Abstract
Background
Evaluate the functional outcome of a specific program of rehabilitation during conservative treatment of fracture of the greater tuberosity.
Methods
We retrospectively studied the records of 22 patients, with minimally displaced greater tuberosity fracture, according to inclusion criteria. All patients have received an early (one week after the injury) rehabilitation program based on physical analgesic therapy means, techniques for recovering range of motion, strengthening exercises, proprioceptive stabilization exercises and usability advices. The evaluation was done at baseline, one, two and three months of the end of physical treatment.
Results
Pain, perceived disability and range of motion were improved significantly since the end of rehabilitation. The improvement of function (Constant score) was significant at different evaluation times. The functional result seems to be poor when patients are aged and pain is severe at baseline.
Conclusion
During conservative treatment of fracture of the greater tuberosity, earlier rehabilitation allows rapid range of motion and functional recovery limiting care duration. After fracture healing, the rehabilitation program becomes similar to that advocated in rotator cuff disease. Whatever the initial treatment choice, rehabilitation must be considered at the waning of the first week.
Résumé
Objectifs
Évaluer le résultat fonctionnel d’un programme de rééducation fonctionnelle au cours du traitement conservateur de la fracture du trochiter.
Patients et méthodes
Il s’agit d’une étude rétrospective portant sur 22 dossiers de patients traités orthopédiquement pour une fracture du trochiter, sélectionnés selon des critères d’inclusion. Tous les patients ont été rééduqués selon un protocole précis, démarré au bout de la première semaine du traitement et basé sur les moyens antalgiques, les techniques de récupération des amplitudes articulaires, les exercices de renforcement musculaire, le travail proprioceptif et le travail en ergothérapie. L’évaluation a été faite au début et à la fin du programme rééducatif et à un, deux et trois mois.
Résultats
La douleur, le handicap et la mobilité articulaire de l’épaule ont été améliorés significativement dès la fin du programme. L’amélioration de la fonction (score Constant) a été significative aux différents temps d’évaluation. Le résultat fonctionnel paraît médiocre chez les patients âgés et ceux ayant une douleur intense au début de l’étude.
Conclusion
Au cours de la prise en charge orthopédique de la fracture du trochiter, la rééducation précoce permet une récupération articulaire et fonctionnelle rapide limitant ainsi la durée de la prise en charge thérapeutique. Après consolidation de la fracture, le programme de rééducation devient semblable à celui de la tendinopathie de la coiffe des rotateurs. Quel que soit le choix thérapeutique, nous recommandons une prise en charge rééducative au décours de la première semaine.
1
English version
1.1
Introduction
Fracture of the proximal humerus is a common injury and accounts for approximately 4% to 5% of all fractures . The incidence increases with age and accelerates over the age of 50 years. Greater tuberosity (GT) fractures represent a particular entity and are estimated to be 20% of them .
The majority of proximal humerus fractures are not displaced or minimally displaced .
For these fractures, conservative treatment is generally the preferred option. The arm is immobilised to maintain fracture stability and to provide pain relief during healing. This is usually followed by physiotherapy and exercises aimed at restoring the function and mobility of the injured arm.
There are few trials evaluating physical treatment options for proximal humeral fracture in adults .
Our aim is to report and evaluate the functional outcome after a specific early rehabilitation program in isolated minimally displaced GT fractures.
1.2
Materials and methodology
We retrospectively studied the records of 22 patients, with minimally displaced GT fracture. Fractures were classified according to Neer classification .
The inclusion criteria are an isolated fracture of the GT (without shoulder dislocation and other fractures of the upper limb), with a displacement of less than 5 mm, treated conservatively (Mayo-clinic immobilisation).
1.2.1
Evaluation
The evaluation at baseline, one, two and three months of the end of physical treatment covered:
- •
pain and disability using a Visual Analog Scale (VAS);
- •
function using the Constant score (CS) over 75 points;
- •
active and passive shoulder range of motion (ROM).
