Background: In most children proximal humeral fractures are treated non-operatively with generally good results. The aim of the study was to evaluate the clinical outcome of closed/open reduction in children with severely displaced proximal humeral fractures. Materials and Methods: The charts of 15 patients (8 girls and 7 boys; mean age: 9.4 years) with proximal humeral fractures who were managed at our institution were reviewed from October 2011 to December 2013. Results: There were 7 metaphyseal fractures and 8 physeal injuries which were angulated according to Neer-Horowitz score as grade II (n=2), grade III(n=4) and grade IV(n=9). Associated lesions comprised open fracture with head trauma in a 2 year old female child which was operated on primarily and the 14 others by secondary intention. All patients were treated surgically with either closed (n = 5) or open (n=10) reduction and internal fixation with Kirschner wire or titanium elastic nails (TENs). They were assessed for clinical and radiological healing at a mean follow up of 1.25 years ranging from 0.5 to 2.0 years. Conclusion: Surgical option is indicated for severely displaced and unstable fractures in older children and adolescents. In addition to the periosteum , long head of the biceps, deltoid muscle, and bone fragments in combination can prevent fracture reduction. Key words: Proximal humerus fracture, Children, Open reduction, Operative

Joshi, Ruban Raj

Narang, Sagar

Sundararaj, G D

Journal of Lumbini Medical College

English

Background: In most children proximal humeral fractures are treated non-operatively with generally good results. The aim of the study was to evaluate the clinical outcome of closed/open reduction in children with severely displaced proximal humeral fractures. Materials and Methods: The charts of 15 patients (8 girls and 7 boys; mean age: 9.4 years) with proximal humeral fractures who were managed at our institution were reviewed from October 2011 to December 2013. Results: There were 7 metaphyseal fractures and 8 physeal injuries which were angulated according to Neer-Horowitz score as grade II (n=2), grade III(n=4) and grade IV(n=9). Associated lesions comprised open fracture with head trauma in a 2 year old female child which was operated on primarily and the 14 others by secondary intention. All patients were treated surgically with either closed (n = 5) or open (n=10) reduction and internal fixation with Kirschner wire or titanium elastic nails (TENs). They were assessed for clinical and radiological healing at a mean follow up of 1.25 years ranging from 0.5 to 2.0 years. Conclusion: Surgical option is indicated for severely displaced and unstable fractures in older children and adolescents. In addition to the periosteum , long head of the biceps, deltoid muscle, and bone fragments in combination can prevent fracture reduction. 
Key words: Proximal humerus fracture, Children, Open reduction, Operative

Ruban Raj Joshi, Dr

Sagar Narang, Dr

G D Sundararaj, Dr

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Fractures of the proximal humerus in children and adolescents

Journal of Lumbini Medical College (JLMC)

