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Functional Outcome after Minimally Displaced Fractures of the Proximal Part of the Humerus*

KENNETH J. KOVAL, M.D., MAUREEN A. GALLAGHER, PH.D., JOSEPH G. MARSICANO, M.D., FRANCES CUOMO, M.D., ASHGAN MCSHINAWY, B.S. and JOSEPH D. ZUCKERMAN, M.D., NEW YORK, N.Y.

Investigation performed at the Department of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, New York City

	Abstract

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One hundred and four patients who had a minimally displaced fracture of the proximal part of the humerus (a so-called one-part fracture) were managed with a standardized therapy regimen and followed for more than one year. The clinical outcome was assessed on the basis of pain, function, and the range of motion of the shoulder. The duration of follow-up averaged forty-one months (range, twelve to 117 months). All fractures united without additional displacement. Eighty patients (77 per cent) had a good or excellent result, fourteen (13 per cent) had a fair result, and ten (10 per cent) had a poor result. Ninety-four patients (90 per cent) had either no or mild pain in the shoulder, eight (8 per cent) had moderate pain, and two (2 per cent) had severe pain. Functional recovery averaged 94 per cent; forty-eight patients (46 per cent) had 100 per cent functional recovery. At the time of the most recent follow-up, forward elevation of the injured shoulder averaged 89 per cent; external rotation, 87 per cent; and internal rotation, 88 per cent that of the uninjured shoulder. The percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy less than fourteen days after the injury than for the patients who had started such therapy at fourteen days or later.

	Introduction

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Fractures of the proximal part of the humerus account for 4 to 5 per cent of all fractures^7,12. Approximately 85 per cent of fractures of the proximal part of the humerus are minimally displaced (a so-called one-part fracture)⁹ and are assumed to heal well with non-operative management^1,11. Few studies, however, have documented the results of such fractures^2,8,13, and, to our knowledge, there have been no detailed analyses of the functional outcomes. The purpose of this study was to evaluate the functional outcomes in a consecutive series of patients who had a minimally displaced fracture of the proximal part of the humerus.

	Materials and Methods

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Between January 1986 and April 1994, 128 adults who had a one-part fracture of the proximal part of the humerus were managed by the Shoulder Service at the Hospital for Joint Diseases. The standard trauma series of radiographs (scapular anteroposterior, scapular lateral, and axillary radiographs) was made to evaluate the fracture pattern. A one-part fracture of the proximal part of the humerus, as defined by Neer^9,10, has less than one centimeter of displacement and less than 45 degrees of angulation between the major fracture fragments. For a fracture to be included in the study, two orthopaedic surgeons had to agree on the classification after independent review of the radiographs.

Of the 128 patients, four died and twenty were lost to follow-up before the one-year examination. Thus, 104 patients had been followed for a minimum of one year. The average age of the patients was sixty-three years (range, twenty-four to ninety-four years), and eighty-three patients (80 per cent) were women. The dominant extremity was injured in fifty (48 per cent) of the 104 patients. All fractures were the result of a fall, and each was an isolated injury. Forty-four fractures (42 per cent) were of the surgical neck, thirty-one (30 per cent) were of the greater tuberosity, and twenty-nine (28 per cent) consisted of multiple fracture lines in several anatomical regions of the proximal part of the humerus. Four of the 104 patients had been managed non-operatively before the injury for rotator-cuff disease on the side of the fracture; three of them had been managed with oral administration of anti-inflammatory medication and one had received a subacromial injection of steroids.

