From the Guidelines
Most proximal humeral fractures can be treated non-operatively with good functional outcomes. The treatment for a proximal humerus fracture depends on the severity and displacement of the fracture, as well as patient-specific factors such as age and bone quality 1.
Non-Operative Treatment
For non-displaced or minimally displaced fractures, conservative management with a sling for immobilization for 2-3 weeks is often sufficient, followed by gentle pendulum exercises starting around week 2-3, and progressive physical therapy for range of motion and strengthening exercises over 3-4 months.
Operative Treatment
However, displaced three-part and four-part fractures may require surgical intervention, such as open reduction and locking plate osteosynthesis, although this is associated with considerable complication 1.
Alternative Surgical Options
In geriatric patients with pre-existing rotator cuff dysfunction or after the failure of first-line treatment, reverse shoulder arthroplasty may provide satisfactory shoulder function 1.
Pain Management
Pain management is crucial and can include acetaminophen or NSAIDs like ibuprofen for 1-2 weeks as needed.
Rehabilitation
The rehabilitation protocol after both non-operative and operative treatment aims to restore shoulder function while minimizing pain and complications, with a cautious progression in cases where surgery is involved.
Key Considerations
The treatment approach considers factors like patient age, activity level, bone quality, and fracture pattern, with the goal of achieving the best possible outcome in terms of morbidity, mortality, and quality of life 1.
From the Research
Treatment Options for Proximal Humerus Fractures
- Nonoperative treatment is often effective for proximal humerus fractures, especially for undisplaced or minimally displaced fractures 2
- Open reduction and internal fixation (ORIF) with locking plates is a common operative treatment modality for displaced fractures 3, 2, 4
- Other surgical options include hemiarthroplasty, tension-band fixation, and minimally invasive fixation with intramedullary nails 5
Surgical Techniques and Implants
- Locking plates are the most common device used for ORIF of proximal humerus fractures, but technical detail is critical to minimize the risk of implant failure and reoperation 2, 4
- Proper technique for internal fixation of the proximal humerus requires an understanding of osseous and neurovascular anatomy 4
- Biomechanical studies have shown that locked plating of proximal humerus fractures provides stable fixation, and cadaveric and finite element models underscore the importance of screw placement in the posteromedial metaphysis 4
Postoperative Rehabilitation
- Early active motion rehabilitation after ORIF of proximal humerus fractures may not be inferior to a restrictive treatment protocol, even in older and more comorbid patient populations 3
- Some evidence suggests that immediate physiotherapy compared with delayed physiotherapy results in less pain and potentially better recovery in people with undisplaced or stable fractures 5
- Mobilisation at one week instead of three weeks may alleviate short-term pain without compromising long-term outcome 5
Complications and Outcomes
- Complications of ORIF of proximal humerus fractures include axillary nerve neurapraxia, avascular necrosis, and screw cutout 6
- Unplanned reoperations may be necessary in some cases, including revision for loose hardware removal or component removal and revision to shoulder arthroplasty 6
- Patient-reported outcome measurements, range of motion, and radiographic results can be used to evaluate the effectiveness of treatment for proximal humerus fractures 6, 3