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Proximal Humeral Fracture

Proximal humerus physeal fractures are uncommon and account for fewer than 5% of fractures in children. They can be broadly divided into 2 types ,Salter-Harris I or Salter-Harris II.

A Salter-Harris II is the more common injury and is typically an injury of adolescents following blunt trauma to the shoulder.

A Salter-Harris I is more common in children under 5 years of age. Salter-Harris I injuries can occur as an overuse injury with resultant secondary fracture. Typically, a widening of the physis can be seen.

Radiographic evaluation of the shoulder is performed with standard AP and axial or scapula Y views of the shoulder. Contralateral shoulder views can be requested for comparison.

The combined views allow assessment of the severity of the displacement.

The epiphysis tends to abduct and externally rotate due to the pull of the rotator cuff (supraspinatus and infraspinatus). The humeral shaft is usually displaced into a shortened, adducted and anterior position due to the pull of deltoid and pectoralis major.

Anatomically, the proximal humeral physis contributes to 80% of humeral growth. It closes between the ages of 16-17 in females and at around 18 in males.

The decision making is for type of fixation is down to a balance of providing a stable reduction without compromising growth potential. Where growth arrest is not a concern, a Philos plate would provide the most robust fixation as it provides adequate fixation in the epiphyseal and metaphyseal fragments. In descending order of stability, this is followed by cannulated screws, flexible nails and Kirshner wire pinning.

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- See: Proximal Humeral Physeal Injuries

- Discussion:
- classification of proximal humeral fractures:
- anatomic neck fracture:
- one part fracture
- two part fractures
- two part surgical neck fracture
- two part tuberosity fractures:
- lesser tuberosity frx;
- greater tuberosity frx;
- three part fractures
- four part fracture:
- fracture dislocation:
- head split fragment:
- Clinical and Radiographic Outcomes After Surgical Treatment of Proximal Humeral Fractures with Head-Split Component.t

  - displacing forces:
- following frx of humerus, frx fragments may be displaced as a result of pull of muscles inserting into two parts;
- w/ frx of surgical neck, upper frag is usually abducted and externally rotated by the muscles inserting onto greater tubercle,
while lower frag is adducted & internally rotated by internal rotators; (see rotator cuff);
- in frx of shaft, angulation & overriding may result from muscular pull;
- fractures of the middle & lower third of humeral shaft are frequently associated w/ injuries of the encircling radial nerve;

- Radiographs:
- an axillary view is mandatory for proximal humeral fractures, as it is the view that shows the most angulation and displacement;
- ref: Conservative management of proximal humeral fractures: can poor functional outcome be related to standard transscapular radiographic evaluation?

- Non Operative Treatment:
- references:
- Functional results following frx of proximal humerus. A controlled clinical study comparing two periods of immobilization.
- Conservative treatment of fractures and fracture-dislocations of the upper end of the humerus.
- Operative versus non-operative treatment for two-part surgical neck fractures of the proximal humerus

- Operative Treatment of Proximal Humerus Fractures: 

- Lateral Plating Technique
- Shoulder Replacement

- Complications:
  - Non Union of Humeral Fractures:
- Avascular Necrosis:
main indicators of AVN:
- calcar length ( <8 mm), medial hinge integrity, and anatomic neck fracture
- Initial post-fracture humeral head ischemia does not predict development of necrosis
- [Dislocated multiple fragment fractures of the head of the humerus. Does dislocation of the humeral head fragment signify a worse prognosis?].
- Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus.
Complex proximal humerus fractures: Hertel's criteria reliability to predict head necrosis.

- Vascular Complications:
Axillary artery injury secondary to displaced proximal humeral fractures: a report of two cases.
- Axillary artery injury from humeral neck fracture: a rare but disabling traumatic event
- Axillary artery injury after proximal humeral fracture: a review of 2 cases.
- Vascular Injury Accompanying Displaced Proximal Humeral Fractures: Two Cases and a Review of the Literature
- Proximal humerus fractures with associated axillary artery injury.
- Proximal humerus fracture with injury to the axillary artery: a population-based study.
- Delayed Radial Nerve Injury from a Brachial Artery Pseudoaneurysm Following a Four-Part Proximal Humerus Fracture: A Case Report and Literature Review.

Job 31:22 (King James Version): Then let mine arm fall from my shoulder blade, and mine arm be broken from the bone.