Do patients with Neer 4 (Neer classification) proximal humerus fractures fare well with non-operative management?

From the Guidelines

Patients with Neer 4 proximal humerus fractures generally do not fare well with non-operative management, and surgical intervention is typically recommended. These complex fractures involve four or more displaced fragments of the proximal humerus, making them inherently unstable and difficult to heal properly without surgical fixation. According to the most recent and highest quality study, non-operative treatment of displaced three-part and four-part fractures, such as Neer 4, remains controversial due to the considerable complications associated with open reduction and locking plate osteosynthesis, and the outcome of hemiarthroplasty being closely related to tuberosity healing 1. Non-operative treatment usually consists of initial immobilization in a sling for 2-3 weeks followed by gentle pendulum exercises and progressive range of motion therapy, but this approach often leads to malunion, nonunion, avascular necrosis of the humeral head, and poor functional outcomes in Neer 4 fractures.

Some key points to consider when deciding between operative and non-operative management include:

• The patient's age and bone quality, as elderly patients with severe osteoporosis may have compromised fixation and increased surgical risk
• The patient's functional demands and comorbidities, as those with low functional demands and significant medical comorbidities may be considered for non-operative management despite the poorer expected outcomes
• The fracture characteristics, including the complex displacement pattern in Neer 4 fractures that typically disrupts blood supply to the humeral head and creates mechanical instability. Reverse shoulder arthroplasty may provide satisfactory shoulder function in geriatric patients with pre-existing rotator cuff dysfunction or after the failure of first-line treatment, as suggested by the study 1.

The decision between operative and non-operative management should be individualized based on these factors, with a focus on minimizing morbidity, mortality, and optimizing quality of life. In general, surgical intervention is recommended for Neer 4 proximal humerus fractures to improve functional outcomes and reduce the risk of complications.

From the Research

Non-Operative Management of Neer 4 Proximal Humerus Fractures

• The study 2 compared surgical and non-surgical treatments of 3- and 4-part fractures of the proximal humerus in adults, including Neer type IV fractures, and found that non-surgical treatment had a lower complication rate (21.1%) compared to surgical treatment (60%).
• The consensus statement 3 suggests that non-operative treatment of proximal humerus fractures may be suitable for older, sicker patients, but does not specifically address Neer 4 fractures.
• A systematic review and network meta-analysis 4 found that reverse shoulder arthroplasty (RSA) had improvements in clinical and functional outcomes compared to other treatment options, including non-operative management, for displaced proximal humerus fractures, but did not specifically address Neer 4 fractures.
• A survey of orthopedic shoulder and trauma surgeons 5 found that the preferred management of proximal humerus fractures differed between shoulder and trauma surgeons, with trauma surgeons preferring non-operative management for low-functioning patients with significantly displaced fractures or non-reconstructable injuries.
• A systematic review and meta-analysis 6 found that early mobilization (within one week from injury) was safe and may confer short-term functional benefits compared to delayed mobilization for non-surgically treated proximal humerus fractures, but did not specifically address Neer 4 fractures.

Complications and Outcomes

• The study 2 found that non-surgical treatment of Neer 4 fractures had a lower complication rate compared to surgical treatment.
• The systematic review and network meta-analysis 4 found that RSA had the lowest rate of malunion and osteonecrosis compared to other treatment options.
• The survey of orthopedic shoulder and trauma surgeons 5 found that the preferred management of proximal humerus fractures differed between shoulder and trauma surgeons, which may impact outcomes.

Treatment Recommendations

• The consensus statement 3 suggests that non-operative treatment of proximal humerus fractures may be suitable for older, sicker patients.
• The systematic review and meta-analysis 6 found that early mobilization was safe and may confer short-term functional benefits for non-surgically treated proximal humerus fractures.