1. Proximal Humeral Fracture in Children
ยงยส จีระธัญญาสกุล
รพ.วชิระภูเก็ต

2. 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 yrs

3. 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

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

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

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

7. Distal Clavicle Fracture
often intact periosteum
usually remodels
nonoperative tx

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

9. Distal Clavicle Injuries Periosteal Sleeve

10. Medial Clavicular Injuries
medial clavicular physis last to close – yo
clavicle shaft usually anterior
may displace posteriorly
serendipity view or CT if suspect

11. 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

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

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

14. 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

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

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

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

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

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

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

27. 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

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

29. Metaphyseal Fracture

30. Remodeling over 6 Months

31. 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

32. Percutaneous Pinning may lead to pin migration

33. Pinning
bend pins to prevent migration
threaded tips

34. 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

35. 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

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

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

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

39. Shoulder Immobilization- Coaptation Splint

40. 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

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

42. Thank You