Review Article
Evaluation and Management of Pediatric Proximal Humerus Fractures Abstract Charles A. Popkin, MD William N. Levine, MD Christopher S. Ahmad, MD
In the pediatric population, sports participation, falls, and motor vehicle accidents can result in proximal humerus fractures. Because the proximal humeral growth plate is responsible for up to 80% of the growth of the humerus, the remodeling of these fractures in children is tremendous. Most of these injuries can be treated with a sling or hanging arm cast, although older children with decreased remodeling capacity may require surgery. Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuerosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts. Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent.
P From the Center for the Developing Athlete, Columbia University Medical Center, New York, NY. Dr. Levine or an immediate family member serves as an unpaid consultant to Zimmer and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery and the American Orthopaedic Association. Dr. Ahmad or an immediate family member serves as a paid consultant to Arthrex and has received research or institutional support from Arthrex, Major League Baseball, and Stryker. Neither Dr. Popkin nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2015;23: 77-86 http://dx.doi.org/10.5435/ JAAOS-D-14-00033 Copyright 2015 by the American Academy of Orthopaedic Surgeons.
roximal humerus fracture patterns vary based on the mechanism of injury and the patient’s age at the time of the injury. Pediatric proximal humerus fractures are not common. Studies estimate that these fractures constitute approximately 2%1,2 of all pediatric fractures and 3% to 6.7% of all physeal fractures.3,4 Pediatric proximal humerus fractures are also associated with both aneurysmal and unicameral bone cysts and as a complication of radiation therapy for malignant tumors involving the proximal humerus.
Anatomy The secondary ossification center for the humeral head usually appears by age 4 to 6 months and may be present in up to 20% of newborns.5 The ossification centers for the greater and lesser tuberosities develop by ages 3 and 5 years, respectively.3,6 The tuberosities then fuse at age 5 to 6 years. The three secondary ossification
centers (humeral head, greater tuberosity, and lesser tuberosity) combine before age 6 years to form the epiphysis of the proximal humerus.3,6 The proximal humeral physis is responsible for approximately 80% of the longitudinal growth of the humerus.2,7-9 This high activity level explains the tremendous remodeling of proximal humerus fractures in the pediatric population. The younger the patient, the higher the potential for remodeling. Final union between the humeral head and the shaft occurs from age 16 to 19 years, when the proximal humeral growth plate closes. In children younger than age 5 years, the proximal humeral physis has a transverse shape similar to a hockey puck. As the child ages, the shape of the physis becomes more conical. The vascular supply to the proximal humerus is derived from the axillary artery. The anterior and posterior circumflex arteries branch off the axillary artery before it becomes the brachial artery. The
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Evaluation and Management of Pediatric Proximal Humerus Fractures
traditional teaching is that the arcuate artery, which comes off the ascending branch of the anterior circumflex artery, is the dominant artery. However, recent studies have called this into question. Hettrich et al10 used gadoliniumenhanced MRI to quantitatively assess the vascularity of the proximal humerus and demonstrated that the posterior circumflex humeral artery may be more dominant than previously thought. Additional work has also suggested that there may be strong anastomoses between the anterior and posterior circumflex vessels.11 The close proximity of the axillary nerve to the proximal humerus makes it vulnerable to injury after a fracture, fracture-dislocation, or percutaneous pinning of the proximal humerus. The axillary nerve is a branch of the posterior cord of the brachial plexus. It enters the quadrangular space along with the posterior circumflex artery and divides into anterior and posterior branches. These branches supply innervation to the deltoid muscle and teres minor muscle and sensation to the lateral shoulder. An anatomic study on percutaneous pinning of proximal humerus fractures found that proximal lateral pins can be as close as 3 mm to the anterior branch of the axillary nerve.12 To avoid injury, the authors recommend that the starting point for the proximal lateral pin should be at or distal to a point twice the distance from the top to the inferior most margin of the humeral head.12 The glenohumeral joint capsule covers the articular surface of the proximal humerus, including most of the medial epiphysis and the proximal, posteromedial part of the humeral metaphysis (intra-articular structures). A large part of the proximal humeral growth plate is an extracapsular structure. The capsular attachment provides a strong connection to the proximal posteromedial segment of
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the metaphyseal humerus. Interestingly, the posteromedial periosteum is stronger and thicker than the periosteum covering the anterolateral proximal humerus. The strong posteromedial capsular attachment and the difference in periosteal thickness help to explain why the metaphyseal fragment can become incarcerated within the anterolateral periosteum while the posteromedial part of the metaphysis remains with the proximal fragment.13 It also explains why the apex anterior angulation is the most frequent proximal humerus fracture angulation because the fracture hinges on the intact thickened posterior periosteum. Numerous muscles insert onto the proximal humerus and can influence the direction of fracture fragment displacement. The muscles of the rotator cuff are grossly evident at 13 to 14 weeks of gestation, and the shoulder joint and surrounding tissues resemble that of an adult shoulder by the time of birth.14 The four rotator cuff muscles insert onto the epiphysis, the pectoralis major muscle inserts onto the anteromedial humeral metaphysis, and the deltoid muscle inserts onto the lateral humerus.3 The rotator cuff muscles are all attached to the proximal fragment when a proximal humerus fracture occurs (ie, metaphyseal fracture proximal to the insertion of the pectoralis and Salter-Harris type I, II, and III fractures). The subscapularis muscle largely cancels the rotational forces of the teres minor and infraspinatus (external rotators).3 The humeral shaft is pulled anteriorly and adducted from the pectoralis major muscle (Figure 1). The deltoid muscle is attached to the distal fragment (shaft) and pulls it proximally. For most fractures involving the pediatric proximal humerus, the fracture line passes through the zone of provisional calcification, a part of the zone of hypertrophy in the
growth plate. The fracture may traverse several zones of the growth plate. The fractures often spare the proliferative zone and the cells responsible for bone growth.3
Mechanism of Injury A fracture that occurs in the first week of life with no known postnatal trauma is considered a birth fracture.15 During the descent down the birth canal, the infant’s arm can be placed in a variety of compromised positions that can result in a physeal fracture of the proximal humerus.16 However, fractures of the clavicle are much more common during delivery than are fractures of the proximal humerus.17 Vaginal deliveries, breech presentation, prolonged labor, and macrosomia (.4.5 kg)15 are risk factors for a birth fracture.18,19 It is important to mention that prenatal size is not always an accurate predictor of a birth fracture because fractures can occur in infants of normal or low birth weight, as well. Birth fractures of the proximal humerus are classic physeal separations or Salter-Harris type I injuries (Figure 2). Reports of SalterHarris type II fractures are rare but are likely underreported because, in many infants, the proximal humerus is not yet ossified.18 In most pediatric and adolescent age groups, boys are three to four times more likely than girls to sustain a proximal humerus fracture.20 Two classic traumatic mechanisms are thought to be responsible for this injury in children and adolescents. The first is direct trauma from either a fall directly onto the shoulder or a blunt force or strike. The blow is typically to the posterior shoulder3 and results in an injury to the metaphysis, physis, and/or epiphysis. The second mechanism is an indirect fall onto an outstretched hand, with the arm abducted and externally rotated.21
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Fractures of the proximal humerus are typically the result of moderateenergy trauma associated with motor vehicle crashes or sports participation. Hockey, football, horseback riding,22 and gymnastics are sports thought to put participants at a higher risk for proximal humerus fracture. Overuse injuries associated with repetitive throwing in baseball are a special subsection of pediatric proximal humerus fractures that deserves mention. Little League shoulder (LLS) is a fracture of the proximal humeral growth plate that occurs from overthrowing in baseball players aged 11 to 14 years. Avulsion fracture of the lesser tuberosity is typically seen in throwing athletes aged 12 to 15 years and in fly fishermen; it is a result of repetitive microtrauma that causes an incomplete traction injury to the lesser tuberosity.23,24 A proximal humerus fracture in a child younger than 2 years should raise concern for child abuse as a possible etiology.21 Unlike fractures in other locations of the body, there are no classic radiographic findings on imaging of the shoulder that are suggestive of child abuse. Loder and Bookout25 reported that fractures involving the humerus may be the second most common long bone injury associated with child abuse. However, the incidence of proximal humerus fractures associated with child abuse remains unknown.
Clinical Features In the neonate, diagnosis of a proximal humerus fracture can be challenging. The findings can range from subtle irritability with certain arm movements to a more pronounced refusal to move the arm. The term for the inability of the infant to move the fractured arm is called pseudoparalysis. The differential diagnosis for
Figure 1
Illustration of the proximal humerus demonstrating the deforming forces that act on a fracture to produce a Salter-Harris type II fracture pattern.
a birth fracture of the proximal humerus includes brachial plexus injury, clavicle fracture, osteomyelitis, or a septic shoulder joint. In toddlers, children, and adolescents with proximal humerus fractures, the presentation is more straightforward and includes pain that is readily apparent, guarding, and arm dysfunction. The patient will often have swelling and ecchymosis, with an altered contour of the ipsilateral shoulder. Refusal to move the arm is common, and many patients prefer holding the arm internally rotated against the body. Neurologic complications can be seen with severely displaced proximal humerus fractures; thus, a thorough neurovascular examination is an essential part of the initial evaluation.
