What is the recommended management for displaced proximal humerus fractures?

Management of Displaced Proximal Humerus Fractures

Most displaced proximal humerus fractures should be treated non-operatively with a removable splint or sling followed by early controlled mobilization, as this approach provides good functional outcomes for the majority of patients. 1

Initial Assessment and Classification

• Radiographic evaluation including CT scan is essential to determine:
  • Fracture pattern and displacement
  • Humeral neck angulation
  • Number of fracture fragments (Neer classification)

Treatment Algorithm

Non-operative Management (First-line for most cases)

• Indicated for:

  • Minimally to moderately displaced fractures
  • Elderly patients with osteoporotic bone
  • Patients with significant comorbidities

• Protocol:

  1. Immobilization with removable splint or sling
  2. Early controlled mobilization as soon as pain allows (typically within 1-2 weeks)
  3. Three-phase rehabilitation:
     • Initial phase (0-2 weeks): Sling immobilization with pendulum exercises
     • Early mobilization phase (2-6 weeks): Progressive active-assisted range of motion
     • Strengthening phase (6-12 weeks): Progressive resistive exercises and scapular stabilization

Surgical Management

• Consider for:

  • Severely displaced fractures (especially 3-part and 4-part)
  • Young, active patients with good bone quality
  • Fractures with vascular compromise

• Surgical options (in order of increasing fracture complexity):

1. Percutaneous Pinning/Cannulated Screws

   • Best for: Simple 2-part fractures
   • Advantages: Minimal soft tissue disruption, preservation of blood supply
   • Disadvantages: Limited stability in comminuted or osteoporotic fractures

2. Open Reduction and Internal Fixation (ORIF) with Locking Plates

   • Best for: 2-part and 3-part fractures, selected 4-part fractures
   • Advantages: Improved stability, especially with locking plates in osteoporotic bone
   • Disadvantages: Risk of avascular necrosis, hardware complications

3. Hemiarthroplasty

   • Best for: Severe 4-part fractures in elderly patients
   • Advantages: Eliminates risk of avascular necrosis
   • Disadvantages: Functional outcomes dependent on tuberosity healing

4. Reverse Shoulder Arthroplasty (RSA)

   • Best for: Complex fractures in elderly patients with pre-existing rotator cuff dysfunction
   • Advantages: Better functional outcomes than hemiarthroplasty in elderly patients 2
   • Disadvantages: More expensive, limited implant longevity

Evidence-Based Recommendations

The most recent evidence from a network meta-analysis of randomized controlled trials suggests that RSA offers the best improvements in abduction, constant scores, and flexion with the lowest rates of malunion and osteonecrosis compared to other surgical options for carefully selected patients 2. However, this must be balanced against the fact that most proximal humerus fractures can be successfully treated non-operatively 1, 3.

Follow-up and Monitoring

• Regular 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

Complications and Prevention

• Common complications include:

  • Avascular necrosis (especially in 4-part fractures)
  • Malunion
  • Shoulder stiffness
  • Hardware complications (if surgical fixation used)

• Prevention strategies:

  • Early controlled mobilization to prevent stiffness
  • Careful surgical technique to preserve blood supply
  • Appropriate implant selection based on fracture pattern and bone quality

Special Considerations

• In cases with vascular compromise, emergent reduction is indicated 1
• For elderly patients with complex fractures, reverse shoulder arthroplasty may provide better functional outcomes than other surgical options 2
• Consider patient's age, activity level, bone quality, and comorbidities when selecting treatment approach

The evidence supports that most proximal humerus fractures can achieve good functional outcomes with non-operative management, while surgical intervention should be reserved for specific fracture patterns and patient populations 1, 3.