Nonoperative Treatment for Displaced Proximal Humeral Fractures in Elderly Patients: Correlation Between Deviations and Clinical Outcomes

Gracitelli, Mauro Emilio Conforto; Yamamoto, Gustavo Jum; Malavolta, Eduardo Angeli; Andrade-Silva, Fernando Brandão; Kojima, Kodi Edson; Ferreira Neto, Arnaldo Amado

doi:10.1055/s-0040-1716760

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Revista Brasileira de Ortopedia

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Original Article • Rev. bras. ortop. 57 (02) • 2022 • https://doi.org/10.1055/s-0040-1716760 copy

Nonoperative Treatment for Displaced Proximal Humeral Fractures in Elderly Patients: Correlation Between Deviations and Clinical Outcomes^* * Study developed at the Instituto de Ortopedia e Traumatologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objectives

To describe the functional result of the conservative treatment of displaced proximal humerus fractures (PHF) using the American Shoulder and Elbow Surgeons (ASES) score after 12 months and assess whether the different initial classifications and radiographic measurements are related to clinical results.

Methods

Forty patients > 60 years old, with displaced PHUs submitted to conservative treatment were evaluated at standardized times (3, 6, and 12 months). The American Society of Shoulder and Elbow Surgeons (ASES), Constant-Murley and Single Assessment Numeric Evaluation (SANE) scales were used as clinical outcomes. Radiographic variables included the Neer and Resch classifications, the presence and displacement of tuberosity fracture, metaphyseal comminution, medial periosteal lesion, and angular and translational deviations of the head in the coronal and sagittal plane.

Results

The result of the ASES score was 77.7 23.2 for the whole sample, the mean absolute values of the Constant-Murley score were 68.7 16 and 82.6% for the scale relative to the contralateral side. The SANE scale at 12 months was 84.8 19. We observed that the severity of the Neer classification and the coronal plane angular deviation (measured by the head-shaft angle) and the presence of fractures in both tuberosities negatively influenced the ASES score after 12 months of treatment.

Conclusion

Nonoperative treatment of displaced proximal humerus fractures in elderly patients results in good clinical results. Clinical results are negatively influenced by the angular deviation of the humeral head and the presence of fractures of the greater and lesser tubercles, as well as by the Neer classification.

Keywords:
shoulder fractures; complications; conservative treatment; diagnostic imaging

Metaphyseal comminution
No
Yes
Medial periosteal lesion
No
Yes
Tuberosity fracture
No tuberosity fracture
Greater tuberosity fracture
Lesser and greater tuberosities fracture
Greater tuberosity deviation
Up to 2 mm inferior to the top of the humeral head
Up to 2 mm superior to the top of the humeral head
Over 2 mm from the top of the humeral head
Lesser tuberosity deviation
Up to 2 mm
2 to 5 mm
> 5 mm
Diaphyseal head angle, front view
125° to 150°
110° to 124° or 151° to 165°
< 110° or >166°
Diaphyseal head angle, lateral view
No deviation
Moderate (0-20°)
Severe (> 45°)
Diaphyseal deviation, front view
Up to 5 mm
5 to 10 mm
> 10 mm
Diaphyseal deviation, lateral view
Up to 5 mm
5 to 10 mm
> 10 mm

	n	%
Gender
Male	7	17.5
Female	33	82.5
Side
Right	13	32.5
Left	27	67.5
Dominant side affected?
Yes	15	37.5
No	25	62.5
Smoking
No	31	77.5
Smoker	7	17.5
Former smoker	2	5.0
Diabetes
No	30	75.0
Yes, non-insulin-dependent	8	20.0
Yes, insulin-dependent	2	5.0

	n	Mean	Standard deviation	Median	IQR
ASES
3 months	39	57.7	24.5	56.3	42.8
6 months	39	71.6	24.3	80.7	36.0
12 months	40	77.7	23.2	85.2	40.1
SANE
3 months	39	66.2	22.6	70.0	40.0
6 months	39	82.2	19.4	85.0	22.5
12 months	40	84.8	19.0	90.0	20.0
Constant-Murley
3 months	39	55.6	16.7	60.0	31.0
6 months	40	64.8	15.9	68.5	28.5
12 months	40	68.7	16.0	72.0	24.0
Relative Constant score for the contralateral limb
6 months	39	80.1%	18.7%	87.2%	37.8%
12 months	39	82.6%	23.6%	89.5%	31.3%

	ASES score at 12 months
	Mean	Standard deviation	Median	IQR	p-value
Neer classification
2 parts	88.4	15.4	94.2	19.9
3 parts	79.0	21.5	85.2	32.3
4 parts	61.0	28.3	47.5	56.0	0.031
Diaphyseal head angle, coronal view
125° to 150°	93.4	7.8	96.3	11.9
110° to 124° or 151° a 165°	74.5	25.2	78.4	45.4
< 110° or >166°	64.3	25.0	56.5	48.2	0.004
Angular deviation, coronal view
Minimal deviation	84.7	20.4	93.8	26.1
Severe valgus (>166°)	60.0	22.3	58.1	41.9
Severe varus (<110°)	66.2	27.1	56.5	54.9	0.034
Tuberosity fracture
No tuberosity fracture	84.7	19.7	94.2	38.4
Greater tuberosity fracture	82.8	20.3	88.1	27.5
Lesser and greater tuberosities fracture	61.5	26.9	50.4	54.6	0.031
Resch classification
1	94.2	6.4	95.9	12.6
2	88.1	16.8	88.1	NA
3	64.4	27.1	61.5	53.0
4	76.2	23.7	84.9	44.8	0.052
Metaphyseal comminution
No	75.8	23.7	85.4	49.7
Yes	77.7	25.2	85.0	36.7	0.570
Medial periosteal lesion
No	82.9	22.3	93.2	27.3
Yes	71.6	24.7	78.5	51.7	0.168

Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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[1] Address for correspondence Mauro E. C. Gracitelli, Ph.D, Rua Dr. Ovídio Pires de Campos, 333, 3° andar, Cerqueira Cesar, São Paulo, SP, 05403-010, Brazil (e-mail: mgracitelli@gmail.com).