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J Shoulder Elbow Surg (2015) 24, 677-681

J Shoulder Elbow Surg (2015) 24, 677-681 www.elsevier.com/locate/ymse Does fracture of the dominant shoulder have any
J Shoulder Elbow Surg (2015) 24, 677-681 www.elsevier.com/locate/ymse Does fracture of the dominant shoulder have any

www.elsevier.com/locate/ymse

Does fracture of the dominant shoulder have any effect on functional and quality of life outcome compared with the nondominant shoulder?

J Shoulder Elbow Surg (2015) 24, 677-681 www.elsevier.com/locate/ymse Does fracture of the dominant shoulder have any

Carlos Torrens, MD*, Juan Francisco Sanchez, MD, Anna Isart, MD, Fernando Santana, MD

Department of Orthopedics, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain

Hypothesis: Proximal humeral fractures involving the dominant arm are not predisposed to worsen the functional outcome and the quality of life compared with proximal humeral fractures of the nondominant arm. Methods: This was a retrospective study including 179 consecutive proximal humeral fractures divided into 2 groups: fractures involving the dominant arm (n ¼ 97) and fractures involving the nondominant arm (n ¼ 82). Both groups were prospectively assessed for 2 years, and at the end of the follow-up, all patients underwent functional assessment by Constant score and quality of life assessment through the 36-Item Short Form Health Survey (SF-36). Results: At the 2-year follow-up, the mean Constant score of the whole series was 65.5 (64.1 in the domi- nant group and 66.8 in the nondominant group). No significant differences were noted between groups in the total Constant score or among any of the items of the Constant score (total Constant score, P ¼ .43; pain, P ¼ .63; activities of daily living, P ¼ .70; forward elevation, P ¼ .57; abduction, P ¼ .52; lateral rotation; P ¼ .90; internal rotation, P ¼ .32; and strength, P ¼ .24). The mean physical component sum- mary score of the SF-36 at the 2-year follow-up was 40.8 (39.7 in the dominant group and 41.9 in the nondominant group). The mean mental component summary score of the SF-36 at the 2-year follow-up was 43.5 (44.2 in the dominant group and 42.7 in the nondominant group). No significant differences were noted between groups in any item of the SF-36 (physical component summary score, P ¼ .29; mental component summary score, P ¼ .51). Conclusion: No significant difference could be found relating to dominance in functional outcome and in the quality of life perception in proximal humeral fractures. Dominance of the affected shoulder has no influence and should not be used to make treatment decisions. Level of evidence: Level III, Retrospective Cohort, Treatment Study. 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.

Keywords: Fracture; proximal humerus; dominance; conservative treatment; surgical treatment; outcome; osteoporosis; quality of life

The Ethical Committee of the CEIC–Parc de Salut Mar approved this study: No. 2012/4955/I. *Reprint requests: Carlos Torrens, MD, Hospital del Mar, Passeig Mar ıtim 25-29, E-08003 Barcelona, Spain. E-mail address: 86925@parcdesalutmar.cat (C. Torrens).

Treatment of displaced proximal humeral fractures (PHFs) remains unclear. Whereas some authors advocate for surgical treatment of complex PHFs, others consider that conservative treatment remains a good option for most

1058-2746/$ - see front matter 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.

http://dx.doi.org/10.1016/j.jse.2014.10.006

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C. Torrens et al.

PHFs. 5,6,12,13 Routinely, factors affecting treatment deci- sion include age, comorbidity, fracture patterns, and asso- ciated injuries, and there is a tendency toward a surgical decision in younger patients, with more complex fractures, and with associated injuries that require surgery. 6 Functional outcomes of PHF seem to be strongly influ- enced by age, gender, treatment, intraoperative or post- operative complications, and ability to obtain anatomic restoration. 8,9,11 Although it is clear that the quality of life is strongly impaired in fractures affecting the dominant hand, 3,10 little evidence is available about the consequences of PHFs affecting the dominant shoulder compared with those affecting the nondominant shoulder in terms of functional outcome and quality of life perception. However, domi- nance is frequently considered to be relevant in planning what decision to take in PHF. The objective of this study was to determine whether PHF involving the dominant arm is predisposed to worsen the functional outcome and quality of life compared with PHF involving the nondominant arm and whether mortality and a level of autonomy can also be affected.

