What is the best course of treatment for a 70-year-old male with a displaced (1 cm) surgical neck fracture of the humerus after 4 weeks, who is hesitant to undergo surgery?

Management of Displaced Surgical Neck Fracture of Humerus in a 70-Year-Old Male Who Declines Surgery

For a 70-year-old male with a 1 cm displaced surgical neck fracture of the humerus that remains displaced after 4 weeks and who declines surgery, non-operative management with appropriate rehabilitation is the recommended approach, accepting the possibility of functional limitations but avoiding surgical risks.

Understanding the Clinical Situation

This case presents several important considerations:

• 70-year-old male patient
• Surgical neck fracture of the humerus
• 1 cm displacement
• 4 weeks since injury
• Patient preference against surgical intervention

Non-Operative Management Approach

Initial Management

1. Accept non-operative treatment

   • Most proximal humeral fractures can be treated non-operatively with good functional outcomes 1
   • The patient's preference against surgery should be respected, especially since non-operative treatment is a valid option

2. Pain Management

   • Appropriate analgesics for comfort
   • Consider NSAIDs if not contraindicated
   • Opioids may be necessary initially but should be minimized

Immobilization and Rehabilitation

1. Sling Support

   • A sling should be worn for comfort only and may be discarded as early as the patient's pain allows 1
   • At 4 weeks post-injury, transition from immobilization to controlled motion is appropriate

2. Physical Therapy Protocol

   • Begin range-of-motion exercises including shoulder, elbow, wrist, and hand motion 1
   • Start with pendulum exercises and passive range of motion
   • Progress to active-assisted and then active range of motion as tolerated
   • Above chest level activities should be restricted until fracture healing is evident 1
   • Avoid overly aggressive physical therapy as it may increase the risk of further displacement 1

3. Functional Goals

   • The most important aim is to regain the level of mobility and independence enjoyed before the fracture 1
   • Early identification of individual goals and needs are essential 1

Expected Outcomes and Monitoring

Functional Prognosis

• Patient should be informed that non-operative treatment of a displaced surgical neck fracture may result in:
  • Good pain relief in most cases
  • Potential limitation in range of motion, particularly in elevation and rotation
  • Possible malunion but often with acceptable functional outcomes

Follow-up Schedule

1. Clinical and Radiographic Monitoring

   • Follow-up radiographs at 2-week intervals to assess healing
   • Clinical assessment of pain, range of motion, and function

2. Criteria for Reconsidering Surgery

   • Increasing displacement
   • Intolerable pain
   • Progressive functional limitation
   • Development of avascular necrosis (rare)

Potential Complications and Management

Non-Union

• Risk of non-union exists with non-operative management of displaced fractures
• If non-union develops, surgical options would need to be reconsidered despite patient preference 2, 3, 4
• Surgical treatment of non-union can provide significant improvement in pain but more modest improvement in function 3

Malunion

• Some degree of malunion is expected with non-operative management of displaced fractures
• Functional adaptation is often possible, especially in older patients

Patient Education

• Explain the natural history of the injury and expected outcomes with non-operative treatment
• Discuss the importance of compliance with rehabilitation protocol
• Set realistic expectations regarding recovery timeline and potential functional limitations
• Emphasize the importance of follow-up appointments to monitor healing

Prevention of Future Fractures

• Consider evaluation for osteoporosis
• Recommend calcium and vitamin D supplementation (1000-1200 mg/day calcium, 800 IU/day vitamin D) 1
• Fall prevention strategies
• Consider bone health referral if appropriate

Conclusion

While surgery might typically be considered for a 1 cm displaced surgical neck fracture of the humerus, non-operative management is a reasonable alternative for this 70-year-old patient who declines surgery. The focus should be on optimizing functional outcomes through appropriate rehabilitation while accepting that some degree of malunion and functional limitation may occur.