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Figure 1. Anteroposterior radiograph of the left shoulder.
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Figure 2. Lateral radiograph of the left shoulder.
A 14-year-old adolescent presents with left shoulder pain following a fall 2 days prior. He is unable to lift the arm to the side or in front of him. Anteroposterior and lateral radiographs of the left shoulder (Figures 1 and 2) are obtained.
Based on the patient’s radiographs, which of the following is the best treatment?
Submit your diagnosis to see full explanation.
Proximal humerus fractures account for <5% of fractures in children and the peak age of occurrence is 15 years old.1 Nearly all proximal and midshaft fractures of the humerus in the pediatric population can be treated nonoperatively with good outcomes. Bone remodeling and correction of fracture displacement are more likely to occur in younger patients, before epiphyseal closure between the humeral head and the shaft occurs at ages 16 to 19 years. Once the epiphysis closes, remodeling is not likely to occur. Currently, no widely accepted criteria exist that categorize fracture displacements according to those eligible for nonoperative treatment. One age-dependent guideline permits up to 75° of angulation in children <7 years of age, up to 60° in children from 8 to 11 years of age, and up to 45° in children >12 years of age.2
A hanging arm cast is a common treatment modality that allows for passive fracture reduction as gravity provides traction on the humerus. The long arm hanging cast is generally continued for 3 to 4 weeks or until early healing is identified on radiograph. In older pediatric patients with significant fracture displacement, closed reduction and percutaneous pinning may be considered as a minimally invasive option.3,4
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).
References
- Watts E, Shirley E, Skaggs D. Proximal humerus fracture – pediatric. OrthoBullets website. https://www.orthobullets.com/pediatrics/4004/proximal-humerus-fracture–pediatric. Accessed February 19, 2019.
- Dobbs MB, Luhman SL, Gordon JE, Strecker WB, Schoenecker PL. Severely displaced proximal humeral epiphyseal fractures. J Pediatr Orthop. 2003(2); 23:208-215.
- Bahrs C, Zipplies S, Ochs BG, et al. Proximal humeral fractures in children and adolescents. J Pediatr Orthop. 2009;29(3):238-242.
- Baxter MP, Wiley JJ. Fractures of the proximal humeral epiphysis. Their influence on human growth. J Bone Joint Surg Br. 1986;68(4):570-573.
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