What is the treatment for a surgical neck fracture of the humerus?

Treatment of Surgical Neck Fracture of the Humerus

Most proximal humeral fractures, including surgical neck fractures, can be treated non-operatively with good functional outcomes, while displaced fractures may require surgical intervention depending on fracture characteristics and patient factors.

Initial Assessment and Classification

When evaluating a surgical neck fracture of the humerus, consider:

• Degree of displacement
• Fracture pattern (2-part, 3-part, or 4-part)
• Patient age and functional status
• Bone quality
• Presence of comorbidities

Treatment Algorithm

Non-Operative Management

Non-operative treatment is appropriate for:

• Non-displaced or minimally displaced fractures
• Stable fracture patterns
• Elderly or low-demand patients
• Patients with significant comorbidities

The non-operative approach includes:

1. Initial sling immobilization for comfort
2. Early active rehabilitation once pain allows
3. Progressive range of motion exercises

This approach is supported by the ProFHER trial, which found no statistically or clinically significant differences in outcomes between surgical and non-surgical treatment for most displaced proximal humeral fractures over a 2-year period 1.

Surgical Management

Surgical intervention should be considered for:

• Significantly displaced fractures
• Unstable fracture patterns
• Younger, active patients
• Fractures with associated vascular injury

Surgical options include:

1. Open Reduction and Internal Fixation (ORIF) with Locking Plate

   • Provides stable fixation
   • Allows for early mobilization
   • Better for younger patients with good bone quality

2. Intramedullary Nailing

   • Less invasive than plating
   • Comparable outcomes to locking plates
   • A 2017 study showed no significant differences in pain scores, shoulder function (ASES and UCLA scores), or range of motion between IM nailing and locked plate fixation at 2-year follow-up 2

3. Hemiarthroplasty or Reverse Shoulder Arthroplasty

   • Reserved for severe comminution, poor bone quality, or elderly patients
   • Reverse shoulder arthroplasty may provide better function in geriatric patients with pre-existing rotator cuff dysfunction 3

Rehabilitation Protocol

Regardless of treatment approach:

1. Early protected range of motion exercises (within pain limits)
2. Progressive strengthening as healing progresses
3. Focus on rotator cuff strengthening and scapular stabilization

Complications to Monitor

• Nonunion (requiring potential bone grafting and revision fixation) 4, 5
• Avascular necrosis of the humeral head
• Hardware-related issues (impingement, screw penetration)
• Stiffness and loss of motion
• Infection

Special Considerations

• Osteoporotic bone requires special attention to fixation techniques
• Elderly patients may benefit from a less invasive approach to minimize surgical risks
• The risk of subsequent fractures should be evaluated in patients over 50 years 3

Cost-Effectiveness

The ProFHER trial demonstrated that surgical intervention was, on average, £1780.73 more expensive per patient than non-surgical treatment, with no significant improvement in outcomes 1. This suggests that non-operative treatment may be more cost-effective for many patients with these fractures.

Pitfalls to Avoid

• Overly aggressive surgical intervention in elderly, low-demand patients
• Inadequate fixation in osteoporotic bone
• Delayed mobilization leading to stiffness
• Failure to address underlying osteoporosis in older patients

The EULAR/EFORT guidelines emphasize that appropriate treatment of fractures in elderly and multimorbid patients with fragile bones requires a balanced approach regarding operative versus non-operative treatment 3.