In patients with high-energy injuries, fractures of the proximal humerus can be associated with dislocations of the glenohumeral joint. Fracturedislocations of the shoulder are infrequent injuries, but they are described in the literature. Anterior dislocation is most commonly associated with proximal humerus fracture;26 however, posterior27 and inferior28 dislocations have been described, as well. In the neonate, associated injuries can include fractures of the clavicle and injury to the brachial plexus.
Imaging Standard radiographs of the shoulder, including AP, scapula Y, and axillary views, should be obtained.
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Evaluation and Management of Pediatric Proximal Humerus Fractures
Table 1
Figure 2
Neer and Horwitz Classification of Proximal Humerus Fractures Grade I II III IV
Displacement ,5 mm ,1/3 of the shaft width 2/3 of the shaft width .2/3 of the shaft width
Reproduced with permission from Neer CS II, Horwitz BS: Fractures of the proximal humeral epiphyseal plate. Clin Orthop Relat Res 1965;41:24-31.
The proximal humeral physis appears box-shaped on the AP view, tent-shaped on the AP view in external rotation, and cone-shaped on the AP view in internal rotation. Comparison views of the uninjured side can be obtained, if necessary. Many times, axillary views of the shoulder can be difficult to obtain secondary to pain. In these cases, a Velpeau axillary view may be helpful. The importance of obtaining a good axillary radiograph for an orthogonal view of the fracture cannot be overstated. This view can reveal the apex anterior angulation commonly seen with proximal humerus fractures. In certain cases, a Neer and Horwitz grade IV fracture can be seen only on axillary radiographs. In addition, it is not uncommon to see inferior subluxation of the humeral head with proximal humerus fractures; this can be misread as a glenohumeral dislocation. Advanced imaging, such as MRI or CT, is rarely warranted as part of the workup unless there is concern for a more complicated injury, including lesser tuberosity avulsion fracture, fracture associated with cysts, or an associated glenohumeral dislocation.
Classification The most commonly used classification system for pediatric proximal humerus
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Illustrations of the Salter-Harris classification system for pediatric proximal humerus fractures. Type I fractures are common in infants and toddlers, whereas metaphyseal fractures and type II fractures are seen in children aged 5 to 11 years and .11 years, respectively. Type III and IV fractures are unusual and are associated with high-energy trauma.
fractures is the Neer and Horwitz classification3 (Table 1). The SalterHarris classification system is also commonly used (Figure 2). Isolated physeal separation (Salter-Harris I) is seen in newborns and toddlers, with a second peak of physeal separation seen in the young adolescent thrower (LLS). Most fractures involving the proximal humerus in children aged 5 to 11 years are metaphyseal, and Salter-Harris type II fractures are predominantly seen in children older than 11 years.29 Salter-Harris type III and IV injuries are rarely seen and are usually associated with high-energy trauma.26
Management In pediatric patients with proximal humerus fractures, the potential for remodeling is great; therefore, most of these fractures can be successfully treated nonsurgically (Figure 3). Traditionally, nonsurgical management of pediatric proximal humerus fractures has produced good to excellent results in all pediatric age groups. This is certainly true
for patients with birth fractures involving the proximal humerus. Typically, a safety pin is all that is needed to immobilize the arm by attaching a small stockinette-like sling or pinning the sleeve to the shirt. Birth fractures of the proximal humerus heal rapidly, and immobilization is rarely required beyond 2 to 3 weeks. Abundant callus is typically apparent on radiography by this point. Neer and Horwitz grade I and II proximal humerus fractures in children and older adolescents also should be treated nonsurgically. Various methods of immobilization have been advocated, and good results have been obtained using hanging arm casts, slings, slings and swathes, and even Velpeau bandages (Figure 4). The arm is immobilized for 3 to 4 weeks, depending on the clinical examination and radiographic evidence of healing. Statue of Liberty shoulder spica casting and olecranon traction pins are primarily of historical significance and are not used routinely. Although Statue of Liberty and other abduction casts can be used after closed reduction to achieve successful results,
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Figure 3
Initial AP (A) and axillary (B) radiographs of the proximal humerus in a 12-year-old boy with a closed Neer and Horwitz grade IV fracture treated with a hanging arm cast. AP (C) and axillary (D) radiographs of the shoulder made 3 months after treatment demonstrating fracture healing and initial remodeling. The proximal humerus eventually remodeled fully, and the patient returned to sports uneventfully. (Courtesy of Lori A. Karol, MD, Dallas, TX.)
loss of reduction and the required position of the arm are commonly cited reasons this technique has fallen out of favor. Nonsurgical care is not recommended for patients with open Neer and Horwitz grade I and II fractures, vascular injury, or polytrauma.29 Controversy exists with regard to the management of Neer and Horwitz grade III and IV pediatric proximal humerus fractures (Figure 5). Two factors must be considered for appropriate treatment of these fractures: (1) the chronologic and skeletal age of the patient and (2) the amount of displacement and angulation present. In the literature, there is no absolute criteria with regard to the amount of displacement or angulation that requires surgical management. Some authors recommend surgery for fractures with .40° of angulation or 50% displacement.30 Others say nonsurgical management is acceptable in patients aged ,10 years with up to 60° of angulation;7 however, in patients older than 10 years, nonsurgical measures are acceptable in the setting of only 20° to 30° of angulation.2 Dobbs et al29 described a treatment algorithm for displaced proximal humeral epiphyseal frac-
tures that incorporated age-dependent limitations, with angulation up to 75°, 60°, and 45° of angulation in patients aged ,7 years, 8 to 11 years, and $12 years, respectively. In Germany, national guidelines for management of pediatric proximal humerus fractures recommend the use of AP and axillary radiographs to guide decision making.7 These national guidelines advocate for nonsurgical management of these fractures in children younger than 10 years with ,60° of angulation (total combined on both views) and ,10° of valgus deformity. In patients older than 10 years, criteria for nonsurgical management includes a total angulation of ,30° and ,10° of valgus deformity. A range of acceptable angulation and displacement has been reported in the literature to support nonsurgical treatment, but no consensus has been reached (Table 2). Some authors recommend nonsurgical treatment for grade III or IV Neer and Horwitz fractures if the patient is younger than 10 years,2,33 whereas other authors use age 11 or 12 years as the cut-off.21,30 In a systematic review of the literature on pediatric proximal humerus
Figure 4
Photograph of an 11-year-old girl wearing a hanging arm cast for treatment of a pediatric proximal humerus fracture.
fractures, Pahlavan et al33 highlighted a recent trend toward broadening surgical indications, especially in the older adolescent patient who has limited remodeling potential. The authors divided patients into three groups based on age: ,10 years, 10 to 13 years, and .13 years. For children younger than 10 years, nonsurgical treatment was advocated because the remodeling potential was expected to minimize the chance of significant shortening, persistent angulation, or malunion. Children
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Evaluation and Management of Pediatric Proximal Humerus Fractures
tion, we consider surgery in the setting of neuromuscular disorders or nerve palsies because remodeling cannot be reliably predicted in the absence of normal muscular forces. For cases in which deformity may persist after fracture healing, we advocate pinning, even in patients younger than 10 years. It should be noted that, in up to 9.4% of surgical cases, the biceps tendon can be interposed in the fracture site and may require an open incision to successfully reduce the fracture before pinning.33
Figure 5
Special Cases Little League Shoulder
AP (A) and scapula Y radiographs (B) of the shoulder demonstrating a Neer and Horwitz grade IV fracture of the proximal humerus in a 12-year-old boy. He was treated with closed reduction and percutaneous pinning.
