From the Research
I strongly recommend surgical intervention for a surgical neck fracture of the humerus, specifically open reduction and internal fixation (ORIF) or intramedullary nailing, to minimize morbidity, mortality, and improve quality of life. The choice between ORIF and intramedullary nailing depends on the fracture pattern and patient factors, with ORIF being more suitable for complex fractures and intramedullary nailing for simpler fracture patterns 1.
Key Considerations
- Significant displacement (>5mm), angulation (>45 degrees), or articular surface involvement are indications for surgical intervention.
- Preoperative prophylactic antibiotics, such as cefazolin 2g IV or clindamycin 600mg IV, should be administered 30-60 minutes before incision.
- Postoperative pain management may include acetaminophen, NSAIDs, and short-term opioids.
- Physical therapy should commence within 1-2 weeks, focusing on passive range of motion exercises, progressing to active motion and strengthening exercises.
Surgical Approach
- ORIF using plates and screws is a standard approach, but intramedullary nailing may be appropriate in select cases, particularly for two-part fractures or concomitant shaft fractures 1.
- The choice of surgical approach should be individualized based on fracture characteristics and patient factors.
Outcomes
- Surgical fixation provides better alignment and earlier mobilization compared to conservative management, reducing the risk of malunion, nonunion, or impaired shoulder function.
- High union rates and satisfactory outcomes can be achieved with both ORIF and intramedullary nailing, although intramedullary nailing may result in lower blood loss 1.
Evidence Base
The most recent and highest quality study, published in 2024, compared outcomes of operative treatment for two and three-part proximal humerus fractures with or without ipsilateral shaft fractures and head-split patterns, using intramedullary nailing versus open reduction internal fixation 1. This study found similar outcomes for both treatments, with high union rates and satisfactory results, although intramedullary nailing had lower blood loss.