Proximal Humerus, Scapula, and Clavicle

The clavicle is the most common site of all obstetrical fractures, with an incidence of 1% to 13% of all births.⁸³,¹⁰⁶,¹⁶⁰,¹⁹²,¹⁹⁴,²⁷²,⁴²⁷,⁴⁷⁴,⁴⁸⁰,⁵⁶⁷

The incidence of obstetrical clavicle fractures is increased for larger-birth weight infants.⁴⁰,¹⁰⁶,²⁷²,³³²
In addition, deliveries requiring the use of instruments or specialized
obstetric maneuvers are more likely to result in clavicular fractures.¹⁰⁶,¹⁹⁴,²⁷²,³³²
Based on these findings, it has been postulated that fractures in these
difficult deliveries result from lateral-to-medial pressure on the
shoulders during passage through the narrow birth canal. However,
despite the above trends, the majority of birth-related clavicular
fractures occur in deliveries of average-birth weight infants who
receive routine and otherwise uneventful obstetrical care. Thus, on the
whole, obstetrical clavicle fractures are sometimes unavoidable
consequences of vaginal deliveries for anatomic or physiologic reasons
that may not be evident before or even after delivery.

The most common mechanism of clavicular fractures in children is a fall onto the shoulder.³⁰²,⁴¹²,⁵²⁵ Other mechanisms include accidents where the traumatic insult is applied directly to the clavicle.⁵²⁵
Indirect applications of force, typically falling onto an outstretched
hand, are much less likely to result in clavicular fractures.⁵²⁵
Clavicular fractures may also occur in children victimized by child
abuse, but no pathognomonic pattern for isolated clavicular fractures
resulting from child abuse has been described.²³⁸,²⁹³

A significant amount of energy can be applied directly
to the clavicle during athletic activities such as football or
indirectly through athletic activities such as gymnastics. Most
commonly, the direct mechanism is responsible for clavicle fractures,
AC joint injuries, or sternoclavicular joint injuries.³¹⁴,⁴¹² A large proportion of these sports injuries may be preventable with the use of protective equipment and adequate padding.⁵¹² Although rare, stress fractures of the clavicle have been reported.²,⁵⁹³

Clavicular fractures in newborns may be difficult to
identify. The presence of generalized edema may prevent the palpation
of normal clavicular margins.¹⁹⁶ To
minimize pain, newborns with clavicular fractures demonstrate
pseudoparalysis of the affected arm, characterized by voluntary
splinting or immobilization of the ipsilateral arm.¹²⁵,³⁷⁴
This pseudoparalysis is similar in presentation to a brachial plexus
birth injury. To reduce the pull of the sternocleidomastoid muscle
across the fracture site, affected infants turn their head toward the
side of the fracture. In addition, infants with acute clavicular
fractures typically exhibit an asymmetric Moro reflex.⁴⁴³,⁴⁸⁵
In the absence of radiographic confirmation, the diagnosis of clavicle
fracture may be suspected and later confirmed after a mass is noticed
in the affected clavicle. This mass represents a healing fracture
callus that forms 7 to 10 days after the initial trauma. Often by this
point, the fracture is sufficiently stabilized by fracture callus that
it causes little discomfort to the infant. At this stage of healing,
the pseudoparalysis will resolve. If there is an associated, unresolved
birth palsy, neurologic limitations would persist.

Diagnosis of clavicular fractures in older children is
usually straightforward. Children have moderate to severe pain around
the area of the fracture and voluntarily immobilize and stop using the
affected arm. Tenderness, ecchymosis, and edema are invariably present;
in fractures with large displacement, a bony prominence or deformity
may be noted. Most children with clavicular fractures keep their heads
turned to the side of the fracture to relax the sternocleidomastoid
muscle.¹⁹⁶

Swelling, tenderness, and ecchymosis may be detected
over the affected joints in children with either AC or sternoclavicular
joint injuries. The children usually self-protect against painful
motion of the limb. True dislocations of the AC joint or the
sternoclavicular joint are rare. Injuries to the medial and lateral end
of the clavicle in children are more commonly physeal fractures.