older than 13 years are expected to have minimal potential for remodeling; therefore, surgical management for Neer and Horwitz grade III and IV fractures should be considered (Figure 6). Surgical options include open or closed percutaneous pinning, flexible nailing, placement of cannulated screws, and plate fixation. Several studies demonstrate good and excellent surgical outcomes in patients older than 13 years.2,29,31 For children aged 10 to 13 years, Pahlavan et al33 recommended treating fractures on a case by case basis, taking into account sex, skeletal bone age, and potential for remodeling. Dobbs et al29 analyzed the treatment outcomes of a subset of 28 patients aged .15 years (19 patients) with severely displaced proximal humeral epiphyseal fractures. Follow-up was
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an average of 4 years. These patients had Neer and Horwitz grade III or IV proximal humerus fractures that were treated in the operating room with closed reduction and percutaneous pinning, open reduction with either screw or pin fixation, or closed reduction and immobilization. All of the fractures healed with Neer and Horwitz grade I or II displacement. Although these findings suggest that good results can be achieved with surgery, there is no consensus with regard to the optimal treatment approach. Good results have been reported with nonsurgical management of displaced fractures in teenagers.3 Because of good results reported by several authors,2,29,31,32 we recommend surgical treatment for most grade III and IV fractures in children older than 11 years. In addi-
LLS is an overuse injury caused by rotational stresses generated by throwing, resulting in repetitive microtrauma to the proximal humeral growth plate.34 Pitchers aged 11 to 14 years are most commonly affected, and a thorough history typically reveals several months of worsening shoulder pain with throwing in the context of an increase in the normal throwing regimen. Examination findings include tenderness on the anterolateral proximal humerus as well as pain and weakness with resisted shoulder abduction and internal and external rotation. Imaging will reveal widening of the proximal humeral growth plate and, in more advanced cases, fragmentation, sclerosis, and even cyst formation (Figure 7). For subtle cases, comparison radiographs of the uninjured arm may be necessary. Management of LLS involves cessation of throwing for 3 months followed by a throwing program that emphasizes proper mechanics. Risk factors for LLS include noncompliance with USA baseball pitch count recommendations, pitching on multiple teams, and poor pitching mechanics35,36 (Tables 3 and 4). Furthermore, young throwers should follow USA baseball recommendations to
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take at least 3 months away from throwing sports every year.
Lesser Tuberosity Avulsion Fractures An unusual and often missed fracture involves an avulsion of the lesser tuberosity.37 Two mechanisms of injury have been described for this fracture. The first is overuse, which is seen with repetitive throwing. The other mechanism is a sudden, forceful, external rotation abduction moment to the shoulder. This can occur with a fall backward onto an outstretched hand, placing increased tension on the subscapularis muscle and resulting in injury to the lesser tuberosity.24 Ice hockey and wrestling are sports associated with this fracture type. Diagnosis can usually be made with a careful physical examination. Pain with resisted external rotation, weakness with internal rotation, and positive belly press, lift off, and bear hug tests should heighten suspicion for lesser tuberosity avulsion fracture. Axillary radiographs typically aid diagnosis (Figure 8). MRI is also recommended because lesser tuberosity avulsion fractures are frequently associated with other softtissue injuries, including biceps subluxation, humeral avulsion of the glenohumeral ligament (HAGL), bony HAGL lesions, and coracoid impingement.38 Nonsurgical management of this injury should be reserved for nondisplaced fractures. Surgical management can be performed with an open or arthroscopic approach, with good results demonstrated using both techniques. Neglected lesser tuberosity fractures can be a source of persistent pain and loss of function.37
Proximal Humerus Fracture-dislocations Proximal humerus fracture-dislocations are rare but do warrant mention. These
Table 2 Summary of Published Criteria for Acceptable Angulation and Displacement of Neer and Horwitz Grade III and IV Pediatric Proximal Humeral Fractures for Nonsurgical Treatmenta
Study
Patient Age (yr)
Fernandez et al2
101
Bahrs et al7
,10 101
Dameron and Reibel13 Binder et al21 Dobbs29 Beaty30 Burgos-Flores et al31 Hutchinson et al32 a
111 ,12 121 10–11 121 10–12 121 131 121
Acceptable Angulation and Displacement for Neer and Horwitz Grade III and IV Fractures 20°–30° angulation, valgus deformity ,10° ,60° angulation and ,10° valgus deformity ,30° angulation and ,10° valgus deformity ,20° of angulation and 50% displacement ,30° of angulation Anatomic Up to 60° angulation Up to 45° angulation Up to 40°–70° angulation ,40° angulation and 50% displacement Angulation .30% in one plane or 50% displacement ,40° angulation, recommend surgery on all grade IV fractures
There are no agreed-upon criteria.
patients should be taken to the operating room for an attempted closed reduction of the glenohumeral joint. Once the joint is reduced, careful review of radiographs is necessary to determine if the joint is reduced, to classify the fracture, and to determine if the proximal humerus fracture requires fixation. In the case of an irreducible glenohumeral joint, an open deltopectoral approach is used. Osteonecrosis and growth plate arrest are worrisome potential complications associated with this injury, and the child should be monitored closely after fracture healing.39
Proximal Humerus Fractures Associated With Cysts Aneurysmal and simple bone cysts are commonly located in the proximal humerus. Because of the thin cortex associated with these lesions, patho-
logic fractures can occur. Management of these lesions remains varied and controversial, but the goal is to prevent recurrence of the fracture.40 The fracture is allowed to heal in a sling for 6 to 12 weeks and then the cyst is addressed, if necessary. A small number of cysts may heal spontaneously after the fracture. If the cyst persists for 3 months, many treatment options can be used to help heal the cyst, including injections, percutaneous and open curettage, and resection with or without fixation. Risks associated with management of these lesions include growth arrest, additional bone destruction, refracture, and recurrence of the cyst.40,41
Rehabilitation For pediatric proximal humerus fractures treated with immobilization,
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Evaluation and Management of Pediatric Proximal Humerus Fractures
Table 3
Figure 6
Little League Baseball Pitch Count Recommendations36 Pitcher Age (yr)
No. of Pitches Per Daya
17–18 13–16 11–12 9–10 7–8
105 95 85 75 50
a Any pitcher who has thrown more than 41 pitches in a day cannot play the position of catcher for the remainder of the day.
Table 4 Rest Requirements for Pitchers36 (A) AP radiograph of the shoulder demonstrating a Neer and Horwitz grade IV fracture of the proximal humerus in a 13-year-old boy. The patient sustained the fracture in a fall while skiing. Closed reduction of the fracture was not possible because of an entrapped biceps tendon. (B) Fluoroscopic image of the proximal humerus following open reduction and percutaneous pinning.
Pitcher Age (yr) 7–14
Figure 7 15–18
AP external rotation radiograph (A) and coronal magnetic resonance image (B) of the shoulder demonstrating Little Leaguer’s shoulder. Notice the widening of the lateral physis seen on the radiograph and the edema around the lateral physis on the magnetic resonance image. (Courtesy of Jonathan K. Kazam, MD, New York, NY.)
No. of Pitches Thrown
Days of Rest Before Pitching Again
$66 51–65 36–50 21–35 $76 51–75 26–50 1–25
4 3 2 1 4 3 2 1
then be transitioned to a collar and cuff or a sling for an additional 2 weeks. Light activities are permitted starting at 6 weeks, and a gradual increase in motion and strength takes place over the subsequent 6 weeks. The goal should be to have the child resume all activities by 3 to 4 months. The exact timetable of return to sport depends on the severity of the initial fracture and the type of sport or activity.
Outcomes healing typically occurs in 4 to 6 weeks. For fractures that require percutaneous fixation, the pins are
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removed approximately 3 to 4 weeks after initial radiographic evidence of fracture healing. The child should
Because of the remodeling potential of the humerus in young patients with proximal humeral fractures, treatment
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outcomes are generally good to excellent. In a study of 43 patients with proximal humeral fractures (10 treated nonsurgically, 33 treated surgically) Bahrs et al7 found no complications at a mean follow-up of 39 months, with excellent Constant scores reported in those with nondisplaced and displaced fracture patterns. In a systematic review of pediatric proximal humerus fractures, Pahlavan et al31 reported excellent overall outcomes; most patients were able to return to activity with no restrictions, no residual loss of function, and no major complications.
Complications Although most treatment outcomes for pediatric proximal humerus fractures are excellent,7 some complications have been reported, including pain, weakness, and loss of motion. Neer and Horwitz grade III and IV injuries can result in limb shortening and restricted motion.3,31,32 Complications associated with percutaneous pinning include pin-tract infections, pin migration, and osteomyelitis. Osteomyelitis that develops after pinning is a common reason cited by many surgeons for avoiding surgical management of these fractures if they feel there is a good chance for healing and remodeling without intervention. Although osteomyelitis of the humeral head is uncommon, it can be a devastating complication that requires multiple débridements and antibiotics to eradicate.42 In patients with restricted range of motion, loss of motion during shoulder abduction is most commonly described.43 Although nonunion of proximal humeral fractures has not been reported in the pediatric literature, malunion can occur and can be problematic in the older adolescent who does not have the same remodeling potential
Figure 8
Axillary radiograph of the shoulder showing a chronic lesser tuberosity avulsion fracture. The white arrow points to the hypertrophied lesser tuberosity avulsion fracture retracted medially by the pull of the subscapularis muscle. The yellow arrow points to the donor site.
as the younger child. Malunion can result in varus malalignment and, if abduction and flexion are limited, a corrective osteotomy may be required. Neurologic injury is another rare complication seen with proximal humerus fractures and fracture-dislocations. In most cases, nerve injury is transient and resolves in 3 to 6 months.
