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3. Proximal humerus fractures  Relatively uncommon ( <3% ),most commonly in adolescents  Almost exclusively salter-harris type I or II  In general heal & remodel because : thick periosteom,universal motion,great growth of region ( 80% )

4. Mechanism of injury  Birth fracture  Direct trauma ( outstretched hand )  Direct blow to the lateral aspect of the shoulder  Child abuse  Less common: malignant or benign tumor,pituitary gigantism,joint neuropathy

5. Sign & symptom  Infant : irritable,pseudoparalysis  Older children: pain, swelling,deformity  Displaced fx => epiphysis abd & ext. rot distal fragment ant.medial rot  Undisplaced fx=> arm ininternal rotation

6. Radiographic study  Not useful < 6month  sonography & CT  Comprision xray & vanishing sign  In older children: AP axillary lateral view (difficult) transthorasic axillary view or Y view apical oblique view(AP Xray with 45” caudal tilt)  CT scan (R/O dislocation)  MRI (R/O occult fx)  Bone scan( R/O occult fx but difficult to interpret )

7. Classification  Salter- harris : type I : infants & small children type II: adolescent type III & IV : rare because universal motion or combind with dislocation  Neer-Horwitz: grade I: < 5 mm displacement grade II: 5mm to 1/3 diameter of shaft grade III: 1/3 to 2/3 diameter grade IV: more  Stress fx of metaphysis or slipped epiphysis due to chronic or repetitive trauma such as throwing,gymnastic, localised radiation therapy

8. treatment  Nearly all proximal humeral fx can be traeted nonoperatively regardless age & grade  Grade I & II: treated symptomaticlly without attempt at reduction  Grade III & IV: controversial - all agree <6month treated symptomatically -closed reduction (traction  abduction  forward flextion  external rotation (under fluoroscopic guidance )  imobilization 2 to 3 weeks occasionally reduction is lost or we cannot obtain adequate closed reduction  existing deformity is accepted & managed symptomatically ( family reassurance )

9. Operative treatment:  -intraarticular fx -open fx -neurovascular injury -polytraumatised patient

10. Complication of proximal humerus fx  Rare 1- shortening (not important): more after surgury or pathologic fx UBC 2-varus –valgus deformity 3-AVN 4-brachial & axillary nerve injury(typically transient & return in 3month EMG ) 5-brachial artery disruption 6- hypertrophic scarring ( after deltopectoral aproach  axillary or ant.axillary incision better )

11. Little league shoulder  Also called proximal humeral epiphysiolysis, osteochondrosis or traction apophysitis  Is overuse injury most commonly in pitchers & occasionally other overhead athletes.  Nonspecific shoulderpain,often at beginningof the season or after a significant change in training protocol  Tendernes along P.H physis,painful or limited ROM  Due to rotary torque  Xray : normal or widening Of PHP /stress fx my be present with methaphyseal lucency & periosteal new bon formation  Almost always respond to rest

12. Clavicle  The first bone to ossify & the last physis to closed (medial )often not untile the 3 rd decade  Clavicle fx is 8% to 15% of all pediatric fx  Most fx in middle third (76% to 85%)

13. Mechanisem of fx  Newborn  during delivery  Children & adolescents  1-fall on outstretched hand or side of shoulder 2-direct blow ( most the lateral end fx )

14. Sign & symptom  Newborn infants: -pseudoparalysis (mistakan for brachial plexsus inj.) -head turn toward fx ( to reduce pull of SCM) -asymetric moro reflex -edema  Older children: -pain,tenderness,ecchymosis,edema,deformity,decreas motion,turninig head (attention to atlantoaxial subluxation)

15. Radiographic evaluation  Xray : -AP -serendipity view (40 degree cephalic tilt) for medial clavicle injuy -stress view : for lateral end  CT scan :evaluation of medial clavicl inj. Or lateral  Sonography : dislocation of medial end in new born

