A recent pragmatic trial concluded that there was no useful difference between intervention and nonoperative management for some displaced PHFs, provoking a debate about the quality of the trial methodology including, importantly, the methods of radiological assessment of the fractures, the methods of functional outcomes assessments and the expertise (judgement and surgical aptitude) of the treating clinicians. Clinicians who advocate surgical intervention to restore the shape of the proximal humerus, with the intention of restoration of the centre of rotation of the glenohumeral joint for optimal deltoid function, accept that they will potentially interrupt, and possibly adversely affect, the cascade of healing processes, leading to complications of the intervention. Clinicians who advocate nonoperative treatment for displaced PHF accept that they are relying on the patients’ tolerance of malunion at the completion of healing. For any displaced fracture treated nonoperatively, the outcome will be defined by the original displacement: the patient will inevitably heal with a malunion, and the functional value of the shoulder will reflect this. Management of PHF, as for all fractures, combines an assessment of the mechanical and biological factors affecting fracture healing with a judgement about the likely prognosis for healing and function based on a multiplicity of intrinsic (shoulder) and extrinsic (comorbid) factors. The functional outcome of a proximal humeral fracture (PHF) is never that of a completely normal shoulder, however treated.
0 kommentar(er)
