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PROXIMAL HUMERUS FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Pediatric Proximal Humerus fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Pediatric Proximal Humerus Fractures, the historical and specifically named fractures include no fracture eponyms.

Proximal humerus fractures are relatively rare in the pediatric population. This type of fracture may occur at any age but is most frequently seen in adolescents aged 11–15 years, particularly in males. The mechanism of injury typically involves either a backward fall on an outstretched hand or a direct blow to the lateral aspect of the shoulder, although newborns may also experience a birth-related proximal humerus fracture. Pediatric proximal humerus fractures can be purely metaphyseal or may involve the physis and/or epiphysis, with metaphysis fractures more likely to occur in small children and fractures through the physis more likely in adolescents. Conservative treatment with immobilization is typically recommended for most pediatric proximal humerus fractures due to the incredible capacity for remodeling in this population, while surgery may be indicated for severely displaced fractures and those that fail nonsurgical methods.1-3

Definitions

  • A pediatric proximal humerus fracture is a disruption of the mechanical integrity of the proximal humerus.
  • A pediatric proximal humerus fracture produces a discontinuity in the proximal humeral contours that can be complete or incomplete.
  • A pediatric proximal humerus fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.4-6
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting or casting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typical unstable pediatric proximal humerus fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern1,7

  • Metaphyseal proximal humeral fractures are classified by their anatomic location, displacement, and angulation.
  • The Neer-Horowitz classification system is commonly used to classify pediatric proximal humerus fractures based on the degree of displacement:
    • Grade I: displacement <5 mm
    • Grade II: displacement between 5 mm and one-third of the humeral shaft diameter
    • Grade III: displacement between one-third and two-thirds of the humeral shaft diameter
    • Grade IV: displacement greater than two-thirds of the humeral shaft diameter

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the pediatric proximal humerus require antibiotics with surgical irrigation and wound debridement.4,8,9

R - Rotation

  • Pediatric proximal humerus fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: ≥1 fracture lines defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted
  • About 85% of pediatric proximal humerus fractures are nondisplaced or minimally displaced. The other 15% are severely displaced and are most common in children under 3 years and over 12 years.3
  • Most pediatric proximal humerus fractures displace in the varus direction, with the humeral head moving medial to and behind the humeral shaft.7

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
  • Pediatric proximal humerus fractures can have fragment involvement at the glenohumeral joint.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to post-traumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised, and the risk of post-traumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Related Anatomy3,7,10-12

  • The shoulder is a complex that consists of four joints, with the acromioclavicular and glenohumeral joints being most important for movement. The acromioclavicular joint is a gliding joint formed by the articulation of the acromion and the clavicle. The glenohumeral joint is a ball-and-socket joint formed by the head of the proximal humerus and the glenoid fossa of the scapula.
    • The proximal humerus consists of an anatomic neck, the humeral head, the surgical neck, and the greater and lesser tuberosities. The anatomic neck represents the fused epiphyseal plate and lies proximal to the two tuberosities, while the surgical neck is located below the humeral head and is the weakest area of the humerus. The greater tuberosity is the anatomic footprint and insertion point for three of the four rotator cuff muscles, while the lesser tuberosity is the insertion point for the tendon of the subscapularis muscle.
    • The humeral head articulates with the shallow glenoid fossa of the scapula, and this articulation allows for complex and dynamic ROM in several planes, making the glenohumeral joint the most mobile of the body.
  • Key ligaments of the shoulder include the coracohumeral ligament, which attaches the greater tuberosity to the coracoid process of the scapula, and the superior, middle, and inferior glenohumeral ligaments. These three ligaments form the glenohumeral joint capsule that connects the glenoid fossa to the humerus.
  • Key muscles of the shoulder include the pectoralis major, latissimus dorsi, and teres major muscles, as well as the rotator cuff muscle complex, which is comprised of three muscles with tendons that insert onto the greater tuberosity (i.e., supraspinatus, infraspinatus, and teres minor) and the large subscapularis tendon, which attaches to the lesser tuberosity.
  • The proximal humerus physis accounts for nearly 80% of the longitudinal growth of the humerus, which is why the potential for remodeling is so great at this location. There are three ossification centers at this physis: one at the humeral head, one at the lesser tuberosity, and one at the greater tuberosity. All three ossification centers fuse into a single proximal epiphyseal center around 6 years of age.

