What is the treatment for a proximal humeral head fracture?

From the Guidelines

Treatment for a proximal humeral head fracture should be based on the fracture pattern and displacement, with conservative management recommended for minimally displaced fractures and surgical intervention for significantly displaced fractures. For minimally displaced fractures, conservative management is typically recommended, including a sling for immobilization for 2-3 weeks, followed by gentle pendulum exercises starting around week 2-3, and progressive physical therapy for range of motion and strengthening exercises over 3-4 months 1. Pain management includes acetaminophen (500-1000mg every 6 hours) or NSAIDs like ibuprofen (400-600mg every 6-8 hours) for 1-2 weeks as needed. For significantly displaced fractures (>1cm displacement or >45° angulation), surgical intervention may be necessary, including open reduction and internal fixation (ORIF) with plates and screws, intramedullary nailing, or shoulder arthroplasty in severe cases, particularly in elderly patients with poor bone quality 1. The goal of treatment is to restore shoulder function while minimizing pain and complications. Recovery typically takes 3-6 months, with most patients regaining functional range of motion, though some limitation in overhead activities may persist. Regular follow-up with radiographs is essential to ensure proper healing and alignment. It's worth noting that, according to the most recent evidence, noncontrast MRI may be useful in assessing rotator cuff integrity in patients with proximal humeral fractures that do not undergo surgical fixation 1. However, the primary consideration should be the fracture pattern and displacement, guiding the decision between conservative and surgical management. In cases of metastatic disease, prophylactic surgery may be recommended for persistent or increasing local pain despite radiation therapy, or for specific involvement of the proximal femur or other long bones 1. But for a proximal humeral head fracture, the treatment approach should prioritize restoring shoulder function and minimizing complications, with the choice of treatment depending on the specifics of the fracture. Key considerations include:

• Fracture pattern and displacement
• Patient age and bone quality
• Presence of rotator cuff tears or other associated injuries
• Need for pain management and rehabilitation The most important factor is to prioritize treatment that minimizes morbidity, mortality, and improves quality of life, with the choice of treatment guided by the most recent and highest-quality evidence 1.

From the Research

Treatment Options for Proximal Humeral Head Fractures

• The optimal treatment of complex proximal humeral fractures in adults remains controversial, with various studies suggesting different approaches 2, 3, 4, 5, 6.
• Surgical treatment is indicated based on the fracture pattern, patient-related factors, and the risk of avascular head necrosis, with options including open reduction and plate fixation (ORIF), minimally invasive stabilization, and reverse total shoulder arthroplasty (RTSA) 2, 3, 5.
• Conservative treatment may be suitable for undisplaced or stable fractures, with early physiotherapy potentially leading to better outcomes 4.

Surgical Techniques

• ORIF involves the use of plates and screws to stabilize the fracture, with the goal of achieving anatomic reduction and preserving the vascular supply of the fragments 2, 3.
• Minimally invasive stabilization procedures allow for anatomic reconstruction in the majority of fresh proximal humeral fractures, using techniques such as ligamentotaxis and direct reduction maneuvers 3.
• RTSA is a viable option for acute proximal humeral fractures, particularly in elderly patients with poor bone quality, and can provide quicker recovery and predictable outcomes 5.

Complications and Outcomes

• Complications of surgical treatment include postoperative stiffness, fixation failure, and late osteonecrosis, with reoperation rates ranging from 10% to 30% 2, 5.
• Outcomes of surgical treatment vary depending on the fracture pattern, patient factors, and surgical technique, with some studies suggesting better results with RTSA for acute fractures 5.
• The time from injury to regaining good pain-free function is significantly shorter in patients undergoing acute RTSA, highlighting the importance of early intervention 5.