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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.