What is the management plan for non-operative proximal humerus fracture?

Non-Operative Management of Proximal Humerus Fractures

Non-operative treatment is the recommended approach for most proximal humerus fractures, as it demonstrates high rates of radiographic healing (98%), good functional outcomes, and modest complication rates compared to surgical intervention. 1

Patient Selection for Non-Operative Management

• Most appropriate for:
  • Minimally displaced fractures (displacement <2 cm)
  • Stable fracture patterns
  • Elderly patients with lower physical demands
  • Patients with significant comorbidities increasing surgical risk

Initial Management

Immobilization

• Use arm sling for initial immobilization (more comfortable than body bandage)
• Duration: 1-3 weeks depending on fracture stability and pain
• Early mobilization (starting at 1 week instead of 3 weeks) alleviates short-term pain without compromising long-term outcomes

Pain Management

• Implement multimodal analgesia approach:
  • Regular paracetamol administration throughout treatment period
  • Cautious use of opioids, particularly in patients with renal dysfunction
  • Avoid codeine due to constipation, emesis, and cognitive dysfunction risks
  • Consider peripheral nerve blocks (femoral/fascia iliaca) for supplemental pain control

Rehabilitation Protocol

Phase 1 (Weeks 1-3)

• Pendulum exercises starting within first week
• Gentle passive range of motion exercises
• Pain control and edema management

Phase 2 (Weeks 3-6)

• Progress to active-assisted range of motion exercises
• Begin gentle strengthening exercises
• Focus on scapular stabilization

Phase 3 (Weeks 6-12)

• Progress to active range of motion exercises
• Increase strengthening program
• Begin functional activities

Phase 4 (3-4 months)

• Return to full activities based on radiographic healing and functional recovery
• Continue strengthening and range of motion exercises

Monitoring and Follow-up

• Radiographic evaluation at:

  • Initial presentation
  • 2-3 weeks (to ensure no displacement)
  • 6 weeks
  • 3 months
  • 6 months (if needed)

• Expected outcomes:

  • Average range of motion: 139° forward flexion, 48° external rotation, 52° internal rotation
  • Average Constant score: 74 (range 55-81)

Potential Complications

• Varus malunion (most common complication)
• Avascular necrosis (uncommon, only 13 cases reported in systematic review)
• Nonunion (rare, approximately 2% risk)
• Stiffness and reduced range of motion

Special Considerations

• Osteoporosis evaluation and treatment should be initiated
• Nutritional supplementation may be beneficial as many patients are malnourished
• Implement early thromboprophylaxis to prevent deep vein thrombosis
• Ensure adequate intake of calcium and vitamin D
• Advise smoking cessation and limitation of alcohol intake

When to Consider Surgical Intervention

• Displacement >2 cm
• Young patients with high physical demands
• Unstable fracture patterns
• Failed non-operative management with increasing displacement

Evidence Summary

The PROFHER randomized clinical trial found no significant difference between surgical and non-operative treatment in patient-reported clinical outcomes over 2 years following fracture occurrence 2. Non-operative treatment avoids the complications associated with surgery, which include a higher risk of requiring additional operations (approximately 1 in 9 surgically treated patients) 3.

A systematic review of non-operative treatment demonstrated high rates of radiographic healing (98%), good functional outcomes, and modest complication rates, supporting non-operative management as the primary approach for most proximal humerus fractures 1.