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

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?
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 97) and fractures involving the nondominant
arm (n 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 dominant 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 .43;
pain, P .63; activities of daily living, P .70; forward elevation, P .57; abduction, P .52; lateral
rotation; P .90; internal rotation, P .32; and strength, P .24). The mean physical component summary 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 .29; mental
component summary score, P .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 CEICParc de Salut Mar approved this

study: No. 2012/4955/I.
*Reprint requests: Carlos Torrens, MD, Hospital del Mar, Passeig
Mar
tim 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

678
PHFs.5,6,12,13 Routinely, factors affecting treatment decision include age, comorbidity, fracture patterns, and associated 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 influenced by age, gender, treatment, intraoperative or postoperative 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, dominance 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 prospectively involving 196 consecutive PHFs attended at our institution 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 97) and PHF involving the nondominant arm (n 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 prostheses, and 5 osteosynthesis with angular plates. Conservative treatments 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 Neers 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/intraobserver 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 significantly differ between groups (Table I). Both groups were prospectively 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 (SF36).1,2,4 Mortality and level of autonomy, assessed by asking the
patient if he or she was fully independent for activities of daily

C. Torrens et al.
Table I Gender, type of fracture, treatment, and ASA distribution according to dominance
Dominant (%) Nondominant (%) P value
Gender
Female
Male
Type of fracture
1 part
2 parts
3 parts
4 parts
Treatment
Surgery
Conservative
ASA class
1
2
3
4

54.3
53.8

45.7
46.2

.55
.55

62.5
47.8
60.3
50.0

37.5
52.2
39.7
50.0

.18
.15
.18
.59

53.9
54.4

46.1
45.6

.53
.53

47.8
48.9
58.3
50.0

52.2
51.1
41.7
50.0

.84
.84
.80
.48

ASA, American Society of Anesthesiologists physical status classification 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 c2 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 nondominant 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 .43; pain,
P .63; ADLs, P .70; forward elevation, P .57;
abduction, P .52; lateral rotation, P .90; internal
rotation, P .32; and strength, P .24).
The mean physical component summary score of the SF36 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 significant differences were noted between groups in any item
of the SF-36 (physical component summary score, P .29;
mental component summary score, P .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

Table II

679

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

Age
Total Constant score
Pain
ADLs
Forward elevation
Abduction
Lateral rotation
Internal rotation
Strength
SF-36 Physical
SF-36 Role
SF-36 Bodily
SF-36 General health
SF-36 Vitality
SF-36 Social
SF-36 Role emotional
SF-36 Mental health
SF-36 Physical component
SF-36 Mental component

Group

Mean

SD

Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant
Dominant
Nondominant

69.8
67.4
64.1
66.8
12.3)
12.5)
16.2)
16.0)
125y
129y
119y
124y
6.8)
6.8)
6.9)
7.3)
9.4)
10.5)
37.6
40.0
40.5
39.7
41.9
42.4
40.7
42.3
45.7
45.0
41.1
41.6
41.3
41.0
42.8
40.6
39.7
41.9
44.2
42.7

10.8
14.6
21.3
20.9
2.9
3.0
4.2
4.3
44
39
44
40
3.1
3.1
2.5
2.5
5.3
5.5
12.9
13.7
14.4
13.4
11.4
12.9
10.4
11.1
11.0
12.6
14.8
13.3
14.8
14.6
12.4
12.5
11.3
11.9
13.2
12.7

P value
.21
.43
.63
.70
.57
.52
.90
.32
.24
.31
.74
.84
.40
.76
.85
.90
.31
.29
.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 .87). As far as ADLs are concerned, 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 .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 significant differences could be found in the mortality rate and
autonomy levels between PHFs affecting the dominant arm
and PHFs affecting the nondominant arm.

680
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 displaced 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 treatment 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 al9 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 discriminate the effect of dominance. Neuhaus et al8 sought to
determine the factors influencing the outcome among patients 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. S
udkamp et al11
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 comparable populations according to age, sex, and fracture
pattern, dominance has no influence on functional outcomes and the quality of life perception in PHF. No significant 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 followup. This study failed to corroborate the statement of
S
udkamp et al11 that fractures of the dominant shoulder
lead to a more complex fracture pattern because no significant differences were noted in the fracture distribution
between groups. May be the bigger sample used in the
study of S
udkamp et al could detect this factor (that was
not evident among the more limited sample of 179 patients included in this study).

C. Torrens et al.
The strengths of the study include the number of patients
included, comparable populations, and prospective collection 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
The treatment decision of PHF has to be made after
consideration of age, comorbidities, and fracture patterns 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
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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