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Clinico-radiological and functional outcome of Neer’s 2 part, 3 part and 4 part proximal humeral fractures in elderly treated by conservative management in a tertiary care centre of North India

PHF’s are classified as 2 3 part and 4 part fractures, with three part and four part containing more number of displaced fragments. 6 In minimally displaced or undisplaced fractures, the treatment is conservative. For three part and four part fractures, the treatment options are both conservative and operative. 7-8 Operative treatment is associated with higher risk of complications due to the implant or the surgical procedure. 9 In the recent studies, the results do not support the surgical treatment for patients with displaced fractures of the proximal humerus, Rangan et al. 10 Till date, research has not been able to identify the evident and reliable differences in the outcome of operative and conservative treatment, and the management remains ABSTRACT Background: Treatment of proximal humeral fractures is challenging. Despite a rising incidence in proximal humeral fractures, there is still no evidence for the best treatment option, especially for the elderly patients. The aim of this prospective study was to evaluate the radiological in terms of union and functional outcome in terms of pain, range of motion of conservatively managed proximal humeral fractures in elderly patients. Methods: This was an observational prospective study of 35 patients aged above 65 years with proximal humeral fractures including 2 part, 3 part and 4 part based on Neer’s classification, treated by conservative method. Functional outcome was assessed by using Constant score at follow up of 1 year. Results: Out of 35 patients, 21(60%) were female and 14 (40%) were male with mean age of 76.8 (range 65 to 91years). On the basis of Neer’s classification, majority of patients (15, 42.8%) had 3 part fracture. Radiological union was achieved within 13 to 24 weeks, with an average of 18.4 weeks. Out of 35, 5 (14.3%) had excellent outcome, 8 (22.8%) had good functional outcome, 16 (45.7%) had moderate outcome, 6 (17.14%) had poor outcome. The results were comparable with the existing literature. Conclusion: In the present study, our data shows that the proximal humeral fractures can be effectively managed conservatively in the elderly patients. Two part fractures have best functional outcome and four part fractures have highest rate of complications.


INTRODUCTION
Proximal humeral fractures account for 4 to 6% of all fractures. [1][2][3] Proximal humeral fractures are among the most common fractures in the elderly population. 4 There is high incidence of proximal humeral fractures due to increasing life expectancy and the consequent rise of osteoporotic bone fractures. 5 According to Neer's classification, PHF's are classified as 1 part, 2 part, 3 part and 4 part fractures, with three part and four part containing more number of displaced fragments. 6 In minimally displaced or undisplaced fractures, the treatment is conservative. For three part and four part fractures, the treatment options are both conservative and operative. [7][8] Operative treatment is associated with higher risk of complications due to the implant or the surgical procedure. 9 In the recent studies, the results do not support the surgical treatment for patients with displaced fractures of the proximal humerus, Rangan et al. 10 Till date, research has not been able to identify the evident and reliable differences in the outcome of operative and conservative treatment, and the management remains controversial. [11][12][13] Similar observations were reported by the Cochrane review. 14

Aim
The aim of this study was to evaluate the clinicoradiological and functional outcome of Neer's 2, 3 and 4 part humeral fractures treated with conservative method.

METHODS
This was an observational prospective study of 35 patients (n=35) satisfying the inclusion criteria treated by conservative method from June 2019 to May 2021 done at the Post graduate department of orthopaedics, Government medical college, Jammu. Patients satisfying the selection criteria were included in the study after proper history, clinical examination and written informed consent for undergoing the study. The fractures were classified on the basis of on Neer's classification. 15,16 The data was analysed by appropriate statistical methods. Functional outcome was evaluated by Constant Score at 1year follow up, and was compared with the existing literature. 17 Pain was evaluated by visual analogue scale. 18

Inclusion criteria
Patients with closed proximal humeral fracture including two, three and four part fractures within 2 weeks, with age more than 65 years were included in the present study.

Exclusion criteria
Fractures presenting after 2 weeks, minimally displaced fractures, isolated greater tuberosity fractures paediatric fractures, open fractures and pathological fractures, fractures with neurovascular injury, patients with neurological disorders.

Investigations
Appropriate radiological investigations were done in the form of antero-posterior and axillary views and fractures were classified according to Neer's classification. Adjacent joint X-rays were also done. In doubtful and complex fractures, CT scan was also done.

Technique
Patients with proximal humeral fractures were treated by immobilizing the shoulder in an arm pouch. Oral analgesics, calcium and vitamin D supplements were given.

