Proximal humeral fractures : aspects of treatment with special reference to displaced fractures in the elderly

Abstract

The purpose of this thesis was to study the clinical and functional outcome after various treatments of displaced fractures of the proximal humerus in an elderly patient group. Conservative treatment consisting of a short period of immobilisation and an early start of active exercises guided by physiotherapy has been compared with different surgical techniques. Retrospective studies have been supplemented with a prospective randomized one. Open reduction and internal fixation has been compared with conservative treatment and results from prosthetic replacement presented. All fractures were classified according to Neers' classification and the evaluation at the review was done according to Constant scoring system.

In paper I a comparison between Neer's and Constant's scorings systems was performed. The 3-year follow up reviewed a good functional outcome of shoulder function in 96% of patients with a three part fracture, but only in 33% of patients with a four-part fracture. There was a strong agreement between the Constant score and patients opinion. In paper II, a retrospective study with a long term follow-up (10-years) after conservative treatment of displaced fractures of the proximal humerus good functional outcome was achieved despite relatively low scoring, and poor fracture reduction. Patients contentment of their injured shoulder was high, with a mean active flexion above the horizontal level. I paper III 27 patients were treated primarily with a hemiarthroplasty for their displaced fractures of the proximal humerus and have been followed for 3 years. We conclude that one third of them still had some pain and disability. The R.O.M. was decreased compared to other series reported. The average flexion and abduction was below the horizontal plain.

A prospective, randomised study was performed to assess and compare results after surgical (tension band technique) and conservative treatment in patients with displaced three- or four-part fracture of the proximal humerus (paper IV). At the three years review there was no difference in the functional outcome between the two groups. Regardless type of treatment shoulder function was optimized within one year, and further improvement was not observed.

In attempt to eluminate the etiology behind displaced three- and four-part fractures of the proximal humerus in middle-aged men, a bone mass density investigation was done (paper V). In our series of 20 patients, there were 14 men with osteopenia. Nine had had a previous fracture and seven were smokers. Blood tests did not disclose the etiology in the present series, but dietary disturbances in association with alcohol abuse could have had effects on the bone mass density. Conservative treatment has given results comparable with those after surgery and shoulder function achieved after conservative treatment was maintained over a long period. Results showed that conservative treatment should always be considered in the treatment of displaced fractures of the proximal humerus, and in particular in elderly patients with a three-part fracture.