Fractures of the proximal humerus are among the most frequent injuries encountered in orthopaedic practice, representing approximately 5.03% of all fractures, with a mean age at presentation of 55.4 years in men and 67.0 years in women.¹ Their incidence rises sharply with advancing age, and they now constitute the third most common osteoporotic fracture in the aging population after fractures of the hip and distal radius.^2,3 More than 70% of affected patients are aged 60 years or older, and women account for roughly three-quarters of this demographic, reflecting the strong association between proximal humerus fractures (PHFs) and post-menopausal bone fragility.⁴ With increasing life expectancy worldwide, the absolute burden of these fractures is expected to grow substantially, making the definition of an optimal, resource-appropriate treatment pathway a matter of considerable clinical and public health importance.

The Neer classification, based on the displacement of the four principal anatomical segments of the proximal humerus, remains the most widely used framework for describing these injuries and guiding treatment.⁵ Two-part fractures of the surgical neck form a distinct and common subgroup, particularly in older patients, in whom the injury typically follows a low-energy fall onto the outstretched hand.⁶ Although approximately 85% of all PHFs are undisplaced or minimally displaced and are managed conservatively with predictably good results, the ideal treatment of displaced two-part surgical neck fractures continues to generate debate.^4,7

Over the past two decades there has been a clear trend towards increased operative intervention, driven by the introduction of locking plate technology, intramedullary devices and reverse shoulder arthroplasty.^4,7 Yet the superiority of surgery over non-operative care has not been convincingly demonstrated. The multicentre PROFHER randomised trial found no significant difference in patient-reported outcomes between surgical and non-surgical treatment of displaced PHFs involving the surgical neck over two years, results that were sustained at five years.⁸ Similarly, randomised and comparative studies of displaced two- and three-part fractures have reported comparable functional results between operative and conservative treatment, with surgery carrying an added risk of implant-related complications and reoperation.^9,10 Against this background, conservative management — a short period of sling immobilisation followed by structured, early rehabilitation — remains an attractive option, particularly in patients above 40 years of age in whom bone quality may compromise fixation.

Reliable, validated outcome instruments are essential to judge the success of any treatment strategy. The Constant–Murley Score (CMS), which combines subjective parameters of pain and activities of daily living with objective assessment of range of motion and power, is the most widely used shoulder-specific score in Europe and permits comparison across studies.¹¹ The present study was therefore undertaken to report our institutional experience of the functional outcome, measured primarily by the CMS, of conservatively managed displaced two-part surgical neck fractures of the proximal humerus in patients above 40 years of age.

This prospective, descriptive, hospital-based study was carried out in the Department of Orthopaedics, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, over an 18-month period between 2022 and 2024, after obtaining institutional ethical committee clearance. Written informed consent was obtained from every participant, and data were recorded in a pre-designed proforma. A minimum sample of 24 patients was recruited by convenience sampling from those admitted through the emergency and outpatient departments. All patients above 40 years of age presenting with an acute, displaced two-part fracture of the proximal humerus involving the surgical neck, as defined by the Neer classification,5 were included. Patients with two-part fractures of the greater or lesser tuberosity, those younger than 40 years, and those unwilling to participate were excluded. On admission, a detailed history was obtained and a thorough clinical examination of the skeletal system and soft tissues was performed, with particular attention to the neurovascular status of the limb and associated injuries. Radiographic evaluation comprised anteroposterior and, where feasible, axillary views of the shoulder, on the basis of which fractures were classified. All patients were managed conservatively. The injured limb was immobilised in a collar-and-cuff sling or shoulder immobiliser for two weeks, during which adequate analgesia was provided. Pendulum exercises of the shoulder were commenced promptly, together with active mobilisation of the elbow, wrist and fingers, and patients were encouraged to use the injured upper limb for light everyday tasks. After the initial two weeks, graduated active range-of-motion exercises of the shoulder were begun under the supervision of a physiotherapist, and the number of physiotherapy sessions attended was documented at each visit. Patients were followed up for a total of one year, with scheduled assessments at 3, 6 and 12 months after injury. At each visit, pain, shoulder function and range of motion were evaluated clinically. Functional outcome was measured with the Constant–Murley Score (CMS), which allots 15 points for pain, 20 for activities of daily living, 40 for range of motion and 25 for power,11 and with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire as a secondary patient-reported measure.12 CMS results were categorised as good, moderate or poor for descriptive purposes. Data were entered into a Microsoft Excel spreadsheet and analysed using SPSS version 27.0 (SPSS Inc., Chicago, IL, USA) and GraphPad Prism version 5. Numerical variables were summarised as mean and standard deviation, and categorical variables as counts and percentages. Paired and unpaired t-tests were applied to compare means, and the Z-test of proportions and chi-square test were used where appropriate. A p-value ≤ 0.05 was considered statistically significant.

Twenty-four patients were enrolled, of whom 23 (95.8%) completed the full 12-month follow-up schedule; one patient was lost to follow-up after the 6-month visit. The demographic profile of the cohort is summarised in Table 1. The mean age was 54.56 years (SD 1.26). The 60–70-year age group was the most frequently affected (41.67%), followed by the 51–60-year group (25.00%), and females outnumbered males with a male-to-female ratio of 1:1.4.