Original Research Articlejlmc.edu.np—–—————————————————————————————————————————ABSTRACT:Background: In most children proximal humeral fractures are treated non-operatively with generally good results. The aim of the study was to evaluate the clinical outcome of closed/open reduction in children with severely displaced proximal humeral fractures. Materials and Methods: The charts of 15 patients (8 girls and 7 boys; mean age: 9.4 years) with proximal humeral fractures who were managed at our institution were reviewed from  October 2011 to December 2013. Results: There were 7 metaphyseal fractures and 8 physeal injuries which were angulated according to Neer-Horowitz score as grade II (n=2), grade III(n=4) and grade IV(n=9). Associated lesions comprised open frac-ture with head trauma in a 2 year old female child which was  operated on primarily and the 14 others by secondary intention. All patients were treated surgically  with either closed (n = 5) or open (n=10) reduction and internal fixation with Kirschner wire or titanium elastic nails (TENs). They were assessed for clinical and radiological healing at a mean follow up of 1.25 years ranging from 0.5 to 2.0 years. Conclusion: Surgical option is indicated for severely displaced and unstable fractures in older children  and adolescents. In addition to the periosteum , long head of the biceps, deltoid muscle, and bone fragments in combination can prevent fracture reduction.Key words: Proximal humerus fracture,  Children, Open reduction,  Operative.—–—————————————————————————————————————————71J. Lumbini. Med. Coll. Vol 1, Issue 2, July-Dec 2013___________________________________________________________________________________a - Lecturer, b - Associate Professor, c - Professor and Head,d - Department of Orthopaedic Surgery & Traumatology,     Lumbini Medical College Teaching Hospital(LMCTH),      Palpa, Nepal.Corresponding Author:Dr. Ruban Raj Joshi,e-mail: dr_rubanjoshi@yahoo.comHow to cite:Joshi RR, Narang S, Sundararaj GD. Fractures of the proxi-mal humerus in children and adolescents. J Lumbini Med Coll, 2013;1(2):71-75. doi: ___________________________________________________________________________________Joshi RRa,d, Narang Sb,d, Sundararaj GDc,dFractures of the proximal humerus in children and adolescentsfact, approximately 80% of the longitudinal growth of the humerus comes from the proximal humeral phy-sis.4 The concern for disruption of the bone growth and remodelling leads surgeons to choose non-operative treatment regardless of the degree of displacement, angulation, rotation or translation. However, immobi-lization by a cast is lengthy, uncomfortable and hard for children to tolerate. The residual deformities after non-operative treatment, such as upper limb length discrepancy, humerus varus or humerus valgus, can lead to cosmetic problems due to the decreasing abil-ity of remodelling in older children.5 Therefore, some surgeons in recent years have recommended closed or open reduction and internal fixation for proximal hu-merus fractures in children, especially in teenagers.6,7 Introduction Proximal humeral fractures account for only 1% of all fractures in children and 3 to 6% of all epiphyseal injuries.1 The majority of proximal humeral fractures are either undisplaced or minimally displaced (Neer- Horowitz grade I–II) and can be managed non-opera-tively with a satisfactory outcome.2,3 However, in cases of severe humeral fractures with significant bone dis-placement (Neer- Horowitz grade III–IV), especially in teenagers, non-operative treatment is controversial. An important concern of surgeons while dealing with paediatric proximal humeral fracturesis the growth of the bone and the resulting remodelling potential. In Fig 1: Sex distributionJ. Lumbini. Med. Coll. Vol 1, Issue 2, July-Dec 2013 jlmc.edu.npJoshi RR et. al. Fractures of the proximal humerus in children and adolescents.72The methods of internal fracture fixation include per-cutaneous K-wires, staples, screws or plates.8–10 How-ever, complications such as pin tract infection, pin migration, osteomyelitis and loss of reduction have been reported using these modes of fracture fixation.8-11Methods: This was a retrospective study of patients treatedfor proximal humeral fractures at the Department of Orthopedic Surgery, Lumbini Medical College and Teaching Hospital, Palpa,  from October 2011 to De-cember 2013. There were 15 patients, 8 girls and 7 boys (Fig 1); their mean age was 9.4 years. All patients were skeletally immature as defined by open proximal humeral