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A 9-year-old boy sustains an injury to his right shoulder during a skateboarding fall. He complains of pain and deformity. No deficits are present on neurovascular exam. Shoulder radiographs are provided in Figure A. Which of the following is the most appropriate treatment?
Immobilization in a sling and follow-up radiographs
Closed reduction and percutaneous pinning
Closed reduction and spanning external fixation
Closed reduction and intramedullary fixation
Open reduction internal fixation with a plate construct
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Figure A demonstrates a Salter-Harris II proximal humerus physeal fracture. 80% of the longitudinal growth of the humerus occurs through the proximal humerus allowing tremendous remodeling potential. The vast majority of these fractures can be treated non-operatively. A moderate reduction often occurs with simply positioning the patient upright and allowing gravity traction. Surgical indications include open fracture, neurovascular injury, and severely displaced fractures in a patient approaching skeletal maturity.
Rockwood and Wilkins recommend closed reduction and possible surgical fixation of fractures displaced more than 50% in adolescents greater than 11 years old.
Illustrations A and B demonstrate healing of this clinical case at 2 months and 6 months following injury.
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Which of the following answers represents the ratio of growth from the proximal and distal growth plates in a humerus, respectively?
The ratio of growth from the proximal and distal humerus (80:20 respectively) is of very significant importance when treating pediatric fractures involving each area. Due to the enormous remodeling potential from the significant growth remaining at the proximal humerus, most fractures, even when significantly angulated and displaced can be treated non operatively. However, fractures involving the distal humerus are often treated surgically in order to decrease the probability of post traumatic deformity and functional impairment.
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HPI - 2 year old boy, fell off a two wheeler, was brought in by parents with complaints of not moving the right upper limb. No other significant injuries
How would you manage this fracture?
HPI - Fall down on rt abducted rt shoulder while playing football
Where and how would you have performed the closed reduction.
Educational video describing growth distribution in children's long bones.