All patients were managed with a standardized regimen. At the time of the initial injury, the upper extremity was examined carefully to ensure that the proximal part of the humerus could be moved with most of the motion occurring at the glenohumeral joint and not at the fracture site; all 128 fractures were considered stable during the range of motion of the shoulder tolerated by the patient. The involved extremity was placed in a sling for relief of pain. Within one week after the initial injury, all patients had a follow-up evaluation, were given instructions for range-of-motion exercises for the upper extremity, and were referred to the physical therapist on the Shoulder Service. The physical therapist supervised active range-of-motion exercises for the elbow, wrist, and hand in combination with assisted passive range-of-motion exercises for the shoulder. The exercises for the shoulder were begun with the patient in the supine position for forward elevation, external rotation, and internal rotation to the chest. The patient attended supervised physical-therapy sessions once or twice each week and performed the exercises two, three, or four times daily at home. A sling was used for four to six weeks until the fracture had united clinically. When use of the sling was discontinued, an active range-of-motion program was initiated, starting with the patient in the supine position, with gradual progression to the sitting position; isometric strengthening exercises for the deltoid and rotator-cuff muscles were then added. When good active motion of the shoulder was achieved, isotonic (resistive) exercises for the deltoid and rotator-cuff muscles were added. Approximately twelve weeks after the fracture, a more vigorous stretching program was begun.

Data were collected through a review of the charts, telephone interviews, and physical examination. All patients completed a detailed questionnaire on the functional status and were examined by us (K. J. K., J. G. M., F. C., and J. D. Z.) at the time of follow-up.

Patients were asked to assess pain on a scale of 0 to 4 points, with 0 indicating no pain; 1, mild pain; 2, moderate pain; 3, severe pain; and 4, totally disabling pain. Mild pain did not limit daily activities and necessitated only the occasional use of non-prescription medication; moderate pain caused some limitation of normal activities and necessitated the use of prescription medication at least once a week; severe pain was present daily, markedly limited activities, and necessitated the use of prescription medication nearly every day; and totally disabling pain prevented the use of the extremity for the activities of daily living.

Functional ability was assessed with regard to fifteen tasks. First, the patients were asked to grade the over-all physical impairment according to their ability to perform various activities of daily living (bathing, dressing, eating with a utensil, using the toilet, food-shopping, cleaning, doing laundry, cooking, and combing the hair). They graded each activity on a scale of 0 to 4 points, with 4 indicating that they were completely independent; 3, that they needed some help; 2, that they needed moderate help; 1, that they needed substantial help; and 0, that they were completely dependent. The patients also were asked to indicate the degree to which they were limited in their ability to use the injured extremity to wash the contralateral axilla, use a back pocket, use the hand with the extremity at the shoulder level, carry ten to fifteen pounds (4.5 to 6.8 kilograms) with the extremity at the side, use the hand overhead (reach), and sleep on the side of the injury. A score of 4 indicated no limitation; 3, mild limitation; 2, moderate limitation; 1, severe limitation; and 0, an inability to perform the activity. To determine the functional recovery, the scores for the fifteen tasks were added, and the sum was expressed as a percentage of the possible total of 60 points.

The range of motion was evaluated, on both the injured and the uninjured side, in three planes: active forward elevation, external rotation with the elbow at the side, and internal rotation. Forward elevation and external rotation were measured in degrees. Internal rotation was evaluated according to the anatomical landmark that the patient could reach (a score of 10 points was given for the iliac wing; 20 points, the posterior aspect of the ilium; 30 points, the lumbar spine [the fifth lumbar vertebra]; 40 points, the middle of the back [the third lumbar vertebra]; 50 points, the cephalad portion of the back [the twelfth thoracic vertebra]; and 60 points, the inferior aspect of the scapula [the seventh thoracic vertebra]). To assess the recovery of motion, the total number of degrees of forward elevation and external rotation was added to the points determined for internal rotation; the total for the injured shoulder then was expressed as a percentage of the total for the contralateral shoulder.

The over-all result was rated as excellent, good, fair, or poor. An excellent result was given when the patient had no pain and at least 90 per cent recovery of function and motion; a good result, when the patient had mild pain and 80 to 89 per cent recovery of function and motion; a fair result, when the patient had moderate pain and 70 to 79 per cent recovery of function and motion; and a poor result, when the patient had severe pain and less than 70 per cent recovery of function and motion. For a result to be considered to be in a particular category, the patient had to fulfill all of the criteria of that category.

