Overview
Relatively uncommon injuries in the pediatric population (approximately 2% of pediatric fractures)
High remodeling potential due to an active proximal humeral physis
Management depends primarily on patient age, displacement, and remaining growth potential
Anatomy
The proximal humerus is a key component of shoulder motion and stability
Radiographic appearance of secondary ossification centers
Proximal humeral epiphysis at 6 months
The greater tuberosity appears at 1-3 years
Lesser tuberosity appears at 4-5 years
Deforming forces:
Pectoralis major and deltoid → medial and anterior displacement of the shaft
Supraspinatus, infraspinatus, teres minor → external rotation of the greater tuberosity (proximal fragment)
Pediatric-specific considerations:
A thick periosteum may block closed reduction
The long head of the biceps tendon is the most common interposed structure
The proximal humeral physis contributes ~80% of humeral longitudinal growth
Physeal closure begins in mid-adolescence
Epidemiology
The annual incidence is approximately 30 per 100,000 children
Male predominance (x3), peak in early adolescence
Common mechanisms:
Direct trauma (a fall directly onto the shoulder or a blunt force or strike)
Indirect fall onto an outstretched hand, with the arm abducted and externally rotated
Special considerations:
Neonates and infants: consider birth-related injury
history of forced obstetric maneuvers, high gestational weight, and breech presentation
Little League shoulder (LLS):
Fracture of the proximal humeral growth plate that occurs from overthrowing in baseball players aged 11 to 14 years.
X-rays: physeal widening and metaphyseal changes, not an actual fracture
Pathologic fractures may occur in the setting of benign bone lesions
unicameral bone cysts (UBC), nonossifying fibromas, aneurysmal bone cysts (ABC)
Child abuse: in a child younger than 2 years should raise concern
Classification
Neer–Horowitz classification (most commonly used)
Type I: < 5mm displacement
Type II: < 1/3 shaft width displacement
Type III: 1/3–2/3 shaft width displacement
Type IV: > 2/3 shaft width displacement
Salter–Harris classification:
Applicable for physeal injuries
Less useful for metaphyseal fractures
Clinical Presentation
Pain, swelling, and localized tenderness in the shoulder
Limited shoulder motion or refusal to move the arm
Many patients prefer holding the arm internally rotated against the body.
Visible deformity in displaced fractures
Neurovascular assessment:
Check distal pulses
Check brachial plexus nerve function, especially the axillary nerve.
Associated injuries:
In patients with high-energy injuries, fractures of the proximal humerus can be associated with dislocations of the glenohumeral joint.
Neonatal: clavicle fracture, injury of the brachial plexus
Imaging
Plain radiographs are the diagnostic standard
AP shoulder view
Scapular Y view
Axillary view (or Velpeau view if abduction is not tolerated)
CT scan
Reserved for complex fractures or fracture-dislocations, intra-articular extension
Used selectively due to radiation concerns
MRI
Indicated when a pathological fracture is suspected
Ultrasound
Useful in neonates
Operator dependent
Treatment
High remodeling capacity favors nonoperative management in most cases
Decision-making factors:
Patient age
Degree of displacement and angulation
Skeletal maturity
Acceptable criteria for non-operative management
<10 years old = any degree of angulation
10-12 years old = < 60-75° of angulation
>12 years old = < 45° of angulation or 2/3 displacement
Nonoperative Management
Indications:
Non-displaced or minimally displaced fractures
Younger patients with significant growth remaining
Methods:
Sling and swathe
Shoulder immobilizer
Coaptation splint
Duration:
Typically 3–4 weeks
Outcomes:
Excellent functional recovery
Rare need for secondary surgical intervention
Neonatal: 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.
Operative Management
There is no absolute criteria with regard to the amount of displacement or angulation that requires surgical management.
Closed reduction +/- fixation
Unacceptable criteria for non-operative management as described above
Open reduction internal fixation
The deltopectoral approach is commonly used
Failed closed reduction or soft tissue interposition
Neurovascular compromise
Open fracture
Risk factors associated with surgery:
Older age
Greater injury severity
Surgical Techniques
Closed reduction and percutaneous pinning
Most commonly used technique
Short operative time
Low blood loss
Elastic stable intramedullary nailing (ESIN)
Preserves soft tissues
Allows relative stability and remodeling
Plate fixation
Rarely indicated
Reserved for severe deformity in near-skeletal maturity
Outcomes
Overall prognosis is excellent
Nonoperative treatment:
High rates of full range of motion
Low pain rates at follow-up
Operative treatment:
Good functional outcomes
Higher-grade fractures are associated with:
Increased residual angulation
Limb length discrepancy
Motion limitation
Complications
Rare
Nonoperative:
Mild malunion
Transient stiffness
Operative:
Pin tract infection (most common)
Malunion
Rare neurovascular injury
Pin migration
Key Points
Most pediatric proximal humerus fractures can be treated nonoperatively.
Remodeling potential decreases with age.
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.
Both operative and nonoperative treatments yield favorable outcomes.
References:
1- Kim AE, Chi H, Swarup I. Proximal Humerus Fractures in the Pediatric Population. Curr Rev Musculoskelet Med. 2021 Dec;14(6):413-420. doi: 10.1007/s12178-021-09725-4. Epub 2021 Oct 28. PMID: 34709578; PMCID: PMC8733110.
2- Popkin, C. A., Levine, W. N., & Ahmad, C. S. (2015). Evaluation and management of pediatric proximal humerus fractures. The Journal of the American Academy of Orthopaedic Surgeons, 23(2), 77–86. https://doi.org/10.5435/JAAOS-D-14-00033