Proximal Humerus Fracture - Pediatric

Topic updated on 10/16/14 5:09pm
  • Includes both physeal and metaphyseal fractures
  • Epidemiology
    • accounts for < 5% of fractures in children
    • most common in adolescents (peak age at 15 years) due to increase in sports participation
  • Mechanism
    • direct or indirect trauma
      • overuse injury commonly seen in throwers
    • associated with birth trauma in neonates
  • Pathoanatomy
    • displacement pattern is due to deforming forces of muscle attachments
      • rotator cuff musculature produces abduction and external rotation of the proximal fragment
      • pectoralis major and deltoid muscles create adduction and shortening of the distal fragment
    • gravity is used for reduction in attempt to overcome deforming forces
    • distal shaft fragment is often displaced anteriorly through the weaker and thinner periosteum
  • Prognosis
    • excellent secondary to the abundant remodeling potential of the proximal humerus and range of motion of the shoulder joint
  • Three centers of ossification
    • humeral head appears at 6 mos
    • greater tuberosity appears at 3 yrs
    • lesser tuberosity appears at 5 yrs
  • Secondary ossification centers unite together at age 6-7
  • 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) 
  • 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
  • Little Leaguer's shoulder
    • is a SH-I fracture secondary to overuse  
    • radiographs reveal a mild widening of the physis and metaphyseal changes
  • 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
  • Symptoms
    • pain, dysfunction, ecchymosis in older children
  • Physical exam
    • pseudoparalysis in newborns
  • Radiographs
    • obtain AP, lateral, and scapula Y views of shoulder  
      • typically enough to allow evaluation of displacement and to rule out associated glenohumeral dislocation
  • Ultrasound
    • ultrasound may be neccessary in newborns before secondary ossification centers are formed
  • Nonoperative 
    • immobilization   
      • indications
        • any amount of displacement in children 6 and under
        • almost all treated nonoperativley in any age due to remodeling ability and shoulder range of motion
          • excellent functional results expected
      • technique
        • immobilization with a sling, sling and swathe, shoulder immobilizer, or coaptation splint
        • begin gentle glenohumeral ROM exercises in 1-2 weeks when pain is controlled
  • Operative
    • operative reduction
      • indication
        • severly displaced fractures in adolescents 
          • <50% apposition or >45° angulation
          • Neer-Horowitz III-IV 
        • open fractures in any age 
        • fractures associated with vascular injuries
        • intra-articular displacement
      • technique
        • closed reduction
          • performed with the arm in 90° abduction and 90° external rotation
          • blocks to reduction can include
            • long head the biceps tendon
            • joint capsule
            • periosteum
        • percutaneous pinning 
          • two or three lateral pins 
          • starting point must consider branches of axilary nerve 
        • open reduction
          • required if block is present or acceptable reduction is unable to be obtained
        • fracture stabilization
          • stabilized with immobilization, percutaneous pins, screw fixation or retrograde flexible nail fixation
  • Nerve injuries
    • occur in less than 1% of cases
    • typically are neuropraxias
    • associated with a medially displaced shaft
      • close proximity to brachial plexus
    • functional recovery by 9 months without treatment
  • Malunion
    • deformities are well tolerated due to range of shoulder motion
  • Growth arrest
    • rare


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Qbank (3 Questions)

(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? Topic Review Topic
FIGURES: A          

1. Immobilization in a sling and follow-up radiographs
2. Closed reduction and percutaneous pinning
3. Closed reduction and spanning external fixation
4. Closed reduction and intramedullary fixation
5. Open reduction internal fixation with a plate construct

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

1. 80:20
2. 60:40
3. 50:50
4. 40:60
5. 20:80

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