What is the best management approach for an elderly, frail female patient with a mildly displaced fracture of the humeral neck, osteopenic bones, and a history of a fall, who also has signs of atelectasis in the lower lobe of the left lung and narrowing of the glenohumeral joint space?

Management of Mildly Displaced Proximal Humeral Neck Fracture in an Elderly, Frail Patient

Non-operative treatment with sling immobilization is the recommended approach for this elderly, frail patient with a mildly displaced humeral neck fracture, as surgery provides no functional benefit over conservative management and avoids operative risks in this high-risk population. 1

Primary Treatment Decision

Conservative management with sling immobilization should be initiated immediately, as the landmark PROFHER randomized clinical trial demonstrated no significant difference in Oxford Shoulder Score between surgical and nonsurgical treatment at 2 years (39.07 vs 38.32 points, p=0.48) for displaced proximal humeral fractures involving the surgical neck. 1

Key Supporting Evidence:

• Most proximal humeral fractures, including displaced surgical neck fractures, can be treated non-operatively with good functional outcomes. 2
• Non-operative treatment is as effective as surgical fixation for two-part surgical neck fractures in older patients. 3
• Surgery in the PROFHER trial resulted in 10 additional medical complications during the postoperative hospital stay (including cardiovascular, respiratory, and gastrointestinal events) with no functional benefit. 1

Specific Non-Operative Protocol

Immobilization Phase (Weeks 0-3):

• Apply a simple sling for comfort and support (not rigid immobilization, as this is a shoulder fracture, not requiring the prolonged immobilization discussed for other fracture types). 1
• Allow pendulum exercises within pain tolerance starting at 7-10 days to prevent shoulder stiffness. 2

Early Mobilization Phase (Weeks 3-6):

• Begin passive range of motion exercises under physiotherapy supervision. 2
• Progress to active-assisted exercises as pain permits. 2

Strengthening Phase (Weeks 6-12):

• Initiate progressive resistance exercises focusing on rotator cuff and scapular stabilizers. 2

Critical Concurrent Management Issues

Pulmonary Complications:

The atelectasis in the left lower lobe requires immediate attention, as this represents a significant morbidity risk in an elderly, frail patient:

• Incentive spirometry every 2 hours while awake. 2
• Early mobilization out of bed to prevent further respiratory complications. 2
• Consider chest physiotherapy if atelectasis persists or worsens. 2

Osteoporosis Evaluation (Mandatory):

All patients over 50 with fragility fractures require systematic osteoporosis evaluation and treatment:

• Order DEXA scan for bone density assessment. 4, 5
• Check vitamin D, calcium, and parathyroid hormone levels. 4, 5
• Initiate bisphosphonate therapy (or alternative anti-resorptive agent) to prevent subsequent fractures. 2

Pain Management:

Multimodal analgesia should be provided to facilitate early mobilization and prevent deconditioning:

• Acetaminophen scheduled dosing as first-line. 2
• Short-term opioids only if necessary, with careful monitoring in elderly patients. 2
• Avoid NSAIDs given potential for impaired fracture healing and GI/renal complications in elderly. 2

When Surgery Should Be Considered (Exceptions)

Surgery would only be indicated if:

• Gross displacement develops on follow-up radiographs (>1cm translation or >45° angulation). 2
• Vascular or neurological compromise occurs. 2
• The patient is young, high-functioning, and has specific functional demands (not applicable here). 1

Follow-Up Protocol

Radiographic Monitoring:

• Repeat X-rays at 1-2 weeks to ensure no displacement progression. 2
• Repeat X-rays at 6 weeks to assess early healing. 2

Functional Assessment:

• Evaluate shoulder range of motion at 6 weeks, 3 months, and 6 months. 1
• Expect gradual improvement over 6-12 months, with most recovery occurring in the first year. 6

Common Pitfalls to Avoid

Do not pursue surgery based solely on radiographic appearance of displacement, as functional outcomes are equivalent to conservative treatment and surgery adds significant morbidity risk in frail elderly patients. 1

Do not neglect the pulmonary complication, as respiratory complications are a major cause of morbidity and mortality in elderly trauma patients. 2

Do not fail to address osteoporosis, as this patient has a 50% risk of subsequent fracture without treatment. 2

Do not immobilize for prolonged periods, as shoulder stiffness is a major complication that can be prevented with early gentle mobilization. 2, 1