Management of Pediatric Proximal Humerus Fractures

Abstract

Proximal humerus fractures have an outstanding potential to remodel due to their proximity to the proximal humeral physis. Fractures in young children can be treated nonoperatively with excellent outcomes. The incidence peaks in adolescent patients and these injuries most commonly occur after a fall or direct trauma. The muscle attachments of the proximal humerus act as deforming forces and anatomic structures such as the periosteum and biceps tendon may act as blocks to reduction. Operative management is uniformly indicated for patients with open fractures, ipsilateral elbow or forearm injury, associated neurovascular injury, or poly-trauma patients. Operative treatment may be further considered in older children with minimal growth remaining and with fractures that are considered significantly displaced by available classification systems. Unfortunately, there are significant challenges in recommending treatment based on displacement and age alone. The purpose of this paper is to review what is known about these injuries and how they can be treated in light of current deficiencies in the literature; this may stimulate further work to refine indications for treatment based upon age and displacement. Key Concepts•The proximal humerus physis is responsible for 80% of the growth of the entire bone, and proximal humerus fractures have tremendous potential to remodel.•Proximal humerus fractures occur most commonly due to a fall or direct trauma but other causes include overuse injury and pathologic lesions.•Treatment indications for pediatric proximal fractures are guided by age of the patient, fracture displacement, and associated injuries; the majority of these injuries may be treated nonoperatively.•Outcomes after operative and nonoperative management of proximal humerus fractures are generally good.

Figure 1

Deforming forces around the proximal humerus. a) The supraspinatus, infraspinatus, and teres minor insert into and externally rotate the greater tuberosity. b) The subscapularis inserts into the lesser tuberosity and pulls the tuberosity anteromedially. c) The pectoralis major inserts into the intertubercular sulcus and displaces the shaft of the humerus anteromedially. d) The deltoid inserts into the deltoid tuberosity of the humeral shaft and abducts the humerus. Created with BioRender.com.

Figure 2

This two-year-old suffered a right upper extremity injury as a result of nonaccidental trauma. At 2 weeks, she was referred to an orthopaedic practice for management and a nonoperative approach was chosen. Eighteen months later, her fracture remodeled and her function was normal. Case courtesy of Ken Noonan, MD.

Figure 3

This is a 6-year-old girl who sustained a proximal humerus fracture. Despite the displacement, she was treated nonoperatively. At 4.5 months, she had excellent healing and remodeling of the fracture displacement with no pain or residual dysfunction. If the fracture occurred in adolescence, the subsequent length discrepancy is not associated with functional outcomes and is not often apparent.

Figure 4

This is a 14-year-old patient who was injured when his ATV ran into a barn. Operative fixation of all three fractures was performed. Case courtesy of Ken Noonan, MD.

Figure 5

Two adolescent males with proximal humerus fractures treated with closed reduction and sling immobilization in the emergency room with different outcomes likely as a result of patient age at injury. Case courtesy of Ken Noonan, MD.

Figure 6

This 12-year-old girl has soft tissue interposition that may be best managed by reduction. Case courtesy of Ken Noonan, MD.

Figure 7

This 14-year-old female was managed with a hanging arm cast and had reduction of the deformity by 1 week. Surgery was avoided. Case courtesy of Steve Frick, MD.