growth plates on the injured side at the time of injury based on plain radiographs. The most com-mon cause was tumbling during play or sports, fol-lowed by traffic accidents. None of the fractures was pathological. There were no associated neurovascular injuries in the arms There were 7 metaphyseal frac-tures and 8 epiphyseal fractures (two cases of type I and six cases of type II according to the Salter-Harris classification) (Fig 2 & 3). According to  Neer-Horow-itz classification, there were two cases of  type 2, four were type 3 and nine were type 4 (Fig 4). There was a 2 years girl (Fig 8) with an open proximal humer-us fracture (Gustilo type IIIA) due to fall from height and  was accompanied by head injury. Indications for surgery in all the patients were irreducibility in nine cases and re-displacement in six. All the children were treated with either closed or open reduction with K wires or TENs for severely displaced proximal hu-meral fractures. Open reduction via deltopectoral ap-proach & internal fixation with K wires was required in nine cases & one case (Fig 8; 9A,B) with an open fracture(Gustilo IIIA) was operated emergently with debridement  & k wire fixation. The remaining three patient had closed reduction internal fixation with K wires. Two patients were managed by closed reduction and  TENs were inserted by retrograde route (Fig 11).Outcome assessment: We undertook a retrospective review to evalu-ate outcomes including, clinical results, complications related to treatment and radiological assessments. Pa-tients were assessed clinically and radiographically at 6 weeks. 3 months, 6 months and annually and were ex-amined for fracture healing, angulation at the fracture site, premature closure of the growth plate and short-ening of the humerus. Radiological evaluations were carried out using anteriorposterior and lateral views of the humerus We adjudged the result excellent if shoul-der function was similar to the normal side, good if the function was normal with radiologic imperfections and fair when both were abnormal. The potential complica-tions related to treatment include neurovascular injury, Fig 2: Type of Fxs (MF: Metaphyseal fracture; PF: Physeal fractures)Fig 3: Salter Harris TypeFig 4: Neer - Horowitz gradeFig 5: Clinical picture of 11 years old boy with left proximal humerus fractureJ. Lumbini. Med. Coll. Vol 1, Issue 2, July-Dec 2013Joshi RR et. al. Fractures of the proximal humerus in children and adolescents.jlmc.edu.np73deep infection, pin tract infection, pin migration, loss of reduction and skin irritation. The evaluation of the clinical outcomes was both objective and subjective.Results : Patient presented to us at mean of 2 days fol-lowing injury & surgery was carried out at a mean of 4 days after their initial injury. A total of 5 fractures were reduced by closed reduction, while 10 patients underwent open reduction (Table 2), including one case with an open fractures (Fig 8) ; in seven cases it was found that the fracture site was interposed with periosteum, and in the other two cases the fracture site was interposed with the long head of the biceps & bone fragment. K-wire fixation was most common-ly used (85.7%), followed by retrograde elastic stable intramedullary nailing (14.28 %)(Table 1).  The surgi-cal approach utilized included a formal delto-pectoral approach in the majority of cases, in three cases, an oblique incision was made over the metaphysis an-terolaterally in order to obtain access to an interposed bony fragment. Postoperatively, all patients who were treated with K wire fixation were immobilised using a U splint until radiological union, at which time pins were removed. The follow up period averaged 1.25 years (range = 0.5 to 2.0 years). Radiological healing duration averaged 34 days (range = 28 - 40 days). At follow up, excellent and good results (Table 3) were achieved in all the patients and had non-painful shoul-der range of motion and normal rotator cuff strength (comparable to the opposite side) and returned to ac-tivities at a mean of 2.3. months from the time of the surgery. Implant removal was performed after a dura-tion of 6 to 10 weeks for K wires and after 6 months for TENs fixation.  