Figure 1: Anteroposterior radiograph of the humerus.
Figure 2: The patient’s humerus 6 weeks after sustaining the injury.
A 9-year-old presents to the emergency department (ED) with pain in her left arm after falling off a trampoline earlier in the day. She reports immediate pain, weakness, and deformity to the left arm after the fall. An anteroposterior radiograph is obtained in the ED, and shows a displaced proximal one-third humerus fracture (Figure 1). On physical examination, the patient’s skin and neurovascular status distal to the fracture are both intact.
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Pediatric humeral shaft fractures are almost always treated nonoperatively. Pediatric patients have excellent remodeling potential, which will straighten the fracture after 6 to 8 weeks of immobilization. Conservative treatments include a coaptation splint, functional humeral brace such as the Sarmiento or Galveston brace, simple sling, and a hanging cast for a period of 6 weeks.
This patient was treated in the ED with a coaptation split with a sling that allowed gravity to help reduce the fracture. Coaptation splints are often used in the ED for humeral shaft fractures as they provide excellent immobilization of the entire arm. The sling should be worn loosely to allow the arm to “dangle”. A sling that pulls the arm up proximally will angulate the fracture. Figure 2 shows remodeling of the fracture with abundant callus formation at 6 weeks after the fracture.
A Sarmiento brace is a rigid shell with adhesive straps that wrap circumferentially around the arm at the fracture site. This provides soft tissue compression at the fracture site, which helps reduce the fracture. A functional humeral brace like the Sarmiento brace allows for range of motion of the elbow when the patient can tolerate it.
A hanging cast may be used for shortened oblique fractures to provide extra gravitational weight to reduce the fracture. The hanging cast should extend 2 cm proximal to the fracture, so it is generally used for more distal fractures.
Typically, a coaptation splint is placed in the ED with a sling for initial immobilization of humeral shaft fractures. At 1 to 2 weeks post-fracture a function humeral brace or sling alone can be used.
Watts E, Souder C. Humeral shaft fracture – pediatric. OrthoBullets. Updated November 21, 2018. Accessed November 21, 2020. https://www.orthobullets.com/pediatrics/4005/humeral-shaft-fracture–pediatric