What is the close treatment for a left three-part proximal humerus fracture?

Closed Treatment of Left Three-Part Proximal Humerus Fracture

For a left three-part proximal humerus fracture in adults, closed treatment consists of short-term immobilization (typically 1-2 weeks maximum) followed by early active range of motion exercises, avoiding prolonged immobilization that leads to stiffness and poor functional outcomes. 1

Initial Immobilization Strategy

• Use a simple sling or neutral-rotation brace for comfort during the first 1-2 weeks, with emerging evidence suggesting neutral-rotation positioning may provide superior outcomes compared to traditional internal rotation slings 2
• Avoid prolonged immobilization beyond 2 weeks, as this is the critical period where harmful effects of immobilization begin to significantly impact shoulder function 3
• The neutral-rotation brace shows trends toward better range of motion (elevation 159° vs 140°, external rotation 47° vs 37°) and functional scores compared to simple slings at one year 2

Early Mobilization Protocol

• Begin pendulum exercises and passive range of motion within the first few days to week, as early controlled stress through the fracture site optimizes bone repair without increasing complication rates 3
• Progress to active-assisted range of motion exercises by week 2-3, focusing on forward elevation, external rotation, and internal rotation 3
• Avoid heavy lifting, exhausting physical activity, and blunt force to the arm for 3 months post-injury 4

Critical Imaging Requirements

• Obtain standard shoulder radiographs including AP views in internal and external rotation plus an axillary or scapula-Y view to assess fracture displacement 5
• Order CT without contrast for all three-part fractures, as CT is superior for characterizing complex fracture patterns and changes clinical management in up to 41% of proximal humeral fractures 5
• Use three-dimensional volume-rendered CT images to assess humeral neck angulation, which directly affects functional outcomes 5

Neurovascular Assessment

• Assess neurovascular status immediately and continuously throughout treatment, as vascular compromise can lead to permanent nerve and muscle dysfunction 5
• Document radial pulse, capillary refill, and sensory/motor function of the axillary, radial, median, and ulnar nerves 5

Common Pitfalls to Avoid

• Do not immobilize for more than 2 weeks routinely, as prolonged immobilization is the primary cause of poor functional outcomes in conservatively managed proximal humerus fractures 3
• Do not rely solely on radiographs for treatment planning; CT provides essential information about fracture complexity that may indicate surgical intervention is more appropriate 5
• Recognize that up to 40% of humeral head fractures have complete rotator cuff tendon tears that may require delayed surgical attention if conservative management fails 5

When Closed Treatment May Fail

• Three-part fractures with significant displacement (>1 cm or >45° angulation) often require surgical fixation rather than closed treatment 1, 6
• Patient age, bone quality, and functional demands influence whether closed treatment will provide acceptable outcomes 1
• If closed treatment is attempted but fails to maintain acceptable alignment on follow-up radiographs at 1-2 weeks, surgical intervention should be reconsidered 1