Proximal humeral fractures in children
- Leticia Manning Ryan, MD, MPH, FAAP
Leticia Manning Ryan, MD, MPH, FAAP
- Assistant Professor of Pediatrics
- Division of Emergency Medicine
- Johns Hopkins Children's Center
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — Adult and Pediatric Emergency Medicine
- Senior Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Proximal humeral fractures represent fewer than 5 percent of all pediatric fractures [1,2]. These fractures may occur either through the physis (growth plate) or in the metaphysis. One of the most important features of humeral fractures is their ability to remodel. The majority of these fractures can be treated with a sling and swathe or with a shoulder immobilizer.
This review addresses proximal fractures of the humerus in children. Fractures of the midshaft and distal humerus, including supracondylar fractures, are presented separately. (See "Evaluation and management of supracondylar fractures in children" and "Epicondylar and transphyseal elbow fractures in children" and "Evaluation and management of condylar elbow fractures in children" and "Midshaft humeral fractures in children".)
The humerus is the largest bone in the upper extremity. The proximal humerus articulates with the glenoid of the scapula to form the glenohumeral (shoulder) joint. The muscles and tendons of the rotator cuff, the acromion, and ligamentous attachments such as those between the coracoid process of the scapula and the acromion, serve to both stabilize the glenohumeral articulation and provide for a wide range of shoulder joint motion.
The pediatric humerus has distinctive structural features that influence fracture risk, fracture pattern, and the potential for healing [3,4]:
●Periosteum – In the humerus bone, a thick periosteal sleeve is present along the shaft which limits fracture displacement and promotes healing in proximal humeral fractures . (See "General principles of fracture management: Fracture patterns and description in children", section on 'Fracture patterns'.)
- Mizuta T, Benson WM, Foster BK, et al. Statistical analysis of the incidence of physeal injuries. J Pediatr Orthop 1987; 7:518.
- Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B 1997; 6:79.
- Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am 2006; 53:41.
- Della-Giustina K, Della-Giustina DA. Emergency department evaluation and treatment of pediatric orthopedic injuries. Emerg Med Clin North Am 1999; 17:895.
- Bachman D, Santora S. Orthopedic trauma. In: Textbook of Pediatric Emergency Medicine, Fleisher GR, Ludwig S. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1537.
- Shrader MW. Proximal humerus and humeral shaft fractures in children. Hand Clin 2007; 23:431.
- Benjamin, HJ, Hang, BT. Common acute upper extremity injuries in sports. Clin Pediatr Emerg Med 2007; 8:15.
- Caviglia H, Garrido CP, Palazzi FF, Meana NV. Pediatric fractures of the humerus. Clin Orthop Relat Res 2005; :49.
- Shaw BA, Murphy KM, Shaw A, et al. Humerus shaft fractures in young children: accident or abuse? J Pediatr Orthop 1997; 17:293.
- Kohler R, Trillaud JM. Fracture and fracture separation of the proximal humerus in children: report of 136 cases. J Pediatr Orthop 1983; 3:326.
- Cimpello LB, Khine H, Avner JR. Practice patterns of pediatric versus general emergency physicians for pain management of fractures in pediatric patients. Pediatr Emerg Care 2004; 20:228.
- Dong L, Donaldson A, Metzger R, Keenan H. Analgesic administration in the emergency department for children requiring hospitalization for long-bone fracture. Pediatr Emerg Care 2012; 28:109.
- Probst BD, Lyons E, Leonard D, Esposito TJ. Factors affecting emergency department assessment and management of pain in children. Pediatr Emerg Care 2005; 21:298.
- SHULMAN BH, TERHUNE CB. Epiphyseal injuries in breech delivery. Pediatrics 1951; 8:693.
- Dameron TB Jr, Reibel DB. Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg Am 1969; 51:289.
- Beringer DC, Weiner DS, Noble JS, Bell RH. Severely displaced proximal humeral epiphyseal fractures: a follow-up study. J Pediatr Orthop 1998; 18:31.
- Beaty JH. Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992; 41:369.
- Markel DC, Donley BG, Blasier RB. Percutaneous intramedullary pinning of proximal humeral fractures. Orthop Rev 1994; 23:667.
- Bishop JY, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res 2005; :41.
- Neer CS 2nd, Horwitz BS. Fractures of the proximal humeral epiphysial plate. Clin Orthop Relat Res 1965; 41:24.
- Ellefsen BK, Frierson MA, Raney EM, Ogden JA. Humerus varus: a complication of neonatal, infantile, and childhood injury and infection. J Pediatr Orthop 1994; 14:479.
- Drew SJ, Giddins GE, Birch R. A slowly evolving brachial plexus injury following a proximal humeral fracture in a child. J Hand Surg Br 1995; 20:24.
- PERTINENT ANATOMY
- MECHANISM OF INJURY
- Children and adolescents
- Pathologic fracture
- Child abuse
- PHYSICAL FINDINGS
- Proximal humerus fractures
- Neonatal fracture
- Associated findings
- RADIOGRAPHIC FINDINGS
- Proximal humeral fractures
- Neonatal fractures
- Proximal humeral fracture description
- INITIAL TREATMENT
- Orthopedic consultation
- Child protection
- DEFINITIVE CARE
- Children and adolescents
- FOLLOW-UP CARE
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS