Functional outcome of operative vs conservative management of 4 part proximal humerus fracture: A prospective comparative study

Abstract

Background: Proximal humerus fractures are most common injuries involving the shoulder next to clavicle. Most of the injuries are due to high energy impact occurring during RTA, fall from height, fall due to convulsion or epilepsy. Fractures are associated with sever commination and collapse of articular surface leading to dislocation and severe pain, swelling. Generally, these Neers 4-part fractures are managed by surgery with PHILOS plate. However, in our study of 15 patients managed conservatively showed better results compared to patients managed operatively with PHILOS. Methods: This is a prospective interventional study of 30 cohort cases of proximal humerus fracture – Neers 4 part. Patients willing for operations are treated with PHILOS and those non-willing and who were not fit for surgery were managed conservatively with sling. Early rehabilitation and pendulum exercises started at the beginning of 2-week post op. Patients were admitted and followed at our institution from 2015 t0 2017. Outcome analysed at the end taking into consideration of clinical and radiological improvements. Functional outcome will be assessed by Constant Murley score at the end of study. Results: In our series of 30 patients, majority of the patients were males, with RTA and fall from height in field being the commonest mode of injury in young population and domestic fall being the most common mode of injury in elderly. Fractures managed conservatively showed good range of shoulder movements with less complications compared to operated cases. However early mobilisation and pain management were seeming to be well with PHILOS in immediate post-operative days but shoulder strength and long-term pain controlled better in non-operative cases. Majority of the fractures united with a good to moderate outcome in 50% of the patients. Malunions were the only complications in non-operative cases and in PHILOS there were some incidences of screw perforation, AVN, plate impingement and infection along with malunion. Conclusions: though many studies conclude Proximal Humerus locking compression plate is an advantageous implant because of its angular stability, particularly in communited osteoporotic bones in elderly patients, thus allowing early mobilization. It has many complications. In our study non operated Neers 4-part proximal humerus fractures did well at the end of study without suffering any complications. In fact, non-operated group was more confident in shoulder movements during physiotherapy. Hence, it’s better to manage these fractures conservatively.