JAMA: Among patients with a displaced fracture in the upper arm near the
shoulder (proximal humeral), there was no significant difference between
surgical treatment and nonsurgical treatment in patient-reported
outcomes over two years following the fracture, results that do not
support the trend of increased surgery for patients with this type of
fracture, according to a study in the March 10 issue of JAMA.
Proximal humeral fractures account for 5 percent to 6 percent of all
adult fractures; an estimated 706,000 occurred worldwide in 2000. The
majority occur in people older than 65 years, and the age-specific
incidence of these fractures is increasing. Approximately half of these
fractures are displaced, the majority of which involve the surgical neck
(located on the upper portion of the humerus). Surgical treatment is
being increasingly used, contributing to increased treatment costs for
upper limb fractures. A review of results from randomized clinical
trials found insufficient evidence to conclude whether surgical
intervention produces consistently better outcomes than nonsurgical
treatment, according to background information in the article.
Amar Rangan, F.R.C.S. (Tr. & Orth.), of James Cook University
Hospital, Middlesbrough, England, and colleagues randomly assigned 250
patients (average age, 66 years) who sustained a displaced fracture of
the proximal humerus involving the surgical neck to surgical treatment
(fracture fixation or humeral head replacement) or nonsurgical treatment
(sling immobilization). Standardized outpatient and community-based
rehabilitation was provided to both groups. Patients were followed up
for 2 years and 215 had complete follow-up data. The data for 231
patients (114 in surgical group and 117 in nonsurgical group) were
included in the primary analysis.
The researchers found that there were no statistically or clinically
significant differences between surgical and non-surgical treatment
either overall or at individual time points (at 6, 12, and 24 months)
for the Oxford Shoulder Score (OSS), a shoulder-specific outcome measure
that provides a total score based on the patient’s subjective
assessment of pain and function. In addition, there were no clinically
or significant differences on measures of health-related quality of
life, complications related to surgery or shoulder fracture,
complications requiring secondary surgery or treatment, and death.
Ten medical complications (2 cardiovascular events, 2 respiratory
events, 2 gastrointestinal events, and 4 others) occurred in the
surgical group during the postoperative hospital stay.
“These results do not support the trend of increased surgery for
patients with displaced fractures of the proximal humerus,” the authors
conclude.
(doi:10.1001/jama.2015.1629; Available pre-embargo to the media at http://media.jamanetwork.com)
Editor’s Note:
Please see the article for additional information, including other
authors, author contributions and affiliations, financial disclosures,
funding and support, etc.