What is the non-surgical treatment schedule for a proximal humerus fracture?

Non-Surgical Treatment Schedule for Proximal Humerus Fractures

For most patients with displaced proximal humerus fractures, non-surgical treatment is recommended as it produces equivalent clinical outcomes to surgery while avoiding surgical complications and costs. 1, 2

Initial Management (0-3 weeks)

• Immobilization: Sling immobilization is the primary initial treatment 1, 2

  • Duration: Typically 3-4 weeks for stable fractures
  • Position: Arm in neutral rotation, slight abduction with elbow at 90 degrees
  • Type: Simple arm sling or shoulder immobilizer depending on patient comfort

• Pain Management:

  • Appropriate analgesics based on pain severity
  • Ice application for 15-20 minutes several times daily to reduce swelling and pain

• Imaging:

  • Initial radiographs to confirm diagnosis and fracture pattern
  • CT scan may be necessary for complex fracture patterns to better characterize displacement and angulation 3
  • Follow-up radiographs at 1-2 weeks to ensure no further displacement

Early Rehabilitation Phase (3-6 weeks)

• Begin gentle passive range of motion exercises after initial immobilization period:

  • Pendulum exercises
  • Passive forward elevation
  • External rotation as tolerated
  • Avoid active movements and resistance during this phase

• Continue sling use between exercise sessions and at night

  • Gradually decrease sling use as comfort allows

• Clinical follow-up at 4-6 weeks with repeat radiographs to assess healing

Intermediate Rehabilitation Phase (6-12 weeks)

• Progress to active-assisted range of motion exercises:

  • Supine forward elevation
  • Standing forward elevation with assistance
  • External and internal rotation exercises
  • Scapular stabilization exercises

• Discontinue sling use completely by 6-8 weeks for most patients

• Clinical follow-up at 12 weeks with radiographs to confirm healing progression

Advanced Rehabilitation Phase (12 weeks - 6 months)

• Begin strengthening exercises once adequate healing is confirmed:

  • Rotator cuff strengthening
  • Deltoid strengthening
  • Progressive resistance training
  • Functional movement patterns

• Return to normal activities gradually based on progress and comfort

Important Considerations

• Supervised vs. Unsupervised Rehabilitation: Recent evidence shows no significant difference in outcomes between physiotherapist-supervised exercises and unsupervised home-based exercises in older adults with 2-part proximal humerus fractures 4

• Expected Outcomes:

  • Most patients can expect good functional recovery with non-surgical management
  • At 1 year, typical difference in Constant scores between injured and contralateral shoulder is approximately 8.2 points 5
  • DASH score typically improves to within 10.2 points of baseline function 5

• Complications to Monitor:

  • Delayed union or nonunion (risk approximately 7%) 5
  • Stiffness and adhesive capsulitis
  • Rotator cuff tears (present in up to 40% of humeral head fractures) 3

• Indications for Surgical Consultation:

  • Progressive displacement during follow-up
  • Severe pain or functional limitation despite appropriate rehabilitation
  • Nonunion at 3-6 months

Special Populations

• Elderly Patients:

  • May require longer immobilization (4-6 weeks)
  • Gentler rehabilitation progression
  • Focus on functional activities rather than strength restoration

• Young, Active Patients:

  • More aggressive rehabilitation timeline may be appropriate
  • Higher functional goals may necessitate more intensive therapy

Non-surgical management remains the standard of care for most proximal humerus fractures, with the ProFHER trial demonstrating no significant difference in Oxford Shoulder Scores between surgical and non-surgical treatment over a 2-year period 1, 2.