16. Classification of clavicle fx  Type I : middele part (lateral to SCM,medial to coracoclavicular lig.)  Type II : distal end ( lateral to CC lig.)  Type III : medial end (medial to SCM)

17. Type II

18. Type III  Epiphysis of medial supported with SC lig. & capsul  physis unprotected  trauma in children typically result in fx trough physis rather than dx of SCj in adult (salter fx type I or II)  This type classified : 1- ant (more frequent) 2- post (more serious)

19. Treatment  Neonate: asymptomatic: benign neglected symptomatic: sling & swatch 1-2weeks  Children & adolescents: midshaft fx :- rarely need to reduction -bump of callus remodel within 6- 9month - comfortable 8 bandag or sling 1 to 4 (bandag not immobilize fx, comfort patient by holding shoulder back) -reduction only skin in jeopardy - open reduction: neurovasculr jnj. or open inj. that is unstable following irrigation & debridment

20. treatment of Medial physeal separation  Because a significant remodeling  conservative treatment is the rule  If significant cosmatic deformity,may attempt a closed reduction & often this inj. Are quiet stable after reduction, if lost we accept it  If posterior displacement is with airway, esophgeal or neurovascular impingment  closed reduction or open reduction

21. Treatment of lateral end  All type I,II,III can manag be managed symptomticlly ( sling & harness)  Type IV,V,VI usually requier open reduction,often by repairing the periosteal sleeve,( avoiding percutanous pins)

22. Scapula fracture  Scapular body fx are often comminuted with multi direction line  Infra spinatus portion is more more frequntly fx  Abundant muscle  prevent displacement  Scapular neck fx:if C.Clig & clavicle intact  displacement is minimal /// If this lig. Torn or if fx is lateral to coracoid process  articular fragment displaced downward & inward bythe weight of limb

23. Mechanism of scapular fx  Most commonly direct trauma  High energy trauma  result in significant injury to adjacent structres DIAGNOSIS:  often delayed or missed  Shuold be considered in upper thorasic or arm trauma  True AP xray is necessary  CTscan is helpfull

24. Treatment  Vast majority of scapular fx managed conservatively, directed toward patient comfort ( sling,sling&swath,shoulder immobilizer)  Open reduction : 1- significantly displaced intra-articular fx 2-glenoid rim fx associated with subluxation of humeral head 3-unstabl fx through scapular neck including ipsilateral fx of neck & clavicle////displaced fx involving both the scapular spine & neck

25. Fracture of proximal metaphysis & shaft of humerus  More common inchildren than adolescents  Less common in children than adult,but as in adults,are frequently associated with radial nerve injury  Are the second most common birth fracture  61% of all new fx in child abuse

26. Mechanism of fx  Proximal metaphysis: -usually high-energy direct trauma - minimal trauma  suspicion of pathologic fx (UBC & other benign tumor)  Shaft: -most direct force : like fall on the side of arm (usually transvers or comminuted) -indirect force : fall on outstretched hand (oblique or spiral fx)

27. diagnosis  Obvious deformity,localized swelling,pain  clinical diagnosis straightforward classification Location: proximal,middle,distal Patteren:spiral,short oblique,transverse Anatomically:proximal to the pectoralis major,between it & deltoid,below deltoid insertion Ao –ASIF:interobserver variability

28. Treatment  Infants with obstetric fx : imoblization 1-3 weeks /// effort to control aligment are not necessary (remodelling potential is great)/// follow-up only for brachial plexus  Proximal humral fx :remodeling potential is great  these fx rarely require more than symptomatic treatment (sling) - occasionally percutaneous fixation (polytraumatized patient or open fx)

29. Treatment  Humeral shaft: -generally managed with closed technique -initially placed in a coaption splint 2-3weeks then managed in sling or hanging arm cast -end to end aligment not necessary (overriding 1 to 1.5 cm can be easily accepted) -angulation more than 15-20 degree in either plan is not desirable -rotational aligment should be maintain -clinical appearance is more important than radiographic alligment -open reduction: polytraumatised patient or open fx