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Paediatric shoulder - proximal humerus fracture

Proximal humerus fracture in children with radiographic assessment of the injury.

10 questions 2 source pages 1 fact-check flags

Images appear with the first question taken from each source page — tap a question to open it.

Q1What is the appearance and fusion timing of the proximal humeral ossification centres?▸

Head: 3 months
Greater tuberosity: 1 year; lesser tuberosity: 3 years
Fusion GT-HT-LT: 6yo
Fusion to shaft: 18 years

Q2Describe the Neer classification and the deforming forces.▸

Neer (physeal plate fracture): I <5mm displacement; II <1/3 shaft width; III 1/3-2/3; IV >2/3
Deforming forces: proximal cuff
Deforming forces: distal deltoid and pec major

Q3What is unacceptable alignment in proximal humerus fractures?▸

Neer III/IV
<7yo - >75deg
7-12yo - >60deg
>12yo - >45

Q4What is the management of proximal humerus fractures?▸

Rule out NAI
CR manoeuvre: 90 degrees flexion, 90 degrees abduction + ER
<12 years: shoulder spica cast; >12 years: pinning or swathe/shoulder immobiliser
Pahlavan (J Child Orthop 2011, >550 cases): children over 13yo may benefit from anatomic reduction and fixation
Flexible IM nail vs percutaneous pinning: pinning more complications but shorter surgical time and less blood loss

Q5Describe the X-ray and initial assessment.▸

Basal neck of femur fracture in a skeletally immature patient, minimally displaced in this view (see cross table lateral)
Hx: mechanism of injury (ATLS), r/o fracture in same limb, nerve injury
Surgical emergency in Delbet type 1-3 to decrease AVN risk

Q6Describe the vascular anatomy of the proximal femur by age.▸

<4 years: MFCA (lateral epiphyseal artery), LFCA, metaphyseal artery
4-10 years: MFCA; metaphyseal artery blocked by physis; LFCA regresses
10-14 years: MFCA + ligament teres artery
>14 years: MFCA + metaphyseal artery (anastomosis of metaphyseal and epiphyseal artery redevelops), extracapsular arterial ring, ascending cervical retinacular artery, ligament teres artery

Q7Describe the Delbet classification and AVN risk.▸

Type 1 transphyseal: 40% AVN (100% if positive dislocation of epiphysis from acetabulum)
Type 2 transcervical: 30%
Type 3 basal neck: 20%
Type 4 trochanteric: 5%

Q8What is the treatment and fixation strategy?▸

r/o NAI in non-walking child; conservative: <4 years + non-displaced -> hip spica cast
Operative: Displaced fracture or > 4 y.o; ORIF for dislocated transphyseal fracture, otherwise CR + pinning/screw/DHS
Fixation: transphyseal pin (type 1 or proximal type 2 with minimal metaphyseal bone for anchorage; consider post op hip spica if young), screws sparing physis (type 2-4 + young), transphyseal screws near skeletal maturity (avoid posterior cortex protrusion)
Type 4: paediatric DHS/ locking side plate; + capsulotomy in type 1-3

Q9What is the post-operative rehab and follow-up?▸

TTWB minimum 6 weeks; progression to FWB 6-12 weeks
Return to activity when radiographically healed
Removal of implant: old no, young yes
Need long term FU for physeal arrest and AVN

Q10What are the complications and the Ratliff classification of AVN?▸

AVN risk factors: 3-8 years old, type 1 fracture
Ratliff I: complete head - epiphyseal artery (all), worst prognosis; II: partial epiphysis - limited epiphyseal artery; III: between physis and fracture line - superior metaphyseal artery, best prognosis
Coxa vara (neck shaft angle <130 degrees) due to malunion; <3 years likely remodels; <8 years trochanteric apophysis growth arrest; older + Trendelenburg gait -> valgus osteotomy
Coxa valga in type 4 fracture; physeal arrest + LLD; chondrolysis

Fact check

Coxa vara is defined as a neck-shaft angle <130 degrees — imprecise — Most sources define coxa vara as a neck-shaft angle <120 degrees; the threshold quoted varies with age and author — (medium confidence) — source

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Paediatric shoulder - proximal humerus fracture

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