Proximal Humeral Fracture in Children ยงยส จีระธัญญาสกุล รพ.วชิระภูเก็ต

Developmental Anatomy Ossification 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

Clavicle Fracture most common fx in children 50% in <10 yo usually midshaft almost always heals, usually clinically insignificant malunion remodels within 1 year complications very uncommon

Clavicle Fracture Patterns most in middle 5% distal < 5% medial greenstick common beware nutrient foramen- not a fx

Clavicle Birth Fracture large baby pseudoparalysis simple immobilization if no BP palsy active movement should return early

Congenital Pseudarthrosis of the Clavicle right side except with dextrocardia if symptomatic in older child – excise, tricortical graft, fixation

Distal Clavicle Fracture often intact periosteum usually remodels nonoperative tx

Distal Clavicle Fractures- Classification similar to adults based on amount & direction of displacement

Distal Clavicle Injuries Periosteal Sleeve

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

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

Scapula Fractures - Classification can have fracture through common growth center of coracoid and glenoid

Scapula Fractures - Classification body neck glenoid acromion coracoid intraarticular / extrarticular

Glenohumeral Dislocations rare in children < 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

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

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

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

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

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

shape of the physis is conical, with the apex pointing postermedial medial metaphysis is intra-articular fractures of the proximal humerus < 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

Proximal Humeral Physeal Fractures Neer – Horowitz Classification grade I < 5 mm grade II < 1/3 shaft width grade III < 2/3 shaft width grade IV > 2/3 shaft width

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

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

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 (> Neer II) in older adolescents, recurrent displacement

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

J Bone Joint Surg Am. 1969;51:289-297. THOMAS B. DAMERON, JR. and DONALD B. REIBEL

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

Early Healing Noted 3 Weeks after Closed Reduction in Adolescent initial film 3 weeks after closed reduction

Metaphyseal Fracture

Remodeling over 6 Months

Pinning Proximal Humerus usually don’t 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

Percutaneous Pinning may lead to pin migration

Pinning bend pins to prevent migration threaded tips

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

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 >12 yrs - treatment like adults

Birth Fractures simple immobilization pseudoparalysis little attention to realignment or reduction needed

Pathologic Humeral Fracture - UBC fallen leaf sign & also pseudosubluxation inferiorly

Humeral Shaft Fractures- Treatment usually closed methods sling and swathe coaptation splint fracture bracing hanging arm cast

Shoulder Immobilization- Coaptation Splint

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

Indications for Open Reduction Shoulder Region Fractures open fractures displaced intraarticular fractures multiple trauma to facilitate rehabilitation severe displacement with suspected soft tissue interposition

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