Nonoperatively Treated Proximal Humerus Fractures: Randomized Trial of Immediate Versus Delayed Initiation of Exercises

Document Type : RESEARCH PAPER

Authors

1 Medisch Centrum Leeuwarden, The Netherlands

2 Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

3 Maasstad Ziekenhuis, Rotterdam, The Netherlands

4 Dell Medical School--The University of Texas at Austin, USA

Abstract

Objectives: There is debate about when to start exercises in the nonoperative treatment of a proximal humerus fracture. This randomized trial compared immediate and one-month delayed shoulder exercises in the nonoperative treatment of fractures of the proximal humerus.
Methods: Twenty-six patients with a fracture of the proximal humerus who chose nonoperative treatment were randomized to start pendulum exercises within a few days and 24 were randomized to delayed exercises and started with active self-assisted stretching 1 month after fracture. Three and six months after the injury, patients completed the Disabilities of the Arm Shoulder and Hand questionnaire to measure capability, a measure of pain intensity, and had motion measurements.
Results: There was no significant difference in forward flexion (primary outcome) six months after injury between patients that started motion exercises immediately compared to 1 month after injury (p = 0.85). There was no difference in any motion measurement, pain intensity, upper extremity specific disability (DASH score) three or six months after injury. Conclusion: Delaying exercises for a month does not affect recovery from nonoperative treatment of a fracture of the proximal humerus. People can choose whether to start exercises immediately or wait until they feel comfortable.
Level of evidence: II

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  1. Koval KJ, Gallagher MA, Marsicano JG, Cuomo F, McShinawy A, Zuckerman JD. Functional outcome after minimally displaced fractures of the proximal part of the humerus. J Bone Joint Surg Am. 1997; 79(2):203-207. doi: 10.2106/00004623-199702000-00006.
    2. Carbone S, Razzano C, Albino P, Mezzoprete R. Immediate intensive mobilization compared with immediate conventional mobilization for the impacted osteoporotic conservatively treated proximal humeral fracture: a randomized controlled trial. Musculoskelet Surg. 2017; 101(Suppl 2):137-143. doi: 10.1007/s12306-017-0483-y.
    3. Kristiansen B, Angermann P, Larsen TK. Functional results following fractures of the proximal humerus. A controlled clinical study comparing two periods of immobilization. Arch Orthop Trauma Surg. 1989; 108(6):339-341. doi: 10.1007/BF00932441.
    4. Lefevre-Colau MM, Babinet A, Fayad F, et al. Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture. A randomized controlled trial. J Bone Joint Surg Am. 2007; 89(12):2582-2590. doi:10.2106/JBJS.F.01419.
    5. Rennie D. CONSORT revised--improving the reporting of randomized trials. JAMA. 2001; 285(15):2006-2007. doi:10.1001/jama.285.15.2006.
    6. Hudak PL, Amadio PC, Bombardier C. Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder and hand) [corrected]. The Upper Extremity Collaborative Group (UECG). Am J Ind Med. 1996; 29(6):602-608. doi: 10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-L.                           7. Bruinsma WE, Guitton TG, Warner JJP, Ring D, Science of Variation Group. Interobserver reliability of classification and characterization of proximal humeral fractures: a comparison of two and three-dimensional CT. J Bone Joint Surg Am. 2013; 95(17):1600-1604. doi:10.2106/JBJS.L.00586.
    8. Ford I, Norrie J. Pragmatic Trials. N Engl J Med. 2016; 375(5):454-463. doi: 10.1056/NEJMra1510059.
    9. Rangan A, Handoll H, Brealey S, et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015; 313(10):1037-1047. doi:10.1001/jama.2015.1629.
    10. Coste M, Aggarwal V, Shah NV, et al. Comparing Relative Value Units among Shoulder Arthroplasty, Hemiarthroplasty, and ORIF for Proximal Humerus Fractures in the Elderly: Which is Most worth Your Time? Arch Bone Jt Surg. 2021; 9(4):406-411. doi:10.22038/abjs.2020.51204.2539.
    11. Stenquist DS, Barger J, Mohamadi A, et al. Impact of Age on Functional Outcome After Reverse Shoulder Arthroplasty Performed for Proximal Humerus Fractures or Their Sequelae. Arch Bone Jt Surg. 2023; 11(1):29-38. doi:10.22038/ABJS.2022.56366.2798.
    12. Shu R, Crijns T, Ring D, Fatehi A, Science of Variation Group. Surgeons Consider Initial Nonoperative Treatment With Potential for Future Conversion to Reverse Arthroplasty a Reasonable Option for Older, Relatively Infirm, and Less-Active Patients. J Orthop Trauma. 2022; 36(5):265-270. doi:10.1097/BOT.0000000000002278.