What is the best treatment for a 54-year-old female with a displaced fracture?

Treatment of Displaced Neer 2-3 Proximal Humerus Fracture in a 54-Year-Old Healthy Female

For a healthy, physiologically fit 54-year-old female with a displaced Neer 2-3 proximal humerus fracture, non-operative treatment with immobilization and early functional rehabilitation should be the first-line approach, as most proximal humeral fractures achieve good functional outcomes without surgery. 1

Primary Treatment Recommendation

• Most proximal humeral fractures can be treated non-operatively with good functional outcomes, even when displaced. 1
• Initial management consists of brief immobilization (1-2 weeks) followed by early range-of-motion exercises to prevent stiffness. 1
• Given this patient's excellent physiological status and age (54 years), she has the biological capacity to heal well with conservative management. 1

When to Consider Surgical Intervention

Treatment of displaced three-part fractures remains controversial, with the following considerations: 1

• Open reduction and locking plate osteosynthesis is associated with considerable complications in the elderly population, though your patient at 54 may tolerate this better than geriatric patients. 1
• Surgical intervention may be considered if:
  • The fracture is a true 3-part pattern with significant displacement and the patient demands high shoulder function 1
  • There is vascular compromise to the humeral head 1
  • The patient fails conservative management after 6-8 weeks 1

Surgical Options If Conservative Treatment Fails

• Reverse shoulder arthroplasty may provide satisfactory shoulder function in patients with pre-existing rotator cuff dysfunction or after failure of first-line treatment. 1
• However, at age 54, this patient is relatively young for arthroplasty, making initial conservative management even more appropriate. 1
• If surgery becomes necessary, locking plate fixation would be preferred over arthroplasty given her age and activity level, despite the complication risks. 1

Critical Pitfalls to Avoid

• Avoid rushing to surgery for displaced 2-3 part proximal humerus fractures, as the complication rates with operative management are substantial. 1
• Do not allow prolonged immobilization beyond 2 weeks, as shoulder stiffness is a major source of disability in these fractures. 1
• Ensure adequate pain control to facilitate early mobilization and prevent frozen shoulder. 1

Post-Fracture Osteoporosis Evaluation

• Each patient aged 50 years and over with a recent fracture should be evaluated systematically for the risk of subsequent fractures. 1
• Order bone density testing (DXA), vitamin D levels, and calcium levels. 2
• Initiate pharmacological treatment with drugs demonstrated to reduce vertebral, non-vertebral, and hip fracture risk. 1
• Ensure adequate calcium and vitamin D intake, smoking cessation, and alcohol limitation. 1