Session X - Upper Extremity
The Impacted Varus Proximal Humeral Fracture. Which Factors Affect Outcome?
Charles M. Court-Brown, MD, FRCS; Margaret M. McQueen, MD, FRCS; Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
Purpose: A prospective analysis of 99 impacted varus (OTA, A2.2) proximal humeral fractures was undertaken to study the outcome of nonoperative management and to assess whether age, increasing varus deformity during treatment, and physical therapy altered the prognosis.
Methods: In a 4-year period, 135 consecutive patients with impacted varus (OTA, A2.2) proximal humeral fractures were treated and prospectively documented in one trauma unit. Two patients were treated operatively and 34 either died or were lost to follow-up. The remaining 99 patients were followed at a research clinic at 6, 13, 26, and 52 weeks after the injury. The Neer score was used to monitor their progress, with patient examinations performed by an independent research physical therapist. Radiological assessment was performed by one surgeon to prevent inter-observer error. Varus displacement was estimated by measuring the angle between the humeral diaphysis and a line drawn between the greater tuberosity and the inferior articular surface on the initial and final radiographs. The effect of age, increasing varus displacement during nonoperative treatment and physical therapy was assessed. Tests for association were undertaken using multiple regression or logistic regression.
Results: The average age of all 135 patients, 106 women and 39 men, was 68 years. The mean Neer score of the 99 patients followed throughout the study was 59.7 at 6 weeks, 73.9 at 13 weeks, 81.7 at 26 weeks, and 86.7 at 52 weeks. Application of the Neer outcome criteria showed that 78.5% of patients had a good or excellent result 1 year after injury. Analysis of the effect of age on outcome showed a positive correlation, with a decreasing Neer score at 1 year recorded among older patients. The mean Neer score in patients less than 40 years of age was 94.5 and 82.1 in the over-80-year age group. There was no correlation between increasing varus malalignment during treatment and function or pain at 1 year. Radiological analysis showed a mean increase in varus displacement of the humeral head of 12o (range, 0° to 41o) during treatment. The average Neer score for patients with less than 5o of varus displacement during treatment was 89.7 compared with 91.1 for patients with 25° to 29o of varus displacement. The possibility of increasing pain due to greater tuberosity impingement associated with varus displacement was studied by assessing pain, using Neer's criteria, at each examination between 6 and 52 weeks. There was no correlation between pain and varus displacement. Univariate analysis of the use of physical therapy suggested that there might be a correlation with function, but multivariate analysis indicated that the older, less fit patients tended not to receive physical therapy. Our results do not suggest that physical therapy is useful.
Discussion: In a recent epidemiological study of proximal humeral fractures, the A2.2 impacted varus fracture was shown to be the third most common proximal humeral fracture. Despite this finding, there has been no previous study of the outcome of this fracture. There is, however, a common assumption that the increasing varus deformity that commonly follows nonoperative treatment of this fracture leads to subacromial impingement, restricted shoulder function, and pain. However, analysis of our data shows that this is not the case. Although progressive varus deformity is common in the A2.2 fracture, it does not cause deterioration in function or increase in pain. The results of nonoperative treatment are good, particularly in younger patients. Older patients have poorer results, but it is unlikely that surgery will improve function in this group of patients. Physical therapy does not appear to help patients.
Conclusions: Nonoperative management of the OTA A2.2 proximal humeral fracture gives good results, regardless of the degree of varus displacement during treatment and whether physical therapy is used. The results indicate that the parameter that affects outcome is age.