What is the recommended treatment for a minimally displaced humeral neck fracture?

Management of Minimally Displaced Humeral Neck Fractures

Most proximal humeral fractures, including minimally displaced humeral neck fractures, can be treated non-operatively with good functional outcomes. 1

Non-Operative Management

Indications for Non-Operative Treatment

• Minimally displaced fractures (less than 5mm displacement)
• Stable fracture pattern
• Adequate bone quality
• Patient factors (elderly, low functional demands)

Non-Operative Treatment Protocol

1. Immobilization:

   • Use a removable sling or brace for 2-3 weeks
   • Avoid rigid immobilization as it may lead to stiffness

2. Pain Management:

   • Appropriate analgesics based on pain severity
   • Consider local ice application for the first 48-72 hours

3. Rehabilitation Timeline:

   • Week 1-2: Pendulum exercises and gentle passive range of motion
   • Week 3-4: Progress to active-assisted range of motion
   • Week 4-6: Begin active range of motion without resistance
   • Week 6-12: Progressive strengthening exercises

4. Follow-up Imaging:

   • Radiographs at 1-2 weeks to ensure no secondary displacement
   • Additional imaging at 6 weeks to assess healing

Surgical Management Considerations

While non-operative management is preferred for minimally displaced fractures, certain circumstances may warrant surgical intervention:

Indications for Surgical Intervention

• Secondary displacement during follow-up
• Patient factors requiring earlier mobilization
• Associated injuries requiring surgical management
• Young, active patients with high functional demands

Surgical Options (if needed)

1. Intramedullary Nailing:

   • Provides good outcomes comparable to plate fixation 2
   • Less invasive with potentially fewer soft tissue complications
   • 2-year outcomes show satisfactory results with good range of motion

2. Locking Plate Fixation:

   • Alternative when intramedullary nailing is contraindicated
   • May be preferred for certain fracture patterns
   • Similar functional outcomes to intramedullary nailing at 2-year follow-up 2

Special Considerations

Elderly Patients

• Focus on early mobilization to prevent complications
• Consider bone quality when deciding between operative and non-operative management
• Implement an interdisciplinary care program to improve outcomes

Monitoring for Complications

• Avascular necrosis (rare in minimally displaced fractures)
• Malunion or non-union
• Stiffness and reduced range of motion
• Post-traumatic arthritis

Follow-up Protocol

• First follow-up at 1-2 weeks
• Second follow-up at 4-6 weeks
• Additional follow-ups at 3 months and 6 months
• Final assessment at 1 year

Pitfalls to Avoid

• Prolonged immobilization leading to stiffness
• Inadequate radiographic follow-up that might miss secondary displacement
• Aggressive early rehabilitation that could lead to displacement
• Underestimating the importance of dedicated rehabilitation

By following this evidence-based approach to managing minimally displaced humeral neck fractures, patients can achieve good functional outcomes while avoiding unnecessary surgical interventions and their associated risks.