Anteroposterior x-ray of a 14-year-old boy’s right shoulder following a fall while snowboarding
Outlet x-ray taken of the patient’s right shoulder
A 14-year-old boy presents to the emergency department after a snowboarding injury earlier in the day. He went off a 20-foot jump and landed awkwardly on his right shoulder. Anteroposterior and outlet x-rays show displaced Salter-Harris type II proximal humerus fracture.
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The patient sustained a Salter-Harris type II proximal humerus fracture with >75% displacement. The proximal humeral physis typically closes between the ages of 14 and 17 years in girls and between 16 and 18 years in boys.1
Treatment of displaced proximal humerus fractures in the pediatric population depends on the degree of displacement and patient age. Remodeling potential is inversely proportional to age, and therefore, younger patients have a greater ability to correct fracture displacement when healing than older patients. Treatment with closed reduction and immobilization in patients <11 years of age is recommended regardless of fracture displacement. In patients >11 years old, it becomes more important to achieve adequate reduction.
Maintaining alignment following fracture reduction and during healing can also be a challenge. Loss of reduction can be as high as 50% in patients who undergo closed reduction and immobilization alone, and internal fixation is often required to achieve acceptable alignment in older patients. Closed reduction and percutaneous pinning are used routinely in patients >11 years of age to ensure reduction is maintained through healing. Placing two percutaneous pins stabilizes the fracture adequately. The pins can be removed at 4 weeks postoperatively or when evidence of healing is seen on x-ray.2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Souder C. Proximal humerus fracture—Pediatric. http://www.orthobullets.com/pediatrics/4004/proximal-humerus-fracture–pediatric. Updated October 16, 2014. Accessed February 21, 2016.
- Beaty JH, Kasser JR, eds. Rockwood and Wilkins’ Fractures in Children. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006:704-715.