Fractures of the proximal humerus may occur through either the anatomic or the surgical neck of the humerus. The anatomic neck is located just below the humeral head. The surgical neck is the region below the tubercles. Impacted fractures of the surgical neck of the humerus are seen most frequently in older women after a fall on an outstretched arm. These are essentially non-displaced fractures. Active middle-aged patients who are injured in a fall may suffer severely displaced humeral neck fractures with associated rotator cuff damage.
The patient presents with the affected arm hanging limp at the side and supported by the uninjured hand. Neurovascular assess-ment of the extremity is essential to evaluate fully the extent of injury and the possible involvement of the neurovascular bundle (nerves and blood vessels) of the arm.
Many impacted fractures of the surgical neck of the humerus are not displaced and do not require reduction. The arm is supported and immobilized by a sling and swathe that secure the supported arm to the trunk (Fig. 69-7). A soft pad is placed in the axilla to absorb moisture and avoid skin breakdown. Limitation of mo-tion and stiffness of the shoulder occur with disuse. Therefore, pendulum exercises are begun as soon as tolerated by the patient. (In pendulum or circumduction exercises, the nurse or physical therapist instructs the patient to lean forward and allow the af-fected arm to abduct and rotate [see Fig. 69-6].) Early motion of the joint does not displace the fragments if motion is carried out within the limits imposed by pain.
These fractures require 6 to 10 weeks to heal, and the patient should avoid vigorous activity (eg, tennis) for an additional 4 weeks. Residual stiffness, aching, and some limitation of ROM may per-sist for 6 months or longer.
When a humeral neck fracture is displaced, treatment consists of closed reduction, open reduction with internal fixation, or replacement of the humeral head with a prosthesis. In this type of fracture, exercises are started only after a prescribed period of immobilization.