Atlantoaxial (C1-C2) rotatory displacement (subluxation)
and clavicular fracture occur together on rare occasions. Attributing
acute torticollis entirely to the clavicular fracture may delay the
diagnosis of atlantoaxial displacement, and delayed diagnosis of
atlantoaxial displacement increases the risk of permanent atlantoaxial
rotatory fixation.³,⁵⁷
When present, the child’s head will be laterally bent toward and
rotated away from the fractured clavicle. The diagnosis of C1-C2
subluxation is best confirmed by dynamic computed tomography (CT).

Posterior fracture-dislocations of the medial clavicle
are particularly worrisome for associated injury or compression of the
great vessels, the esophagus, or the trachea.¹⁸⁴,⁵⁹¹
Suspicion of these injuries is further increased in children who have
difficulty speaking, breathing, or swallowing. Pulses in the
ipsilateral upper extremity may be diminished or absent, and the neck
veins may be distended if there is vascular compromise from the
displaced medial clavicle. Any of these injuries associated with
posterior sternoclavicular joint dislocations can be life-threatening,
and precautionary diagnostic and treatment steps should be taken at the
onset of treatment. If available, a thoracic or vascular surgeon should
be consulted or notified prior to reduction attempts.

Imaging Studies. An anteroposterior (AP) radiograph of
the clavicle is the standard study for a clavicular fracture. In
addition, ultrasonography has been a valuable supplement in
establishing the diagnosis of clavicular fractures in neonates.²³⁰,²⁸⁵,²⁸⁷ Ultrasonography can be used to detect occult clavicular fractures.²⁰³,⁴⁴² Bone healing may be detected on ultrasound 1 week before on radiographs.

For older children, other radiographic studies may be
necessary to supplement the AP radiograph in evaluating the clavicular
fracture. For fractures in the middle third of the clavicle, several
views may be beneficial: cephalad-directed views, the apical oblique
view, and the apical lordotic view. The cephalad-directed views are
helpful in illustrating the degree of fracture displacement. These
views are taken with the x-ray beam 20 to

40 degrees cephalad to the clavicle (Fig. 17-2A).
The apical oblique view is taken with the x-ray beam 45 degrees lateral
to the axial axis of the body and 20 degrees cephalad to the clavicle.
This view is better suited to identify fractures in the middle third of
the clavicle, where significant curvature is present in the bone.⁵⁷⁴
The apical lordotic view is a perpendicular view of the AP radiograph.
It is taken laterally with the shoulder abducted more than 130 degrees (Fig.17-2B).
This degree of shoulder abduction, however, can cause significant
discomfort in children with acute clavicular fractures. Therefore, this
radiographic view may be better suited for evaluating the healing of
the clavicular fracture rather than for the initial assessment of the
fracture.⁴⁵⁶

Fractures in the lateral aspect of the clavicle may
require additional radiographic views for full assessment. In addition
to the views mentioned above, an axillary lateral view is helpful in
evaluating the fracture and its displacement. If the injury to the
lateral clavicle or the AC joint is not obvious on the radiographs, a
radiographic stress view with the child holding 5 to 10 pounds of
weight with his or her hand or having an assistant gently pull on the
arm downward is helpful. The stress view may show subtle injuries to
the distal clavicle or the degree of instability with ligamentous
injuries to AC joint. If enhanced evaluation of the AC joint is
desired, a CT scan should be performed.

Additional radiographic views are usually necessary to
characterize fractures of the medial third of the clavicle and
sternoclavicular injuries. The “serendipity” view, where a broad x-ray
beam with 40 degrees of cephalic tilt projects both clavicles on the
same film, is helpful for evaluating fractures in this portion of the
clavicle (Fig. 17-3).⁴⁵⁹
By comparing with the uninjured contralateral side, the location of
injury and the degree of displacement often can be determined. However,
this view can be difficult to interpret, especially for mild injuries.
Currently, CT is the best method for evaluating injuries in the medial
third of the clavicle. Thin slice CT provides detailed information
about the morphology of the medial clavicle, the medial physis, the
degree of displacement, and possible injury to the underlying
intrathoracic structures (Fig. 17-4). Virtually
every acute injury of the medial end of the clavicle should be
evaluated with CT, and it also is useful for follow-up of chronic
injuries.

