From the Guidelines
For a 78-year-old female with an acute, mildly displaced humeral neck fracture (6 mm displacement), non-surgical management is typically recommended. This approach is based on the principle of minimizing risks associated with surgery in elderly patients, especially when the fracture is minimally displaced, as indicated by studies such as 1 which, although focused on fragility fractures, underscores the importance of managing osteoporotic fractures with a consideration for the patient's overall health and risk profile. Treatment should begin with a sling or shoulder immobilizer for 2-3 weeks to provide support and reduce pain, followed by gentle pendulum exercises starting around week 3 to maintain range of motion.
Pain management is crucial and should include acetaminophen 650-1000 mg every 6 hours as needed, possibly supplemented with NSAIDs like ibuprofen 400-600 mg three times daily if not contraindicated by other medical conditions. It's essential to monitor for potential side effects and interactions with other medications the patient may be taking. Physical therapy should be initiated at approximately 4-6 weeks post-injury, focusing on progressive range of motion exercises and eventually strengthening to improve functional outcomes.
The patient should be monitored with follow-up X-rays at 2,6, and 12 weeks to ensure proper healing and to assess for any increase in displacement. If pain persists beyond expected timeframes or displacement increases on follow-up imaging, surgical intervention may need to be reconsidered. The guidance from 1 on the appropriateness of simple immobilization for minimally displaced fractures supports this conservative approach, although it's more directly related to foot and ankle conditions, the principle of conservative management for non-significantly displaced fractures can be broadly applied. However, the most recent and relevant guidance for managing fragility fractures in older adults, such as that provided by 1, emphasizes a comprehensive approach to care that includes prevention of subsequent fractures, highlighting the importance of considering the broader context of osteoporosis management in elderly patients with fractures.
From the Research
Treatment Options for Proximal Humerus Fractures
The treatment for a 78-year-old female with an acute, mildly displaced fracture (approximately 6 mm) through the neck of the humerus can be considered based on the following options:
- Conservative treatment: This approach is suitable for non-displaced or minimally displaced fractures, with good outcomes in 80% to 90% of patients 2.
- Surgical intervention: This may be considered for fractures with significant displacement, instability, or compromise of the humeral head 2, 3, 4.
- Open reduction and internal fixation (ORIF): This technique can provide stable fixation and promote healing, with good functional results in elderly patients 5, 4, 6.
- Minimally invasive techniques: The Humerus Block is a minimally invasive technique that has shown good functional and radiographic outcomes in selected patients with proximal humeral fractures 3.
- Arthroplasty: This may be considered for elderly patients with advanced bone loss, where anatomical reduction of bone fragments is difficult or impossible 4, 6.
Considerations for Treatment
When deciding on a treatment plan, the following factors should be considered:
- Fracture pattern and displacement: The amount of displacement and the pattern of the fracture can influence the treatment decision 2, 4.
- Patient age and bone quality: Elderly patients with osteoporosis may require special consideration, with a focus on stable fixation and early rehabilitation 5, 4.
- Patient functional demands: Active patients with significant functional demands may require more aggressive treatment to achieve optimal outcomes 2, 6.
- Potential complications: The risk of complications, such as avascular necrosis, malunion, and osteonecrosis, should be considered when selecting a treatment option 3, 6.