Fig. 29.1
The square method to identify the extent of the proximal humeral metaphyseal segment. The square is drawn with one of its side on the proximal humeral physeal plate and the length of its sides is the same as the width of the proximal humeral growth plate. The metaphyseal area will lie inside this square
The next step is to define the fracture type. In paediatric fractures, the most common fracture types are either shaft fractures (segment 2) or the epi-metaphyseal fractures (segment 1 and 3). Epiphyseal injuries are intra-articular by definition whereas metaphyseal fractures are extra-articular injuries identified with the square technique. Therefore, the original severity coding A-B-C used in adults was replaced by the location of fracture according to (E) epiphysis, (M) metaphysis or (D) diaphysis and this change would enable the users of this classification system to differentiate intra-articular versus extra-articular injuries.
As a result, paediatric proximal humeral fractures would be basically encoded as either 11-E or 11-M for epiphyseal or metaphyseal fractures respectively (Fig. 29.2). Then a child code, according to the fracture morphology is used for each specific fracture type E or M. Therefore, similar fracture morphology are given the same child code regardless the fracture type (Table 29.1). A fracture severity is used to distinguish simple 0.1, wedge 0.2 (partially unstable fracture with three fragments including a fully separated fragment), and complex 0.3 (totally unstable fracture with more than three fragments) (Table 29.2).
Fig. 29.2
The general outline of the AO Paediatric Comprehensive Classification of Long Bone Fractures and its specific use in the paediatric proximal humerus
Table 29.1
Child codes according to different fracture types. Comprehensive AO Paediatric Classification of Long Bone Fractures
Type | Child codes | Description |
|---|---|---|
E | /1 | Salter-Harris I |
/2 | Salter-Harris II | |
/3 | Salter-Harris III | |
/4 | Salter-Harris IV | |
/5 | Tillaux fracture (two plane) | |
/6 | Triplane fracture | |
/7 | Ligament avulsion | |
/8 | Flake fracture | |
/9 | Other epiphyseal injuries | |
M | /2 | Green stick fracture |
/3 | Complete fracture | |
/7 | Avulsion injuries | |
/9 | Others not-classified |
Table 29.2
Different patterns of paediatric proximal humeral fractures according to comprehensive AO Paediatric Classification of Long Bone Fractures
Simple fractures | Wedge/complex fractures | ||
|---|---|---|---|
Code | Description | Code | Description |
11-E/1.1 | Simple Salter-Harris type I (Simple epiphysiolysis) | ||
11-E/2.1 | Simple Salter-Harris type II (Simple epiphysiolysis with metaphyseal wedge) | 11-E/2.2 | Epiphysiolysis with multifragmentary metaphyseal wedge |
11-E/3.1 | Simple Salter-Harris type III (Simple epiphyseal fracture) | 11-E/3.2 | Multifragmentary epiphyseal fracture |
11-E/4.1 | Simple Salter-Harris type IV (Simple epi- metaphyseal fracture) | 11-E/4.2 | Multifragmentary epimetaphyseal fracture |
11-E/8.1 | Single intraarticular flake fracture | 11-E/8.2 | Multiple intraarticular flake |
11-M/2.1 | Metaphyseal torus/buckle fracture | ||
11-M/3.1 | Complete, simple metaphyseal | 11-M/3.2 | Complete, multifragmetary metaphyseal |
Interestingly, all previous classifications didn’t describe separately fractures of the proximal humerus associated with glenohumeral dislocation, which is quite rare in paediatric population. Intrathoracic dislocation of the humeral head is also exceedingly rare. The only reported case in paediatric population was by Simpson et al who have described a young 14-year-old girl with intrathoracic dislocation of the humeral head [11]. She was hit from the left side by a speeding motor vehicle and she was thrown about 6 m landing on her right side. The right upper extremity was held in 80° of abduction and 70° of external rotation. Radiographic signs were: increase in the width of the intercostal space at the level at which the humeral head is seen on the initial radiograph of the chest (in this case was between 2nd and 3rd ribs) and outline of pleura around the humeral head. Fracture dislocation with intrathoracic displacement of the humeral head was then confirmed on CT examination. Reduction of the humeral head was achieved by gentle lateral traction and if difficult, manipulation of the humeral head through small thoracotomy can be performed.
Acute Complications
Brachial plexus and neurological complications following proximal humeral fractures are rare in skeletally immature patients. In the series of Hwang et al., 4 patients (0.7 %) of the 578 cases of proximal humerus fractures had concomitant brachial plexus and/or major peripheral nerve palsies [12]. Fractures that might cause neurovascular injury may be epiphyseal or metaphyseal and either radial, ulnar or median nerves can be affected. Medial translation and valgus angulation of the distal fracture fragment into the axilla is an important cause of neuropraxia or even axonotomesis of the brachial plexus. Full neurological recovery is expected with appropriate fracture care however, given the proximal location of these injuries, neurologic recovery may take up to 6–9 months. It is expected as well that those patients may complain of pain syndrome with dysesthesias and burning sensation, which completely resolve with neurologic recovery. They may benefit from drugs to treat neuropathic pain during this period.