Classification. Because of differences in the mechanism
and rate of injury, prognosis, and treatment options, clavicular
fractures

are broadly categorized by their anatomic location: medial third, middle third, and distal third (Fig. 17-5). Most clavicular fractures occur at the middle third, with the reported rates ranging from 76% to 85%.³⁸⁶,⁴¹² The second most common site of clavicular injury is the distal third, with the reported rates between 10% and 21%.³⁸⁶,⁴¹²,⁴⁵¹,⁴⁶⁹ Fractures in the medial third of the clavicle are relatively uncommon and represent only 3% to 5% of all clavicular fractures.⁴¹²,⁴⁶⁹

The commonly used classification for clavicular fracture is based on the anatomic location of the fracture (see Fig. 17-5).⁸
Type I fractures occur in the middle third of the clavicle and
generally include all fractures lateral to the sternocleidomastoid
muscle and medial to the coracoclavicular ligament. Type II fractures
are in the distal clavicle, including all injuries lateral to the
coracoclavicular ligament. Type III fractures are medial to the
sternocleidomastoid muscle. Within this general framework, further
classifications exist for injuries to the distal and medial ends of the
clavicle.

Distal Clavicular Injuries.
Distal clavicular fractures lateral to the coracoclavicular ligament
and injuries to the AC joint are categorized by a system proposed by
Dameron and Rockwood

(Fig. 17-6).¹²⁵
Although derived from the system for adult distal clavicular injuries,
this classification system incorporates the observation that the distal
clavicle displaces through a disruption in its periosteal sleeve rather
than by true disruption of the coracoclavicular ligaments. Also, true
AC dislocations rarely occur in children. Most injuries in this region
are either metaphyseal or physeal fractures.¹⁵⁹,⁴²⁰
However, because distal clavicular epiphyseal ossification does not
occur until age 18 or 19, these injuries may have the radiographic
appearance of an AC dislocation rather than a fracture
(pseudodislocation).¹⁵⁹,⁴²⁰,⁵⁴³

Type I AC injuries are caused by low-energy trauma and
are characterized by mild strains of the ligaments or periosteal tears.
No gross changes are seen on radiographs. Type II injury includes
complete disruption of the AC ligaments or lateral periosteal
attachment, with mild damage to the superolateral aspect of the
periosteal sleeve. Mild instability of the distal clavicle results from
this type of injury, and minimal widening of the AC joint may be seen
on a radiograph. In type III injury, complete disruption of the AC
ligaments or periosteal attachment occurs in addition to a large
disruption in the superolateral periosteal sleeve. Noticeable superior
displacement of the distal clavicle is seen on an AP radiograph, and
the coracoid-clavicle interval is 25% to 100% greater than on the
contralateral uninjured side.⁷³,¹²⁶
Similar soft tissue disruptions are seen in type IV injuries. The
distal clavicle, however, is displaced posteriorly and is often
embedded in the trapezius muscle.³¹
Minimal changes may be noted on an AP radiograph, and an axillary
lateral radiograph may be required to identify the posterior clavicular
displacement. Type V injuries are similar to type III injuries; the
difference lies in the fact that the superior aspect of the periosteal
sleeve is completely disrupted in type V injuries. This allows
displacement of the distal clavicle into the subcutaneous tissues,
occasionally splitting the deltoid and the trapezius muscles. On an AP
radiograph, the coracoid-clavicle interval is more than 100% greater
than on the contralateral uninjured side. In type VI injuries, the
distal clavicle is displaced inferiorly, with its distal end located
inferior to the coracoid process.¹⁸⁸

Medial Clavicular Injuries.
The medial physis of the clavicle is the last physis in the body to
close, and the fusion of this epiphysis to the shaft occurs as late as
23 to 25 years of age.²⁷⁴,⁵⁷² The sternoclavicular ligaments attach primarily to the epiphysis, leaving the physis unprotected outside the capsule.²⁹⁶
Because of its unique anatomy, traumatic insults to the medial end of
the clavicle in children usually result in fractures through the physis
rather than dislocations through the sternoclavicular joint. Therefore,
these injuries are categorized most appropriately in the Salter-Harris
classification system.⁴⁸¹ Most
fractures at the medial end of the clavicle are Salter-Harris type I or
II fractures. These injuries are further subdivided by the direction of
the clavicular displacement, either anterior or posterior. Although
anterior displacement of the clavicle occurs more frequently, more
attention is given to fractures with posterior displacement due to the
possibility of concomitant mediastinal injuries requiring emergent
intervention. Many anterior instability patients have ligamentous
laxity and no significant traumatic history. Posterior
fracture-dislocations are usually secondary to an adduction force, such
as a soccer goalie fall on the ground.

