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Introduction
  • Physeal and metaphyseal proximal humerus fractures
  • Epidemiology
    • incidence
      • < 5% of fractures in children
    • demographics
      • most common in adolescents (peak age at 15 years)
    • fracture pattern
      • Salter-Harris classification 
        • SH-I is most frequent in <5 year olds
        • SH-II is most frequent in >12 year olds
      • Metaphyseal fractures
        • typically occur in 5 to 12 year olds
  • Pathophysiology
    • mechanism of injury
      • blunt trauma
      • indirect trauma
        • overuse injury in throwers (Little Leaguer's shoulder)
          • SH-I fracture secondary to overuse  
            • mild widening of the physis and metaphyseal changes
    • pathoanatomy
      • displacement pattern 
        • proximal fragment (epiphysis)
          • position
            • abducted and externally rotated 
          • forces
            • pull from rotator cuff muscles
        • distal fragment (shaft)
          • position
            • anterior, adducted and shortened 
          • forces
            • pull from pectoralis major and deltoid muscle
  • Prognosis
    • excellent 
      • abundant remodeling potential of the proximal humerus 
      • due to range of motion of the shoulder joint
Anatomy
  • Osseous sturctures
    • Three primary centers of ossification
      • humeral head appears at 6 mos
      • greater tuberosity appears at 3 yrs
      • lesser tuberosity appears at 5 yrs
  • Growth 
    • Proximal humerus physis closes at 14-17 in girls, 16-18 in boys
      • 80% of humerus growth comes from the proximal physis
        • highest proximal:distal ratio difference (femur is second with 30:70 proximal:distal ratio) 
Classification
  • Neer-Horowitz Classification
Neer-Horowitz Classification
Type I  • Minimally displaced (<5m)
 
Type II  • Displaced < 1/3 of shaft width

Type III  • Displaced greater than 1/3 and less than 2/3 of shaft width
Type IV  • Displaced greater than 2/3 of shaft width
 
Presentation
  • History
    • identify any precipitating injury
  • Symptoms
    • shoulder pain
    • dysfunction
    • deformity
    • ecchymosis
  • Physical exam
    • inspection of skin
    • motion and tenderness of neck, ipsilateral sternoclavicular joint and elbow
    • neurovascular examination
      • brachial plexus distribution
      • vascular examination of arm
Imaging
  • Radiographs
    • standard views
      • obtain AP, lateral, and scapula Y or axillary views of shoulder  
    • as needed views
      • hand or elbow for bone age
      • contralateral shoulder for comparison views
    • findings
      • stress fractures in athletes
      • glenohumeral dislocation (very rare with associated fracture)
      • assess maximum angulation of fracture displacement
      • identify pathologic fracture if present
  • Classify fracture type: newborn, acute fracture, stress fracture, pathologic fracture
  • Ultrasound
    • ultrasound may be neccessary in newborns before secondary ossification centers are formed
Treatment
  • Nonoperative 
    • immobilization   
      • indications
        • acceptable alignment for non-operative management
          • <10 y/o = any degree of angulation
          • 10-13 y/o = up to 60 degrees of angulation
          • >13 = up to 45 degrees of angulation and 2/3 displacement
      • technique
        • immobilization modalities
          • sling +/- swathe
          • shoulder immobilizer
          • coaptation splint
        • closed reduction is an option for fractures with unacceptable alignment.  Identify if unstable after closed reduction.  Warn family of risk for reduction loss.
  • Operative
    • operative reduction and fracture fixation
      • indications
        • severely displaced fractures > 13 years old
          • Neer-Horowitz III-IV 
            • >66% displaced 
        • severely angulated fractures in > 9 year old
        • open fractures in any age 
        • fractures associated with vascular injuries
        • intra-articular displacement
      • techniques
        • closed reduction +/- k-wire fixation
          • reduction maneuver
            • longitudinal traction
            • shoulder abduction to 90 degrees
            • external rotation 
          • percutaneous pinning 
            • two or three lateral threaded pins 
            • starting point must consider branches of axilary nerve (lateral) and musculocutaneous nerve (anterior)
            • ideally divergent pattern across fracture
        • open reduction +/- k-wire fixation
          • indications
            • unacceptable closed reduction maneuver
            • blocks to reduction
              • long head the biceps tendon (most common)
              • joint capsule
              • periosteum
              • deltoid muscle
          • approach
            • deltopectoral interval
          • fixation methods
            • wire fixation (smooth or threaded)
            • cannulated screw
            • retrograde flexible nails
Complications
  • Loss of reduction
    • risk factors
      • unstable fractures treated with closed reduction WITHOUT pinning  
  • Axillary nerve Injuries
    • occur in less than 1% of case due to injury alone
      • typically are neuropraxias
      • associated with a medially displaced shaft
    • higher risk with percutaneous pinning 
      • avoid lateral pin entry 5-7cm distal to acromion
  • Malunion
    • varus malalignment, more common in younger patients 
      • may cause glenohumeral impingement 
  • Limb-length inequality
    • fracture shortening
      • <3cm usually well tolerated
    • growth arrest
      • usually rare
  • Hypertrophic scar
    • deltopectoral approach with open reduction and fixation
  • Pin site infection
 

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Questions (2)

(OBQ10.186) 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? Review Topic

QID:3279
FIGURES:
1

Immobilization in a sling and follow-up radiographs

71%

(2553/3571)

2

Closed reduction and percutaneous pinning

27%

(970/3571)

3

Closed reduction and spanning external fixation

0%

(5/3571)

4

Closed reduction and intramedullary fixation

0%

(17/3571)

5

Open reduction internal fixation with a plate construct

1%

(20/3571)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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.

ILLUSTRATIONS:

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Question COMMENTS (15)

(OBQ10.198) Which of the following answers represents the ratio of growth from the proximal and distal growth plates in a humerus, respectively? Review Topic

QID:3291
1

80:20

83%

(1248/1498)

2

60:40

10%

(147/1498)

3

50:50

0%

(4/1498)

4

40:60

3%

(48/1498)

5

20:80

3%

(50/1498)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

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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Question COMMENTS (2)
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