How to manage a minimally displaced humerus surgical neck fracture in a 70-year-old man with a history of frozen shoulder, diabetes (Diabetes Mellitus), and hypertension (Hypertension)?

From the Guidelines

Management of a minimally displaced humerus surgical neck fracture in this 70-year-old man with frozen shoulder, diabetes, and hypertension should primarily involve non-operative treatment. The recommended approach is functional bracing for 2-3 weeks, followed by early progressive range of motion exercises. Initially, the patient should use a sling for comfort while awake and a pillow support while sleeping for the first 1-2 weeks. Pain management should include acetaminophen 1000mg every 6 hours and, if needed, tramadol 50mg every 6 hours as needed for breakthrough pain, avoiding NSAIDs due to hypertension 1. Physical therapy should begin at 2-3 weeks, focusing on pendulum exercises and passive range of motion, progressing to active-assisted and then resistive exercises by 6-8 weeks. Close monitoring of blood glucose is essential as pain and reduced mobility may affect diabetes control, and the patient's blood pressure should be managed according to the standards of medical care for patients with diabetes mellitus, with a target blood pressure goal of <130/80 mmHg if it can be safely achieved 1. The patient should follow up at 1,3,6, and 12 weeks with radiographs to ensure proper healing. This conservative approach is preferred because the patient's age and comorbidities increase surgical risks, while his history of frozen shoulder makes early mobilization particularly important to prevent additional stiffness. Surgery would only be considered if significant displacement occurs during follow-up or if functional outcomes are poor after 4-6 weeks of conservative management. Key considerations in managing this patient include:

• Monitoring and controlling blood pressure to reduce the risk of cardiovascular events and microvascular complications 1
• Managing pain effectively without exacerbating hypertension or affecting diabetes control
• Early mobilization to prevent additional stiffness and promote healing
• Regular follow-up to assess fracture healing and adjust the treatment plan as necessary.

From the Research

Management of Minimally Displaced Humerus Surgical Neck Fracture

• The management of a minimally displaced humerus surgical neck fracture in a 70-year-old man with a history of frozen shoulder, diabetes, and hypertension requires careful consideration of the patient's overall health and the fracture characteristics.
• According to 2, early mobilization is a sufficient therapy for management of minimally displaced and/or impacted fractures of the proximal humerus, with a median Constant score of 89 points and no non-unions reported.
• The study by 3 compared the outcomes of patients who underwent either open reduction internal fixation with a locking plate and screws or closed reduction internal fixation with an antegrade intramedullary nail (IMN) for displaced surgical neck fracture of the humerus, and found no significant differences in pain or range of motion between groups at the 2-year follow-up.

Consideration of Comorbidities

• The patient's history of frozen shoulder may affect the management of the fracture, as frozen shoulder can limit shoulder mobility and affect the outcome of treatment.
• The study by 4 reported that glucocorticoid therapy combined with pregabalin and a home exercise program is an effective treatment for frozen shoulder, with significant improvements in DASH, ASES, and Constant scores.
• The patient's diabetes and hypertension should also be considered when planning treatment, as these conditions can affect bone healing and overall health.

Surgical Options

• Reverse total shoulder arthroplasty (RTSA) is an option for surgical treatment of complex proximal humeral fractures in patients ≥65 years of age, as reported by 5.
• However, the indications for RTSA and the optimal surgical treatment for minimally displaced fractures are still debated, and more research is needed to determine the best approach for this patient population.
• The study by 6 highlighted the importance of avoiding complications and improving results when treating proximal humerus fractures, and emphasized the need for orthopaedic surgeons to be familiar with various surgical techniques and implants.