Treatment of the birth-related clavicle fracture is
nonoperative. If the infant appears to be in significant discomfort,
the affected arm can be immobilized to the body for a short period of
time, typically less than 2 weeks. Immobilization of the affected arm
can be easily and effectively accomplished by using a safety pin

to attach the long shirt sleeve to the shirt or simple stockinette sling.²⁷⁹,³⁶¹,⁴⁸⁴
The parents should be warned not to disturb the upper extremity by
unnecessary movements in the acute period. In addition, they should be
informed that the infant will develop a noticeable mass over the
fracture site that will typically resolve within 6 months.⁴⁴³

In older children, good to excellent results also can be
expected from nonoperative treatment with a sling or figure-of-eight
splint. This is particularly true in younger children. Furthermore,
reduction of clavicle fracture is seldom necessary because of the great
potential for remodeling these fractures.⁴²²

A sling to support the weight of the arm is sufficient
treatment in most cases of diaphyseal clavicle fractures. Use of a
sling is typically well tolerated by children and is not associated
with any of the difficulties of the figure-of-eight splint. Treatment
of both nondisplaced and displaced clavicular fractures with a sling
has shown remarkably good results. In fact, in comparison with a
figure-of-eight splint, treatment of clavicular fractures with a sling
resulted in similar final outcomes.¹³,²⁷³,⁵²⁴
One review found that complications such as nonunion, malunion, and
neurovascular problems were so rare in pediatric clavicle fractures
that follow-up beyond the initial visit was not necessary.⁸¹

Nonoperative treatment with a figure-of-eight splint has also produced successful outcomes.²⁷³,³⁹⁸,⁴⁴³,⁴⁸⁶
Although reduction of the fracture is not required for a successful
outcome, correct application of the figure-of-eight splint retracts the
shoulders and may achieve improved alignment of the fracture.⁴²²
However, the figure-of-eight splint can be difficult to keep in proper
alignment and sometimes is poorly tolerated because of discomfort.
Caution must be exercised when using the figure-of-eight splint in
order to avoid known complications, such as edema, compression of the
axillary vessels, and brachial plexopathy.¹⁷¹,³²⁴,³⁹⁸

Historically, indications for operative treatment of
middle third clavicular fractures include severely displaced and
irreducible fractures that threaten skin integrity, concomitant
vascular injury requiring repair, irreducible compression of the
subclavian vessels, compromise of the brachial plexus, and open
fractures.²⁵²,²⁶⁷,³⁹⁶,⁴³⁹,⁵⁹⁸
In addition, as discussed separately in this chapter, concomitant
displaced fractures in various regions of the scapula, including the
acromion, the coracoid, and the scapular neck, may compromise the SSSC
and require operative repair.²⁰²
However, a prospective, randomized study reported that operatively
treated adult clavicle fractures had improved functional outcomes,
decreased time to union, and fewer symptomatic malunions and nonunions
than those treated nonoperatively with a sling.⁸⁴
While the patients treated operatively also had more hardware-related
complications, the study supported primary plate fixation of midshaft
clavicle fractures in adults. Therefore, internal fixation can be
offered to active, skeletally mature adolescents and young adults with
displaced diaphyseal clavicle fractures (Fig. 17-8).

For the surgical case, either plating or intramedullary fixation

can be performed. Various precontoured clavicle plates are available.
Intramedullary stabilization with elastic nails or screws is a less
invasive procedure.²⁸⁰,³⁰⁴
Because of the subcutaneous location of the clavicle, implant
prominence can be expected and may lead to soft tissue irritation.⁸⁴

Injuries to the distal clavicle in the pediatric
population typically are pseudodislocations of the AC joint, with
fractures through the metaphysis or the physis and fracture
displacement through the torn periosteum.¹⁵²,⁴²⁰
The AC joint and the coracoclavicular ligaments usually are undamaged.
Therefore, exceptional potential remodeling exists for these fractures,
allowing successful nonoperative treatment for most injuries to the
distal clavicle.

Most investigators agree that nondisplaced or minimally
displaced injuries of the distal clavicle (types I, II, and III) are
treated without surgery.⁵⁰,¹²⁵,²²³,⁴²⁰,⁴⁶⁰
These injuries are managed with a sling immobilization followed by
early rehabilitation with range-of-motion exercises. Most children
treated with nonoperative management have no significant long-term
functional or cosmetic deficits.