One girl developed marked keloids and two patients had minor valgus deformity with of no clinical significance. Neither physeal arrest nor Implants n PercentK wires 13 86.7ESIN 2 13.3Total 15 100.0Table 1: Type of ImplantsTreatment n PercentCRIF 5 33.3ORIF 10 66.7Total 15 100.0Table 2: Treatment (CRIF: Closed reduction internal fiixation; ORIF: Open reduction internal fixation)Fig 7(A & B): Immediate Postoperative radiographs after K-wire fixationFig 6(A &B): Pre-operative anteroposterior (AP) radiograph, Salter-Harris type II fracture of the proximal humerus fractureFigure 8: 2 years old child with open proximal right  humerus fracture sustained from a fall while playingFigure: 9(A) Injury film; (B)Immediate Post op radiographs after K-wire fixationJ. Lumbini. Med. Coll. Vol 1, Issue 2, July-Dec 2013 jlmc.edu.npJoshi RR et. al. Fractures of the proximal humerus in children and adolescents.74avascular necrosis was observed. Major complications, such as deep infections, neurovascular injuries, loss of reduction and nail migration, were not observed. Skin irritation relating to prominent hardware occurred in three cases, and resolved following implant removal.Discussion: Traditionally, proximal humerus fractures in skeletally immature patients have been treated non-op-eratively due to the tremendous potential for remodeling and the wide functional arc of motion of the shoulder. As a result, even significantly angulated and displaced fractures have achieved union in positions that have al-lowed for normal or near-normal functional outcome. In children up to 10 years of age, axial malalignment of the proximal humerus of as much as 600 in varus, anteversion, or retroversion can be corrected by remod-eling; however, beyond 10 years of age, the remodeling potential is not as high and correction can be expected only with axial deformities of up to 20–300. Pahlavan et al.,15 in a systematic review of 569 proximal humer-us fractures treated in the literature from 1960 to 2010, found that patients below the age of 10 and above the age of 13 years should be treated as distinct patient populations. Through a review of patient outcomes in their review, the authors found that children less than 10 years of age should be treated non-operatively due to their tremendous remodeling potential, whereas pa-tients above the age of 13 years are candidates for open reduction and fixation due to a much more limited re-modeling potential. Furthermore, Dameron and Reibel evaluated 46 skeletally immature patients with proxi-mal humerus fractures and found that, in their patients above the age of 14 years, poor outcomes were noted due to loss of reduction.5 Kohler and Trillaud 13 report-ed their proximal humeral fracture experience and not-ed that, in their subset of older patients, operative inter-vention was warranted, as irreducible fractures could not remodel. In regards to severe displacement, Neer and Horwitz found that patients with severe displace-Results n PercentExellent 8 53.3Good 7 46.7Total 15 100.0Table 3:  OutcomeFig 11: (A)13 years old boy with proximal metadiaphyseal humeus fracture.(B) Post op reduction radiographs with a single retrograde TEN.Fig 10: (A) 3 months followup showing good function with complete union(B)Fig 12: (A&B) monthsl followup with excellent functionFig 13: (A) 7 months post-operative AP radiographs showing complete healing prior to flexible nail removal; (B) After implant removalJ. Lumbini. Med. Coll. Vol 1, Issue 2, July-Dec 2013Joshi RR et. al. Fractures of the proximal humerus in children and adolescents.jlmc.edu.np75ment (greater than 2/3rds of the humeral shaft) had per-sistent deformity and arm shortening compared to the contralateral side.2 In addition, Schwendenwein et al.14 examined 16 patients with significantly displaced prox-imal humeral fractures who underwent operative inter-vention with excellent results, recommending opera-tive treatment in displaced fractures. Due to the results of studies such as those mentioned above, operative indications for proximal humerus fractures are expand-ing, particularly in adolescent patients with displaced fractures.2,17 As in our nine  patients with age of ten or more, operative intervention can lead to good results. With an understanding of the indications for operative intervention (i.e., increased age, displacement, and an-gulation) which can lead to excellent results. Within our cohort of nine patients, all patients failed attempts at closed reduction either in the emergency room and/or the operating room. Not surprisingly, at the time of open reduction, all of them were found to have ana-tomical structures blocking reduction. Traditionally, the long head of the biceps and/or periosteum has been reported to prevent the reduction of proximal humerus fractures in a closed fashion.2,12,14 Bahrs et al.7 exam-ined 43 patients with proximal humerus