1Soni C, 2Klein J, 1Duran J, 1Shanto T, 2Toro J
1Touro College of Osteopathic Medicine, New Hyde Park, NY, United states; 2Garnet Health Medical Center, Middletown, NY, United states
Introduction
Proximal humerus fractures (PHFs) are the fourth most common fragility fracture in the elderly and account for 6 percent of all adult fractures (1). The frequency of PHFs will likely increase with the rapidly growing elder demographic. Considerable variation remains among surgeons regarding operative and nonoperative management for these fractures (2). Many surgeons resort to surgical fixation, despite recent literature supporting nonoperative management, especially in less severe fractures (3). This study’s purpose was to compare functional outcomes of operatively and nonoperatively managed PHFs at a community hospital.
Methods
A mixed retrospective prospective cohort study of PHFs from 2018 to 2022 at a single Level II community trauma center was performed. Patients aged 60 years and older, with acute PHFs were included. All patients meeting the criteria were contacted via telephone to obtain functional outcomes. Patients with either inadequate information or unavailability for telephone surveys were excluded. Patients were grouped into two cohorts, operative and nonoperative treatment. The primary outcome assessed was the functional outcome measured by the Quick Disabilities of Arm, Shoulder, and Hand (QuickDASH) score. A chart review was completed to collect basic demographic and fracture characteristics to stratify fracture severity using Neer classification scoring. Demographic and clinical characteristics were compared across primary outcomes using Chi-Square test for categorical variables and Student’s t-test for continuous variables, with Fisher Exact test used if the data was not normally distributed.
Results
60 patients met inclusion criteria (37 operative, 23 non-operative). The average age for the operative group and nonoperative group was 72.2 and 78.5, respectively (p<0.02). 78.3 percent of the non-operative cohort did not attend physical therapy while 100 percent of the operative group attended physical therapy (p<0.01). The mean overall QuickDASH score for the operative and non-operative cohorts were 25.3 and 13.5, respectively (p<0.03). When stratified by fracture severity, there was no significant difference in QuickDASH score in the 3-part and 4-part PHF subsets; however, in the 2-part subset, the QuickDASH score of the operative group was worse compared to the non-operative group, 33.5 and 10.5, respectively (p<0.04).
Conclusions
The overall QuickDASH score was statistically worse in the operative group with an absolute difference of 11.8 (p<0.03). Although statistically worse, the absolute difference does not meet the reported minimal clinical important difference (MCID) suggesting that operative fixation for early weight bearing might be a reasonable option and would not have a clinically meaningful difference in functional outcomes compared to nonoperative outcomes (4). In the subgroup analysis, no statistical difference was seen in the 3 and 4-part PHFs; however, the nonoperatively treated 2-part PHFs met the MCID and showed statistical improvement in the nonoperative cohort. Our data suggest that 2 part PHFs should be treated non- operatively while operative fixation in 3 and 4 part PHFs is noninferior in functional outcomes compared to nonoperative treatment.