Summary Fractures of the proximal humerus are seen in children of all ages from newborns to adolescents and are caused by various mechanisms of injury. In most cases, management of these fractures is nonsurgical, with closed techniques used. Surgical management of pediatric proximal humerus fractures is predicated on the extent of fracture displacement and the remodeling potential of the child. For severely displaced Neer and Horwitz grade III and IV fractures of the proximal humerus in the adolescent, there is no consensus on optimal treatment. The existing literature supports surgical and non-
surgical management plans, and acceptable results have been reported with both treatment methods. Further study is needed to optimize treatment recommendations in this subset of older patients. The goal of fracture management is to achieve a stable, near anatomic reduction to minimize any residual deformity. Following fracture management, most children are able to make a full return to sports and activities. Complications resulting from pediatric proximal humerus fractures are rare.
References Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 40 is a level I study. Reference 33 is a level III study. References 2, 3, 7-9, 13, 17, 20, 21, 25, 29, 32, 38, 41-43 are level IV studies. References printed in bold type are those published within the past 5 years. 1. Landin LA: Epidemiology of children’s fractures. J Pediatr Orthop B 1997;6: 79-83. 2. Fernandez FF, Eberhardt O, Langendörfer M, Wirth T: Treatment of severely displaced proximal humeral fractures in children with retrograde elastic stable intramedullary nailing. Injury 2008; 39(12):1453-1459. 3. Neer CS II, Horwitz BS: Fractures of the proximal humeral epiphysial plate. Clin Orthop Relat Res 1965;41:24-31. 4. Peterson CA, Peterson HA: Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 1972;12(4): 275-281. 5. Ogden JA, Conlogue GJ, Jensen P: Radiology of postnatal skeletal development: The proximal humerus. Skeletal Radiol 1978;2:153-160. 6. Leonard J, Hutchinson MR: Shoulder injuries in skeletally immature throwers: Review and current thoughts. Br J Sports Med 2010;44(5):306-310. 7. Bahrs C, Zipplies S, Ochs BG, et al: Proximal humeral fractures in children and adolescents. J Pediatr Orthop 2009;29(3): 238-242.
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Evaluation and Management of Pediatric Proximal Humerus Fractures 8. Baxter MP, Wiley JJ: Fractures of the proximal humeral epiphysis: Their influence on humeral growth. J Bone Joint Surg Br 1986;68(4):570-573. 9. Di Gennaro GL, Spina M, Lampasi M, Libri R, Donzelli O: Fractures of the proximal humerus in children. Chir Organi Mov 2008;92(2):89-95. 10. Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG: Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am 2010;92(4):943-948. 11. Brooks CH, Revell WJ, Heatley FW: Vascularity of the humeral head after proximal humeral fractures: An anatomical cadaver study. J Bone Joint Surg Br 1993; 75(1):132-136. 12. Rowles DJ, McGrory JE: Percutaneous pinning of the proximal part of the humerus: An anatomic study. J Bone Joint Surg Am 2001;83(11):1695-1699. 13. Dameron TB Jr, Reibel DB: Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg Am 1969;51(2): 289-297. 14. Fealy S, Rodeo SA, Dicarlo EF, O’Brien SJ: The developmental anatomy of the neonatal glenohumeral joint. J Shoulder Elbow Surg 2000;9(3):217-222. 15. Caviglia H, Garrido CP, Palazzi FF, Meana NV: Pediatric fractures of the humerus. Clin Orthop Relat Res 2005;432: 49-56. 16. Ekengren K, Bergdahl S, Ekström G: Birth injuries to the epiphyseal cartilage. Acta Radiol Diagn (Stockh) 1978;19(1B): 197-204. 17. Sherr-Lurie N, Bialik GM, Ganel A, Schindler A, Givon U: Fractures of the humerus in the neonatal period. Isr Med Assoc J 2011;13(6):363-365. 18. Jones GP, Seguin J, Shiels WE II: SalterHarris II fracture of the proximal humerus in a preterm infant. Am J Perinatol 2003;20 (5):249-253. 19. Canpolat FE, Köse A, Yurdakök M: Bilateral humerus fracture in a neonate after cesarean delivery. Arch Gynecol Obstet 2010;281(5):967-969. 20. Schwendenwein E, Hajdu S, Gaebler C, Stengg K, Vécsei V: Displaced fractures of the proximal humerus in children require
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open/closed reduction and internal fixation. Eur J Pediatr Surg 2004;14(1):51-55.
and early radiographic results. J Pediatr Orthop 2011;31(6):617-622.
21. Binder H, Schurz M, Aldrian S, Fialka C, Vécsei V: Physeal injuries of the proximal humerus: Long-term results in seventy two patients. Int Orthop 2011;35(10): 1497-1502.
33.
22. Ghosh A, Di Scala C, Drew C, Lessin M, Feins N: Horse-related injuries in pediatric patients. J Pediatr Surg 2000;35(12): 1766-1770.
34. Popkin CA, Posada A, Clifford PD: Little Leaguer’s shoulder. Clin Imaging 2006;30 (5):365-367.
23. Teixeira RP, Johnson AR, Higgins BT, Carrino JA, McFarland EG: Fly fishingrelated lesser tuberosity avulsion in an adolescent. Orthopedics 2012;35(5): e748-e751. 24. Neogi DS, Bejjanki N, Ahrens PM: The consequences of delayed presentation of lesser tuberosity avulsion fractures in adolescents after repetitive injury. J Shoulder Elbow Surg 2013;22(4):e1-e5.
35. Davis JT, Limpisvasti O, Fluhme D, et al: The effect of pitching biomechanics on the upper extremity in youth and adolescent baseball pitchers. Am J Sports Med 2009;37 (8):1484-1491. 36. Little League Baseball and Softball: Regular season pitching rules: Baseball. http://www. littleleague.org/assets/forms_pubs/media/ pitchingregulationchanges_bb_11-13-09. pdf. Accessed November 7, 2014. 37.
Goeminne S, Debeer P: The natural evolution of neglected lesser tuberosity fractures in skeletally immature patients. J Shoulder Elbow Surg 2012;21(8):e6-e11.
38.
Garrigues GE, Warnick DE, Busch MT: Subscapularis avulsion of the lesser tuberosity in adolescents. J Pediatr Orthop 2013;33(1):8-13.
25. Loder RT, Bookout C: Fracture patterns in battered children. J Orthop Trauma 1991;5 (4):428-433. 26. Obremskey W, Routt ML Jr: Fracturedislocation of the shoulder in a child: Case report. J Trauma 1994;36(1):137-140. 27. Torode I, Donnan L: Posterior dislocation of the humeral head in association with obstetric paralysis. J Pediatr Orthop 1998; 18(5):611-615. 28. Isik M, Subasi M, Cebesoy O, Koca I, Pamukcu U: Traumatic shoulder fracturedislocation in a 7-year-old child: A case report. J Med Case Rep 2013;7:156. 29. Dobbs MB, Luhmann SL, Gordon JE, Strecker WB, Schoenecker PL: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23(2): 208-215. 30. Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372. 31. Burgos-Flores J, Gonzalez-Herranz P, Lopez-Mondejar JA, Ocete-Guzman JG, Amaya-Alarcón S: Fractures of the proximal humeral epiphysis. Int Orthop 1993;17(1):16-19. 32. Hutchinson PH, Bae S, Waters PM: Intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: A comparison of complications
Pahlavan S, Baldwin KD, Pandya NK, Namdari S, Hosalkar H: Proximal humerus fractures in the pediatric population: A systematic review. J Child Orthop 2011;5 (3):187-194.
39. Wang P Jr, Koval KJ, Lehman W, Strongwater A, Grant A, Zuckerman JD: Salter-Harris type III fracture dislocation of the proximal humerus. J Pediatr Orthop B 1997;6(3):219-222. 40. Wright JG, Yandow S, Donaldson S, Marley L; Simple Bone Cyst Trial Group: A randomized clinical trial comparing intralesional bone marrow and steroid injections for simple bone cysts. J Bone Joint Surg Am 2008;90(4):722-730. 41. Violas P, Salmeron F, Chapuis M, Sales de Gauzy J, Bracq H, Cahuzac JP: Simple bone cysts of the proximal humerus complicated with growth arrest. Acta Orthop Belg 2004;70(2):166-170. 42. Beringer DC, Weiner DS, Noble JS, Bell RH: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18(1):31-37. 43. Larsen CF, Kiaer T, Lindequist S: Fractures of the proximal humerus in children: Nineyear follow up of 64 unoperated on cases. Acta Orthop Scand 1990;61(3):255-257.
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Evaluation and Management of Pediatric Proximal Humerus Fractures Abstract Charles A. Popkin, MD William N. Levine, MD Christopher S. Ahmad, MD
In the pediatric population, sports participation, falls, and motor vehicle accidents can result in proximal humerus fractures. Because the proximal humeral growth plate is responsible for up to 80% of the growth of the humerus, the remodeling of these fractures in children is tremendous. Most of these injuries can be treated with a sling or hanging arm cast, although older children with decreased remodeling capacity may require surgery. Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuerosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts. Most pediatric patients with proximal humerus fractures have favorable results, and complications are infrequent.
