Treatment of Minimally Displaced Proximal Humerus Surgical Neck Fracture in Elderly Patients
Non-operative treatment with sling immobilization followed by early rehabilitation is the recommended approach for minimally displaced proximal humerus surgical neck fractures in elderly patients. 1
Primary Treatment Recommendation
Most proximal humeral fractures, including minimally displaced surgical neck fractures, can be treated non-operatively with good functional outcomes. 1 This guideline-based recommendation is supported by the highest quality evidence from the PROFHER randomized clinical trial, which demonstrated no significant difference in outcomes between surgical and non-surgical treatment even for displaced fractures involving the surgical neck. 2
Evidence Supporting Non-Operative Management
The PROFHER trial (250 patients, mean age 66 years) found no statistically or clinically significant difference in Oxford Shoulder Scores between surgical and non-surgical groups over 2 years (difference of 0.75 points, 95% CI -1.33 to 2.84; p=0.48). 2
Non-surgical treatment resulted in comparable complication rates (23 patients in non-surgical group vs 30 in surgical group), with no difference in need for secondary surgery (11 patients in each group). 2
Surgery added an average cost of £1,780.73 per patient without providing better outcomes, with only a 5% probability of being cost-effective. 3
The surgical group experienced 10 additional medical complications during postoperative hospital stay (including cardiovascular, respiratory, and gastrointestinal events) that did not occur in the non-surgical group. 2
Non-Operative Treatment Protocol
Initial management consists of sling immobilization followed by standardized outpatient and community-based rehabilitation. 2
Begin with sling immobilization for comfort and initial fracture stability. 2
Initiate early mobilization with structured physical therapy including muscle strengthening and balance training as soon as pain permits. 4
Implement multidimensional fall prevention strategies given the high-risk elderly population. 4
When Surgery Might Be Considered (Not Applicable Here)
While your patient has a minimally displaced fracture and should be treated non-operatively, it's important to understand that even for displaced three-part and four-part fractures, treatment remains controversial. 1
Open reduction and locking plate osteosynthesis is associated with considerable complications. 1
Reverse shoulder arthroplasty may provide satisfactory function only in geriatric patients with pre-existing rotator cuff dysfunction or after failure of first-line treatment. 1
Critical Pitfall to Avoid
Do not pursue surgery based on radiographic appearance alone. The PROFHER trial definitively showed that even displaced fractures involving the surgical neck do not benefit from surgical intervention in terms of patient-reported outcomes, complications, or mortality. 2, 3 Since your patient has a minimally displaced fracture, the case for non-operative management is even stronger.
Secondary Fracture Prevention
Every patient aged 50 years and over with a fragility fracture requires systematic evaluation for osteoporosis risk. 1, 4