Is early mobilization a viable option after intramedullary nailing of 4-parts proximal humerus fractures?

IntroductionAfter centromedullary nailing (CMN) of 4-parts (4P) cephalo-tuberositary fractures of the proximal humerus (PH), shoulder immobilization for a few weeks is usual, although no scientific justification does support this attitude, nor the duration of immobilization. The objective of this study was to assess the impact of early mobilization after CMN of PH 4P fractures on clinical, radiological outcomes and complication rates. The hypothesis was that early mobilization would not lead to a deterioration in results or an increase in the complication rate.Materials and methodsAll patients operated on for a 4P-PH fracture by CMN in our institution between 2010 and 2018 were included retrospectively. 2 groups were formed according to the duration of post-operative immobilization of the shoulder: 0-2 weeks (group A) and 3-6 weeks (group B). All patients had a clinical examination (Range of motion ROM and Constant score) and X-rays of the shoulder at least 24 months of follow-up. 58 patients (average age 66 years (39-89)) were included, with 25 in group A and 33 in group B.ResultsThe average follow-up was 38.5 (24-73) months. The active ROM at the last follow-up was: active anterior elevation 149 degrees (80 degrees-180 degrees) in group A versus 134 (60 degrees-180 degrees) in group B (p = 0.099); active external rotation 145 degrees (15 degrees-70 degrees) in group A versus 42 degrees (15-70 degrees) in group B (p = 0.6). The Absolute Mean Constant score was 78.29 for Group A (45-100) versus 68.59 points (45-96) for Group B (p = 0.065). Regarding complications: in group A, we found 2 retractile capsulitis, 2 pseudarthrosis and 2 osteonecrosis of the humeral head. In group B, we found 5 retractile capsulitis, 1 infection of the surgical site, 3 osteonecrosis of the humeral head and 1 pseudarthrosis.ConclusionEarly mobilization after CMN of 4P-PH fractures did not lead to an increase in the complications rate and in particular secondary displacements or osteonecrosis. There was a trend toward improved clinical outcomes with early mobilization, although this trend was not statistically significant.Evidence levelIV, retrospective study.