Treatment of Moderately Displaced Proximal Humerus Surgical Neck Fracture in Elderly Female
For a moderately displaced surgical neck fracture in an elderly female patient, non-operative treatment with sling immobilization followed by early rehabilitation is the recommended first-line approach, as most proximal humeral fractures in this population can be treated non-operatively with good functional outcomes. 1
Primary Treatment Recommendation: Non-Operative Management
The American College of Rheumatology supports non-operative treatment with sling immobilization as the preferred approach for minimally to moderately displaced proximal humerus surgical neck fractures in elderly patients. 1
Early mobilization with structured physical therapy should begin as soon as pain permits, focusing on muscle strengthening and balance training. 1
This conservative approach avoids the significant complication rates associated with surgical fixation in elderly patients, which can reach 34% with locking plate systems. 2
When to Consider Operative Treatment
If non-operative management fails or the fracture is truly unstable with significant displacement, surgical options include:
Locking Plate Fixation with Cement Augmentation
Cement-augmented locking plate fixation dramatically reduces implant failure rates to 1% compared to 8% without augmentation in elderly patients. 3
This technique requires anatomic reduction and proper surgical technique, as 40% of complications in locking plate fixation are related to incorrect surgical technique present at the end of the operative procedure. 2
Critical technical points include avoiding screw perforation of the humeral head (occurs in 14% of cases) and proper plate positioning to prevent impingement. 2, 4
Mean Constant scores at 2 years reach 76 points with cement augmentation versus 70 points without. 3
Intramedullary Nailing
Multiplanar intramedullary nailing achieves similar functional outcomes to locking plates at 2 years, with DASH scores of 37.8 points versus 32.6 points for cement-augmented plates. 5
Nailing has comparable complication rates (6.7% revision rate) but requires anatomic fracture reduction and accurate implant positioning. 5
This option may be preferable in patients where soft tissue stripping from open plating is a concern. 5
Critical Caveats and Pitfalls
Avoid surgery in elderly patients unless absolutely necessary, as the revision rate for complex proximal humerus fractures treated operatively reaches 29.6% in this population. 4
If surgery is performed, screw cutout occurs in 22% of elderly patients without cement augmentation, making this a major concern. 4
Avascular necrosis develops in approximately 29.6% of operatively treated complex fractures in the elderly, though this rate drops to 5% with proper technique in some series. 4, 6
Essential Concurrent Management
Every patient aged 50 years and over with a fragility fracture requires systematic evaluation for osteoporosis risk through a Fracture Liaison Service. 1
Address vitamin D deficiency and optimize calcium intake before initiating anti-osteoporotic therapy. 1
Implement multidimensional fall prevention strategies given the high-risk elderly population. 1
Long-term continuation of balance training helps prevent subsequent fractures. 7
Algorithm for Decision-Making
Start with non-operative treatment unless:
- Fracture shows progressive displacement on serial radiographs
- Patient has failed conservative management with persistent pain and dysfunction
- Fracture pattern shows true instability (not just moderate displacement)
If surgery is required: