Management of Displaced Surgical Neck of Humerus Fracture in a 70-Year-Old Man
For a 70-year-old man with a 1 cm displaced surgical neck of humerus fracture that has not improved after 4 weeks, surgical intervention with intramedullary nailing is recommended as the preferred treatment approach.
Assessment of the Current Situation
The patient presents with:
- 70 years of age
- Surgical neck of humerus fracture (proximal humerus)
- 1 cm displacement
- 4 weeks since injury without improvement
Treatment Algorithm
Step 1: Evaluate Fracture Characteristics
- 1 cm displacement is significant and unlikely to heal properly without intervention
- At 4 weeks post-injury, the fracture is entering a delayed union phase
- The surgical neck location makes this amenable to specific fixation techniques
Step 2: Surgical Management Options
Recommended Approach: Intramedullary Nailing
Intramedullary nailing is the preferred treatment for this patient because:
- Provides stable fixation for displaced proximal humerus fractures
- Allows for early mobilization and rehabilitation
- Minimizes risk of avascular necrosis compared to more extensive procedures
- Appropriate for older patients with potentially compromised bone quality
The American Academy of Orthopaedic Surgeons guidelines support surgical intervention for displaced fractures, with intramedullary nailing being a recommended approach for surgical neck fractures 1, 2.
Alternative Options (Less Preferred):
Open Reduction and Internal Fixation (ORIF) with Locking Plate
- May be considered if intramedullary nailing is not feasible
- Higher risk of complications in elderly patients with osteoporotic bone
- More extensive soft tissue dissection required
Hemiarthroplasty
- Generally reserved for more severe fracture patterns or when fixation is not possible
- Would be excessive for this particular fracture pattern
Step 3: Post-Surgical Management
Pain Management
- Multimodal analgesia incorporating preoperative nerve block is recommended 3
- Regular acetaminophen with cautious use of opioids
Rehabilitation Protocol
- Begin passive range of motion exercises within 1-2 weeks post-surgery
- Progress to active-assisted motion at 4-6 weeks
- Strengthening exercises starting at 6-8 weeks
Important Considerations
Timing of Intervention
The 4-week delay since injury is concerning but not prohibitive for surgical intervention. While early surgery (within 24-48 hours) is associated with better outcomes for hip fractures 3, the proximal humerus has different considerations. At 4 weeks, the fracture may be entering a delayed union phase, making surgical intervention more challenging but still beneficial compared to continued non-operative management.
Potential Complications
- Avascular necrosis of the humeral head
- Malunion or nonunion
- Hardware-related complications
- Post-traumatic arthritis
Pitfalls to Avoid
Delaying treatment further - At 4 weeks with persistent displacement, further delay will likely lead to malunion and poor functional outcomes 4.
Inadequate fixation - Ensure proper surgical technique with appropriate implant selection to prevent fixation failure in potentially osteoporotic bone.
Overly aggressive early rehabilitation - While early motion is important, it must be balanced with allowing adequate healing to prevent fixation failure.
Expected Outcomes
With appropriate surgical intervention and rehabilitation, the patient can expect:
- Improved pain control
- Restoration of functional range of motion
- Return to activities of daily living
- Prevention of long-term complications associated with malunion
The ProFHER trial showed that for many proximal humerus fractures, non-surgical treatment can be effective 5. However, this particular case involves significant displacement that has persisted for 4 weeks, placing it outside the typical scenario where conservative management would be recommended.