Estudio prospectivo de la precisión diagnóstica y análisis comparativo de tres métodos terapéuticos para las fracturas de la extremidad proximal de húmero en adultos

Abstract

Prospective trial of diagnosis accuracy and comparation of three treatments for proximal humerus fracture in adults. Introduction Proximal humerus fractures involve 6% of all fractures. We are dealing with severe lesions which major risk factor associated until the date, is osteoporosis. They affect three more times to women and it seems to keep growing in number as the life expentancy does it too and the bone quality get worse in elderly people. Treatment of the proximal humerus fractures still being controversial. Although it&apos;s commonly accepted that 3 fragments fractures need surgery, there is few information available about the natural history of these fractures depending on treatment election. Hypothesis There are significative differences in terms of pain and clinical function, depending on the treatment election for proximal humerus fractures; been the conservative option comparable at long term to surgical treatment in which the hemiarthroplasty raises as the most efective procedure for pain relieving. Material and Method Presenting a prospective observational analytical trial. Longitudinal, with a one year follow up and unicentric. The anamnesis and complementary test were analyzed at hospital admission and subsequently continued revisions every three months for a year, evaluating the functional questionary of CONSTANT-MURLEY and DASH, including shoulder range of motion. A total of 36 patients divided into three treatment groups were included in the study, 12 treated conservatively, 12 treated by osteosynthesis and 12 with hemiarthroplasty, there being no differences between the three groups with respect to their characteristics (Fisher = 1). Results The three groups of treatment showed improved pain management measured by visual analogue scale (VAS) pain scale. Overall, the pain average measured by VAS were reduced from 4.25 (2.25), registered in the first month since the fracture, to 1.33 (2.19) at the end of follow-up (p <0.001).), as well as the disability of the upper limb. The mean score on the DASH scale was reduced from 50.48 (18.78) in the first month to 30.17 (17.21) at the end of follow-up (p <0.001). The arthroplasty group obtained worse shoulder functionality according to the Constant-Murley scale [average score at the end of follow-up 48.33 (18.75) (p <0.001)], followed by the group treated with osteosynthesis (52.29 (11, 89) p <0.001). The patients treated with conservative treatment obtained a greater range of motion than the surgical treatment groups (At the end of follow-up, in the conservative treatment group, the average of flexion was 138, 5º ± 35.11, and abduction was 126, 83º ± 28.62. In the osteosynthesis group, the flexion was 100.83 ± 30.31 and the abduction was 98.42 ± 29.77, and in the hemiarthroplasty group flexion was 87.58 ± 36.97, and abduction 88.58 ± 37.33), and greater functionality of the shoulder (first year Constant score of 66.38 (17.95) p <0.001). More complications were shown in the osteosynthesis treatment group than the hemiarthroplasty group (p <0.05). Conclusions We have found no benefits in the surgical intervention of fractures of the proximal extremity of the humerus in three or four fragments, in terms of functionality or pain elimination compared to conservative treatment with an adequate rehabilitation protocol for the injury, fundamentally in elderly patients or patients with comorbidities. Regarding surgical treatment, we observed in hemiarthroplasty group a better evolution in the perception of pain, they require shorter hospital stay, with a similar economic cost in comparison to osteosynthesis group. However, the osteosynthesis group showed superiority with regard to the hemiarthroplasty group in terms of functionality. Therefore, we consider essential the assessment of the functional demand of the patient for decision making. We have reported a progressive pain decrease in all groups. In the first month the pain seems to be higher in the group with conservative treatment, however, during the follow-up the surgical groups showed poor pain control. The hemiarthroplasty group has shown worse functionality, more disability of the upper limb and the worst ranges of motion at one year of follow-up. We found complications in 30.5% of all groups patients, requiring revision surgery in 13.9% of them. In the other hand, the osteosynthesis group we have reported more complications of the osteosynthesis material.