Humeral fractures in children may occur at any location.
Proximal epiphyseal fractures occur in infants as well as later in childhood.
Infants Consider the possibility of child abuse if these fractures are seen. Unlike the femur, avascular necrosis of the epiphysis is very rare.
Children and adolescents Considerable displacement is common. Manage by immobilizing the arm in a sling for 3 weeks. Accept side-to-side alignment and considerable angulation, as remodeling will correct the deformity.
Adolescents at end of growth Reduction at this age is sometimes difficult because of button-holing of the metaphysis into the deltoid or interposition of the biceps tendon between the fragments. If angulation exceeds 60°, attempt a closed reduction. Often the reduction is unstable and the deformity recurs.
Sometimes it is possible to prevent this loss of reduction by placing one or more K wires percutaneously across the fragments. Pin tract inflammation is common. Remove the wires in 2 weeks. Sometimes the position can be maintained with a shoulder spica cast or brace. Be aware that if the fracture is opened and internally fixed, the surgical scar is usually more unsightly than the slight shoulder asymmetry from malunion.
Remodeling Proximal humeral fracture management is influenced by the extraordinary remodeling potential of the upper humerus. This remodeling is due to the great growth potential of the proximal epiphysis and the forgiving effect of the mobile shoulder joint.
Pathologic fractures are common. Most are due to unicameral bone cysts.
Shaft Fractures These are uncommon injuries in children. Look for radial and ulnar nerve and arterial injury. Nearly all nerve injuries recover spontaneously. Operative fixation is necessary only for polytrauma, open injuries, and other unusual situations.
Infants Consider child abuse if these fractures are seen.
Children Manage young children by simple immobilization in a sling and swath. In older children, immobilize with the elbow flexed to a right angle in a soft dressing. Place pads to align fragments. Overwrap with fiberglass. Healing is usually sufficient at 3 weeks to convert to a sling.
Adolescents Be concerned about residual midshaft angulation exceeding 20°–30° in the patient nearing maturity. Because remodeling may be incomplete, operative fixation may be necessary.