Incidence

  • The incidence of pediatric proximal humerus fractures is about 1–3/1,000 persons per year. These injuries account for 0.5–5% of all pediatric fractures and 4–7% of all epiphyseal fractures.1,7,13
  • Most pediatric proximal humerus fractures occur between the ages of 10–15.3,7
  • Proximal humerus fractures account for about one-third of all humerus fractures in newborns.7
  • These injuries are more common in males, with a reported male-to-female ratio of 3 to 1.2.3

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ICD-10 Codes

  • PROXIMAL HUMERUS FRACTURE - PEDIATRIC

    Diagnostic Guide Name

    PROXIMAL HUMERUS FRACTURE - PEDIATRIC

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    PROXIMAL HUMERUS FRACTURE - PEDIATRIC    
    SURGICAL NECK - 2 PART    
    - DISPLACED S42.222_S42.221_ 
    - NONDISPLACED S42.225_S42.224_ 
    SURGICAL NECK - 3 PART S42.232_S42.231_ 
    SURGICAL NECK - 4 PART S42.242_S42.241_ 
    GREATER TUBEROSITY    
    - DISPLACED S42.252_S42.251_ 
    - NONDISPLACED S42.255_S42.254_ 
    LESSER TUBEROSITY    
    - DISPLACED S42.262_S42.261_ 
    - NONDISPLACED S42.265_S42.264_ 
    TORUS UPPER END OF HUMERUS S42.272_S42.271_ 
    OTHER FRACTURE UPPER END    
    - DISPLACED S42.292_S42.201_ 
    - NONDISPLACED S42.295_S42.294_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S42
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain
Fracture deformity
Swelling, ecchymosis & tenderness
Abrasion
Typical History

A typical patient is a 10-year-old boy who injured himself while skateboarding. The boy dropped into a halfpipe and attempted to ascend one of its sides but did not have enough speed to reach the proper height. As a result, he fell backwards and landed on his arm, which was abducted, while his elbow was extended, and shoulder was extended and rotated externally. The impact of the fall produced a Salter Harris II fracture in the proximal humerus of the boy’s right arm and led to immediate pain, swelling, and difficulty moving the shoulder.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • When treating closed pediatric proximal humerus fractures, the treating surgeon has 4 basic goals:4,9
    1. A shoulder with a normal appearance. The X-ray may not need to be perfect, but the shoulder should have no obvious deformity (i.e., the shoulder looks normal!)
    2. Avoid shoulder stiffness by maintaining a normal functional ROM (i.e., the shoulder works!)
    3. The shoulder is not painful (i.e., the shoulder does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (i.e., the glenohumeral joint does not develop early post-traumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • Most pediatric patients with proximal humerus fractures can be treated conservatively with a period of immobilization, particularly those under 10 years of age, regardless of the degree of fracture displacement. 1,2,7This is primarily due to the incredible potential for healing and remodeling of the proximal humerus.
  • Several immobilization options are available, including hanging arm casts, slings, slings with swathes, and Velpeau bandages. In most cases the arm is immobilized for 3­–4 weeks.
    • For nondisplaced and minimally displaced fractures, a sling or sling plus swathe are typically used. The arm is positioned along the side with the elbow flexed at 90° and the forearm resting against the torso. The entire upper extremity except for the wrist and fingers is included in the immobilization system.
  • For infants with proximal humerus fractures, the arm should be immobilized with a sling and swath for about 2–4 weeks.
Operative
  • Surgical treatment of pediatric proximal humerus fractures must always be an individualized therapeutic decision.1,2,7  However, surgical pediatric proximal humerus fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced pediatric proximal humerus fracture involving the glenohumeral joint.
    3. Open pediatric proximal humerus fractures. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Other possible indications for surgical intervention include children older than 10 years and patients with significantly displaced intra-articular fractures or neurovascular compromise. 
  • Elastic stable intramedullary nailing (ESIN)
    • Generally considered the treatment of choice for pediatric proximal humerus fractures.
    • Involves minimally invasive retrograde nailing of the proximal humerus with the patient in an eccentric supine position towards a radiolucent arm table. The fluoroscopy view should show the entire humerus, including the head. An alternative approach is lateral decubitus with the arm vertical and abducted on an arm support.
  • Closed reduction and percutaneous pinning (CRPP)
    • May be used when the degree of displacement is unacceptable or as an alternative to retrograde ESIN for surgeons who are not proficient with that procedure.
    • Closed reduction involves traction, abduction, forward flexion, and external rotation of the arm with the patient under general anesthesia
    • If the fracture is unstable, percutaneous fixation with smooth K-wires is the preferred method of fixation, which are inserted through the lateral aspect of the shoulder.
    • Closed reduction is followed by immobilization for 4–6 weeks.
  • Open reduction and internal fixation (ORIF)
    • Rarely needed and generally reserved for patients with severely displaced intra-articular fractures, neurovascular compromise, or those who failed closed reduction.
    • A deltopectoral approach is usually the preferred approach, and humeral head fractures should be treated with countersunk cancellous screws.