P From the Center for the Developing Athlete, Columbia University Medical Center, New York, NY. Dr. Levine or an immediate family member serves as an unpaid consultant to Zimmer and serves as a board member, owner, officer, or committee member of the American Board of Orthopaedic Surgery and the American Orthopaedic Association. Dr. Ahmad or an immediate family member serves as a paid consultant to Arthrex and has received research or institutional support from Arthrex, Major League Baseball, and Stryker. Neither Dr. Popkin nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article. J Am Acad Orthop Surg 2015;23: 77-86 http://dx.doi.org/10.5435/ JAAOS-D-14-00033 Copyright 2015 by the American Academy of Orthopaedic Surgeons.
roximal humerus fracture patterns vary based on the mechanism of injury and the patient’s age at the time of the injury. Pediatric proximal humerus fractures are not common. Studies estimate that these fractures constitute approximately 2%1,2 of all pediatric fractures and 3% to 6.7% of all physeal fractures.3,4 Pediatric proximal humerus fractures are also associated with both aneurysmal and unicameral bone cysts and as a complication of radiation therapy for malignant tumors involving the proximal humerus.
Anatomy The secondary ossification center for the humeral head usually appears by age 4 to 6 months and may be present in up to 20% of newborns.5 The ossification centers for the greater and lesser tuberosities develop by ages 3 and 5 years, respectively.3,6 The tuberosities then fuse at age 5 to 6 years. The three secondary ossification
centers (humeral head, greater tuberosity, and lesser tuberosity) combine before age 6 years to form the epiphysis of the proximal humerus.3,6 The proximal humeral physis is responsible for approximately 80% of the longitudinal growth of the humerus.2,7-9 This high activity level explains the tremendous remodeling of proximal humerus fractures in the pediatric population. The younger the patient, the higher the potential for remodeling. Final union between the humeral head and the shaft occurs from age 16 to 19 years, when the proximal humeral growth plate closes. In children younger than age 5 years, the proximal humeral physis has a transverse shape similar to a hockey puck. As the child ages, the shape of the physis becomes more conical. The vascular supply to the proximal humerus is derived from the axillary artery. The anterior and posterior circumflex arteries branch off the axillary artery before it becomes the brachial artery. The
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Evaluation and Management of Pediatric Proximal Humerus Fractures
traditional teaching is that the arcuate artery, which comes off the ascending branch of the anterior circumflex artery, is the dominant artery. However, recent studies have called this into question. Hettrich et al10 used gadoliniumenhanced MRI to quantitatively assess the vascularity of the proximal humerus and demonstrated that the posterior circumflex humeral artery may be more dominant than previously thought. Additional work has also suggested that there may be strong anastomoses between the anterior and posterior circumflex vessels.11 The close proximity of the axillary nerve to the proximal humerus makes it vulnerable to injury after a fracture, fracture-dislocation, or percutaneous pinning of the proximal humerus. The axillary nerve is a branch of the posterior cord of the brachial plexus. It enters the quadrangular space along with the posterior circumflex artery and divides into anterior and posterior branches. These branches supply innervation to the deltoid muscle and teres minor muscle and sensation to the lateral shoulder. An anatomic study on percutaneous pinning of proximal humerus fractures found that proximal lateral pins can be as close as 3 mm to the anterior branch of the axillary nerve.12 To avoid injury, the authors recommend that the starting point for the proximal lateral pin should be at or distal to a point twice the distance from the top to the inferior most margin of the humeral head.12 The glenohumeral joint capsule covers the articular surface of the proximal humerus, including most of the medial epiphysis and the proximal, posteromedial part of the humeral metaphysis (intra-articular structures). A large part of the proximal humeral growth plate is an extracapsular structure. The capsular attachment provides a strong connection to the proximal posteromedial segment of
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the metaphyseal humerus. Interestingly, the posteromedial periosteum is stronger and thicker than the periosteum covering the anterolateral proximal humerus. The strong posteromedial capsular attachment and the difference in periosteal thickness help to explain why the metaphyseal fragment can become incarcerated within the anterolateral periosteum while the posteromedial part of the metaphysis remains with the proximal fragment.13 It also explains why the apex anterior angulation is the most frequent proximal humerus fracture angulation because the fracture hinges on the intact thickened posterior periosteum. Numerous muscles insert onto the proximal humerus and can influence the direction of fracture fragment displacement. The muscles of the rotator cuff are grossly evident at 13 to 14 weeks of gestation, and the shoulder joint and surrounding tissues resemble that of an adult shoulder by the time of birth.14 The four rotator cuff muscles insert onto the epiphysis, the pectoralis major muscle inserts onto the anteromedial humeral metaphysis, and the deltoid muscle inserts onto the lateral humerus.3 The rotator cuff muscles are all attached to the proximal fragment when a proximal humerus fracture occurs (ie, metaphyseal fracture proximal to the insertion of the pectoralis and Salter-Harris type I, II, and III fractures). The subscapularis muscle largely cancels the rotational forces of the teres minor and infraspinatus (external rotators).3 The humeral shaft is pulled anteriorly and adducted from the pectoralis major muscle (Figure 1). The deltoid muscle is attached to the distal fragment (shaft) and pulls it proximally. For most fractures involving the pediatric proximal humerus, the fracture line passes through the zone of provisional calcification, a part of the zone of hypertrophy in the
growth plate. The fracture may traverse several zones of the growth plate. The fractures often spare the proliferative zone and the cells responsible for bone growth.3
Mechanism of Injury A fracture that occurs in the first week of life with no known postnatal trauma is considered a birth fracture.15 During the descent down the birth canal, the infant’s arm can be placed in a variety of compromised positions that can result in a physeal fracture of the proximal humerus.16 However, fractures of the clavicle are much more common during delivery than are fractures of the proximal humerus.17 Vaginal deliveries, breech presentation, prolonged labor, and macrosomia (.4.5 kg)15 are risk factors for a birth fracture.18,19 It is important to mention that prenatal size is not always an accurate predictor of a birth fracture because fractures can occur in infants of normal or low birth weight, as well. Birth fractures of the proximal humerus are classic physeal separations or Salter-Harris type I injuries (Figure 2). Reports of SalterHarris type II fractures are rare but are likely underreported because, in many infants, the proximal humerus is not yet ossified.18 In most pediatric and adolescent age groups, boys are three to four times more likely than girls to sustain a proximal humerus fracture.20 Two classic traumatic mechanisms are thought to be responsible for this injury in children and adolescents. The first is direct trauma from either a fall directly onto the shoulder or a blunt force or strike. The blow is typically to the posterior shoulder3 and results in an injury to the metaphysis, physis, and/or epiphysis. The second mechanism is an indirect fall onto an outstretched hand, with the arm abducted and externally rotated.21
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Fractures of the proximal humerus are typically the result of moderateenergy trauma associated with motor vehicle crashes or sports participation. Hockey, football, horseback riding,22 and gymnastics are sports thought to put participants at a higher risk for proximal humerus fracture. Overuse injuries associated with repetitive throwing in baseball are a special subsection of pediatric proximal humerus fractures that deserves mention. Little League shoulder (LLS) is a fracture of the proximal humeral growth plate that occurs from overthrowing in baseball players aged 11 to 14 years. Avulsion fracture of the lesser tuberosity is typically seen in throwing athletes aged 12 to 15 years and in fly fishermen; it is a result of repetitive microtrauma that causes an incomplete traction injury to the lesser tuberosity.23,24 A proximal humerus fracture in a child younger than 2 years should raise concern for child abuse as a possible etiology.21 Unlike fractures in other locations of the body, there are no classic radiographic findings on imaging of the shoulder that are suggestive of child abuse. Loder and Bookout25 reported that fractures involving the humerus may be the second most common long bone injury associated with child abuse. However, the incidence of proximal humerus fractures associated with child abuse remains unknown.
Clinical Features In the neonate, diagnosis of a proximal humerus fracture can be challenging. The findings can range from subtle irritability with certain arm movements to a more pronounced refusal to move the arm. The term for the inability of the infant to move the fractured arm is called pseudoparalysis. The differential diagnosis for
Figure 1
Illustration of the proximal humerus demonstrating the deforming forces that act on a fracture to produce a Salter-Harris type II fracture pattern.
a birth fracture of the proximal humerus includes brachial plexus injury, clavicle fracture, osteomyelitis, or a septic shoulder joint. In toddlers, children, and adolescents with proximal humerus fractures, the presentation is more straightforward and includes pain that is readily apparent, guarding, and arm dysfunction. The patient will often have swelling and ecchymosis, with an altered contour of the ipsilateral shoulder. Refusal to move the arm is common, and many patients prefer holding the arm internally rotated against the body. Neurologic complications can be seen with severely displaced proximal humerus fractures; thus, a thorough neurovascular examination is an essential part of the initial evaluation.
