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Developmental AnatomyOssification Centers & Physes
• scapular ossification centers – acromion, coracoid, glenoid, medial border
• proximal humeral physis – tent shaped, 80% of longitudinal growth
• medial clavicular physis – last to close 23-25 yrs
Clavicle Fracture
• most common fx in children
• 50% in <10 yo• usually midshaft• almost always heals,
usually clinically insignificant malunion
• remodels within 1 year• complications very
uncommon
Clavicle Fracture Patterns
• most in middle• 5% distal• < 5% medial• greenstick common• beware nutrient
foramen- not a fx
Clavicle Birth Fracture
• large baby• pseudoparalysis• simple immobilization• if no BP palsy active
movement should return early
Congenital Pseudarthrosis of the Clavicle
• right side• except with
dextrocardia• if symptomatic in
older child – excise, tricortical graft, fixation
Distal Clavicle Fracture
• often intact periosteum
• usually remodels• nonoperative tx
Distal Clavicle Fractures- Classification
• similar to adults• based on amount
& direction of displacement
Distal Clavicle Injuries Periosteal Sleeve
Medial Clavicular Injuries
• medial clavicular physis last to close – 22-24 yo
• clavicle shaft usually anterior
• may displace posteriorly
• serendipity view or CT if suspect
Scapula Fractures
• may be a sign of significant trauma
• usually nonoperative treatment
• growth centers may be confused with fracture
• axillary view often helpful
coracoid base fracture
Scapula Fractures - Classification
• can have fracture through common growth center of coracoid and glenoid
Scapula Fractures - Classification
• body• neck• glenoid• acromion• coracoid• intraarticular /
extrarticular
Glenohumeral Dislocations
• rare in children < 12 years old• high risk of recurrent instability when initial
dislocation occurs in childhood or adolescence
• anterior, Posterior or Inferior direction• traumatic or atraumatic etiology
Glenoid Dysplasia
• may predispose to instability
• may be primary or secondary (after brachial plexus palsy)
Traumatic Shoulder Dislocation
• gentle reduction• immobilization for
approx 3 weeks• shoulder rehabilitation• surgical stabilization
/reconstruction reserved for recurrent instability
Atraumatic Instability
• often multiple joint ligamentous laxity
• multidirectional instability usually present
• may be voluntary (discourage)
• rotator cuff strengthening
Proximal Humeral Fracture
• birth injuries• 0-5 yo SH I• 5-11 yo
metaphyseal• 11-maturity SH II• others rare (III, IV)
• proximal humeral epiphysis does not ossify until about age 6 months
• fusion occurs at about age 15 in girls and 17 in boys.
• shape of the physis is conical, with the apex pointing postermedial
• medial metaphysis is intra-articular• fractures of the proximal humerus < 5% of
children's fractures• birth injuries are transphyseal, with the proximal
humeral epiphysis not yet ossified at birth, the malalignment of the shaft to the glenoid is the only radiographic finding
Proximal Humeral Physeal Fractures Neer – Horowitz Classification
• grade I < 5 mm• grade II < 1/3 shaft
width• grade III < 2/3 shaft
width• grade IV > 2/3 shaft
width
• pull of rotator cuff & subscapularis on proximal fragment leave it abducted, flexed, and externally rotated
• pectoralis major pulls the distal fragment into adduction
• Dameron's acceptable reduction recommendation of 20 degrees in the older child is often quoted
• nonoperative treatment is favored for all fractures
• remodeling potential of proximal humerus is perhaps the most impressive in the body & mobility of shoulder surely compensates for residual deformity at skeletal maturity
• treatment options : manipulation and immobilization in sling &
swatheclosed reduction and percutaneous
pinningopen reductionno reduction using simply symptomatic
immobilization with arm in sling & swathe
Treatment• closed treatment for vast majority• if markedly displaced, attempt closed
reduction and immobilize• reserve closed reduction and pinning, open
reduction for fractures with significant displacement (> Neer II) in older adolescents, recurrent displacement
• reduction with traction, abduction, and flexion has been described, but with the generous remodeling potential of this site, good results are uniform
• proximal humeral fractures primarily are seen in infancy and adolescents
• fractures prior to adolescence are more often metaphyseal
• in adolescent, primarily physeal injuries, the vast majority Type II
J Bone Joint Surg Am. 1969;51:289-297.THOMAS B. DAMERON, JR. and DONALD B. REIBEL
Proximal Humerus – Acceptable Alignment
• great remodeling potential – 80% of humeral length contributed by proximal physis
• shoulder ROM compensatory• age dependent? – some studies state that even
older adolescents have acceptable functional outcomes after nonoperative treatment of prox humerus fxs
Early Healing Noted 3 Weeks after Closed Reduction in Adolescent
initial film 3 weeks after closed reduction
Metaphyseal Fracture
Remodeling over 6 Months
Pinning Proximal Humerus
• usually don’t need to• most recent studies quote high complication
rates (pin migration, infection)• if used leave pins long and bend outside
skin, consider threaded tip pins• even in older adolescents remodeling
occurs• few functional deficits
Percutaneous Pinningmay lead to pin migration
Pinning
• bend pins to prevent migration
• threaded tips
Complications of Proximal Humerus Fractures
• malunion with loss of shoulder ROM – rarely functionally significant
• shortening – up to 3 -4 cm seemingly well tolerated
• neurologic & vascular compromise less common than in adults
Humeral Shaft Fractures in Children
• neonates - birth trauma• birth- 3 yrs - consider possible non-accidental
trauma• 3-12 yrs - often pathologic fracture through
benign bone tumor or cyst• >12 yrs - treatment like adults
Birth Fractures
• simple immobilization• pseudoparalysis
• little attention to realignment or reduction needed
Pathologic Humeral Fracture - UBC
fallen leaf sign & also pseudosubluxation inferiorly
Humeral Shaft Fractures- Treatment
• usually closed methods
• sling and swathe• coaptation splint• fracture bracing• hanging arm cast
Shoulder Immobilization- Coaptation Splint
Humeral Shaft Outcomes
• malunion common, but usually little functional loss
• remodels well• initial fx shortening may be compensated for
by later overgrowth• nonunion uncommon• radial nerve palsy less common, if occurs
usually neuropraxia
Indications for Open ReductionShoulder Region Fractures
• open fractures• displaced intraarticular fractures• multiple trauma to facilitate rehabilitation• severe displacement with suspected soft
tissue interposition
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