Review Question - QID 218817

The patient presents with a "floating elbow" in the setting of a proximal-third humerus fracture and a distal-third both-bone forearm fracture. "Floating elbows" are an indication for pediatric humerus fracture fixation.

Though nonsurgical treatment may be undertaken for a majority of pediatric humeral shaft fractures, there are several indications to pursue operative fixation. These include open fractures, associated shoulder girdle injuries, unacceptable or unstable alignment, ipsilateral forearm fractures ("floating elbows"), and polytrauma patients whose constellation of injuries will necessitate prolonged rehabilitative courses with the need for walking aids/assistive devices and mobilization via the upper extremities. Fixation in the pediatric setting most often involves the use of flexible intramedullary nails or closed versus open reduction with k-wire pinning (Illustration A).

Kelly et al. performed a review of flexible intramedullary nailing of pediatric humerus fractures. The authors report that certain patient factors or fracture characteristics may make surgical stabilization with flexible nails a good choice. These include unstable proximal-third fractures in children nearing skeletal maturity, unstable distal metaphyseal-diaphyseal junction fractures, shaft fractures in polytraumatized patients or patients with ipsilateral both-bone forearm fractures (floating elbow), and prophylactic stabilization of benign diaphyseal bone cysts or surgical stabilization of pathologic fractures. They conclude that nails may be inserted in an antegrade or retrograde manner.

Marengo, et al. performed a study to retrospectively investigate the clinical and radiological outcomes of humeral shaft fractures treated by elastic nailing in patients less than 16 years of age. All patients were followed for at least 1 year after their index procedure. They found that all fractures healed and that DASH scores were improved in all patients with a mean score of 3. They concluded that clinical and functional outcomes in children and adolescents with humeral shaft fractures treated with elastic nailing were acceptable.

Figures A and B demonstrate a proximal-third humerus fracture and a both-bone forearm fracture, respectively, in a patient with open physes. Illustration A demonstrates a post-operative radiograph of the same proximal humerus status-post operative pinning.

Incorrect Answers:
Answer 1: The mechanism of the injury itself does not constitute an indication for operative fixation; however, a polytraumatized patient could be indicated for humerus fixation if their other injuries would dictate a prolonged course of rehabilitation requiring the use of the upper extremities for mobilization.
Answer 2: The patient's age would be a contraindication for fixation if he did not have an ipsilateral forearm fracture, as most all pediatric humeral shaft fractures are treated non-operatively.
Answer 3: Again, the patient's young age and presence of open physes would actually present contraindications to operative fixation if the patient did not have an ipsilateral forearm fracture.
Answer 5: A radial nerve injury occurs in < 5% of pediatric humerus fractures, is more common in middle and distal-third fractures, and is not an indication for operative fixation given that nearly all are neuropraxias that self-resolve.