Proximal Humeral Fractures

Paed Shoulder Fracture

 

Mechanism

 

FOOSH

 

Variations

 

Neonates

- difficult vaginal delivery

 

Little leaguers shoulder

- stress fracture from repetitive throwing

- physeal widening / lateral physeal fragmentation or calcification

 

Unicameral bone cyst

 

Types

 

Metaphyseal 70%

 

Physeal 30%

- SHII > SHI

 

Issues

 

Great remodelling potential

 

Shoulder ROM compensatory

 

Physis

 

80% of longitudinal growth of the humerus

 

Closure

Females 16

Males 18

 

Deforming forces

 

Varus deformity most common

 

Neer-Horwitz Classification

 

Type I - < 5 mm displacement

 

Type 1 Paed SNOHPaed SNOH Fracture Type 1

 

Type II - < 1/3rd shaft width

 

 Paediatric Shoulder Fracture SH 2

 

Type III - 1/3 - 2/3rd shaft width

 

Paed SNOH Type 3Paed SNOH Type 3

 

Type IV - > 2/3rd shaft width

 

Paediatric SNOH Off Ended

 

Management

 

Nonoperative Management

 

Guidelines

 

Age                           Acceptable alignment

 

< 5                            Up to 70° angulation, 100% displacement

5-12                          Up to 60° angulation

> 12                          Up to 40° angulation, 50% displacement

 

Case:  16 year old boy

 

Pediatric Proximal Humeral Fracture Remodelling PrePediatric Proximal Humeral Fracture Remodelling Post

Initial injury                                              18 months post injury

 

Case:  18 year old boy

 

Paed 18 1Paed 18 2

Initial xray                                               18 month xray

 

Operative Management

 

Indications

 

Unclear

- older adolescents with minimal remodelling potential

- Types III / IV

 

Results

 

Hohloch et al. PLoS One 2017

- systematic review

- subgroup Neer III / IV

- good excellent outcomes:  nonoperative 82%, K wire 95%, flexible nails 98%

 

Kraus et al. JSES 2014

- type Neer III / IV in juveniles

- 15 K wires, 16 flexible nails

- no difference in outcomes between two groups

 

Marengo et al. J Paediatr Orthop 2015

- 14 patients average age 10 years treated with retrograde flexible nails

- no loss of position, no growth arrest

 

Options

 

1.  Manipulation under anaesthesia (MUA)

2.  K wire / percutaneous pinning

3.  Retrograde flexible nails

 

Open reduction

 

Indication

 

Failure of closed reduction

 

Pandya et al. J Child Orthop 2012

- 10 open reductions

- blocks to reduction: biceps (90%), periosteum (90%), deltoid (70%), bone fragments (10%)

 

Technique

- deltopectoral approach

- protect blood supply / ascending branch medial circumflex humeral

 

Manipulation under anesthesia

 

Risk loss of reduction and second surgery

 

Paediatric SNOH Pre MUAPaediatric Shoulder Post MUA

 

Percutaneous pinning

 

JSJS Essential Surgical Technique

 

Technique

- K wires from metaphysis into head

- +/- K wire from GT down into metaphysis

- axillary nerve at risk

- begin distal

- dissect down to bone before inserting K wire

 

Paediatric Shoulder K wiresPaediatric Shoulder K wire Lateral

 

TENS

 

Paed SNOH TENS 1Paed SNOH TENS 2

 

Surgical technique PDF

 

Technique

 

2 x drill holes in lateral supracondylar ridge

- 1 cm proximal to lateral epicondyle

- pass 2 x TENS

- standard 0.4 of diameter of bone

- usually 2.5 mm

- radial nerve at risk