fractures (33 treated operatively), in which 17 could not be closed re-duced under general anesthesia. In seven cases, the bi-ceps was entrapped, and in two cases, periosteum was entrapped. Yet, in our study, we found not only the peri-osteum and long head of the biceps  entrapped within the fracture site, but also deltoid muscle , as well as bony fragment. As a result, it would be quite difficult to achieve a reduction via closed means with these multi-ple structures within the fracture site. A myriad of open approaches can be utilized, although formal delto-pec-toral approaches were most commonly used. With knowledge of the appropriate indications for operative treatment and the need for a formal open approach to adequately address all interposed structures, it is criti-cal to understand the different fixation methods at the disposal of the treating surgeon. In our series, 85.7 % of patients underwent K-wire fixation, 14.28 % with flex-ible nails. All of our patients achieved excellent func-tional and radiographic outcomes, regardless of the implant utilized. Burgos-Flores et al.6 noted excellent results in 22 patients with displaced proximal humerus fractures treated with K-wire fixation at a mean of 6.8 years after surgery. Disadvantages of K-wire fixation include non-rigid fixation necessitating cumbersome post-operative immobilization, pin tract infections, and the need for secondary procedures to remove hard-ware. In addition, there is a risk for hardware breakage. In conclusion, operative treatment of proximal humer-us fractures, particularly in adolescents with severe displacement/angulation and failure of closed meth-ods, is increasingly being seen as an acceptable mo-dality of management. In addition to the long head of the biceps, periosteum, deltoid muscle, and bone frag-ments in combination can prevent fracture reduction. Surgeon preference and skill should dictate implant choice, as patients achieved excellent functional and radiographic outcomes at the final follow-up with the use of K-wires, flexible nails, or cannulated screws. The risk of physeal damage with these implants is low. Further randomized, controlled studies are neces-sary so as to examine the operative treatment of prox-imal humeral fractures in the adolescent population.1. Bishop JY, Flatow EL (2005) Pediatric shoulder trau-ma. Clin Orthop Relat Res 432:41–482. Neer CS, Horowitz BS (1965) Fractures of the proxi-mal humeral epiphyseal plate. Clin Orthop Relat Res 41:24–313. Larsen CF, Kiaer T, Lindequist S (1990) Fractures of the proximal humerus in children. Nine-year follow-up of 64 unoperated on cases. Acta Orthop Scand 61:255–2574. Pritchett JW (1988) Growth and prediction of growth in the upper extremity. J Bone Joint Surg Am 70:520–5255. Dameron TB Jr, Reibel DB (1969) Fractures involving the proximal humeral epiphyseal plate. J Bone Joint Surg Am 51:289–2976. Burgos-Flores J, Gonzalez-Herranz P, Lopez-Monde-jar JA et al (1993) Fractures of the proximal humeral epiphysis. Int Orthop 17: 16–197. Bahrs C, Zipplies S,Ochs BGet al (2009) Proximal hu-meral fractures in children and adolescents. J Pediatr Orthop 29:238–2428. Herscovici D Jr, Saunders DT, JohnsonMP et al (2000) Percutaneous fixation of proximal humeral fractures. Clin Orthop Relat Res 375: 97–1049. Vander Have K, Herrera J, Kohen R et al (2008) The use of locked plating in skeletally immature patients. J Am Acad Orthop Surg 16: 436–44110.  Watford KE, Jazrawi LM, Eglseder WA Jr (2009) Per-cutaneous fixation of unstable proximal humeral frac-tures with cannulated screws. Orthopedics 32:16611. Hutchinson PH, Bae DS, Waters PM (2011) Intra-medullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: a comparison of complications and early radiographic results. J Pediatr Orthop 31:617–62212. Pahlavan S, Baldwin KD, Pandya NK, Namdari S, Ho-salkar H (2011) Proximal humerus fractures in the pe-diatric population: a systematic review. J Child Orthop 5:187–19413. Kohler R, Trillaud JM (1983) Fracture and fracture sep-aration of the proximal humerus in children: report of 136 cases. J Pediatr Orthop 3:326–33214. Schwendenwein E, Hajdu S, Gaebler C, Stengg K, Ve´csei V (2004) Displaced fractures of the proximal humerus in children require open/closed reduction and internal fixation. Eur J Pediatr Surg 14:51–5515. Baxter MP, Wiley JJ (1986) Fractures of the proximal humeral epiphysis. 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Fractures of the proximal humerus in children and adolescents

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