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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].

Clinical Scenario

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.

Search Strategy

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

Search Outcome

105 articles found two of which were relevant and of sufficient quality for inclusion.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Hodgson SA et al, 2007, UK	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, 2007, France	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)

Comment(s)

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.

References

1. 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
2. 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