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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) who get SH-II fractures
    • 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) is NOT a fracture
          • SH-I fracture secondary to overuse  
            • mild widening of the physis and metaphyseal changes
    • pathoanatomy
      • proximal fragment (epiphysis) displacement
        • abducted and externally rotated because of pull from rotator cuff muscles
      • distal fragment (shaft) displacement
        • anterior, adducted and shortened because of 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
  • Radiographic appearance of secondary ossification centers
    • proximal humeral epiphysis at 6 mos
    • greater tuberosity appears at 1-3 yrs
    • lesser tuberosity appears at 4-5 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) 
        • high remodeling potential (most fractures can be treated nonoperatively)
Classification
  • Neer-Horowitz Classification
Neer-Horowitz Classification
Type I  • Minimally displaced (<5mm)
 
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
          • <10y = any degree of angulation
          • 10-13y = up to 60° of angulation
          • >13y = up to 45° of angulation and 2/3 displacement
      • technique
        • immobilization modalities
          • sling + swathe
          • shoulder immobilizer
          • coaptation splint
    • closed reduction under anesthesia/analgesia and fluoroscopy, without fixation
      • indications
        • severely displaced (>Neer-Horowitz III or >66%) with >45° angulation and <2y of growth left
      • risk of loss of reduction
  • Operative
    • open reduction and fracture fixation
      • indications
        • severely displaced fractures > 13 years old failed closed reduction
          • >Neer-Horowitz III (>66% displaced) 
        • severely angulated fractures in > 9 year old failed closed reduction
        • 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 axillary 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 of biceps tendon (most common)
              • joint capsule
              • infolded 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 <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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