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Introduction
  • Plastic deformation and greenstick fractures of the humeral shaft are rare
  • Epidemiology
    • incidence
      • represent <10% of humerus fractures in children
  • Pathophysiology
    • mechanism of injury
      • typically associated with trauma
    • pathomechanics
      • neonates
        • hyper-extension or rotational injury during birth
      • adolescents
        • usually direct, high-energy 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
  • Prognosis
    • excellent 
      • associated with enormous remodeling potential and rarely requires surgical intervention  
      • up to 30° of angulation is associated with excellent outcomes due to the large range of motion of the shoulder 
Presentation
  • Symptoms
    • history of traumatic event
    • pain
    • upper arm deformity
  • Physical exam
    • inspection
      • mid-arm swelling and deformity
      • open fractures 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 
Imaging
  • Radiographs
    • recommended views
    • 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
    • analgesia, immobilization
      • indications
        • uncomplicated diaphyseal fracture without intra-articular involvement in a child of any age
        • utilized for almost all pediatric humeral shaft fractures
      • 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
      • techniques
        • flexible intramedullary nail fixation 
        • anterior, anterolateral or posterior approach with 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 30° of angulation is associated with excellent outcomes 
  • Delayed union
    • rare given the capacity to remodel
    • 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  
 

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