Three Part Question
In [the elderly with minimally displaced, uncomplicated neck of humerus fracture] is [early mobilisation better than delayed mobilisation] at [maximising recovery of function].
A 75 year old woman attends the emergency department having fallen at home. She has pain around her left upper arm, and is reluctant to move it. Examination reveals a probable fracture of the humerus and an x-ray confirms this. There are no neurovascular complications or displacement. The Orthopaedic team give differing advice about how you should immobilise her arm and what advice you can give her about when she can start to move it. You wonder if there are any studies that address this.
Medline 1950 to November Week 2 2007
EMBASE 1980 to 2007 Week 52
The Cochrane Library Issue 4 2007
Medline: (exp Shoulder Fractures/ OR proximal adj humer$ adj fracture$.mp.) AND (exp "recovery of function"/ OR mobilis$.mp. OR mobiliz$.mp.) LIMIT to human and English language 55 records
EMBASE: exp Humerus Fracture/ OR (proximal adj humer$ adj fracture$).mp. AND exp MOBILIZATION/ OR mobilis$.mp. OR mobiliz$.mp.) LIMIT to humans and English 50 articles
Cochrane: MeSH descriptor Shoulder Fractures explode all trees
105 articles found two of which were relevant and of sufficient quality for inclusion.
|Author, date and country
||Study type (level of evidence)
|Hodgson SA et al,|
|86 patients with 2-part fractures of the proximal humerus
Immediate physiotherapy (44) vs delayed physiotherapy after 3 weeks (42)||PRCT||Shoulder disability (Croft score) at 1 year||42.8% vs 72.5%|
|Shoulder disability (Croft score) at 2 years||43.2% vs 59.5%|
|Lefevre-Colau et al,|
|64 patients with impacted proximal humeral fractures
Early mobilisation (32) vs conventional treatment (32)||PRCT||Constant score (0 – 100) at 3 months||71 vs 61.1 (P = 0.02)|
|Constant score (0 – 100) at 6 months||81.5 vs 75.4 P = 0.07)|
The studies both point to early mobilisation having a positive early effect on functioning which is very beneficial in this age group. The difference decreases over time, (with the late mobilisation group showing greater late improvement in function. A Cochrane review has been performed on this topic, but this data postdates it.
Clinical Bottom Line
There is evidence to support early mobilisation in uncomplicated fractured neck of humerus in the elderly.
- Hodgson SA, Mawson SJ, Saxton JM et al. Rehabilitation of two-part fractures of the neck of the humerus (two-year follow-up). J Shoulder Elbow Surg 2007;16:143-5
- Lefevre-Colau MM, Babinet A, Fayad F et al. Immediate mobilization compared with conventional immobilization for the impacted nonoperatively treated proximal humeral fracture: A randomized controlled trial. J Bone Joint Surg; 2007 89A:2582-90