Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Proximal Humeral Physeal Injuries

- See:
      - Humeral Shaft Fractures in Children
      - Throwing Shoulder

- Discussion:
     - most of these injuries are either Salter I or II fractures;
     - frx separations of proximal humeral epiphysis occur most often between ages of 11 and 15 years;
     - 80% of longitudinal growth of humerus occurs in proximal physis;
     - large percentage of growth allows significant remodelling following injuryies of proximal humeral physis;
      - Anatomy of Proximal Humeral Physis
             - references:
                     - Growth plate activity in the upper extremity.
                     - Growth and predictions of growth in the upper extremity.

     - associated injuries:
            - brachial plexus injuries;
                   - look for decr sensation to pain;
                   - ref: Brachial Plexus Palsy Following Proximal Humerus Fracture in Patients Who Are Skeletally Immature.
      - classification:
            - type I epiphyseal injury:
                   - in newborns, frxs are usually Salter Harris type I injuries;
            - type II epiphyseal frx:
                   - in older children, they are most always Salter Harris type II;
            - type III, IV, and V frx:
             - rare because of greater mobility of the glenohumeral joint;
                   -  references:
                            - Proximal humerus Salter type III physeal injury with posterior dislocation.
                            - Salter-Harris type III fracture-dislocation of the proximal humerus.
     - diff dx of proximal humeral injuries:
            - tumor of proximal humerus
            - little league shoulder
            - clavicle frx;
            - normal varient (accentuated w/ humerus externally rotated)

- Diagnostic Studies:
     - in the new born consider ultrasound inorder to diagnose this injury;

- Non Operative Treatment:
     - young children: (less than 5 years of age);
            - up to 70 deg of frx angulation and minimal apposition is acceptable;
            - use shoulder immobilizer, if reduction is accetable;
            - w/ displaced frxs, reduction is attempted by traction & gentle manipulation;
     - children from 5 to 12 years:
            - upto 45 deg of fracture angulation and 50% apposition is acceptable;
            - displaced frx will tend to redisplace if arm is placed in a shoulder immobilizer;
            - closed reduction may be required for significantly displaced or angulated fractures in children near the end of growth;
            - frx can be immobilized w/ arm at side or in slight abduction;
    - teenager:
            - up to 25 deg fracture angulation and 30% apposition is acceptable;
     - pathologic frx:
            - w/ pathologic frxs (from ABC or unicameral bone cysts) consider  immobilizing arm & allowing frx to heal before any other treatment;
     - references:
            - Fractures of the proximal humerus in children. Nine-year follow-up of 64 unoperated on cases.
            - Operative Versus Nonoperative Treatment of Displaced Proximal Humeral Physeal Fractures: A Matched Cohort

- Operative Indications:
     - operative treatment is rarely indicated;
     - displaced frxs w/ intra-articular extension (SH IV) or frxs assoc w/ N/V injuries are indications for surgical treatment;
     - see: percutaneous pinning
     - references:
            - Intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: a comparison of complications and early radiographic results.
            - Operative Versus Nonoperative Treatment of Displaced Proximal Humeral Physeal Fractures: A Matched Cohort

Fractures of the proximal humeral epiphysis.  Their influence on humeral growth.  

Fractures of the proximal humeral epiphysis.  

Severely displaced proximal humeral epiphyseal fractures.

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, August 19, 2015 1:34 pm

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