The treatment of displaced types IV, V, and VI distal
clavicle fractures remains controversial. Some investigators report
that most children experience no functional deficits regardless of the
method of treatment.⁵⁰,²²³
Others report that distal clavicular injuries with either fixed or
gross displacement should be treated with open reduction. In the young,
this involves periosteal repair and internal fixation in the older
patient to prevent permanent deformity.²⁸,⁷³,¹²⁵,¹²⁷,¹⁵⁹,²²³,⁴²⁰,⁴⁶⁶
One report suggested that although displaced distal clavicular injuries
in children under 13 years of age may be amenable to nonoperative
treatment, those in children over 13 years of age should be treated
with open reduction and internal fixation.¹⁵² Any intra-articular fracture fragment displacement, similar to an adult injury, requires anatomic reduction and fixation.

Although no clear consensus exists for the treatment of
grossly displaced distal clavicular fractures in children, as long as
the integrity of the SSSC is maintained, it appears that neither
nonoperative nor operative management results in long-term deficit in
the normal function of the shoulder. Treatment options, therefore,
should be individualized for each child and his or her family based on
compliance as well as acceptance of the possible cosmetic deformity.

Most pediatric injuries in the medial clavicle are
fractures through the physis. Similar to distal clavicular injuries,
there is debate regarding the remodeling potential of these fractures.
Acute posteriorly displaced injuries are more commonly treated with
operative reduction and repair now.¹⁹⁸,⁵⁶⁹

Nondisplaced fractures of the medial physis do not
require active intervention. Symptomatic treatment is all that is
required for these stable fractures. In fact, nondisplaced fractures
often are missed during initial examination and are only discovered
after a mass or bump is noted over the medial clavicle and periosteal
healing is seen on the radiograph. The patient and parents should be
informed that the mass is a healing callus surrounding the fracture and
that it should remodel and disappear in 4 to 8 months.

Most anterior displaced sternoclavicular dislocations
are associated with atraumatic, generalized ligamentous laxity, similar
to multidirectional instability of the shoulder. These will
spontaneously reduce with shoulder motion and do not require emergency
room or acute operative care. Appropriate physical therapy and patience
is recommended. Late reconstruction for chronic, symptomatic
instability has variable results.²⁷
There are rare acute, anterior traumatic dislocations. In adults, this
has been seen in power weightlifters with disruption of the anterior
ligaments. Closed reduction can be performed by longitudinal traction
to the affected upper extremity while the shoulder is abducted to 90
degrees.⁴⁸⁴ Gentle posterior
pressure also should be applied over the fracture for reduction. After
the reduction is accomplished, the clavicle should be immobilized with
a figure-of-eight splint.⁴⁸⁴
However, anteriorly displaced sternoclavicular dislocations do not pose
a risk to the underlying mediastinal structures, and once achieved,
maintenance of reduction can be difficult to maintain. Moreover, while
a cosmetic deformity exists, there is no evidence that there is a
decrease in shoulder function.⁴⁸
Therefore, management without reduction and with a sling or
figure-of-eight sling is acceptable. With the rare, anteriorly
displaced physeal fracture, remodeling may occur in the young.

Posteriorly displaced medial clavicular fractures and
sternoclavicular dislocations require immediate evaluation for the
presence of concomitant injuries of the airway and/or great vessels. CT
scans are mandatory to assess the degree of displacement. Nondisplaced
and minimally displaced fractures can be treated without reduction.
These mild injuries can be expected to remodel without significant
residual deformity or pain. For fractures and dislocations with
significant posterior displacement or those associated with compromise
of the airway or great vessels, reduction should be performed. The
timing of this is based on whether the underlying structures are
compressed and whether the compression is causing respiratory or
hemodynamic compromise. Under general anesthesia, closed reduction has
been recommended, followed by open reduction if necessary. It is
advisable to notify thoracic surgery before beginning reduction in the
operating room in case of a mediastinal emergency and surgical
instruments should be prepared for a possible open reduction. Excellent
results have been reported with open reduction and stabilization with
either nonabsorbable or wire suture, and many centers now utilize this
as primary, definitive treatment for posterior fracture-dislocations of
the medial clavicle.¹⁹⁸,⁵⁶⁹