Materials and methods

A retrospective study was conducted with the data collected pro- spectively involving 196 consecutive PHFs attended at our insti- tution from January 2009 to December 2010. Seventeen patients were lost before the final follow-up and were excluded from the study. The mean age of the 179 patients finally included was 68.3 years (59-81 years). There were 140 women and 39 men. Fractures were divided into 2 groups: PHF involving the dominant arm (n ¼ 97) and PHF involving the nondominant arm (n ¼ 82). Seventy-six fractures were surgically treated (41 dominant and 35 nondominant), whereas 103 were conservatively treated (56 dominant and 47 nondominant). Surgical treatments included 50 osteosutures, 19 hemiarthroplasties, 2 reversed shoulder prosthe- ses, and 5 osteosynthesis with angular plates. Conservative treat- ments included a 3-week immobilization with a sling followed by an assisted progressive rehabilitation program. Fracture pattern was studied through radiography (anteroposterior view and outlet view) and computed tomography scan, and after that, fractures were classified according to Neer’s classification system into 8 1-part, 102 2-part, 63 3-part, and 6 4-part fractures with no significant differences between the dominant and nondominant groups. 7 All the fractures were classified by the same senior shoulder specialist (C.T.) after review of all image files, but no interobserver/intra- observer reliability study was done. No epidemiologic or fracture pattern differences were noted between groups (dominant and nondominant). In surgically treated fractures, the American Society of Anesthesiologists physical status classification did not signifi- cantly differ between groups (Table I). Both groups were pro- spectively observed during 2 years, and at the end of the 2-year follow-up, all the patients involved underwent a functional assessment with the aid of the Constant score and quality of life assessment through the 36-Item Short Form Health Survey (SF- 36). 1,2,4 Mortality and level of autonomy, assessed by asking the patient if he or she was fully independent for activities of daily

Table I Gender, type of fracture, treatment, and ASA dis- tribution according to dominance

Dominant (%) Nondominant (%) P value

Gender

 

Female

54.3

45.7

.55

Male

53.8

46.2

.55

Type of fracture

 

1

part

62.5

37.5

.18

2

parts

47.8

52.2

.15

3

parts

60.3

39.7

.18

4

parts

50.0

50.0

.59

Treatment

 

Surgery

53.9

46.1

.53

Conservative 54.4

45.6

.53

ASA class

 

1

47.8

52.2

.84

2

48.9

51.1

.84

3

58.3

41.7

.80

4

50.0

50.0

.48

ASA, American Society of Anesthesiologists physical status classifica- tion system.

living (ADLs) or after the fracture became dependent for some ADLs, were also recorded at the end of the 2-year follow-up.

Statistics

Categorical variables were compared with c 2 test or Fisher exact test as appropriate. Quantitative variables were compared with Student t test. All statistical analyses were conducted with the SPSS statistical software (SPSS Inc., Chicago, IL, USA). The a level was set at .05.

Results

At the 2-year follow-up, the mean Constant score of the entire series was 65.5 (64.1 [standard deviation (SD) 21.3] for the dominant group; 66.8 [SD 20.9] for the nondomi- nant group). No significant differences were noted between groups in the total Constant score or in any of the items of the Constant score (total Constant score, P ¼ .43; pain, P ¼ .63; ADLs, P ¼ .70; forward elevation, P ¼ .57; abduction, P ¼ .52; lateral rotation, P ¼ .90; internal rotation, P ¼ .32; and strength, P ¼ .24). The mean physical component summary score of the SF- 36 quality of life questionnaire at the 2-year follow-up was 40.8 (39.7 [SD 11.3] for the dominant group and 41.9 [SD 11.9] for the nondominant group). The mean mental component summary score of the SF-36 at the 2-year follow-up was 43.5 (44.2 [SD 13.2] for the dominant group and 42.7 [SD 12.7] for the nondominant group). No sig- nificant differences were noted between groups in any item of the SF-36 (physical component summary score, P ¼ .29; mental component summary score, P ¼ .51) (Table II). At the 2-year follow-up, the mean mortality rate was 3.9% (4.1% in the dominant group and 3.7% in the

Influence of dominance in shoulder fractures

679

Table II Mean values and standard deviation of Constant score and SF-36 according to dominance

 

Group

Mean

SD

P value

Age

Dominant

69.8

10.8

Nondominant

67.4

14.6

.21

Total Constant score

Dominant

64.1

21.3

Nondominant

66.8

20.9

.43

Pain

Dominant

12.3 )

2.9

Nondominant

12.5 )

3.0

.63

ADLs

Dominant

16.2 )

4.2

Nondominant

16.0 )

4.3

.70

Forward elevation

Dominant

125 y

44

Nondominant

129 y

39

.57

Abduction

Dominant

119 y

44

Nondominant

124 y

40

.52

Lateral rotation

Dominant

6.8 )

3.1

Nondominant

6.8 )

3.1

.90

Internal rotation

Dominant

6.9 )

2.5

Nondominant

7.3 )

2.5

.32

Strength

Dominant

9.4 )

5.3

Nondominant

10.5 )