Proximal humeral fractures may also cause axillary artery injury. Wera et al reported a case of displaced Salter-Harris type II proximal humeral fractures with absent distal pulses [13]. On exploration, the axillary artery was stretched and thrombosed. This was successfully managed with percutaneous pinning of the proximal humerus for stabilization and vascular reconstruction using reversed saphenous vein graft. Another case was reported in the series of Baxter and Wiley (one case out of 57) with interruption of the brachial artery in the axilla [14].
Treatment
The proximal humeral growth plate accounts for 80 % of the humeral growth and this explains the high remodeling capacity and the rationale for conservative treatment of virtually all proximal humeral fractures in children [2]. This high remodeling potential usually results in excellent functional outcomes in young children regardless of the amount of displacement or angulation. That is why Smith advocated the leave it alone treatment approach while Neer and Horwitz found that it is difficult to justify an operative treatment in the paediatric proximal humeral fractures [8]. However as early as 1969, it was clear that this remodeling potential is less powerful in older children and that angulations of more than 20° are partially corrected in children older than 11 years [15]. The only absolute indications for surgical treatment in younger (under 11) age groups would therefore be neurovascular injury, open fractures or severely displaced fractures where the metaphyseal fragment is tenting and endangering the integrity of the skin.
Interestingly, articles published before 1990 uniformly advocated nonoperative treatment for all paediatric proximal humeral fractures, while after 2000, there are more recommendations for age and deformity specific treatment schemes [16]. This is mainly to achieve the goals of modern fracture treatment through stable anatomical reduction and healing without any residual deformity or functional deficit in ways that are appropriate for children. Multiple age and deformity specific protocols have been suggested, however, there is no universal agreement about age limits and deformity magnitude cutoffs which would define an unacceptable alignment and would be the bases of evidence based practice [16].
According to Beaty, acceptable proximal humeral alignment as well as the magnitude of displacement are age dependent and his recommendations were: (1) in children younger than 5 years, up to 70° of angulation and total displacement is acceptable; (2) in children 5–12 years, 40°–70° of angulation; and (3) in children older than 12 years, 40° of angulation and 50 % apposition would be the limit.
The summary of Dobbs et al provides slightly different figures: (1) in children younger than 7 years, 75° of angulation, (2) in children 8–11 years, 60° of angulation and (3) in children older than 11 years, 45° of angulation is maximum acceptable deformity [17].
On the other hand, according to the national German guidelines, nonoperative treatment is recommended in patients younger than 10 years for proximal humeral fractures with a total angulation of less than 60° and less than 10° valgus deformity. In adolescent patients older than 10 years, fractures with a displacement of less than 30° and a valgus deformity of less than 10° can be also treated nonoperatively. A surgical treatment is recommended in patients younger than 10 years with fractures that were angulated more than 60° or totally displaced. In patients older than 10 years with total displacement and/or an angulatory displacement of more than 30° and/or more than 10° valgus deformity, surgery is also advocated [18].
Pahlavan et al recommended as well another treatment protocol based on their systematic review of all articles published on the treatment paediatric proximal humeral fractures in the last 50 years (January 1960 to April 2010). They grouped children according to their age into three main groups: <10-year-old, 10–13 year-old and >13-year-old. Children <10 years of age can be treated nonoperatively due to the expected high remodeling. Those above 13 years of age with limited remodeling capacity should certainly be offered the choice of appropriate alignment and fixation and be allowed to come to an informed decision, provided the displacement of their fracture warrants it. The interim group should be treated on a case-to-case basis, including their gender, true bone age, and biological capacity to remodel [16].
As we see from these differing publications, no agreement on age limit or deformity parameters can be found. All of the aforementioned recommendations are based on level IV case series. Unfortunately, there are no randomized trials or prospective studies published in this area to try to validate these alignment and displacement limits as well as age specific decision making and to compare nonoperative and operative treatments and therefore the evidence in this area is inconclusive.
Treatment options can range from nonoperative treatment with an arm sling immobilization or collar and cuff for 3–4 weeks till the child is pain free and then progressive mobilization can be started to aggressive open reduction aiming at anatomical alignment and internal fixation. The recommended methods for conservative immobilization are collar and cuff, Gilchrist’s bandage, Desault bandage, Mitella bandage, Velpeau sling, spica cast, hanging cast or traction. In cases of unacceptable alignment or displacement, closed reduction under general anaesthesia can be tried and then followed by either immobilization with one of the previously mentioned methods or by definitive internal fixation using percutaneous pinning or retrograde elastic stable intramedullar nailing. Open reduction is always reserved for cases with failure to achieve acceptable alignment with closed techniques. Open reduction is done through deltopectoral approach and then fixation can be achieved by percutaneous pinning, retrograde elastic stable intramedullary nailing, staples, screws or plates and screws.
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