Technique of Closed Reduction. After induction of
general anesthesia, a bolster is placed in the midline between the
scapulae with the patient in the supine position. This positioning
alone may cause reduction. Gentle longitudinal traction through the
ipsilateral arm is then applied if necessary. If these reduction
maneuvers are unsuccessful, direct reduction using a sterile towel clip
is then attempted. After sterile preparation of the skin, the surgeon
pierces the skin with the towel clip and grasps the medial end of the
clavicle while an assistant applies longitudinal traction to the
ipsilateral upper arm. The clavicle is then manipulated into a reduced
position.⁴⁸⁴ If the above reduction
techniques are unsuccessful or the reduction is unstable, then open
reduction is performed. In many centers, closed reduction is no longer
attempted and open repair is primary treatment due to loss of reduction
by closed treatment.

Technique of Open Reduction. The entire ipsilateral
chest, clavicle, and mediastinum to opposite anterior chest is prepped
in case of a surgical mediastinal emergency with reduction. An anterior
incision is utilized from the midportion of the clavicle to the
sternum. Dissection is carried through the platysma and fascia to the
periosteum while protecting the sensory nerves. Anterior periosteal
incision is started laterally to safely identify the bone. Care is
taken in dissection medially as the clavicle is displaced into the
mediastinum. Anterior dissection is completed to the sternum while
protecting the intact soft tissue attachments medially from the sternum
to the epiphysis in the posteriorly displaced, physeal fractures. A
bone-holding clamp is applied to the clavicle, and the anesthesiologist
is notified that reduction is to be performed. Reduction to anatomic
location is achieved. Careful hemodynamic monitoring is observed. If
all is well, then repair is performed. In the situation of a fracture,
nonabsorbable sutures are passed from the anterior medial metaphysis to
the epiphysis through drill holes. In the less common posterior
dislocation, the sutures are passed from the anterior sternum to the
epiphysis. Periosteal repair is then performed and this provides
anatomic reduction and stability. Internal fixation with metal implants
is contraindicated because of the possibility of implant migration with
resulting potential serious or fatal consequences.¹⁰³

A figure-of-eight harness or sling-and-swathe is used
for postoperative immobilization for 4 to 6 weeks, followed by
range-of-motion and strengthening rehabilitation. Return to sports is
delayed until 3 months.

Serious vascular injuries also have been described in
association with clavicular fractures, including subclavian and
axillary artery disruption, subclavian vessel compression, and the
development of a arteriovenous fistula.³⁷,²⁵²,²⁷⁶,³⁸⁷,⁵⁴⁷
In addition, displaced fractures of the medial clavicle may result in
compression or injury of the great vessels within the mediastinum.¹⁸⁴,⁵⁹¹
Occasionally, these compressions can be relieved nonoperatively by
reducing the fracture and eliminating the excessive pressure on the
vessels.²⁵²,³⁸⁷
However, if nonoperative treatment does not alleviate the vascular
compromise, operative reduction of the fracture and possible vascular
repair may be required. Certainly, if the structural integrity of the
vessels is compromised, operative repair by an experienced vascular or
thoracic surgeon is necessary.

In addition to the compression of the great vessels,
displaced medial clavicular fractures can result in compression of the
trachea and esophagus, causing difficulty with speech, the airway, or
with swallowing (dysphonia or dysphagia).¹⁸⁴,⁵⁹¹ Clavicular fractures resulting from severe trauma can be associated with pneumothorax.¹⁴⁶,³⁸² Rarely, a pneumothorax results from obstetrical clavicular fractures.³⁵⁰

Neurologic deficits of the brachial plexus have been
reported in association with both birth-related and traumatic
clavicular fractures. Brachial plexus palsy may present early or late
after the traumatic insult and occasionally requires operative
reduction of the fracture.³⁷,¹³¹,¹³²,²⁵²,²⁶⁸ Rarely, nerve deficits can result from inappropriate use of the figure-of-eight splints.³²⁴,³⁹⁸ Although permanent nerve deficits have been reported, most brachial plexus injuries resolve spontaneously.²⁶⁸,²⁷⁷

Open reduction and internal fixation devices for
clavicular fractures have been associated with numerous complications,
including hardware irritation, migration, infection, and nonunion.¹⁰³,¹⁷⁰,³⁷³,³⁷⁴,⁴⁰⁸,⁴⁹³,⁴⁹⁴
Although most of these complications can be adequately treated, there
have been serious, even fatal, results from hardware migration.¹⁰³
Therefore, whenever possible, fixation of pediatric clavicular
fractures should use nonmigratory, low-profile hardware. If plate
fixation is utilized, implant removal may be necessary and carries with
it the risk of refracture.

