Proximal Humeral Fracture in Children

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Proximal Humeral Fracturein Children

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Developmental AnatomyOssification Centers
Physes

• scapular ossification centers acromion,
  coracoid, glenoid, medial border
• proximal humeral physis tent shaped, 80 of
  longitudinal growth
• medial clavicular physis last to close 23-25 yrs

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Clavicle Fracture

• most common fx in children
• 50 in lt10 yo
• usually midshaft
• almost always heals, usually clinically
  insignificant malunion
• remodels within 1 year
• complications very uncommon

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Clavicle Fracture Patterns

• most in middle
• 5 distal
• lt 5 medial
• greenstick common
• beware nutrient foramen- not a fx

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Clavicle Birth Fracture

• large baby
• pseudoparalysis
• simple immobilization
• if no BP palsy active movement should return
  early

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Congenital Pseudarthrosis of the Clavicle

• right side
• except with dextrocardia
• if symptomatic in older child excise,
  tricortical graft, fixation

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Distal Clavicle Fracture

• often intact periosteum
• usually remodels
• nonoperative tx

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Distal Clavicle Fractures- Classification

• similar to adults
• based on amount direction of displacement

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Distal Clavicle Injuries Periosteal Sleeve
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Medial Clavicular Injuries

• medial clavicular physis last to close 22-24 yo
• clavicle shaft usually anterior
• may displace posteriorly
• serendipity view or CT if suspect

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Scapula Fractures

• may be a sign of significant trauma
• usually nonoperative treatment
• growth centers may be confused with fracture
• axillary view often helpful

coracoid base fracture
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Scapula Fractures - Classification

• can have fracture through common growth center of
  coracoid and glenoid

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Scapula Fractures - Classification

• body
• neck
• glenoid
• acromion
• coracoid
• intraarticular / extrarticular

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Glenohumeral Dislocations

• rare in children lt 12 years old
• high risk of recurrent instability when initial
  dislocation occurs in childhood or adolescence
• anterior, Posterior or Inferior direction
• traumatic or atraumatic etiology

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Glenoid Dysplasia

• may predispose to instability
• may be primary or secondary (after brachial
  plexus palsy)

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Traumatic Shoulder Dislocation

• gentle reduction
• immobilization for approx 3 weeks
• shoulder rehabilitation
• surgical stabilization /reconstruction reserved
  for recurrent instability

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Atraumatic Instability

• often multiple joint ligamentous laxity
• multidirectional instability usually present
• may be voluntary (discourage)
• rotator cuff strengthening

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Proximal Humeral Fracture

• birth injuries
• 0-5 yo SH I
• 5-11 yo metaphyseal
• 11-maturity SH II
• others rare (III, IV)

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• proximal humeral epiphysis does not ossify until
  about age 6 months
• fusion occurs at about age 15 in girls and 17 in
  boys.

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• shape of the physis is conical, with the apex
  pointing postermedial
• medial metaphysis is intra-articular
• fractures of the proximal humerus lt 5 of
  children's fractures
• birth injuries are transphyseal, with the
  proximal humeral epiphysis not yet ossified at
  birth, the malalignment of the shaft to the
  glenoid is the only radiographic finding

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Proximal Humeral Physeal Fractures Neer
Horowitz Classification

• grade I lt 5 mm
• grade II lt 1/3 shaft width
• grade III lt 2/3 shaft width
• grade IV gt 2/3 shaft width

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• pull of rotator cuff subscapularis on proximal
  fragment leave it abducted, flexed, and
  externally rotated
• pectoralis major pulls the distal fragment into
  adduction
• Dameron's acceptable reduction recommendation of
  20 degrees in the older child is often quoted
• nonoperative treatment is favored for all
  fractures

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• remodeling potential of proximal humerus is
  perhaps the most impressive in the body
  mobility of shoulder surely compensates for
  residual deformity at skeletal maturity
• treatment options
• manipulation and immobilization in sling
  swathe
• closed reduction and percutaneous pinning
• open reduction
• no reduction using simply symptomatic
  immobilization with arm in sling swathe

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Treatment

• closed treatment for vast majority
• if markedly displaced, attempt closed reduction
  and immobilize
• reserve closed reduction and pinning, open
  reduction for fractures with significant
  displacement (gt Neer II) in older adolescents,
  recurrent displacement

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• reduction with traction, abduction, and flexion
  has been described, but with the generous
  remodeling potential of this site, good results
  are uniform
• proximal humeral fractures primarily are seen in
  infancy and adolescents
• fractures prior to adolescence are more often
  metaphyseal
• in adolescent, primarily physeal injuries, the
  vast majority Type II

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J Bone Joint Surg Am. 196951289-297. THOMAS B.
DAMERON, JR. and DONALD B. REIBEL
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Proximal Humerus Acceptable Alignment

• great remodeling potential 80 of humeral
  length contributed by proximal physis
• shoulder ROM compensatory
• age dependent? some studies state that even
  older adolescents have acceptable functional
  outcomes after nonoperative treatment of prox
  humerus fxs

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Early Healing Noted 3 Weeks after Closed
Reduction in Adolescent
3 weeks after closed reduction
initial film
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Metaphyseal Fracture
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Remodeling over 6 Months
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Pinning Proximal Humerus

• usually dont need to
• most recent studies quote high complication rates
  (pin migration, infection)
• if used leave pins long and bend outside skin,
  consider threaded tip pins
• even in older adolescents remodeling occurs
• few functional deficits

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Percutaneous Pinningmay lead to pin migration
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Pinning

• bend pins to prevent migration
• threaded tips

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Complications of Proximal Humerus Fractures

• malunion with loss of shoulder ROM rarely
  functionally significant
• shortening up to 3 -4 cm seemingly well
  tolerated
• neurologic vascular compromise less common than
  in adults

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Humeral Shaft Fractures in Children

• neonates - birth trauma
• birth- 3 yrs - consider possible non-accidental
  trauma
• 3-12 yrs - often pathologic fracture through
  benign bone tumor or cyst
• gt12 yrs - treatment like adults

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Birth Fractures

• simple immobilization
• pseudoparalysis
• little attention to realignment or reduction
  needed

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Pathologic Humeral Fracture - UBC
fallen leaf sign also pseudosubluxation
inferiorly
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Humeral Shaft Fractures- Treatment

• usually closed methods
• sling and swathe
• coaptation splint
• fracture bracing
• hanging arm cast

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Shoulder Immobilization- Coaptation Splint
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Humeral Shaft Outcomes

• malunion common, but usually little functional
  loss
• remodels well
• initial fx shortening may be compensated for by
  later overgrowth
• nonunion uncommon
• radial nerve palsy less common, if occurs usually
  neuropraxia

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Indications for Open ReductionShoulder Region
Fractures

• open fractures
• displaced intraarticular fractures
• multiple trauma to facilitate rehabilitation
• severe displacement with suspected soft tissue
  interposition

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