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Displaced low-energy proximal humerus fracture — MSRA MCQ

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ModerateShoulder InjuriesDisplaced low-energy proximal humerus fractureMSRA

A 72-year-old woman is reviewed in general practice 3 days after tripping on a pavement and falling onto her left shoulder. In the emergency department, radiographs showed a displaced surgical-neck fracture of the proximal humerus. She was discharged in a collar-and-cuff with a virtual fracture-clinic appointment in 1 week. She is concerned that the fracture is displaced and asks for immediate surgery. Her pain is controlled with regular paracetamol. The skin is intact without tenting, there is no glenohumeral deformity, and the hand is warm with normal radial pulse, capillary refill, power and sensation. The radiology report describes no fracture-dislocation and no humeral-head split. What is the most appropriate management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Continue non-surgical management with analgesia and planned fracture-clinic follow-up

Explanation lettering: E = shown as B · B = shown as E

This is an uncomplicated displaced low-energy proximal humerus fracture. Although the fracture is displaced, NICE recommends non-surgical definitive management for displaced low-energy proximal humerus fractures unless there is an important complicating feature. The relevant exceptions include an open wound, skin tenting, vascular injury, fracture-dislocation or humeral-head split. None is present here. Therefore, she should continue analgesia and the immobilisation/follow-up plan already arranged through the fracture service. The GP should explain that displacement alone does not establish an indication for surgery. A is attractive because displacement often prompts concern about fixation, but urgent operative assessment is not indicated in an otherwise uncomplicated injury. B is inappropriate because CT is not routinely needed to decide management where plain radiographs have established an uncomplicated surgical-neck fracture. C risks inadequate early protection and bypasses fracture-service review; rehabilitation should follow the local fracture pathway. E is incorrect because age alone is not an indication for arthroplasty; this is generally reserved for selected complex fracture patterns, such as fracture-dislocations or humeral-head split injuries.

Reference: NICE NG38: Fractures (non-complex): assessment and management — Definitive treatment of proximal humerus fractures in adults (2016) — https://www.nice.org.uk/guidance/NG38/chapter/recommendations NHS Tayside ED Guidance: Specific fracture management in ED (Last reviewed 2019) — https://www.rightdecisions.scot.nhs.uk/nhs-tayside-ed-guidance/trauma-and-orthopaedics/specific-fracture-management-in-ed/