What is the initial management for a non-displaced proximal humerus fracture?

Initial Management of Non-Displaced Proximal Humerus Fractures

Immobilize the fracture with a posterior splint (back-slab) rather than a collar and cuff, as this provides superior pain relief during the critical first 2 weeks after injury. 1

Immobilization Strategy

• Use a posterior splint for initial immobilization for a minimum of 3 weeks, as this method demonstrates better pain control compared to collar and cuff immobilization in prospective studies 2, 1
• The posterior splint should be maintained continuously during the initial immobilization period 1
• After 3 weeks, transition to a staged rehabilitation protocol 3

Critical Monitoring Requirements

• Obtain radiographic follow-up during the first 3 weeks of treatment to confirm the fracture remains non-displaced 1
• Repeat radiographs at the cessation of immobilization (around 3 weeks) before advancing rehabilitation 1
• Be aware that 90% of conservatively treated proximal humerus fractures will settle during healing, with average changes including varus angulation and posterior shortening, though this settling typically does not compromise outcomes 4

Rehabilitation Protocol (Three-Phase Approach)

Phase 1 (Weeks 0-3):

• Strict immobilization in posterior splint 3
• No active motion during this period 3

Phase 2 (Weeks 3-6):

• Begin pendular and active-assisted exercises 3
• Continue to avoid heavy lifting and exhausting physical activity 5

Phase 3 (Week 6 onward):

• Commence active exercises 3
• Avoid heavy lifting and blunt force to the arm for 3 months total 5

Pain Management

• Prescribe paracetamol on a regular basis unless contraindicated 2
• Use opioids cautiously, particularly in elderly patients who commonly have renal dysfunction (40% have GFR <60 ml/min) 2
• Avoid NSAIDs in patients with renal impairment 2
• Consider nerve blocks (femoral or fascia iliaca) for additional pain control if needed 2

Expected Recovery Timeline

• Patients should be counseled that full recovery typically takes an average of 8 months (range 1-24 months), even with optimal treatment 3
• The average Constant score improves from 40 points at injury to 95 points at final follow-up with this protocol 3
• Patient satisfaction typically improves from 4.2/10 to 9.5/10 by final follow-up 3

Common Pitfalls to Avoid

• Do not use collar and cuff as primary immobilization - this provides inferior pain control compared to posterior splinting 2, 1
• Do not skip radiographic follow-up during the first 3 weeks, as displacement can progress and may require surgical intervention if detected early 1, 4
• Do not rush rehabilitation - advancing too quickly before 3 weeks increases risk of displacement 3
• Be aware that age and initial displacement are risk factors for progression of displacement during healing 4