Proximal Humerus Fractures

Key Points:

  • The proximal humeral physis contributes approximately 80% of the growth of the humerus. As such, there is extensive remodeling potential in fractures in younger, skeletally immature patients.
  • Nonsurgical management is appropriate for the majority of young children with proximal humeral fractures.
  • For patients closer to skeletal maturity when the remodeling potential is diminished, one might consider surgical treatments to improve fracture alignment and reduce the possibility of malunion.

Description:

Proximal humerus fractures include fractures involving the proximal humeral physis and metaphysis.  Fractures involving the proximal humeral physis are categorized by the Salter Harris classification system and fractures of the metaphysis are described by the amount of angulation and displacement at the fracture site.

Epidemiology:

Proximal humeral physeal injuries account for approximately 2-3% of all physeal fractures. (Landin, 1997; Neer, 1965) The proximal humeral epiphysis forms from three early ossification centers:  a humeral head center present at or near birth, a greater tuberosity center that appears at age 3 years, and a lesser tuberosity center that appears at age 5 years. The three ossification centers coalesce by 6 years of age. The proximal humeral physis remains open until approximately 16-19 years of age. (Neer, 1965)
 
Proximal humeral fractures are 3-4 times more likely to occur in boys than girls. Most fractures are the result of a fall onto the shoulder or from a direct blow to the proximal arm. (Neer, 1965; Popkin, 2015) Another potential cause of proximal humeral fractures are traumatic births in neonates. In a child less than 3 years of age who presents with a proximal humerus fracture the treating physician should consider nonaccidental trauma. (Popkin, 2015)
 
The proximal humerus is a common site of overuse injuries that mimic fractures. Little League Shoulder is a proximal physeal overuse injury found in overhead throwing athletes. Radiographs demonstrate proximal humeral physeal widening which can be better appreciated if comparison shoulder x-rays are obtained. (Popkin, 2015)

Clinical Findings:

In acute injuries, pediatric patients arrive to the emergency department or clinic with complaints of acute pain, inability to move the arm, or deformity of the proximal arm. The injury is often the result of a fall onto the shoulder or arm. In infants and toddlers, pseudoparalysis or disuse is the most obvious clinical sign. Careful neurovascular examination is warranted as both vascular and neurologic injuries can occur given the proximity of the fracture to these structures. (Baxter, 1986; Popkin, 2015)

Imaging Studies:

Conventional radiology is adequate to visualize most injuries.  Orthogonal views are required and one must document reduction of the shoulder joint, as fracture-dislocations, while rare, are possible. The common radiographs obtained include a standard AP view and an axillary lateral or Velpeau view to demonstrate the fracture and confirm reduction of the shoulder.

Etiology:

Neer and Horwitz described the most commonly used classification system for pediatric proximal physeal humerus fractures. The fractures are divided according to displacement of the distal segment: type 1 displace less than 5 mm, type 2 displace 5mm to 1/3 of the shaft width, type 3 displace up to 2/3 of the shaft width, and type 4 displace greater than 2/3 of the shaft width. (Neer, 1965) The Salter-Harris classification is also routinely used, although it can be difficult to interpret in fractures with small metaphyseal fragments given the obliquity of the physis.  Fractures may also occur only in the proximal metaphysis or diaphysis and not involve the physis.

Treatment:

The treatment of pediatric proximal humeral fractures is based upon age and expected remodeling with growth. Almost any fracture in preadolescent patients can be managed without surgery, given the tremendous healing and remodeling potential as well as the range of motion of the shoulder joint which can compensate for malunion. There is not an absolute consensus of acceptable angulation for children. (Popkin, 2015) Dobbs presented an age-dependent guideline: one may accept up to 75 degrees angulation under 7 years of age, up to 60 degree of angulation from 8-11 years of age, and up to 45 degrees for children older than 12 years of age. (Dobbs, 2003) Many studies have shown near uniformly good results with nonsurgical treatment. (Larsen, 1990; Neer, 1965)
 
The most common nonsurgical modalities are slings or hanging arm casts to encourage some passive reduction using gravity traction.   A fracture cuff or coaptation splint may also be used.  Immobilization is typically used for 3-4 weeks, or until radiographic callus is present. Patients typically are uncomfortable for 7-10 days.

Surgical Options
           
For older patients or uncommon fractures that cannot achieve acceptable alignment via nonsurgical treatments, surgical options may be indicated. Attempts at closed reduction under anesthesia often permit the fracture to obtain an acceptable alignment. If the fracture remains relatively unstable, many surgeons choose percutaneous pin fixation after a closed reduction. Pins are routinely placed retrograde through the metaphysis and enter the humeral epiphysis. If left exposed, the pins can be removed in an outpatient clinic without anesthesia after callus is present. Buried smooth or threaded pins may be used to reduce the incidence of pin site infections or pin migration. In addition to these possible complications, injury to the axillary nerve has also been reported. (Hutchinson, 2011)
 
If an acceptable closed reduction is not possible an open reduction is warranted. Usually performed through a standard axillary approach, the surgeon can expect to find significant periosteal interposition at the fracture site.   Other possible approaches include a deltoid split and a deltopectoral approach.  In addition to the periosteum, the long head of the biceps tendon can be interposed and prevent reduction. (Bahrs, 2009; Neer, 1965) Most surgeons favor percutaneous pin fixation, or occasionally intramedullary or internal fixation, after open reduction to minimize future displacement. (Hutchinson, 2011)
 
Conclusion
The management of pediatric proximal humeral fractures is guided by the expected remodeling potential. The majority of injuries are managed without surgical intervention.

Complications:

References:

  1. Bahrs C, Zipplies S, Ochs, BG, Rether J, Oehms J, Eingarttner C, Rolauffs B, Weise K. Proximal Humeral Fractures in Children and Adolescents. Journal of Pediatric Orthopaedics. 2009; 29(3):238-242.
  2. Baxter MP, Wiley JJ. Fractures of the Proximal Humeral Epiphysis. Journal of Bone and Joint Surgery. 1986; Aug 4:570-573.
  3. Dobbs MB, Luhman SL, Gordon JE, Strecker WB, Schoenecker, PL. Severely Displaced Proximal Humeral Epiphyseal Fractures. Journal of Pediatric Orthopaedics. 2003; 23:208-215.
  4. Hutchinson PH, Bae DS, Waters PW. Intramedullary Nailing Versus Percutaneous Pin Fixation of Pediatric Proximal Humerus Fractures: A Comparison of Complications and Early Radiographic Results. Journal of Pediatric Orthopaedics. 2011; 31(6):617-622.
  5. Landin LA. Epidemiology of Children’s Fractures. Journal of Pediatric Orthopaedics Part B. 1997; 6:79-83.
  6. Larsen CF, Klaer T, Lindequist S. Fractures of the Proximal Humerus in Children. Acta Orthopaedica Scandanavia. 1990; 61(3):255-257.
  7. Neer CS, Horwitz BS. Fractures of the Proximal Humeral Epiphyseal Plate. Clinical Orthopedics and Related Research. 1965; Jul-Aug 41:24-31.
  8. Popkin CA, Levine WN, Ahmad CS. Evaluation and Management of Pediatric Proximal Humerus Fractures. Journal of the American Academy of Orthopaedic Surgeons. 2015; Feb 23(2):77-85.

Top Contributors:

Robert L. Wimberly, MD