What is the treatment for a minimally displaced, slightly comminuted humeral neck fracture?

Treatment for Minimally Displaced, Slightly Comminuted Humeral Neck Fracture

Non-surgical management with early mobilization is the recommended treatment for minimally displaced, slightly comminuted humeral neck fractures to achieve optimal functional outcomes and minimize complications.

Initial Management

• Obtain adequate radiographic evaluation, including CT scan if necessary, to determine fracture pattern, displacement, and humeral neck angulation 1
• For minimally displaced fractures:
  • Immobilization with a removable splint or sling 2
  • Early controlled mobilization as soon as pain allows (within 1-2 weeks) 1
  • Avoid prolonged immobilization as it leads to poorer outcomes

Evidence Supporting Non-Surgical Approach

The PROFHER randomized clinical trial demonstrated no significant difference between surgical and non-surgical treatment for displaced proximal humeral fractures in patient-reported clinical outcomes over 2 years 3. This high-quality evidence strongly supports non-surgical management for minimally displaced fractures, which typically have better outcomes than displaced fractures.

A randomized controlled trial comparing immediate physiotherapy versus 3 weeks of immobilization for minimally displaced proximal humeral fractures found:

• Immediate physiotherapy resulted in faster recovery and better functional outcomes at 1 year (42.8% disability vs 72.5%) 4
• Benefits were maintained at 2 years, though the difference narrowed (43.2% vs 59.5%) 4

Rehabilitation Protocol

1. Initial phase (0-2 weeks):

   • Sling immobilization for comfort
   • Pendulum exercises and gentle passive range of motion

2. Early mobilization phase (2-6 weeks):

   • Progressive active-assisted range of motion exercises
   • Avoid resistance training during this period

3. Strengthening phase (6-12 weeks):

   • Progressive resistive exercises
   • Scapular stabilization exercises
   • Rotator cuff strengthening

Indications for Surgical Intervention

Surgery should be considered only if:

• Fracture displacement increases during follow-up (>10mm displacement) 5
• Complete detachment of the humeral head occurs 5
• Patient develops significant functional limitations despite adequate conservative management

Follow-up Protocol

• Radiographic evaluation at 1,3, and 6 weeks to ensure fracture stability
• Clinical assessment of pain and range of motion at each follow-up
• Consider bone health evaluation and osteoporosis management, especially in older patients 2

Potential Complications

• Stiffness (most common) - prevented by early mobilization
• Malunion - usually well tolerated if minimally displaced
• Avascular necrosis - rare in minimally displaced fractures but requires monitoring
• Secondary displacement - may necessitate surgical intervention

Special Considerations

For elderly patients with osteoporotic bone, careful monitoring is essential as fracture displacement can occur during follow-up. However, even in these patients, non-surgical management remains the first-line treatment for minimally displaced fractures 2.

A network meta-analysis of randomized controlled trials found that non-operative treatment had the lowest rate of conversion to surgical intervention compared to other initial management strategies 6, further supporting conservative management for minimally displaced fractures.