Table 1. Demographic profile of the study population (n = 24)

The distribution of CMS categories at each follow-up interval is shown in Table 2. At 3 months, the majority of patients (83.33%) had a poor CMS and 16.67% a moderate score (p < 0.01). By 6 months there was a clear shift towards better categories, with 75.00% achieving a moderate score, 20.83% remaining poor and one patient (4.17%) attaining a good result; the predominance of the moderate category was statistically significant (p < 0.01). At 12 months, no patient remained in the poor category: 75.00% had a moderate outcome and 20.83% a good outcome (p < 0.01), demonstrating steady functional recovery throughout the year.

Table 2. Distribution of Constant–Murley Score categories at 3, 6 and 12 months

The serial mean CMS values are presented in Table 3. The mean score improved from 51.83 ± 5.85 at 3 months to 59.29 ± 5.17 at 6 months and 65.26 ± 4.88 at 12 months, an overall gain of more than 13 points over the study period. The improvements from 3 to 6 months and from 3 to 12 months were statistically significant, whereas the gain between 6 and 12 months, though consistent, did not reach significance, indicating that the greatest functional recovery occurred within the first six months after injury. No fracture-related complications, secondary displacement requiring surgery, non-union or avascular necrosis were observed, and 20 of 24 patients (83.33%) expressed satisfaction with their outcome at final review.

Table 3. Mean Constant–Murley Score at serial follow-up intervals

The principal finding of this study is that displaced two-part surgical neck fractures of the proximal humerus in patients above 40 years of age can be managed conservatively with progressive and clinically meaningful functional recovery, a very high follow-up completion rate, and no complications. The mean CMS rose steadily from 51.83 at 3 months to 65.26 at 12 months, and by final review no patient remained in the poor category, with more than 95% achieving a moderate or good result. These results are consistent with the broader literature on non-operative treatment of PHFs. Conservative management of undisplaced or minimally displaced fractures yields satisfactory results in 80–90% of patients,2,13 and increasing evidence suggests that this benefit extends to displaced surgical neck fractures. In the prospective multicentre cohort of Hauschild et al., which compared conservative therapy with three operative techniques for two-part surgical neck fractures, no significant difference in outcome was demonstrable at 12 months, and the authors concluded that the main advantage of surgery was confined to earlier recovery of motion and comfort in the first three months.10 The mean 12-month CMS in our series (65.26) is somewhat lower than the value of 74 reported in their conservative arm, which may reflect differences in age distribution, baseline bone quality and rehabilitation intensity between the cohorts. Urda et al., examining three surgical strategies for displaced surgical neck fractures, likewise reported functional results that were no better than — and in some domains inferior to — published conservative series.14 The temporal pattern of recovery observed here, with the largest gains occurring between 3 and 6 months and a plateau thereafter, mirrors the findings of Bonifacio et al., who documented continuous improvement in CMS after conservative treatment of displaced two-part humeral neck fractures in the elderly, with the greatest gains concentrated in the first six months; this underscores the crucial role of early, structured rehabilitation in exploiting the principal window of functional improvement.15 Our protocol of two weeks of sling immobilisation followed by early pendulum and graduated active exercises is supported by evidence that prolonged immobilisation is unnecessary and that early physiotherapy improves recovery.7,16 At the level of randomised evidence, the PROFHER trial found no significant difference in patient-reported outcomes between surgical and non-surgical treatment of displaced PHFs involving the surgical neck, results sustained at five years,8 and Olerud et al. reported only marginal benefits of internal fixation over non-operative care in displaced three-part fractures at the cost of a substantial reoperation rate.9 Meta-analyses of randomised trials similarly show no convincing superiority of surgery in complex PHFs.17,18 Spross et al. reported 97% satisfactory outcomes when conservative treatment was applied through an evidence-based algorithm,19 while Foruria et al. emphasised that fracture pattern and initial displacement, rather than treatment modality alone, predict outcome.20 The limitations of this study include its modest sample size, single-centre design, absence of a surgical comparator arm and reliance on convenience sampling, all of which restrict generalisability. Nevertheless, the prospective design, standardised rehabilitation protocol and near-complete follow-up strengthen the internal validity of our observations.

Conservative management of displaced two-part surgical neck fractures of the proximal humerus, classified by the Neer system, is a safe, beneficial and acceptable mode of treatment in patients above 40 years of age. A short period of sling immobilisation followed by early, supervised mobilisation permits rehabilitation to begin as early as two weeks after injury and produces a steadily improving Constant–Murley Score, with the greatest recovery in the first six months, no complications, and a satisfactory functional outcome in the overwhelming majority of patients at one year.

Passaretti D, Candela V, Sessa P, Gumina S. Epidemiology of proximal humeral fractures: a detailed survey of 711 patients in a metropolitan area. J Shoulder Elbow Surg. 2017;26(12):2117-24.

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