Statistical analyses with the Student t test were performed to assess the clinical result as a function of the age of the patient (less than seventy years old compared with seventy years old or more), whether the fracture involved the dominant upper extremity, the location of the fracture (the surgical neck, the greater tuberosity, or multiple regions), when the supervised physical therapy was begun (before fourteen days compared with at fourteen days or later), and the duration for which the sling was used (fewer than six weeks compared with six weeks or more). In addition, the clinical result was evaluated as a function of the amount of displacement (five millimeters or less compared with more than five millimeters) of the thirty-one isolated fractures of the greater tuberosity. Paired t tests were used to compare the range of motion of the injured shoulder with that of the uninjured shoulder. For all analyses, a p value of less than 0.05 was considered significant.

	Results

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The average duration of follow-up was forty-one months (range, twelve to 117 months). All fractures had united by six to eight weeks, without additional displacement. A supervised physical-therapy program was initiated at an average of thirteen days (range, four to sixty days) after the injury. Thirteen patients did not attend supervised therapy sessions but performed exercises on their own according to the protocol described earlier. Eight patients started supervised physical therapy after three weeks; this delay was due to personal circumstances and was not related to the fracture or to poor health. The average duration of supervised physical therapy was eighteen weeks (range, four to fifty-two weeks). A sling was used for an average of six weeks (range, one to twenty weeks); three patients used the sling for more than twelve weeks, despite the advice of the treating physician.

At the time of the most recent follow-up, forty-six patients (44 per cent) had an excellent result, thirty-four (33 per cent) had a good result, fourteen (13 per cent) had a fair result, and ten (10 per cent) had a poor result. Four of the ten patients who had a poor result had reinjured the shoulder after the fracture (Table I); on the basis of clinical and radiographic evaluation, the four reinjuries were diagnosed as soft-tissue contusion without evidence of a rotator-cuff tear. Of the four patients who had been managed non-operatively for rotator-cuff disease before the fracture, one had an excellent result, two had a fair result, and one had a poor result. With the numbers available, age, involvement of the dominant upper extremity, location of the fracture, amount of displacement of the greater tuberosity, and duration for which the sling was used had no significant effect on the over-all clinical result. However, fifty (86 per cent) of the fifty-eight patients who began supervised physical therapy before fourteen days had a good or excellent result, compared with only thirty (65 per cent) of the forty-six patients who started therapy at fourteen days or later; this difference was significant (p < 0.01).

The functional recovery averaged 94 per cent (range, 40 to 100 per cent), and it was 100 per cent for forty-eight patients (46 per cent). Functional recovery was at least 90 per cent for eighty-four (81 per cent) of the 104 patients, 80 to 89 per cent for thirteen (13 per cent), 70 to 79 per cent for four (4 per cent), and less than 70 per cent for three (3 per cent). Seventy-four patients (71 per cent) were completely independent in all activities of daily living. Food-shopping was the activity that the most patients (twenty-four; 23 per cent) needed help to perform (Table II): sixteen patients needed some help, three patients needed moderate help, three needed substantial help, and two were completely dependent. Fifty patients (48 per cent) had no limitations of the functional use of the injured limb. The functions most frequently reported as being limited were carrying ten to fifteen pounds (4.5 to 6.8 kilograms) with the extremity at the side (thirty-five patients; 34 per cent) and using the hand overhead (thirty-four patients; 33 per cent) (Table III). At the time of the latest follow-up, thirty-nine patients (38 per cent) were employed outside the home. Eighteen of the thirty-nine needed to use the hand with the extremity at or above the shoulder level to perform their job; four of the eighteen classified their job as heavy labor. With the numbers available, age, involvement of the dominant upper extremity, location of the fracture, amount of displacement of the greater tuberosity, timing of the supervised physical therapy, and duration for which the sling was used had no significant effect on the functional recovery.

	Discussion

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Although the literature contains many reports on the treatment of displaced fractures and fracture-dislocations of the proximal part of the humerus, the treatment of one-part (minimally displaced) fractures has received little attention. To our knowledge, we are reporting on the largest series to date of one-part fractures of the proximal part of the humerus.

