There is not an absolute consensus of acceptable angulation for children. 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. The treatment of pediatric proximal humeral fractures is based upon age and expected remodeling with growth. 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. Orthogonal views are required and one must document reduction of the shoulder joint, as fracture-dislocations, while rare, are possible. (Baxter, 1986 Popkin, 2015)Ĭonventional radiology is adequate to visualize most injuries. ![]() Careful neurovascular examination is warranted as both vascular and neurologic injuries can occur given the proximity of the fracture to these structures. In infants and toddlers, pseudoparalysis or disuse is the most obvious clinical sign. The injury is often the result of a fall onto the shoulder or arm. 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. Radiographs demonstrate proximal humeral physeal widening which can be better appreciated if comparison shoulder x-rays are obtained. Little League Shoulder is a proximal physeal overuse injury found in overhead throwing athletes. The proximal humerus is a common site of overuse injuries that mimic fractures. In a child less than 3 years of age who presents with a proximal humerus fracture the treating physician should consider nonaccidental trauma. (Neer, 1965 Popkin, 2015) Another potential cause of proximal humeral fractures are traumatic births in neonates. Most fractures are the result of a fall onto the shoulder or from a direct blow to the proximal arm. ![]() Proximal humeral fractures are 3-4 times more likely to occur in boys than girls. The proximal humeral physis remains open until approximately 16-19 years of age. The three ossification centers coalesce by 6 years of age. (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. ![]() Proximal humeral physeal injuries account for approximately 2-3% of all physeal fractures. 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. Proximal humerus fractures include fractures involving the proximal humeral physis and metaphysis.
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