Post-treatment Management

  • The care and precautions related to immobilization devices for the pediatric proximal humerus fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints and casts, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can usually be mobilized after 4 weeks.
  • For patients treated conservatively, gentle pendulum exercises typically begin about 2–4 weeks after immobilization, while active ROM exercises should be started between 4–6 weeks later, at which point most patients can resume overhead activities. Normal or near-normal shoulder function is typically achieved within 2 months of the injury.1
Complications
  • Mild humerus shortening
    • Occurs more frequently in older children, but rarely leads to any functional disability.1
  • Brachial plexus palsy
  • Stiffness
  • Aseptic necrosis
  • Avascular necrosis
  • Malunion
  • Loss of shoulder ROM
  • Hardware failure
  • Non-union
  • Post-traumatic arthritis
Outcomes
  • Conservative management of pediatric proximal humerus fractures is generally associated with good to excellent results in all pediatric age groups. Due to the high potential for remodeling, even moderately displaced and angulated fractures have been found to heal without significant residual cosmetic or functional deficits.1,2
  • Newborns with proximal humerus fractures usually heal rapidly, in as little as 2–3 weeks.2
  • ESIN has been associated with excellent long-term outcomes; however, compared to CRPP, the operative time is longer.7
Key Educational Points
  • The actual indications for conservative versus surgical treatment in pediatric proximal humerus fractures are controversial, as there are no generally accepted guidelines regarding acceptable angulation and displacement in the medical literature. Some experts advocate for nonoperative treatment in most cases and believe that that internal fixation is used excessively, while others point out that positive outcomes can be achieved with surgery and that postsurgical rehabilitation is simple.1,7
  • For proximal humerus fractures in older children with a minimal history of trauma, the surgeon should be suspicious of a pathologic fracture, as unicameral bone cysts are common in this area.1
  • A complete three-view shoulder series should be performed in all suspected proximal humerus fractures: an anteroposterior (AP) view of the glenohumeral joint, an axillary view, and a scapular Y view.1
  • MRI without contrast is rarely needed unless there is concern that a more complicated injury is present.2
  • Computerized tomography (CT) scanning is rarely needed unless there is concern that a more complicated injury is present.2
References

Cited Articles

  1. Shrader MW. Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23(4):431-435. PMID: 18054670
  2. Popkin CA, Levine WN, Ahmad CS. Evaluation and management of pediatric proximal humerus fractures. J Am Acad Orthop Surg 2015;23(2):77-86. PMID: 25624360
  3. King EC, Ihnow SB. Which Proximal Humerus Fractures Should Be Pinned? Treatment in Skeletally Immature Patients. J Pediatr Orthop 2016;36 Suppl 1:S44-48. PMID: 27100038
  4. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-722. PMID: 27113910
  5. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29(6):1128-1138. PMID: 15576227
  6. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4(4):307-316. PMID: 26649263
  7. Lefevre Y, Journeau P, Angelliaume A, Bouty A, Dobremez E. Proximal humerus fractures in children and adolescents. Orthop Traumatol Surg Res 2014;100(1 Suppl):S149-156. PMID: 24394917
  8. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12(2):119-126. PMID: 28344521
  9. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021-1031. PMID: 23618458
  10. Pencle FJ, Varacallo M. Proximal Humerus Fracture. In: StatPearls. Treasure Island (FL) 2021. PMID: 29262220
  11. Kancherla VK, Singh A, Anakwenze OA. Management of Acute Proximal Humeral Fractures. J Am Acad Orthop Surg 2017;25(1):42-52. PMID: 28002214
  12. Attum B, Thompson JH. Humerus Fractures Overview. In: StatPearls. Treasure Island (FL) 2021. PMID: 29489190
  13. 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. PMID: 21779308
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