Our results were inferior to those that have been reported previously. Clifford reported excellent or satisfactory results for forty-three (93 per cent) of forty-six patients who were followed for at least eighteen months after management with early range-of-motion exercises for a minimally displaced fracture of the proximal part of the humerus. Kristiansen and Christensen reported excellent or good results for forty-five (94 per cent) of forty-eight such fractures that were evaluated at a minimum of two years⁵, and Young and Wallace reported good or acceptable results for thirty-three (97 per cent) of thirty-four such fractures at six months. The results of these studies are difficult to compare with those of the present study, as different rating scales were used to assess the outcomes. The inferior results in our study may be attributable to the use of a more detailed assessment of functional outcome than has been used in other investigations.

The results with regard to pain in our study are comparable with those reported by Young and Wallace. In the series of Lungberg et al., thirty-six (86 per cent) of forty-two patients had pain that did not interfere with the ability to perform daily activities three months after a minimally displaced fracture of the proximal part of the humerus.

Few authors have performed an in-depth evaluation of functional recovery after fracture of the proximal part of the humerus. Kristiansen et al. reported that, in fifty-nine patients, the average recovery of function, defined as strength, reaching ability, and shoulder stability, was 85 per cent one year after a minimally displaced fracture of the proximal part of the humerus⁶.

The range of motion at the time of follow-up in our series is similar to that reported in other series of minimally displaced fractures of the proximal part of the humerus. Kristiansen et al. reported a range of motion that was 88 per cent that of the uninjured side⁶. Young and Wallace found that twenty-one (62 per cent) of thirty-four patients had more than 110 degrees of abduction of the shoulder; twelve patients (35 per cent), more than 60 degrees; and one patient (3 per cent), less than 60 degrees.

Temporary immobilization of the shoulder after fracture of the proximal part of the humerus has been advocated². The timing of physical therapy, however, remains controversial. Clifford reported a significant relationship (p < 0.02) between a delay in supervised physical therapy and a poor clinical result. In contrast, Kristiansen et al. reported, in a prospective, randomized study, that there was no difference with regard to pain, function, or the range of motion of the shoulder at one year between patients who had had immobilization of the shoulder for one week before physical therapy and those who had had immobilization for three weeks before physical therapy⁶. In the present series, the percentage of good and excellent results was significantly greater (p < 0.01) and external rotation was significantly better (p < 0.01) at the time of the latest follow-up for the patients who had started supervised physical therapy before fourteen days than for those who had not begun such therapy until fourteen days or later. The duration for which the sling was used had no effect on the over-all outcome.

No relationship was found between the clinical outcome and the age of the patient, involvement of the dominant upper extremity, location of the fracture, or amount of displacement of the greater tuberosity. Although other authors have reported that older patients have a poorer outcome after a three-part or four-part fracture of the proximal part of the humerus³, to our knowledge the present study is the first in which the effect of age on the outcome after a minimally displaced fracture of the proximal part of the humerus was evaluated. Not surprisingly, pre-existing rotator-cuff disease had an adverse effect on the outcome; three of the four patients who had been managed for rotator-cuff disease before the fracture had a fair or poor result.

The limitations of the current study include the retrospective collection of data, a wide range in the duration of follow-up, and the heterogeneity of the patient population. Although this is the largest series of one-part fractures of the proximal part of the humerus that has been reported to date, to our knowledge, the heterogeneity of the series limited our ability to evaluate the effect of certain patient-related variables (such as gender) on the outcome or to perform more sophisticated statistical analyses. Another limitation is that the rating scale that we used is different from those used in other series. We modified the shoulder-assessment scale of the American Shoulder and Elbow Surgeons⁴ in order to place more emphasis on functional outcome.

	Footnotes

 

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Department of Orthopaedic Surgery, Hospital for Joint Diseases Orthopaedic Institute, 301 East 17th Street, New York, N.Y. 10003.

	References

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