1.2.2
Rehabilitation program
There is currently little quantitative support for rehabilitation protocols, thus, the prescription of such protocols is based on the experience and judgment of the rehabilitation specialist and tradition-based protocols. Our rehabilitation program included 12 sessions (three per week) beginning one week after the injury. It was based on:
- •
analgesic physical therapy: cryotherapy (in case of local inflammatory sign), analgesic electrotherapy and relaxant massotherapy;
- •
at three weeks actively helped, then active techniques are used for recovering ROM. The therapist began by global, then analytic exercises;
- •
significant strengthening exercises are limited before obtaining complete passive shoulder motion. They are executed in isometric mode and used for the long step-down muscles of the humeral head ( pectoralis major and latissimus dorsi );
- •
proprioceptive stabilization exercises seeking abductors muscles ( deltoid and supraspinatus ) and rotators muscles ( subscapularis, infraspinatus and teres minor );
- •
usability advices.
Criteria for success of rehabilitation are: CS more or equal to 60 points, VAS of mobilization shoulder pain less or equal to 20% and VAS of disability felt less or equal to 20%.
1.2.3
Statistics
All statistical analyses were performed with SPSS.10 software. The Wilcoxon test was used to evaluate post-rehabilitation and during follow-up changes. Spearman’s correlation coefficient was used to identify correlations between the parameters studied. The significance threshold was set to P < 0.05 for all tests.
1.3
Results
1.3.1
Study population
They were 16 women and six men with a middle age of 47.45 ± 12.8 years (29 years–67 years). Fourteen patients are active and the majority of them (ten patients) had a manual labor.
The fracture mechanism was a fall of its own height in 18 cases. The energy of the trauma was low in most cases (14/22) ( Table 1 ).
| Age (years) | 47.45 ± 12.80 |
| Gender (♂/♀) | 6/16 |
| Dominant side | |
| Right | 22 (100%) |
| Affected side | |
| Right | 11 (50%) |
| Left | 11 (50%) |
| Mechanism of trauma | |
| Fall | 18 (81.8%) |
| Accident | 2 (9.1%) |
| Traction | 2 (9.1%) |
| Energy trauma | |
| Low | 14 (63.6%) |
| Medium | 4 (18.2%) |
| High | 4 (18.2%) |
| Profession | |
| Power | 4 (18.2%) |
| Manual | 10 (45.5%) |
| Housewife | 8 (36.3%) |
1.3.2
Recovery of pain and handicap
The pain has decreased significantly ( P < 0.001) at the end of the rehabilitation program (gain of 24.6% ± 16.2% compared to the baseline) and at three months (gain of 8.7% ± 6.9% compared to two months evaluation). Perceived disability has decreased significantly from 67.27% ± 20.5% at baseline to 9% ± 8.1% at three months ( P < 0,001) ( Table 2 ).
| Baseline | End of rehabilitation | 1 month | 2 months | 3 months | |
|---|---|---|---|---|---|
| Pain VAS (/100) | 59.6 ± 22.1 | 35 ± 20.8 * | 24 ± 15.9 * | 18.2 ± 13 * | 9.5 ± 7.7 * |
| Handicap VAS (/100) | 67.3 ± 20.5 | 37.3 ± 20 * | 26.36 ± 16.5 * | 21.4 ± 12.7 * | 9.1 ± 8.1 * |
Twenty patients have VAS pain and disability less than 20% at three months.
1.3.3
Recovery of range of motion
The active elevation has increased significantly ( P < 0.001) at the end of rehabilitation program (gain of 54.5°±56° compared to the baseline) and at three months (gain of 14.5°±14.7° compared to two months evaluation). Also, active abduction and passive external rotation have increased significantly in different evaluation times ( Table 3 ). At the end of the rehabilitation program, the test “hand-back” has been improved by at least one listing in 63.6% of cases ( Table 4 ).
| Baseline | End of rehabilitation | 1 month | 2 months | 3 months | |
|---|---|---|---|---|---|
| Active elevation (°) | 86.36 ± 51.5 | 140.9 ± 33 * | 150.9 ± 25.6* | 165.45 ± 14.7 * | 180 * |
| Active abduction (°) | 62.7 ± 39.5 | 123.6 ± 38.9 * | 144.1 ± 28.2* | 161.8 ± 16.2 * | 178.2 ± 3.9 * |
| Passive external rotation (°) | 42.3 ± 23.8 | 62.3 ± 14.2 * | 65.5 ± 13.4 a | 69.5 ± 11.6 a | 77.3 ± 7.7 * |
* P < 0.05 independent t test.
