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Introduction
  • Description
    • a rare physeal and metaphyseal fracture of the proximal humerus 
    • treatment is nearly always nonoperative in younger patients
  • Epidemiology
    • incidence
      • < 5% of fractures in children
    • demographics
      • most common in adolescents (peak age at 15 years), but may occur in younger patients
    • 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
    • pathoanatomy of physeal fractures
      • proximal fragment (epiphysis) displacement
        • abducted and externally rotated due to rotator cuff muscles
      • distal fragment (shaft) displacement
        • anterior, adducted and shortened due to pectoralis major and deltoid muscles
  • Prognosis
    • excellent 
      • abundant remodeling potential of the proximal humerus, particularly in younger patients
      • 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) 
      • Contributes to high remodeling potential 
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 mechanism
  • Symptoms
    • shoulder pain
    • deformity
    • ecchymosis
  • Physical exam
    • inspection of skin
    • motion and tenderness of neck
      • evaluate ipsilateral sternoclavicular joint and elbow
    • neurovascular examination
      • check brachial plexus nerve function
      • perform vascular examination of arm
Imaging
  • Radiographs
    • standard views
      • AP 
      • lateral
      • axillary view (or scapula Y)
    • optional
      • contralateral shoulder for comparison views
      • bone age (rarely required)
    • findings
      • assess maximum angulation of fracture displacement
      • glenohumeral dislocation (very rare with associated fracture)
  • Ultrasound
    • ultrasound may be neccessary in newborns before secondary ossification centers are formed
Differential
  • Little Leaguer's shoulder  
    • an overuse injury in throwers that may demonstrate mild physeal widening and metaphyseal changes
    • not an actual fracture  
  • Pathologic fracture
    • ABC 
    • UBC 
Treatment
  • Nonoperative 
    • immobilization   
      • indications
        • acceptable alignment for non-operative management
          • <10 years old  = any degree of angulation
          • 10-12 years old  = up to 60-75° of angulation
          • >12 years old = up to 45° of angulation or 2/3 displacement
      • technique
        • immobilization modalities
          • sling +/- swathe
          • shoulder immobilizer
          • coaptation splint
  • Operative
    • closed reduction +/- fixation
      • indications
        • unacceptable alignment for non-operative management as described above
    • open reduction internal fixation
      • indications 
        • unable to obtain acceptable reduction due to soft tissue interposition
          • long head of biceps tendon (most common)
          • joint capsule
          • infolded periosteum
          • deltoid muscle
        • open fractures 
        • fractures associated with vascular injuries
        • intra-articular displacement
Techniques
  • Closed reduction ±  fixation
    • reduction maneuver
      • longitudinal traction
      • shoulder abduction to 90 degrees
      • external rotation 
    • fixation options
      • percutaneous pinning
        • two or three lateral threaded pins 
        • starting point must consider branches of axillary nerve (lateral) and musculocutaneous nerve (anterior)
        • ideally separated at fracture
      • retrograde elastic nails
      • Cannulated screws in older patients
  • Open reduction with fixation
    • approach
      • deltopectoral interval
    • fixation methods as above
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 
      • place lateral pin distal to the axillary nerve, which is approximately 5 cm from the acromion in adult patients and propotionally less in smaller patients, or twice the distance from the superior aspect of the humeral head to the inferiormost margin of the humeral head 
  • Malunion
    • severe varus malalignment
      • may cause glenohumeral impingement 
  • Limb-length inequality
    • fracture shortening
      • <3 cm usually well tolerated in patients < 12 years of age
    • growth arrest
      • rare
  • Hypertrophic scar
    • deltopectoral approach with open reduction and fixation
  • Pin site infection
 

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(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%

(3396/4768)

2

Closed reduction and percutaneous pinning

27%

(1289/4768)

3

Closed reduction and spanning external fixation

0%

(6/4768)

4

Closed reduction and intramedullary fixation

1%

(25/4768)

5

Open reduction internal fixation with a plate construct

1%

(38/4768)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

(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%

(1486/1790)

2

60:40

10%

(180/1790)

3

50:50

0%

(4/1790)

4

40:60

3%

(56/1790)

5

20:80

3%

(59/1790)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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