In patients with high-energy injuries, fractures of the proximal humerus can be associated with dislocations of the glenohumeral joint. Fracturedislocations of the shoulder are infrequent injuries, but they are described in the literature. Anterior dislocation is most commonly associated with proximal humerus fracture;26 however, posterior27 and inferior28 dislocations have been described, as well. In the neonate, associated injuries can include fractures of the clavicle and injury to the brachial plexus.
Imaging Standard radiographs of the shoulder, including AP, scapula Y, and axillary views, should be obtained.
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Evaluation and Management of Pediatric Proximal Humerus Fractures
Table 1
Figure 2
Neer and Horwitz Classification of Proximal Humerus Fractures Grade I II III IV
Displacement ,5 mm ,1/3 of the shaft width 2/3 of the shaft width .2/3 of the shaft width
Reproduced with permission from Neer CS II, Horwitz BS: Fractures of the proximal humeral epiphyseal plate. Clin Orthop Relat Res 1965;41:24-31.
The proximal humeral physis appears box-shaped on the AP view, tent-shaped on the AP view in external rotation, and cone-shaped on the AP view in internal rotation. Comparison views of the uninjured side can be obtained, if necessary. Many times, axillary views of the shoulder can be difficult to obtain secondary to pain. In these cases, a Velpeau axillary view may be helpful. The importance of obtaining a good axillary radiograph for an orthogonal view of the fracture cannot be overstated. This view can reveal the apex anterior angulation commonly seen with proximal humerus fractures. In certain cases, a Neer and Horwitz grade IV fracture can be seen only on axillary radiographs. In addition, it is not uncommon to see inferior subluxation of the humeral head with proximal humerus fractures; this can be misread as a glenohumeral dislocation. Advanced imaging, such as MRI or CT, is rarely warranted as part of the workup unless there is concern for a more complicated injury, including lesser tuberosity avulsion fracture, fracture associated with cysts, or an associated glenohumeral dislocation.
Classification The most commonly used classification system for pediatric proximal humerus
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Illustrations of the Salter-Harris classification system for pediatric proximal humerus fractures. Type I fractures are common in infants and toddlers, whereas metaphyseal fractures and type II fractures are seen in children aged 5 to 11 years and .11 years, respectively. Type III and IV fractures are unusual and are associated with high-energy trauma.
fractures is the Neer and Horwitz classification3 (Table 1). The SalterHarris classification system is also commonly used (Figure 2). Isolated physeal separation (Salter-Harris I) is seen in newborns and toddlers, with a second peak of physeal separation seen in the young adolescent thrower (LLS). Most fractures involving the proximal humerus in children aged 5 to 11 years are metaphyseal, and Salter-Harris type II fractures are predominantly seen in children older than 11 years.29 Salter-Harris type III and IV injuries are rarely seen and are usually associated with high-energy trauma.26
Management In pediatric patients with proximal humerus fractures, the potential for remodeling is great; therefore, most of these fractures can be successfully treated nonsurgically (Figure 3). Traditionally, nonsurgical management of pediatric proximal humerus fractures has produced good to excellent results in all pediatric age groups. This is certainly true
for patients with birth fractures involving the proximal humerus. Typically, a safety pin is all that is needed to immobilize the arm by attaching a small stockinette-like sling or pinning the sleeve to the shirt. Birth fractures of the proximal humerus heal rapidly, and immobilization is rarely required beyond 2 to 3 weeks. Abundant callus is typically apparent on radiography by this point. Neer and Horwitz grade I and II proximal humerus fractures in children and older adolescents also should be treated nonsurgically. Various methods of immobilization have been advocated, and good results have been obtained using hanging arm casts, slings, slings and swathes, and even Velpeau bandages (Figure 4). The arm is immobilized for 3 to 4 weeks, depending on the clinical examination and radiographic evidence of healing. Statue of Liberty shoulder spica casting and olecranon traction pins are primarily of historical significance and are not used routinely. Although Statue of Liberty and other abduction casts can be used after closed reduction to achieve successful results,
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Figure 3
Initial AP (A) and axillary (B) radiographs of the proximal humerus in a 12-year-old boy with a closed Neer and Horwitz grade IV fracture treated with a hanging arm cast. AP (C) and axillary (D) radiographs of the shoulder made 3 months after treatment demonstrating fracture healing and initial remodeling. The proximal humerus eventually remodeled fully, and the patient returned to sports uneventfully. (Courtesy of Lori A. Karol, MD, Dallas, TX.)
loss of reduction and the required position of the arm are commonly cited reasons this technique has fallen out of favor. Nonsurgical care is not recommended for patients with open Neer and Horwitz grade I and II fractures, vascular injury, or polytrauma.29 Controversy exists with regard to the management of Neer and Horwitz grade III and IV pediatric proximal humerus fractures (Figure 5). Two factors must be considered for appropriate treatment of these fractures: (1) the chronologic and skeletal age of the patient and (2) the amount of displacement and angulation present. In the literature, there is no absolute criteria with regard to the amount of displacement or angulation that requires surgical management. Some authors recommend surgery for fractures with .40° of angulation or 50% displacement.30 Others say nonsurgical management is acceptable in patients aged ,10 years with up to 60° of angulation;7 however, in patients older than 10 years, nonsurgical measures are acceptable in the setting of only 20° to 30° of angulation.2 Dobbs et al29 described a treatment algorithm for displaced proximal humeral epiphyseal frac-
tures that incorporated age-dependent limitations, with angulation up to 75°, 60°, and 45° of angulation in patients aged ,7 years, 8 to 11 years, and $12 years, respectively. In Germany, national guidelines for management of pediatric proximal humerus fractures recommend the use of AP and axillary radiographs to guide decision making.7 These national guidelines advocate for nonsurgical management of these fractures in children younger than 10 years with ,60° of angulation (total combined on both views) and ,10° of valgus deformity. In patients older than 10 years, criteria for nonsurgical management includes a total angulation of ,30° and ,10° of valgus deformity. A range of acceptable angulation and displacement has been reported in the literature to support nonsurgical treatment, but no consensus has been reached (Table 2). Some authors recommend nonsurgical treatment for grade III or IV Neer and Horwitz fractures if the patient is younger than 10 years,2,33 whereas other authors use age 11 or 12 years as the cut-off.21,30 In a systematic review of the literature on pediatric proximal humerus
Figure 4
Photograph of an 11-year-old girl wearing a hanging arm cast for treatment of a pediatric proximal humerus fracture.
fractures, Pahlavan et al33 highlighted a recent trend toward broadening surgical indications, especially in the older adolescent patient who has limited remodeling potential. The authors divided patients into three groups based on age: ,10 years, 10 to 13 years, and .13 years. For children younger than 10 years, nonsurgical treatment was advocated because the remodeling potential was expected to minimize the chance of significant shortening, persistent angulation, or malunion. Children
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Evaluation and Management of Pediatric Proximal Humerus Fractures
tion, we consider surgery in the setting of neuromuscular disorders or nerve palsies because remodeling cannot be reliably predicted in the absence of normal muscular forces. For cases in which deformity may persist after fracture healing, we advocate pinning, even in patients younger than 10 years. It should be noted that, in up to 9.4% of surgical cases, the biceps tendon can be interposed in the fracture site and may require an open incision to successfully reduce the fracture before pinning.33
Figure 5
Special Cases Little League Shoulder
AP (A) and scapula Y radiographs (B) of the shoulder demonstrating a Neer and Horwitz grade IV fracture of the proximal humerus in a 12-year-old boy. He was treated with closed reduction and percutaneous pinning.
older than 13 years are expected to have minimal potential for remodeling; therefore, surgical management for Neer and Horwitz grade III and IV fractures should be considered (Figure 6). Surgical options include open or closed percutaneous pinning, flexible nailing, placement of cannulated screws, and plate fixation. Several studies demonstrate good and excellent surgical outcomes in patients older than 13 years.2,29,31 For children aged 10 to 13 years, Pahlavan et al33 recommended treating fractures on a case by case basis, taking into account sex, skeletal bone age, and potential for remodeling. Dobbs et al29 analyzed the treatment outcomes of a subset of 28 patients aged .15 years (19 patients) with severely displaced proximal humeral epiphyseal fractures. Follow-up was
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an average of 4 years. These patients had Neer and Horwitz grade III or IV proximal humerus fractures that were treated in the operating room with closed reduction and percutaneous pinning, open reduction with either screw or pin fixation, or closed reduction and immobilization. All of the fractures healed with Neer and Horwitz grade I or II displacement. Although these findings suggest that good results can be achieved with surgery, there is no consensus with regard to the optimal treatment approach. Good results have been reported with nonsurgical management of displaced fractures in teenagers.3 Because of good results reported by several authors,2,29,31,32 we recommend surgical treatment for most grade III and IV fractures in children older than 11 years. In addi-
LLS is an overuse injury caused by rotational stresses generated by throwing, resulting in repetitive microtrauma to the proximal humeral growth plate.34 Pitchers aged 11 to 14 years are most commonly affected, and a thorough history typically reveals several months of worsening shoulder pain with throwing in the context of an increase in the normal throwing regimen. Examination findings include tenderness on the anterolateral proximal humerus as well as pain and weakness with resisted shoulder abduction and internal and external rotation. Imaging will reveal widening of the proximal humeral growth plate and, in more advanced cases, fragmentation, sclerosis, and even cyst formation (Figure 7). For subtle cases, comparison radiographs of the uninjured arm may be necessary. Management of LLS involves cessation of throwing for 3 months followed by a throwing program that emphasizes proper mechanics. Risk factors for LLS include noncompliance with USA baseball pitch count recommendations, pitching on multiple teams, and poor pitching mechanics35,36 (Tables 3 and 4). Furthermore, young throwers should follow USA baseball recommendations to
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take at least 3 months away from throwing sports every year.