| Buttock | 4 (18.2%) | 0 | 0 | 0 | 0 |
| S1 | 10 (45.5%) | 4 (18.2%) | 0 | 0 | 0 |
| L3 | 8 (36.4%) | 14 (63.6%) | 14 (63.6%) | 12 (54.5%) | 4 (18.2%) |
| T12 | 0 | 4 (18.2%) | 8 (36.4%) | 10 (45.5%) | 18 (81.8%) |
1.3.4
Functional recovery
The CS increased significantly ( P < 0,05), from 23 points ± 15,8 points before rehabilitation to 65.2 points ± 5.2 points at three months. This improvement was significant at different evaluation times ( Table 5 ).
| Constant score | Baseline | End of rehabilitation | 1 month | 2 months | 3 months |
|---|---|---|---|---|---|
| Pain (/15) | 2.7 ± 3.4 | 8.2 ± 3.3 * | 9.5 ± 3.4 * | 10.9 ± 2 * | 12.5 ± 2.5 * |
| Level of daily activities (/10) | 3.3 ± 2 | 6.5 ± 1.5 * | 6.9 ± 1.3 * | 7.2 ± 1.2 * | 8.5 ± 0.9 * |
| Level of hand function (/10) | 4.5 ± 2.6 | 6.9 ± 2.4 * | 8.2 ± 1.4 * | 8.7 ± 1 * | 9.5 ± 0.9 * |
| Mobility (/40) | 12.5 ± 10 | 24.2 ± 6.8 * | 28.5 ± 3.4 * | 30 ± 3.70 * | 34.7 ± 3.2 * |
| Total (/75) | 23 ± 15.8 | 45.8 ± 12.1 * | 53.1 ± 7.7 * | 56.8 ± 6.2 * | 65.2 ± 5.2 * |
* P < 0,05 (comparison with previous evaluation), independent t test.
At three months, 22 patients (90%) achieved good results with 60 points over 75 points or more on CS, less than 20 points on VAS pain and less than 20 points on VAS disability .
We conducted an ultrasound examination of the shoulder in two patients with persistent pain (> 50 on VAS) and limited ROM (abduction < 150°). It showed, in both cases, degenerative changes of the supraspinatus tendon without evident tears.
1.3.5
Correlation study
At three months, functional result evaluated by the CS seems to be poor in aged patients and in cases of severe pain at baseline with respectively (r = –0.452, P = 0.035) and (r = –0.497, P = 0.0019). Handicap felt seems to be higher in patients with severe pain and handicap felt at baseline and in whom with severe pain at three months.
1.4
Discussion
The majority of impacted fractures including GT fractures has no displacement and can be treated conservatively with rehabilitation program that includes early ROM exercises.
It may be associated with partial-thickness rotator cuff tears and labral tears, which may be the cause of persistent pain after fracture healing. Keene et al. noted that minimally displaced GT fractures can be associated with rotator cuff tears.
With the supraspinatus tendon inserting on the fragment, we postulate that displacement effectively changes the force vectors of this muscle. This seems likely since previous studies have highlighted the importance of the supraspinatus in aiding shoulder abduction . Unfortunately, we can’t prevent these troubles with exercises but we can just point the strengthening of the supraspinatus muscle and the rotator cuff muscle globally during rehabilitation program. After GT fracture healing, the rehabilitation program became similar to the one in rotator cuff disease.
An alteration of the function of the rotator cuff and a direct mechanical block may compromise abduction . Prominence of the GT with superior or posterior displacement may contribute to symptomatic subacromial impingement . Radiographic evaluation of the shoulder in patients with minimally displaced proximal humeral fractures would be helpful in predicting functional outcome during conservative treatment .
The most widely used objective criterion for the treatment of fractures of the GT is the amount of initial displacement . As our policy, most authors advocate conservative treatment of fractures with less than 5 mm of displacement and surgery for injuries in which it is more than 10 mm , but the optimal management of fragments with distraction of between 5 and 10 mm is unclear . In our patients, fractures displacement was less than 5 mm.
