Fractures of Proximal Humerus – When To Treat Non operatively?

A large number of patients with fractures of proximal humerus can be managed with non operative methods. The principle of treatment by conservative methods is  early protection combined with gradual mobilization.

Elderly people accept non operative treatment quite well.  Even deformities like displacement and angulation are taken very well by these patients. Angulation is well compensated for by shoulder motion.

Method of Treatment

Most patients are placed in a sling for the first week to 10 days. Hand, wrist, and elbow motion begins immediately. After this, the patient is examined by holding the elbow and flexed forearm in one hand and moved while palpating the the tuberosities and biceps groove with the other hand.  If the entire limb moves as one unit it means fracture is becoming glued nad  the patient is started on gentle pendulum range of motion.

If crepitus is felt or there is a slip or giveaway sensation, the patient is left immobilized for another week and then is reassessed.

Radiographs are done after 3 or 4 weeks. If the fracture configuration has not worsened and the feel is solid, gentle assistive exercises  like pulley elevation, external rotation with a stick, extension with a stick are begun along with formal physical therapy.

Gradula stretching exercises are also begunn and continued till maximum range of motion is achieved.

When to put patient on non operative treatment*

Nondisplaced Fractures

• <5mm of superior or 10 mm of posterior greater tuberosity displacement in active people

• <10 mm of superior displacement in non dominant arm of sedentary paients

Surgical neck fractures

• Any kind of bony contact in elderly patients
• Young patients : Less than half shaft diameter displacements  and  less than 45 degree angulation in dominant arm

Lesser Demands

• If the patient is willing to accept stiff shoulder

Poor Health

• If the patient is unable to tolerate surgery and anesthesia

Poor rehabilitation candidate

• The patient is too weak  to pursue rehabilitation
• Patient is unable to understand or remember postoperative instructions.

*Adapted from Rockwood and Wilkins, Fractures in Adults