobilization resulted in a more rapid restoration
of function and a decrease in pain1,2.
The study randomized seventy-four patients (mean age, sixty-three years) to
receive one of two intensive physiotherapy regimens. The immediate mobilization
group received a total of thirty-two two-hour physiotherapy sessions, including
sessions five times a week beginning within seventy-two hours after the fracture.
The conventional group received a similar total number of physiotherapy sessions,
but these began only after three weeks of immobilization in a sling. The primary
outcome measure, the Constant shoulder score at three months, was significantly
greater (between-group difference of 9.9 points) in the immediate mobilization
group as compared with that in the conventional treatment group (p = 0.02 on
both the Student t test and the Mann-Whitney test). The Constant shoulder score
was also significantly improved (10.1 points) at six weeks after treatment in
the immediate mobilization group (p = 0.01 for the Mann-Whitney test and p =
0.02 for the Student t test). Correspondingly, nonsignificant decreases in pain
were seen in the immediate mobilization group at these early (six-week and three-month)
time points. The authors also noted that the Constant shoulder scores did not
differ significantly at the time of the six-month evaluation. Importantly, they
could not detect any difference in union rates between the two groups (all fractures
in both groups healed) and noted that most patients were satisfied or very satisfied
with their treatment at all time points.
The strengths of this study include the randomized design, a statistically
and clinically relevant improvement in outcome (Constant score difference of
10 points), the blinding of the physicians involved in the assessment of the
patients, the fact that the majority of patients completed the assigned course
of treatment, and the implications for directing a change in conventional orthopaedic
practice. However, the reader should examine this paper carefully before applying
such treatment indiscriminately to patients with proximal humeral fractures.
Importantly, the individuals enrolled in this study represent a carefully selected
group of impacted metaphyseal fractures that were intrinsically unlikely to displace
with nonoperative treatment. These types of fractures are mechanically stable,
typically have an extremely low rate of delayed union or nonunion, and are suitable
for early motion of the extremity. Thus, these findings cannot be applied to
all proximal humeral fractures (such as completely displaced, nonimpacted fractures
with obvious instability) as treatment of other types of proximal humeral fractures
may result in an increase in healing complications, such as delayed union and
nonunion. Another potential drawback to the generalizability of these findings
is the relatively intensive physiotherapy regimen that was used in the study.
Thirty-two two-hour sessions of physiotherapy (including a session almost daily
initially in the early mobilization group) may be logistically (and financially)
quite difficult for patients. Even in the relatively young study group (mean
age, sixty-three years) ten patients withdrew from the trial, primarily due to
difficulties in attending the scheduled physiotherapy sessions.
In summary, this appears to be an appropriately designed study with a valid
conclusion: early mobilization can improve function and decrease pain in appropriately
selected individuals with impacted proximal humeral fractures. It should be stressed,
however, that clinicians should not apply this information routinely to all individuals
with these injuries. This technique should be restricted to appropriately selected
individuals who can comply with the fairly intensive physiotherapy regimen. Given
previous studies that have questioned the value of formal physiotherapy in this
setting (as compared with a home exercise program), further research is needed
to determine if similar results can be obtained with a less cumbersome physiotherapy
regimen.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Hodgson SA, Mawson SJ, Saxton JM, Stanley D. Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up). J Shoulder Elbow Surg. 2007;16:143-5.
2. Hodgson S. Proximal humerus fracture rehabilitation. Clin Orthop Relat Res. 2006;442:131-8.
|