Follow up
Patients were assessed clinically and radiologically at 2 weeks, 6 weeks, 3 months, 6 months and 12 months.
Physiotherapy was started at 2 to 4 weeks after immobilization. 11,[19][20][21] Passive exercises were started at 2 weeks and active exercises at 4 weeks. Fracture healing was judged by both clinical (pain and motion at fracture site) and radiological (bridging callus filling the fracture site or trabeculations across the fracture site). At each follow up, functional evaluation of the patient was done to note the range of movements, at the shoulder and elbow, any pain, deformities, and any residual complaint. The occurrence of the complications in treatment like shoulder pain, elbow pain, stiffness, swelling of the shoulder and elbow was noted. After two weeks, X-rays were taken again to check for position of the fracture, head, neck and shaft, and evidence of radiological union. After 3 months, patients were assessed by Constant score which includes severity of pain, activities of daily living, range of motion in terms of forward elevation, lateral elevation, internal rotation and strength. Subsequently, the patients were followed at above mentioned time intervals till 1 year.

Assessment
The Constant-Murley score (CMS) is a 100 point scale composed of number of score parameters. The test is divided into four subscales: pain (15 points), activities of daily living (20 points), strength (25 points), and range of motion: forward elevation, external rotation, abduction and internal rotation of the shoulder (40 points). The higher the score, the higher the quality of the function.

Statistical tool
As this study was not a comparative study, simple statistical methods of mean and percentage were used.

RESULTS
The total number of cases in the present study were 35, out of which 21(60%) were female and 14 (40%) were males, with mean age of 76.8 with range 65 to 91years. In the present study, the major mode of trauma was fall from standing height in 22 (62.8%) of the cases, followed by road traffic accident in 7 (20%) cases, fall from stairs in 4 (11.4%) and assault in 2 (5.7%) patients. Out of 35 patients, 20 (57.2%) had trauma of the left side and 15 (42.8%) had trauma of the right side. On the basis of Neer's classification, 15 (42.8%) patients had 3 part fracture, 12 (34.3%) patients had 2 part fracture and 8 (22.8%) patients had 4 part fracture. In the present study, 16 patients reported on the same day of injury, 4 patients reported after one day, 4 patients after 2 days, 11 patients reported after 1 week of trauma. Mean delay between the trauma and the start of treatment was 4.2 days. Out of 35 cases in the present study 8 patients had associated injuries. 2 cases had rib fracture, 1 patient had head injury, 1 had ipsilateral clavicle fracture, 1 had ipsilateral olecranon fracture, 1 patient had ipsilateral colles fracture, 1 had same tibia and 1 had same side femur fracture. All associated injuries were dealt accordingly.    13 73.1 12 Boons et al 2012. 21 76.4 -Zyto et al1997. 25 74 -Canbora et al 2013. 29 78±8.6 18.2±4.07 Marieke et al 2017. 32 77±7.0 47±30.3 Present study 76. 8

Clinico-radiological consolidation
Fractures were assessed clinically when painless, unaided movements were possible and there was no tenderness. Mean duration of clinical union was 13.2 weeks.

Complications
In the present study of 35 patients, complications were observed in 12 (34.3%) patients. Stiffness was observed in 4 patients, 2 patients had osteonecrosis, varus malunion was observed in 3 patients, varus collapse in 2 patients and persistent shoulder pain in 1 patient, No neurovascular complications were observed. The higher the number of fractured fragments and greater the age, the higher were the complications observed.

DISCUSSION
The treatment for proximal humeral fractures is controversial. Studies have shown that both operative and non operative methods give comparable results in elderly patients. The study given by Rangan et al in the PROFHER randomized clinical trial showed that there was no significant difference in the Oxford shoulder score in the surgical and non surgical group of patients. 10 In the present study, maximum incidence (N=19, 54.3%) was observed in seventh decade of life.   The mean age was 76.8 years, which had similar results to previous studies. In the present study, 14 (40%) were males and 21(60%) were females. In females, the incidence of trauma was also reported higher than males in the previous studies Rangan  In the present study, the major mode of trauma was fall from standing height in 22 (62.8%) of the cases, followed by road traffic accident in 7 (20%) cases, fall from stairs in 4 (11.4%) and assault in 2 (5.7%) which were in agreement with previous studies, Rangan et al and Soni et al. 10,27 In the present study, on the basis of Neer's classification, most common fracture type was 3 part, followed by 2 part and 4 part.

Limitations
Limitations of present study were it was a nonrandomised study. The sample size was less. Our study is not a comparative study. The Constant scoring system is based on both subjective and objective parameters. The subjective parameters can lead to subjective bias. 14 21

Males
Females

CONCLUSION
The treatment of proximal humeral fractures remains challenging. In the present study, our data shows that the proximal humeral fractures can be effectively managed conservatively in the elderly patients. Among the various fracture types, two part fractures have best functional outcome and four part fractures have highest rate of complications. The conservative management is best suited in elderly patients as the osteoporotic bone does not favour towards surgery, also the functional demand is less, complications related to co-morbidities, surgery and anaesthesia are more. The patient needs to be kept for follow up and physiotherapy at regular intervals. Patient compliance is essential for best outcome.