What is the best way to immobilize a proximal humeral fracture?

From the Guidelines

The best way to immobilize a proximal humeral fracture is with a sling and swathe, as this method provides adequate stabilization while allowing for better patient compliance and comfort. This approach is supported by the fact that most proximal humeral fractures can be treated non-operatively with good functional outcomes, as noted in the 2017 EULAR/EORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures 1. The use of a sling and swathe involves positioning the arm slightly forward with the elbow flexed at 90 degrees, while the swathe provides additional stability by preventing external rotation and abduction.

Key considerations for immobilization include:

• Immobilization typically lasts 2-3 weeks for stable fractures, though this may extend to 4-6 weeks for more complex cases
• Gentle pendulum exercises may be started after 1-2 weeks to prevent stiffness, but only as directed by the treating physician
• Pain management with appropriate analgesics is an important adjunct to successful immobilization
• This method is preferred over more restrictive options, such as a shoulder spica cast, as it facilitates easier hygiene and provides sufficient support while the initial inflammatory phase resolves and early healing begins.

It's worth noting that treatment of displaced three-part and four-part fractures remains controversial, with options including open reduction and locking plate osteosynthesis, hemiarthroplasty, and reverse shoulder arthroplasty, each with its own set of considerations and potential complications, as discussed in the EULAR/EORT recommendations 1. However, for the initial immobilization of a proximal humeral fracture, a sling and swathe remains a widely accepted and effective approach.

From the Research

Immobilization Methods for Proximal Humeral Fractures

The best way to immobilize a proximal humeral fracture is a topic of ongoing research, with various studies investigating different methods. Some key findings include:

• The use of a neutral-rotation brace (NRB) may provide better outcomes than a simple sling (SS) in terms of range of motion, subjective shoulder value, and DASH scores 2.
• A study comparing the Gilchrist-type sling and the Desault-type sling found that the former was generally more comfortable 3.
• The use of a custom neutral-position shoulder and elbow sling in combination with a proximal humeral internal locking system (PHILOS) plate may improve outcomes and reduce the incidence of internal fixation failure 4.

Comparison of Immobilization Methods

A comparison of different immobilization methods is necessary to determine the most effective approach. Some studies have investigated:

• The use of early versus delayed mobilization, with some evidence suggesting that early mobilization may result in better recovery and less pain 3, 5.
• The comparison of different types of slings, such as the Gilchrist-type and Desault-type slings 3.
• The use of a custom neutral-position shoulder and elbow sling in combination with a PHILOS plate 4.

Rehabilitation and Treatment

Rehabilitation is a crucial aspect of treating proximal humeral fractures. Some key findings include:

• Early active movements within the limits of pain and discomfort may improve the ultimate result 5.
• The use of advice, exercise, and mobilization of limited joints may help restore upper limb function 6.
• Placing controlled stresses throughout the fracture site at an early stage may optimize bone repair without increasing complication rates 6.