Neer endorsed conservative treatment for fractures displaced less than 10 mm, stating that early functional rehabilitation and ROM resulted in a satisfactory outcome. The current literature recommends surgical treatment for displaced GT-fracture greater than 3 mm .
In a comparative study, Revay et al. reported that the addition of supervised exercises in a swimming pool to self-treatment did not enhance long-term outcome. Participants of the control group (self-treatment only) were reported as having significantly better functional movements, joint mobility and activities of daily living at two and three months follow-up. However, there were no significant differences at one year. The authors suggested that those using the pool may have neglected their home exercises, but they did not evaluate compliance.
In our patients, significant improvement of ROM was obtained within four weeks. We did not prescribe home exercises.
Explanations for poor results after conservative treatment of fractures of the GT have included loss of shoulder elevation and painful movement .
Rotator cuff tears constitute a predictive factor of poor functional result one year after GT fracture . They can be concomitant to fracture or preexisting . It is difficult to distinguish between old and recent lesions. It appears that longitudinal lesions were of traumatic etiologies and transversal one due to degenerative phenomenon . Concerning our series, shoulder sonographic examination had showed degenerative lesions with alteration of the supraspinatus tendon structure without evident tears. In other patients, we cannot eliminate rotator cuff injuries. According to Nanda et al. , these lesions would not affect final function outcome.
In other hand, neurologic injuries were frequently associated to GT fractures. They consist of brachial plexus and circonflexe nerve lesions . Electromyography is of great interest in cases of persistent muscular weakness of the shoulder.
Vascular injuries (axillary artery and vein) were less frequent .
The consequences of the GT fractures are imbalance of the shoulder muscular balance due to the fracture itself and to the immobilisation. So muscles balance equilibration between rotators and abductors of the shoulder is an essential target which procure humeral head stabilization.
Our work shows that the conservative treatment followed by early ambulatory rehabilitation program gives good results after a displacement less than 5 mm GT fracture.
Platzer et al. noted good or excellent results (CS ≥ 80) in 97% of patients with minimally displaced (1–5 mm) fractures of the GT. All patients underwent a regular rehabilitation program including physiotherapy, rotator cuff strengthening exercises and ROM exercises, for a median of ten weeks. Patients with a displacement of more than 3 mm had slightly worse results compared to those with less displacement, but this was not statistically significant.
Young et al. reported that patients with displaced GT fractures did no worse than those with displaced surgical neck fractures. Good or acceptable results were noted by the authors in 97% of cases with conservative treatment of minimally displaced injuries (< 10 mm) of the proximal humeral, qualifying abduction greater than 60° as acceptable. In our patients 90% achieved good functional result (CS ≥ 60 points) at three months follow-up.
Our study has the merit of addressing the functional outcome of early rehabilitation in cases of isolated fracture of the GT. Our rehabilitation program has the distinction of being performed as an outpatient.
One of the limits of this study is the relative small series of patients. In fact, isolated GT fractures only account for a relatively small number of the proximal humeral fractures . In addition, our population depends from the epidemiology of fractures specific to our hospital.
In the other hand, the short follow-up period can be explained by favourable evolution in our patients who don’t consult after three months period and the absence of complications.
Our attitude in cases of GT fractures depends on the amount of displacement. We propose conservative treatment (Mayo-clinic immobilisation) in cases of non-displaced fractures or displacement of less than 5 mm. If it is greater than 10 mm, we opt for the surgical solution.
In cases of displacement between 5 and 10 mm, we recommend a conservative treatment with weekly radiographic examination for three weeks. If it detects secondary displacement, we indicate surgery.
In our opinion, careful follow-up and supervised rehabilitation, similar to rotator cuff tear rehabilitation, is useful to optimize results after both nonsurgical and surgical treatment.
1.5
Conclusion
The amount of displacement determines treatment choice in case of GT fractures. Earlier rehabilitation can allow early ROM and functional recovery limiting care duration. Whatever the initial treatment choice, rehabilitation must be considered earlier.
Disclosure of interest
The authors declare that they have no conflicts of interest concerning this article.
