What is the initial management for a closed displaced fracture of the surgical neck of the left humerus?

Initial Management of Closed Displaced Fracture of Surgical Neck of Left Humerus

Initial management of a closed displaced fracture of the surgical neck of the left humerus should consist of immobilization with a removable splint or sling, followed by early controlled mobilization as soon as pain allows. 1

Assessment and Imaging

• Radiographic evaluation, including potential CT scan, is essential to determine:

  • Fracture pattern and displacement
  • Humeral neck angulation
  • Presence of associated injuries 1

• Clinical assessment should include:

  • Neurovascular status (particularly checking radial pulse and hand perfusion)
  • Skin integrity
  • Associated injuries

Treatment Algorithm

Step 1: Initial Immobilization

• Apply a sling for comfort and fracture stabilization
• Position should maintain the arm in neutral rotation with the elbow at 90° flexion

Step 2: Determine Treatment Approach

For displaced surgical neck fractures, consider:

1. Non-surgical Management (First-line approach)

   • Appropriate for most displaced fractures, even in elderly patients with osteoporotic bone 1
   • The PROFHER trial demonstrated no significant differences in clinical outcomes between surgical and non-surgical treatment over a 2-year period 2
   • Non-surgical treatment resulted in similar Oxford Shoulder Scores (38.32 vs 39.07 points) compared to surgical treatment 2

2. Surgical Management (Consider if):

   • Fracture displacement increases during follow-up
   • Complete detachment of the humeral head occurs
   • Patient develops significant functional limitations despite adequate conservative management 1
   • Vascular compromise is present (emergent reduction indicated) 1

Rehabilitation Protocol

A three-phase rehabilitation protocol is typically used 1:

1. Initial Phase (0-2 weeks):

   • Sling immobilization
   • Gentle pendulum exercises

2. Early Mobilization Phase (2-6 weeks):

   • Progressive active-assisted range of motion exercises
   • Remove posterior splint within 1-2 weeks
   • Begin physical therapy for range of motion exercises

3. Strengthening Phase (6-12 weeks):

   • Progressive resistive exercises
   • Scapular stabilization exercises

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 1

Surgical Options (if indicated)

If surgery becomes necessary, options include:

1. Intramedullary Nailing

   • Minimally invasive approach
   • Comparable outcomes to plating 3

2. Locking Plate Fixation

   • May provide better functional outcomes compared to K-wire fixation 4
   • Allows for more anatomic reduction

3. Percutaneous Pinning

   • Generally has worse radiographic and functional outcomes compared to plates or nails 4

Potential Complications

• Stiffness (most common) - prevented by early controlled mobilization
• Malunion
• Nonunion
• Avascular necrosis
• Neurovascular injury

Clinical Pearls

• Early controlled mobilization is crucial to prevent stiffness
• Regular follow-up is essential to detect potential fracture displacement
• Consider bone health status, especially in elderly patients
• The evidence from the PROFHER trial suggests that non-surgical management is appropriate for most displaced proximal humeral fractures, with no significant difference in outcomes compared to surgical treatment 2, 5