Paediatric - Proximal Humeral fractures

Introduction

Ossification

Proximal humerus ossifies from 3 centres

Head (appears 6 months)
Greater tuberosity (appears 2-3yo)
Lesser tuberosity (appears 5yo)

Tuberosities unite age 5 and fuse with head age 6-14 yo, fuse to shaft by age 19yo.

Proximal humeral physis accounts for 80% of humeral growth.

		Proximal humeral fracture 8YO
		Treated in hanging cast Uniting at 1 month
		Consolidated at 4 months
		Remodeling at 30 months

Classification

Anatomical

Physeal
Metaphysis
Lesser tuberosity
Greater tuberosity

Treatment

Proximal humeral physeal fractures

Most are treated non operatively (even if displaced).

If severely displaced closed reduction may be attempted and held with a hanging cast or "U" slab.

Metaphyseal proximal humeral fractures

Can be treated non operatively.

Bayonet apposition with 1-2 cm of shortening can be accepted.

Closed reduction and percutaneous k wiring allows for more rapid remodeling, however risks infection.

Lesser tuberosity fractures

Acute injuries in athletes should be surgically repaired, to restore the subscapularis tendon and anterior capsule preventing shoulder instability.

Greater tuberosity fractures

Greater tuberosity fractures are associated with luxatio erectae and should be treated with closed reduction and simple immobilization.

Fracture dislocations

The dislocation should be reduced closed if possible.

In Salter-Harris type I and II fracture dislocations, the fracture can be treated non operatively even if the dislocation requires open reduction.

Salter-Harris type III fracture dislocations, closed reduction should be attempted initially. If the dislocation or fracture are not reducible then open reduction is required.