2
Version française
2.1
Introduction
Les fractures de l’extrémité supérieure de l’humérus sont fréquentes, représentant 4 % à 5 % parmi toutes les fractures . Leur incidence augmente de façon importante après l’âge de 50 ans. La fracture du trochiter représente une entité particulière et représente 20 % de ces fractures . La plupart de ces fractures sont peu ou non déplacées . Dans ces cas, on opte souvent pour un traitement conservateur. Le membre supérieur est immobilisé pour stabiliser la fracture et prévenir la douleur durant la période de consolidation. La prise en charge est souvent complétée par la physiothérapie et des exercices visant à restaurer la mobilité et la fonction du membre lésé. Les études évaluant les traitements rééducatifs dans les fractures de l’extrémité supérieure de l’humérus, notamment du trochiter, sont rares .
L’objectif de notre travail est de décrire et d’évaluer le résultat fonctionnel d’un programme de rééducation des fractures peu déplacées du trochiter.
2.2
Patients et méthodes
Il s’agit d’une étude rétrospective portant sur 22 dossiers de patients présentant des fractures du trochiter répertoriées selon la classification de Neer .
Les critères d’inclusion sont une fracture isolée du trochiter (sans luxation de l’épaule ni fracture associée du membre supérieur) de déplacement inférieur à 5 mm et traitée orthopédiquement (immobilisation par Mayo-clinic).
2.2.1
Évaluation
L’évaluation a été réalisée au début et à un, deux et trois mois de la fin du programme de rééducation fonctionnelle. Les paramètres concernés sont :
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la douleur et l’handicap à l’aide d’une échelle visuelle analogique (EVA) sur 100 ;
- •
la fonction à l’aide du score Constant (SC) simplifié sur 75 points (la cotation de la force musculaire sur 25 points n’a pas été réalisée) ;
- •
les amplitudes articulaires actives et passives de l’épaule par mesures goniométriques.
2.2.2
Programme de rééducation fonctionnelle
Il n’y a pas de consensus concernant le programme de rééducation fonctionnelle dans cette pathologie, en effet la prescription de tel programme est souvent basée sur l’expérience et le jugement du médecin rééducateur à partir des protocoles traditionnels. Notre programme était composé de 12 séances à raison de trois séances hebdomadaires. La rééducation a été entamée une semaine après le traumatisme.
Elle comportait :
- •
des moyens physioantalgiques : cryothérapie en cas de signes inflammatoires locaux, électrothérapie antalgique et massothérapie ;
- •
à trois mois, la mobilisation active, aidée puis active, est utilisée pour le gain des amplitudes articulaires de l’épaule. Le thérapeute commence par un travail global, puis analytique ;
- •
les exercices de renforcement musculaires restent limités avant d’obtenir une mobilité passive complète. Ils sont réalisés en mode isométrique et concernent les abaisseurs longs de la tête humérale (pectoralis major et latissimus dorsi) ;
- •
des exercices proprioceptifs de stabilisation sollicitant les muscles abducteurs (deltoïde et supraspinatus ) et les muscles de la coiffe des rotateurs (subscapularis, infraspinatus et teres minor) ;
- •
un travail en ergothérapie.
Les critères de succès du traitement sont un SC supérieur ou égal à 60 points, une EVA douleur mobilité inférieure ou égale à 20 % et une EVA handicap inférieure ou égale à 20 %.
2.2.3
Statistiques
Les analyses statistiques ont été réalisées à l’aide du logiciel SPSS.10. Le test de Wilcoxon a été utilisé pour évaluer les changements des paramètres après rééducation fonctionnelle et durant le suivi. Le coefficient de corrélation de Spearman a été utilisé pour rechercher les corrélations entre les paramètres étudiés. Le seuil de signification a été fixé à p < 0,05 pour tous les tests.
2.3
Résultats
2.3.1
Population d’étude
Il s’agit de 16 femmes et six hommes, ayant un âge moyen de 47,45 ans ±12,8 ans (29 ans–67 ans). Quatorze patients étaient actifs et la majorité d’entre eux (dix patients) avait un travail manuel de force.
Chez 18 patients, le mécanisme de la fracture a été une chute de leurs propres hauteurs. Dans 14 cas, le traumatisme a été de faible énergie ( Tableau 1 ).
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