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Updated: Mar 7 2024

Humeral Shaft Fracture - Pediatric

Images humerus fracture (2).jpg shot 2012-07-27 at 8.34.27 am.jpg shot 2012-07-27 at 11.56.50 am.jpg
  • summary
    • Humeral Shaft Fractures in the pediatric population are usually traumatic in nature, although nonaccidental trauma and pathologic lesions can not be overlooked.
    • Diagnosis is made with plain radiographs. 
    • Treatment is almost always immobilization due to the high remodeling potential of the pediatric humerus.
  • Epidemiology
    • Incidence
      • represent <10% of humerus fractures in children
  • Etiology
    • Pathophysiology
      • mechanism of injury
        • typically associated with trauma
      • pathomechanics
        • neonates
          • hyper-extension or rotational injury during birth
        • adolescents
          • usually direct trauma
      • pathophysiology
        • consider a pathologic process if fracture is a result of a low energy mechanism
        • may be associated with child abuse if age <3 and fracture pattern is spiral
    • Associated conditions
      • radial nerve palsy
        • associated with up to 5% of humeral shaft fractures
  • Presentation
    • History
      • history of traumatic event
    • Symptoms
      • pain
      • arm deformity
    • Physical exam
      • inspection
        • mid-arm swelling and deformity
        • open fractures are rare
      • palpation
        • tenderness to palpation
      • motion
        • weakness or absence of wrist and digit extension if radial nerve palsy is present
        • pseudoparalysis
          • irritability or refusal to move upper limb in neonates
            • reflexes remain intact
  • Imaging
    • Radiographs
      • recommended views
        • full length AP and lateral views of humerus
      • optional views
        • orthogonal views of shoulder and elbow
          • required to rule out associated injuries
      • findings
        • typical fracture patterns are transverse and oblique
        • examine closely for pathologic lesions
  • Treatment
    • Nonoperative
      • immobilization in splint or brace
        • indications
          • utilized for almost all pediatric humeral shaft fractures (if not pathologic) due to remodeling potential
          • acceptable alignment
            • younger children
              • < 35-45 deg angulation
            • older children
              • < 20 deg varus/valgus
              • < 20 deg procurvatum
              • <15 deg rotation malalignment
              • < 2cm shortening
        • techniques
          • sling and swathe or cuff and collar in young children
          • Coaptation splint or hanging arm cast
          • Sarmiento functional brace in older children/adolescents
          • ROM exercises can be initiated in 2-3 weeks once pain is controlled
    • Operative
      • open reduction internal fixation
        • indications
          • open fractures
          • multiply injured patient
          • ipsilateral forearm fractures
            • "floating elbow"
          • associated shoulder injury
          • unacceptable alignment
        • techniques
          • flexible intramedullary nail fixation
          • anterior, anterolateral or posterior approach with 3.5mm or 4.5mm plate fixation
  • Complications
    • Radial nerve palsy
      • occurs in <5%
        • most commonly associated with middle and distal 1/3 fractures
      • typically due to a neuropraxia
      • spontaneous resolution is expected
      • exploration is rarely needed
        • if function has not returned in 3-4 months, EMGs are performed and exploration considered
    • Malunion
      • rarely produces functional deficits, due to the wide range of motion at the shoulder
        • up to 20-30° of angulation is associated with excellent outcomes
    • Delayed union
      • rare
      • may consider ultrasound bone stimulation
    • Limb length discrepancy
      • commonly occurs, but rarely causes functional deficits
    • Physeal growth arrest
      • proximal and distal humerus growth plates contributes 80:20 percent to overall humeral length
  • Prognosis
    • Excellent
      • associated with enormous remodeling potential and rarely requires surgical intervention
      • up to 20° of angulation is associated with excellent outcomes due to the large range of motion of the shoulder
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