What is the recommended treatment for a 59-year-old female with a proximal humerus neck fracture, considering potential comorbidities and osteoporosis risk?

Treatment of Proximal Humerus Neck Fracture in a 59-Year-Old Female

For a 59-year-old female with a proximal humerus neck fracture, conservative management with analgesia, early mobilization, and calcium/vitamin D supplementation is the primary treatment approach for most fracture patterns, while operative intervention should be reserved for significantly displaced multi-part fractures or fracture-dislocations. 1, 2

Acute Fracture Management

Initial Treatment Decision

• Most proximal humerus fractures should be managed conservatively with pain control, brief immobilization (sling for comfort), and early mobilization as pain allows 1, 2
• Conservative therapy is appropriate since most acute symptoms subside over 6-8 weeks as the fracture heals 3
• Consultation with an orthopedic surgeon is indicated only if there are multiple fracture fragments with extensive displacement 2

Operative Indications (Specific Criteria)

Surgical intervention should be considered for:

• Three-part or four-part fractures with significant displacement where anatomic reconstruction cannot be obtained conservatively 1
• Fracture-dislocations of the humeral head 4
• Ischemic humeral head or when anatomic reduction is impossible 1

Surgical Options When Indicated

• For displaced multi-part fractures in osteoporotic bone: Internal fixation using thin, flexible implants that allow load-sharing (not load-bearing) with metaphyseal elastic buttressing is preferred when head preservation is possible 1
• For irreparable fractures or ischemic humeral head: Hemiarthroplasty or reverse total shoulder arthroplasty is the method of choice 4, 1

Critical Osteoporosis Evaluation (Mandatory)

This fracture is a red flag for underlying osteoporosis and requires systematic evaluation regardless of fracture treatment chosen. 3, 5, 6

Immediate Diagnostic Workup

• Obtain DXA scan of spine and hip to measure bone mineral density 3, 5
• Perform vertebral imaging to identify silent vertebral compression fractures 5
• Calculate 10-year fracture risk using FRAX (WHO Fracture Risk Assessment Tool) 3, 5
• Assess clinical risk factors: prior fractures, falls, low body weight, smoking, alcohol use 5

Osteoporosis Treatment Thresholds

Pharmacologic treatment is indicated if:

• T-score ≤ -2.5 at spine or hip 3
• FRAX 10-year risk ≥20% for major osteoporotic fracture OR ≥3% for hip fracture 3, 5
• History of fragility fracture (which this patient now has) 3, 5

Recommended Osteoporosis Treatment

First-line pharmacologic therapy: Oral bisphosphonate (alendronate or risedronate) 3

Alternative therapies if oral bisphosphonates are not appropriate (in order of preference):

• IV bisphosphonates (zoledronic acid) 3
• Teriparatide 3
• Denosumab 3

All patients require:

• Calcium 1,000-1,200 mg/day 3
• Vitamin D 600-800 IU/day (target serum level ≥20 ng/mL) 3
• Weight-bearing exercise as tolerated 3
• Smoking cessation and alcohol limitation 3

Implementation Strategy

• Establish a Fracture Liaison Service (FLS) approach with a dedicated coordinator to ensure osteoporosis evaluation is completed, treatment is initiated, and primary care physician is notified 3, 5
• This systematic approach significantly improves treatment implementation and reduces subsequent fracture risk 3, 5

Critical Pitfalls to Avoid

• Do not delay osteoporosis evaluation: The risk of subsequent fracture is highest immediately after the initial fracture, with a 20% risk of another vertebral fracture within 12 months 3, 5
• Do not rely solely on BMD: Proximal humerus bone density is often underestimated by standard DXA, and cortical index measurements show many patients are at fracture risk despite non-critical femoral densitometry values 7
• Do not use bulky, stiff implants if surgery is needed: In osteoporotic bone, thin and flexible load-sharing constructs with metaphyseal buttressing are mandatory to prevent fixation failure 1
• Do not prescribe prolonged bed rest: Even 10 days of bed rest causes 15% loss of lower extremity strength and 10-15% loss of aerobic capacity, equivalent to a decade of age-related decline 3
• Do not overlook secondary causes of osteoporosis: Up to 30% of women with osteoporosis have underlying secondary causes requiring specific treatment 5