What is the management of a humeral neck fracture?

Management of Humeral Neck Fractures

Initial Assessment and Classification

The management of humeral neck fractures depends critically on fracture displacement, patient age, and functional demands, with most undisplaced fractures treated conservatively and displaced fractures requiring individualized surgical versus nonsurgical decision-making.

Key Diagnostic Considerations

• Vascular assessment is mandatory in all humeral neck fractures due to risk of limb-threatening ischemia and long-term neurovascular compromise 1
• CT imaging is the preferred modality for characterizing proximal humeral fractures when radiographs show a fracture, as it provides superior delineation of fracture patterns and has been shown to have poor inter-observer agreement on radiography alone 1
• Three-dimensional CT reconstruction should be obtained to better characterize fracture patterns and humeral neck angulation, which directly affects functional outcomes 1

Treatment Algorithm

Undisplaced or Minimally Displaced Fractures (Neer Type I)

Nonsurgical treatment with early mobilization is the standard of care for stable, undisplaced humeral neck fractures.

• Posterior splint immobilization provides superior pain relief compared to collar-and-cuff in the first 2 weeks after injury 1
• Early physiotherapy initiated within one week results in less pain and better recovery compared to delayed mobilization after 3 weeks of immobilization 2
• Immobilization should not exceed 1-3 weeks before beginning range-of-motion exercises to prevent stiffness 2
• Supervised versus unsupervised rehabilitation produces similar outcomes when patients receive adequate instruction for self-directed exercise 2

Displaced Two-Part Surgical Neck Fractures

The evidence does not support routine surgical intervention for displaced two-part surgical neck fractures, as functional outcomes are equivalent between operative and nonoperative treatment.

• The landmark PROFHER trial (2015) found no significant difference in Oxford Shoulder Scores between surgical and nonsurgical groups at 2 years (39.07 vs 38.32 points; difference 0.75,95% CI -1.33 to 2.84; P=0.48) 3
• Surgical treatment may provide earlier pain relief at 3 months (51% vs 76% reporting pain, P=0.03) but this advantage disappears by 6-12 months 4
• Surgery carries additional risks including 10 medical complications during hospitalization and similar rates of secondary surgery (11 patients in each group) 3
• Both treatment modalities achieve excellent outcomes with relative Constant Scores of 89.8% at 24 months 4

When surgery is chosen, locking plate fixation is preferred over intramedullary nailing for two-part surgical neck fractures, with evidence suggesting better functional outcomes despite higher complication rates 2

Displaced Three- and Four-Part Fractures

Complex displaced fractures involving the humeral head require careful consideration of surgical options, though high-quality comparative evidence remains limited.

• Hemiarthroplasty versus tension-band fixation: Tension-band wire fixation shows higher re-operation rates for severe injuries 2
• Locking plate fixation is the most commonly used operative modality for complex fractures when anatomic reduction is achievable 5
• Complete detachment of the humeral head (anatomic neck fractures) carries high risk of avascular necrosis and may require arthroplasty 6

Special Considerations for Anatomic Neck Fractures

For posterior shoulder dislocations with anatomic neck fractures, reduction of the dislocation alone without internal fixation is recommended as the initial approach.

• Closed reduction of the dislocated humeral head with impaction of the fracture achieves acceptable fragment repositioning in most cases 6
• Contraindications to this conservative approach include completely detached humeral head or bone fragments displaced >10mm after reduction 6
• Avascular necrosis risk is significant with complete detachment, occurring in approximately 10-15% of cases 6

Postoperative Rehabilitation

When surgery is performed, early active motion protocols produce equivalent or superior outcomes compared to restrictive immobilization.

• No immobilization is necessary after locking plate fixation in appropriately selected patients with adequate bone quality and stable fixation 5
• Early active motion without restrictions shows non-inferior functional outcomes (Constant Score 77.6 vs 81.3, relative CS 89.8% bilaterally) compared to 4-week immobilization protocols 5
• Heavy lifting and exhausting physical activity should be avoided for 3 months postoperatively regardless of mobilization protocol 5
• After hemiarthroplasty, timing of mobilization (early vs delayed) shows similar outcomes, though evidence is limited 2

Critical Pitfalls to Avoid

• Avoid hyperflexion casting in displaced fractures as this can cause limb-threatening ischemia 1
• Do not delay vascular assessment as neurovascular compromise can lead to permanent functional loss 1
• Avoid routine surgery for two-part fractures based solely on displacement, as nonsurgical treatment achieves equivalent 2-year outcomes 3
• Do not assume surgical fixation prevents secondary procedures, as re-operation rates are similar between surgical and nonsurgical groups 3
• Recognize that modern locking plates enable earlier mobilization and restrictive protocols may unnecessarily prolong rehabilitation 5