Lesser Tuberosity Avulsion Fractures An unusual and often missed fracture involves an avulsion of the lesser tuberosity.37 Two mechanisms of injury have been described for this fracture. The first is overuse, which is seen with repetitive throwing. The other mechanism is a sudden, forceful, external rotation abduction moment to the shoulder. This can occur with a fall backward onto an outstretched hand, placing increased tension on the subscapularis muscle and resulting in injury to the lesser tuberosity.24 Ice hockey and wrestling are sports associated with this fracture type. Diagnosis can usually be made with a careful physical examination. Pain with resisted external rotation, weakness with internal rotation, and positive belly press, lift off, and bear hug tests should heighten suspicion for lesser tuberosity avulsion fracture. Axillary radiographs typically aid diagnosis (Figure 8). MRI is also recommended because lesser tuberosity avulsion fractures are frequently associated with other softtissue injuries, including biceps subluxation, humeral avulsion of the glenohumeral ligament (HAGL), bony HAGL lesions, and coracoid impingement.38 Nonsurgical management of this injury should be reserved for nondisplaced fractures. Surgical management can be performed with an open or arthroscopic approach, with good results demonstrated using both techniques. Neglected lesser tuberosity fractures can be a source of persistent pain and loss of function.37
Proximal Humerus Fracture-dislocations Proximal humerus fracture-dislocations are rare but do warrant mention. These
Table 2 Summary of Published Criteria for Acceptable Angulation and Displacement of Neer and Horwitz Grade III and IV Pediatric Proximal Humeral Fractures for Nonsurgical Treatmenta
Study
Patient Age (yr)
Fernandez et al2
101
Bahrs et al7
,10 101
Dameron and Reibel13 Binder et al21 Dobbs29 Beaty30 Burgos-Flores et al31 Hutchinson et al32 a
111 ,12 121 10–11 121 10–12 121 131 121
Acceptable Angulation and Displacement for Neer and Horwitz Grade III and IV Fractures 20°–30° angulation, valgus deformity ,10° ,60° angulation and ,10° valgus deformity ,30° angulation and ,10° valgus deformity ,20° of angulation and 50% displacement ,30° of angulation Anatomic Up to 60° angulation Up to 45° angulation Up to 40°–70° angulation ,40° angulation and 50% displacement Angulation .30% in one plane or 50% displacement ,40° angulation, recommend surgery on all grade IV fractures
There are no agreed-upon criteria.
patients should be taken to the operating room for an attempted closed reduction of the glenohumeral joint. Once the joint is reduced, careful review of radiographs is necessary to determine if the joint is reduced, to classify the fracture, and to determine if the proximal humerus fracture requires fixation. In the case of an irreducible glenohumeral joint, an open deltopectoral approach is used. Osteonecrosis and growth plate arrest are worrisome potential complications associated with this injury, and the child should be monitored closely after fracture healing.39
Proximal Humerus Fractures Associated With Cysts Aneurysmal and simple bone cysts are commonly located in the proximal humerus. Because of the thin cortex associated with these lesions, patho-
logic fractures can occur. Management of these lesions remains varied and controversial, but the goal is to prevent recurrence of the fracture.40 The fracture is allowed to heal in a sling for 6 to 12 weeks and then the cyst is addressed, if necessary. A small number of cysts may heal spontaneously after the fracture. If the cyst persists for 3 months, many treatment options can be used to help heal the cyst, including injections, percutaneous and open curettage, and resection with or without fixation. Risks associated with management of these lesions include growth arrest, additional bone destruction, refracture, and recurrence of the cyst.40,41
Rehabilitation For pediatric proximal humerus fractures treated with immobilization,
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Evaluation and Management of Pediatric Proximal Humerus Fractures
Table 3
Figure 6
Little League Baseball Pitch Count Recommendations36 Pitcher Age (yr)
No. of Pitches Per Daya
17–18 13–16 11–12 9–10 7–8
105 95 85 75 50
a Any pitcher who has thrown more than 41 pitches in a day cannot play the position of catcher for the remainder of the day.
Table 4 Rest Requirements for Pitchers36 (A) AP radiograph of the shoulder demonstrating a Neer and Horwitz grade IV fracture of the proximal humerus in a 13-year-old boy. The patient sustained the fracture in a fall while skiing. Closed reduction of the fracture was not possible because of an entrapped biceps tendon. (B) Fluoroscopic image of the proximal humerus following open reduction and percutaneous pinning.
Pitcher Age (yr) 7–14
Figure 7 15–18
AP external rotation radiograph (A) and coronal magnetic resonance image (B) of the shoulder demonstrating Little Leaguer’s shoulder. Notice the widening of the lateral physis seen on the radiograph and the edema around the lateral physis on the magnetic resonance image. (Courtesy of Jonathan K. Kazam, MD, New York, NY.)
No. of Pitches Thrown
Days of Rest Before Pitching Again
$66 51–65 36–50 21–35 $76 51–75 26–50 1–25
4 3 2 1 4 3 2 1
then be transitioned to a collar and cuff or a sling for an additional 2 weeks. Light activities are permitted starting at 6 weeks, and a gradual increase in motion and strength takes place over the subsequent 6 weeks. The goal should be to have the child resume all activities by 3 to 4 months. The exact timetable of return to sport depends on the severity of the initial fracture and the type of sport or activity.
Outcomes healing typically occurs in 4 to 6 weeks. For fractures that require percutaneous fixation, the pins are
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removed approximately 3 to 4 weeks after initial radiographic evidence of fracture healing. The child should
Because of the remodeling potential of the humerus in young patients with proximal humeral fractures, treatment
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Charles A. Popkin, MD, et al
outcomes are generally good to excellent. In a study of 43 patients with proximal humeral fractures (10 treated nonsurgically, 33 treated surgically) Bahrs et al7 found no complications at a mean follow-up of 39 months, with excellent Constant scores reported in those with nondisplaced and displaced fracture patterns. In a systematic review of pediatric proximal humerus fractures, Pahlavan et al31 reported excellent overall outcomes; most patients were able to return to activity with no restrictions, no residual loss of function, and no major complications.
Complications Although most treatment outcomes for pediatric proximal humerus fractures are excellent,7 some complications have been reported, including pain, weakness, and loss of motion. Neer and Horwitz grade III and IV injuries can result in limb shortening and restricted motion.3,31,32 Complications associated with percutaneous pinning include pin-tract infections, pin migration, and osteomyelitis. Osteomyelitis that develops after pinning is a common reason cited by many surgeons for avoiding surgical management of these fractures if they feel there is a good chance for healing and remodeling without intervention. Although osteomyelitis of the humeral head is uncommon, it can be a devastating complication that requires multiple débridements and antibiotics to eradicate.42 In patients with restricted range of motion, loss of motion during shoulder abduction is most commonly described.43 Although nonunion of proximal humeral fractures has not been reported in the pediatric literature, malunion can occur and can be problematic in the older adolescent who does not have the same remodeling potential
Figure 8
Axillary radiograph of the shoulder showing a chronic lesser tuberosity avulsion fracture. The white arrow points to the hypertrophied lesser tuberosity avulsion fracture retracted medially by the pull of the subscapularis muscle. The yellow arrow points to the donor site.
as the younger child. Malunion can result in varus malalignment and, if abduction and flexion are limited, a corrective osteotomy may be required. Neurologic injury is another rare complication seen with proximal humerus fractures and fracture-dislocations. In most cases, nerve injury is transient and resolves in 3 to 6 months.