5.5

.24

SF-36 Physical

Dominant

37.6

12.9

Nondominant

40.0

13.7

.31

SF-36 Role

Dominant

40.5

14.4

Nondominant

39.7

13.4

.74

SF-36 Bodily

Dominant

41.9

11.4

Nondominant

42.4

12.9

.84

SF-36 General health

Dominant

40.7

10.4

Nondominant

42.3

11.1

.40

SF-36 Vitality

Dominant

45.7

11.0

Nondominant

45.0

12.6

.76

SF-36 Social

Dominant

41.1

14.8

Nondominant

41.6

13.3

.85

SF-36 Role emotional

Dominant

41.3

14.8

Nondominant

41.0

14.6

.90

SF-36 Mental health

Dominant

42.8

12.4

Nondominant

40.6

12.5

.31

SF-36 Physical component

Dominant

39.7

11.3

Nondominant

41.9

11.9

.29

SF-36 Mental component

Dominant

44.2

13.2

Nondominant

42.7

12.7

.51

SD, standard deviation; ADLs, activities of daily living. ) Values expressed according to Constant score. y Values expressed in degrees.

nondominant group) without any significant difference between the groups (P ¼ .87). As far as ADLs are con- cerned, 80% of the patients were independent for ADLs in the dominant group, whereas 84.0% of the patients were independent for ADLs in the nondominant group, without significant differences between the groups (P ¼ .51).

Discussion

Treatment decisions in displaced PHFs are commonly made after consideration of age, comorbidities, and fracture pattern. 9 There is evidence that fractures involving the

dominant hand significantly impair the quality of life, 3,10 but little evidence is published concerning the quality of life impairment in PHF depending on the dominant or nondominant arm affected. This study demonstrates that there is no significant difference in the functional outcome and quality of life between PHF affecting the dominant arm and PHF affecting the nondominant arm, meaning that patients do not experience a decrease in their quality of life perception by the shoulder affected. Moreover, no signifi- cant differences could be found in the mortality rate and autonomy levels between PHFs affecting the dominant arm and PHFs affecting the nondominant arm.

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C. Torrens et al.

Patients suffering a fracture involving the dominant hand have shown severe impairment in their quality of life perception because there are specific tasks that can be done only with the dominant hand. 3,10 Sustaining a dis- placed distal radius fracture may impair quality of life in several areas in terms of health in most patients, whereas impairments in hobbies and social activities may be relevant to only a small subset of patients, and dominance has been shown to have a strong influence on daily activities. 3,10 Even though dominance is usually recorded in treat- ment studies involving PHF, outcomes are normally expressed without any reference to dominance, making it difficult to determine whether patients suffering a PHF affecting the dominant shoulder can be impaired for this condition. Okike et al 9 designed a study to determine the factors associated with the decision for operative vs. nonoperative treatment of displaced PHF and concluded that being younger and having associated injuries requiring surgery, a higher AO classification, a dislocation, and a translation-type displacement were associated with an increased operative rate. Even though they included the side affected as a possible predictor factor, they did not record dominance, making results worthless to discrimi- nate the effect of dominance. Neuhaus et al 8 sought to determine the factors influencing the outcome among pa- tients with PHF through data obtained in the National Hospital Discharge Survey and concluded that older age, concomitant fractures, and certain comorbidities increased the rate of in-hospital complications, but dominance was not included among parameters studied. Sudkamp et al 11 used the path analysis method to test the prognostic value of 10 patient-related and treatment-related factors of 463 PHFs and concluded that there were 6 significant determinant factors affecting the outcome: age, sex, treatment, intraoperative and post-treatment complications, and anatomic restoration. In that study, dominance was not directly associated with the final outcome but showed some significance as an intermediate factor leading to more complex fractures. The results of this study demonstrate that in compa- rable populations according to age, sex, and fracture pattern, dominance has no influence on functional out- comes and the quality of life perception in PHF. No sig- nificant differences could be found in Constant score and SF-36 items between dominant and nondominant PHFs. Furthermore, no significant differences were noted in mortality rate and capacity for ADLs at the 2-year follow- up. This study failed to corroborate the statement of Sudkamp et al 11 that fractures of the dominant shoulder lead to a more complex fracture pattern because no sig- nificant differences were noted in the fracture distribution between groups. May be the bigger sample used in the study of Sudkamp et al could detect this factor (that was not evident among the more limited sample of 179 pa- tients included in this study).

The strengths of the study include the number of patients included, comparable populations, and prospective collec- tion of data. A limitation of the study is the use of a general health questionnaire to detect the quality of life perception instead of specific questions addressed to specific shoulder tasks, but the authors’ purpose was to identify whether the dominance of the shoulder involved had an impact on general quality of life perception rather than an impairment on specific tasks because it is recognized that there is a considerable variability for each patient in determining the importance of each specific task.

Conclusions

Conclusions The treatment decision of PHF has to be made after consideration of age, comorbidities, and

The treatment decision of PHF has to be made after consideration of age, comorbidities, and fracture pat- terns and may not rely on the shoulder affected because no significant differences can be found in function, quality of life perception, mortality rate, and autonomy level between PHFs affecting the dominant arm and PHFs affecting the nondominant arm.

Disclaimer

Disclaimer The authors, their immediate families, and any research foundation with which they are affiliated have

The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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