What is the recommended treatment for an unspecified displaced fracture of the surgical neck of the left humerus?

Management of Displaced Fracture of Surgical Neck of Left Humerus

For displaced surgical neck fractures of the left humerus, surgical intervention is recommended, with options including open reduction internal fixation (ORIF) with locking plates or intramedullary nailing (IMN), both of which yield satisfactory outcomes with no significant differences in pain or range of motion at 2-year follow-up.

Fracture Assessment and Indications for Surgery

• Surgical intervention is indicated for displaced surgical neck fractures of the humerus (>2mm displacement) as current evidence shows an increased rate of nonunion after conservative treatment 1
• Displacement assessment is crucial:
  • <2mm displacement: typically managed conservatively

  • 2mm displacement: surgical intervention is indicated 2

  • Other surgical indications include persistent symptomatic non-unions, reduction of subacromial space, disruption of superior shoulder suspensory complex, and active patients with higher functional demands 2

Surgical Options

1. Open Reduction Internal Fixation (ORIF) with Locking Plate

• Advantages:
  • Better fracture reduction compared to percutaneous pinning 3
  • Provides stable fixation for early mobilization
  • Allows direct visualization of the fracture site
  • Patients treated with plates achieve Constant scores more similar to the non-operated shoulder 3

2. Intramedullary Nailing (IMN)

• Advantages:
  • Minimally invasive approach
  • Less soft tissue disruption
  • Good fracture reduction compared to percutaneous pinning 3
  • Comparable outcomes to locking plates at 2-year follow-up 4

3. Minimally Invasive Plate Osteosynthesis (MIPO)

• Considered when preservation of periosteal blood supply is critical
• Achieves relative stability to allow indirect bone healing with callus formation 1
• Can be performed circumferentially to the humerus (anterior, posterior, anterolateral, anteromedial) 1

Comparative Outcomes

• At 2-year follow-up, both IMN and locked plate fixation yield satisfactory outcomes with no significant differences in:

  • Pain scores
  • American Shoulder and Elbow Surgeons (ASES) scores
  • University of California Los Angeles (UCLA) Shoulder Scores
  • Active range of motion 4

• However, patients treated with locking plates achieved Constant scores more similar to the non-operated shoulder compared to those treated with nails or percutaneous pinning 3

Potential Complications

• IMN complications may include:

  • Nonunion requiring bone grafting
  • Screw loosening 4
  • Shoulder impingement
  • Elbow problems 1

• Plate fixation complications may include:

  • Infection
  • Hardware prominence
  • Neurovascular injury

• Late presentation complications (if treatment is delayed):

  • Avascular necrosis
  • Premature fusion
  • Gross restriction of elbow movements
  • Malunion requiring corrective osteotomy 5, 6

Post-operative Management

• Regular radiographic follow-up at 2-week intervals initially to monitor for complications 2
• Rehabilitation protocol:
  1. Early phase (0-4 weeks): Protected motion, pain control, pendulum exercises
  2. Intermediate phase (4+ weeks): Gentle passive range of motion exercises
  3. Advanced phase: Progress to active-assisted range of motion and strengthening exercises after radiographic evidence of healing 2

Clinical Pearls and Pitfalls

• Failing to verify reduction within 7-14 days can lead to malunions requiring surgical correction
• Neglecting early motion therapy can result in joint stiffness and poor functional outcomes
• Regular clinical and radiographic follow-up for at least 6 months is essential to monitor healing and detect potential complications 2
• Early finger and hand motion is essential to prevent edema and stiffness 2

Special Considerations

• For elderly patients with multiple fractures, orthogeriatric comanagement is recommended 2
• Consider calcium (1000-1200 mg/day) and vitamin D (800 IU/day) supplementation for patients over 50 years with fragility fractures 2
• Implement fall prevention strategies for patients with osteoporotic fractures 2