Summary Fractures of the proximal humerus are seen in children of all ages from newborns to adolescents and are caused by various mechanisms of injury. In most cases, management of these fractures is nonsurgical, with closed techniques used. Surgical management of pediatric proximal humerus fractures is predicated on the extent of fracture displacement and the remodeling potential of the child. For severely displaced Neer and Horwitz grade III and IV fractures of the proximal humerus in the adolescent, there is no consensus on optimal treatment. The existing literature supports surgical and non-
surgical management plans, and acceptable results have been reported with both treatment methods. Further study is needed to optimize treatment recommendations in this subset of older patients. The goal of fracture management is to achieve a stable, near anatomic reduction to minimize any residual deformity. Following fracture management, most children are able to make a full return to sports and activities. Complications resulting from pediatric proximal humerus fractures are rare.
References Evidence-based Medicine: Levels of evidence are described in the table of contents. In this article, reference 40 is a level I study. Reference 33 is a level III study. References 2, 3, 7-9, 13, 17, 20, 21, 25, 29, 32, 38, 41-43 are level IV studies. References printed in bold type are those published within the past 5 years. 1. Landin LA: Epidemiology of children’s fractures. J Pediatr Orthop B 1997;6: 79-83. 2. Fernandez FF, Eberhardt O, Langendörfer M, Wirth T: Treatment of severely displaced proximal humeral fractures in children with retrograde elastic stable intramedullary nailing. Injury 2008; 39(12):1453-1459. 3. Neer CS II, Horwitz BS: Fractures of the proximal humeral epiphysial plate. Clin Orthop Relat Res 1965;41:24-31. 4. Peterson CA, Peterson HA: Analysis of the incidence of injuries to the epiphyseal growth plate. J Trauma 1972;12(4): 275-281. 5. Ogden JA, Conlogue GJ, Jensen P: Radiology of postnatal skeletal development: The proximal humerus. Skeletal Radiol 1978;2:153-160. 6. Leonard J, Hutchinson MR: Shoulder injuries in skeletally immature throwers: Review and current thoughts. Br J Sports Med 2010;44(5):306-310. 7. Bahrs C, Zipplies S, Ochs BG, et al: Proximal humeral fractures in children and adolescents. J Pediatr Orthop 2009;29(3): 238-242.
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Evaluation and Management of Pediatric Proximal Humerus Fractures 8. Baxter MP, Wiley JJ: Fractures of the proximal humeral epiphysis: Their influence on humeral growth. J Bone Joint Surg Br 1986;68(4):570-573. 9. Di Gennaro GL, Spina M, Lampasi M, Libri R, Donzelli O: Fractures of the proximal humerus in children. Chir Organi Mov 2008;92(2):89-95. 10. Hettrich CM, Boraiah S, Dyke JP, Neviaser A, Helfet DL, Lorich DG: Quantitative assessment of the vascularity of the proximal part of the humerus. J Bone Joint Surg Am 2010;92(4):943-948. 11. Brooks CH, Revell WJ, Heatley FW: Vascularity of the humeral head after proximal humeral fractures: An anatomical cadaver study. J Bone Joint Surg Br 1993; 75(1):132-136. 12. Rowles DJ, McGrory JE: Percutaneous pinning of the proximal part of the humerus: An anatomic study. J Bone Joint Surg Am 2001;83(11):1695-1699. 13. Dameron TB Jr, Reibel DB: Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg Am 1969;51(2): 289-297. 14. Fealy S, Rodeo SA, Dicarlo EF, O’Brien SJ: The developmental anatomy of the neonatal glenohumeral joint. J Shoulder Elbow Surg 2000;9(3):217-222. 15. Caviglia H, Garrido CP, Palazzi FF, Meana NV: Pediatric fractures of the humerus. Clin Orthop Relat Res 2005;432: 49-56. 16. Ekengren K, Bergdahl S, Ekström G: Birth injuries to the epiphyseal cartilage. Acta Radiol Diagn (Stockh) 1978;19(1B): 197-204. 17. Sherr-Lurie N, Bialik GM, Ganel A, Schindler A, Givon U: Fractures of the humerus in the neonatal period. Isr Med Assoc J 2011;13(6):363-365. 18. Jones GP, Seguin J, Shiels WE II: SalterHarris II fracture of the proximal humerus in a preterm infant. Am J Perinatol 2003;20 (5):249-253. 19. Canpolat FE, Köse A, Yurdakök M: Bilateral humerus fracture in a neonate after cesarean delivery. Arch Gynecol Obstet 2010;281(5):967-969. 20. Schwendenwein E, Hajdu S, Gaebler C, Stengg K, Vécsei V: Displaced fractures of the proximal humerus in children require
86
open/closed reduction and internal fixation. Eur J Pediatr Surg 2004;14(1):51-55.
and early radiographic results. J Pediatr Orthop 2011;31(6):617-622.
21. Binder H, Schurz M, Aldrian S, Fialka C, Vécsei V: Physeal injuries of the proximal humerus: Long-term results in seventy two patients. Int Orthop 2011;35(10): 1497-1502.
33.
22. Ghosh A, Di Scala C, Drew C, Lessin M, Feins N: Horse-related injuries in pediatric patients. J Pediatr Surg 2000;35(12): 1766-1770.
34. Popkin CA, Posada A, Clifford PD: Little Leaguer’s shoulder. Clin Imaging 2006;30 (5):365-367.
23. Teixeira RP, Johnson AR, Higgins BT, Carrino JA, McFarland EG: Fly fishingrelated lesser tuberosity avulsion in an adolescent. Orthopedics 2012;35(5): e748-e751. 24. Neogi DS, Bejjanki N, Ahrens PM: The consequences of delayed presentation of lesser tuberosity avulsion fractures in adolescents after repetitive injury. J Shoulder Elbow Surg 2013;22(4):e1-e5.
35. Davis JT, Limpisvasti O, Fluhme D, et al: The effect of pitching biomechanics on the upper extremity in youth and adolescent baseball pitchers. Am J Sports Med 2009;37 (8):1484-1491. 36. Little League Baseball and Softball: Regular season pitching rules: Baseball. http://www. littleleague.org/assets/forms_pubs/media/ pitchingregulationchanges_bb_11-13-09. pdf. Accessed November 7, 2014. 37.
Goeminne S, Debeer P: The natural evolution of neglected lesser tuberosity fractures in skeletally immature patients. J Shoulder Elbow Surg 2012;21(8):e6-e11.
38.
Garrigues GE, Warnick DE, Busch MT: Subscapularis avulsion of the lesser tuberosity in adolescents. J Pediatr Orthop 2013;33(1):8-13.
25. Loder RT, Bookout C: Fracture patterns in battered children. J Orthop Trauma 1991;5 (4):428-433. 26. Obremskey W, Routt ML Jr: Fracturedislocation of the shoulder in a child: Case report. J Trauma 1994;36(1):137-140. 27. Torode I, Donnan L: Posterior dislocation of the humeral head in association with obstetric paralysis. J Pediatr Orthop 1998; 18(5):611-615. 28. Isik M, Subasi M, Cebesoy O, Koca I, Pamukcu U: Traumatic shoulder fracturedislocation in a 7-year-old child: A case report. J Med Case Rep 2013;7:156. 29. Dobbs MB, Luhmann SL, Gordon JE, Strecker WB, Schoenecker PL: Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop 2003;23(2): 208-215. 30. Beaty JH: Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372. 31. Burgos-Flores J, Gonzalez-Herranz P, Lopez-Mondejar JA, Ocete-Guzman JG, Amaya-Alarcón S: Fractures of the proximal humeral epiphysis. Int Orthop 1993;17(1):16-19. 32. Hutchinson PH, Bae S, Waters PM: Intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: A comparison of complications
Pahlavan S, Baldwin KD, Pandya NK, Namdari S, Hosalkar H: Proximal humerus fractures in the pediatric population: A systematic review. J Child Orthop 2011;5 (3):187-194.
39. Wang P Jr, Koval KJ, Lehman W, Strongwater A, Grant A, Zuckerman JD: Salter-Harris type III fracture dislocation of the proximal humerus. J Pediatr Orthop B 1997;6(3):219-222. 40. Wright JG, Yandow S, Donaldson S, Marley L; Simple Bone Cyst Trial Group: A randomized clinical trial comparing intralesional bone marrow and steroid injections for simple bone cysts. J Bone Joint Surg Am 2008;90(4):722-730. 41. Violas P, Salmeron F, Chapuis M, Sales de Gauzy J, Bracq H, Cahuzac JP: Simple bone cysts of the proximal humerus complicated with growth arrest. Acta Orthop Belg 2004;70(2):166-170. 42. Beringer DC, Weiner DS, Noble JS, Bell RH: Severely displaced proximal humeral epiphyseal fractures: A follow-up study. J Pediatr Orthop 1998;18(1):31-37. 43. Larsen CF, Kiaer T, Lindequist S: Fractures of the proximal humerus in children: Nineyear follow up of 64 unoperated on cases. Acta Orthop Scand 1990;61(3):255-257.
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