Malunions are common after initial fracture healing, but
most children experience no long-term deformities because of their
tremendous potential for remodeling. Older patients with segmental or
marked fracture displacement may have symptomatic malunions.
Exostectomy or osteotomy have been performed in these circumstances.
Refracture does occur in less than 3% of clavicle fractures. Return to
contact sports should take this risk into consideration. Rare cases of
clavicular reduplication and cleidoscapular synostosis have been
reported.⁴²⁰,⁴⁵² These unusual complications may require additional intervention.

Nonunions following traumatic clavicular fractures
should be distinguished from congenital pseudarthrosis and
pseudarthrosis secondary to other pathologic processes.⁷²,⁷⁷,⁴⁰⁸,⁴²⁹,⁴⁵¹,⁵⁶⁶,⁵⁸⁴ Operative indications for posttraumatic clavicle fracture pseudarthroses are unacceptable cosmetic deformity and pain.⁵⁵,⁷⁷,³⁶⁴,⁵⁸⁴
However, operative repair with grafting and internal fixation of the
pseudarthroses have been associated with additional iatrogenic
complications, such as pneumothorax, subclavian vessel damage, air
embolism, and brachial plexus deficit.¹⁵⁷

Glenoid. Fractures of the glenoid typically occur in a fall onto an upper extremity. This is believed to drive the humeral head

into the glenoid fossa, which in turn results in the fracture.
Depending on the direction of the force, the fracture may injure the
rim of the glenoid or the entire glenoid fossa. Less commonly,
fractures may result from direct trauma to the glenoid.

Body of Scapula. Fractures to the body of the scapula
occur via direct impact or avulsion mechanisms. The direct impact
mechanism is typically of high-energy and rarely is an isolated injury.
As with all other high-energy injuries, child abuse must be excluded as
a cause for scapular injury when no clear traumatic cause is evident.²⁹⁶ The avulsion-type fractures may occur at any of the several muscle attachments on the scapula.

Children with scapular fractures have significant pain
and tenderness around the shoulder girdle and resist movement of the
affected arm. Localized edema may obscure the overall shoulder contour,
which may be more evident by comparison with the contralateral
shoulder. The diagnosis of scapular fractures is frequently missed
because of the attention required by more significant injuries.

Greater than 75% of patients with scapular fractures have associated injuries,⁴,²⁶¹,⁴⁷¹,⁵⁴⁰
many of which are life-threatening. In one reported series, the rate of
death among patients with scapular fractures exceeded 14%.⁵⁴⁰

Because of the proximity of the scapula to the axillary
artery and the brachial plexus, fractures of the scapula often are
associated with neurovascular injury.⁵⁴⁰
The ipsilateral arm must be carefully examined to document arterial or
neurologic deficits before the initiation of treatment. When injury to
axillary or distal vasculature is suspected, an angiogram may be
performed to examine the integrity of the vessels.

Scapular fractures also are associated with several
life-threatening injuries, such as hemothorax, pneumothorax, cardiac
contusions, as well as fractures of the spine, clavicle, rib, and
humerus.³⁷⁷,⁵⁴⁰

Scapular fractures typically are discovered during the
evaluation of the multiply injured patient. In the rare case where the
scapular fracture is the initially identified fracture, a complete
trauma evaluation should be undertaken for head, chest, abdominal, and
retroperitoneal injuries. If suspicion is high, a general trauma
evaluation may be requested. Conversely, scrutiny for fractures of the
scapula should be included in the evaluation of the multiply
traumatized child.

Imaging Studies. Most scapular injuries are identified
initially on the AP chest radiograph from a trauma series. However, AP
and lateral radiographs of the scapula will facilitate detection of
fractures not evident on the AP chest view, as well as allowing better
description of the fracture pattern. In addition to these, other
special radiographic views can aid in fracture characterization. The
Stryker notch view, for example, better reveals coracoid fractures,
whereas the axillary lateral view is better suited to identify glenoid
fractures. The axillary lateral view also is helpful in confirming the
location of the humeral head with the glenoid. When available, CT with
three-dimensional reconstruction provides the most detailed
representation of scapular anatomy. In addition, CT is essential in
characterizing intra-articular injuries of the glenoid.

