Head–Shaft Angle Influences Isometric Shoulder Strength Levels after Intramedullary Nailing of Proximal Humerus Fractures: A Pilot Study

Abstract

Background: Proximal humerus fractures are common fractures of the elderly population which can lead to long-term compromise of a patient’s shoulder function. Closed reduction and internal fixation with intramedullary nailing is a well-established surgical technique yielding good outcomes, as perceived by patients, obtained via Patient-Reported Outcome Measures, and objectified by clinical shoulder testing. Apart from conventional range-of-motion testing and clinical shoulder tests, strength testing of the shoulder is a yet-neglected but meaningful and standardizable outcome parameter. In this study, isometric shoulder strength is evaluated in relation to fracture morphology/postoperative reduction quality as well as with patient-reported outcomes. Methods: 25 patients (mean age 73.2 ± 10.5 years) underwent isometrics strength-testing of the shoulder joint in the scapular plane (abduction) as well as in the sagittal plane (flexion) as well as hand-grip strength-testing at 4.5 ± 1.88 years follow-up. Pre- and postoperative radiographs were analysed. Patients completed ASES and CMS questionnaires. Results: Patients exhibited a decrease in abduction and flexion force (−24.47% and −25.30%, respectively, p < 0.001) using the contralateral, uninjured arm as reference. Abduction force tended to be decreased in three- and four-part fractures. Patient satisfaction correlated negatively with the relatively reduced force of the affected arm. Varus-angulated humeral heads produced significantly lower abduction force output than valgus- or physiologic angulation (p = 0.014), whereas flexion force was unaffected (p = 0.468). The anatomical reduction had no influence on shoulder strength. Conclusions: Proximal humerus fractures may cause a significant reduction in shoulder function, both reported by patients and objectified by shoulder strength testing. Varus head angulation demonstrated the greatest loss of shoulder strength and should be avoided to ensure proper functioning. Further, strength testing seems a valuable outcome parameter for a thorough shoulder examination with easy obtainability.