Treatment of Displaced Surgical Neck Humerus Fractures in Older Adults
For older adults with displaced surgical neck humerus fractures and no significant medical history, nonsurgical treatment with sling immobilization followed by standardized rehabilitation is the recommended approach, as surgery provides no significant clinical benefit over conservative management.
Primary Treatment Recommendation
The landmark PROFHER randomized clinical trial definitively demonstrated that surgical treatment (fracture fixation or humeral head replacement) offers no advantage over nonsurgical management for displaced proximal humeral fractures involving the surgical neck 1. Over a 2-year follow-up period:
- No significant difference existed in the Oxford Shoulder Score between surgical (39.07 points) and nonsurgical groups (38.32 points), with a mean difference of only 0.75 points (95% CI: -1.33 to 2.84; P = 0.48) 1
- Quality of life measures showed no benefit from surgery, with no significant differences in SF-12 physical component scores (P = 0.18) or mental component scores (P = 0.32) 1
- Complication rates were similar between groups (30 surgical patients vs 23 nonsurgical patients; P = 0.28), though the surgical group experienced 10 additional medical complications during postoperative hospitalization, including cardiovascular, respiratory, and gastrointestinal events 1
- Secondary surgery rates were identical (11 patients in each group required subsequent shoulder surgery) 1
Nonsurgical Treatment Protocol
Initial Management
- Immediate sling immobilization should be initiated at presentation 1
- Pain control with multimodal analgesia, avoiding excessive opioid use in older adults 2
Rehabilitation Program
- Standardized outpatient and community-based rehabilitation should begin after initial immobilization period 1
- Early mobilization protocols improve functional recovery and reduce complications 3, 2
- Weight-bearing as tolerated once pain permits 2
When Surgery May Be Considered
While the evidence strongly favors nonsurgical management for most displaced surgical neck fractures, specific clinical scenarios warrant surgical consideration:
Absolute Indications for Surgery
- Open fractures requiring debridement and stabilization
- Vascular compromise not resolved with closed reduction
- Fracture-dislocations that cannot be reduced closed 4
Timing Considerations If Surgery Is Pursued
If surgical intervention becomes necessary despite the evidence against routine surgery:
- Optimal timing is 3-5 days post-injury, which does not increase complication rates compared to surgery within 48 hours 4
- Avoid delays beyond 5 days, as this significantly increases complications (odds ratio 1.637) 4
- For head-split or dislocated fracture patterns specifically, anatomic reconstruction within 48 hours may reduce avascular necrosis risk 4
Surgical Options (If Required)
When surgery is unavoidable, both intramedullary nailing and locking plate fixation yield similar outcomes:
- No significant differences in pain scores, ASES scores (90.2 vs 91.9), UCLA Shoulder Scores (30.7 vs 31.8), or range of motion at 2-year follow-up 5
- Locking plates may achieve Constant scores more similar to the non-operated shoulder compared to intramedullary nails 6
- Percutaneous pinning shows inferior results compared to plates or nails and should be avoided 6
Critical Pitfalls to Avoid
- Do not pursue surgery based solely on radiographic displacement, as fracture appearance does not correlate with functional outcomes in this population 1
- Recognize that surgical complications carry real morbidity in older adults, including 10 medical complications per 114 surgical patients in the PROFHER trial 1
- Avoid the assumption that anatomic reduction equals better function, as the PROFHER trial disproved this for surgical neck fractures 1