In high-energy trauma, the AP chest radiograph should
also be scrutinized for evidence of scapulothoracic dissociation.
Scapulothoracic dissociation typically occurs in patients with massive,
direct trauma to the chest or proximal upper extremity and is highly
associated with ipsilateral neurovascular injury.¹⁵⁰,⁴⁷¹
This devastating injury should be suspected if the medial border of the
scapula is displaced laterally, if there is a clavicular fracture with
a large displacement, or if there is a complete AC joint separation
with large displacement.¹¹,⁴²⁸

Developmental variations in scapular anatomy may confuse
radiographic interpretation. For example, os acromiale is commonly
mistaken for an acute fracture. This variation occurs when the centers
of ossification in the acromion fail to unite.⁹⁹
Os acromiale is considered a normal variant, is present in 10% of
normal shoulders, and is bilateral in 60% of affected individuals.¹¹,³³⁵
Typically, os acromiale is located in the anterior and inferior aspect
of the distal acromion and has a smooth and uniform appearance on
radiographs. Occasionally os acromiale is symptomatic. If radiographic
studies and clinical examination cannot distinguish between a fracture
and a developmental variation, further evaluation with a bone scan may
clarify the diagnosis.¹⁵⁰ Other
variants in scapular anatomy include Sprengel’s anomaly, absent
acromion, bipartite or tripartite acromion, bipartite coracoid, and
coracoid duplication.⁹⁹,²⁹⁰,³⁷⁵,⁴³⁰,⁴⁸³

Classification. Multiple classification systems for
scapular fractures have been reported. Many are descriptive and based
primarily on the anatomic location of fracture. Ada and Miller⁴
divided scapular fractures into categories of acromion, spine,
coracoid, neck, glenoid, and body. In their series of children and
adults, fractures occurred most often in the body (35%), followed by
the neck (27%); fractures of the coracoid were least common (7%).⁴ Thompson et al.⁵⁴⁰
classified scapular fractures into three broad anatomic locations:
fractures of the glenoid and the glenoid neck, fractures of the
acromion and the coracoid, and fractures of the body (Fig 17-9). Other anatomic location-based scapular classifications have been reported by Imatani²⁶¹ and by Wilbur and Evans.⁵⁸³

The classification described below is also based on the
anatomic location of the fracture, with additional subclassifications
based on multiple reported studies (see Fig. 17-9 and Table 17-3).
However, most of these studies are not specific for pediatric scapular
fractures, so application of this classification system and its
supportive studies to pediatric scapular fractures should be
individualized to each child. The fracture should be adequately
evaluated for its anatomic location, displacement, comminution, and
articular involvement. In addition, ipsilateral neurovascular status,
the overall status of the patient, and other concomitant injuries
should be fully characterized.

Fractures of the body and the spine of the scapula,
which make up nearly 50% of all scapular fractures, are broadly
categorized into those with and without displacement. Although an
isolated fracture of the scapular neck is believed to be a stable bony
construct, ipsilateral fractures to both the scapular neck and the
clavicle may lead to disruption of the suspensory mechanism of the
shoulder.²⁰²,³³⁰ Therefore, fractures of the scapular neck are categorized into those with and without concomitant

injury to the clavicle. For similar considerations, fractures of the
coracoid process are categorized into those with and without
concomitant injury to the AC joint.

Fractures of the acromion are categorized into those
with and without displacement. Displaced fractures are further
subclassified based on the presence or absence of subacromial
narrowing. Subacromial space narrowing may occur after inferior
displacement of the acromion or after superior displacement of an
ipsilateral glenoid fracture. When treated conservatively, these
fracture patterns often lead to subacromial impingement in adults and
result in decreased range of shoulder motion and increased shoulder
pain.³⁰⁵ Although its applicability
to acromial fractures in younger children is still debated, this
finding significantly affects the treatment options for acromial
fractures in older children.

Fractures of the glenoid typically occur when the
humeral head is driven onto the glenoid fossa. Depending on the
direction of the force applied to the humeral head, the fracture may
involve the entire fossa or just the rim. If the entire fossa is
involved, the fracture line may then exit in multiple locations about
the scapula. Hence, fractures of the glenoid are classified into five
distinct groups based on their anatomic location and course of the
fracture. This system was initially proposed by Ideberg²⁵⁷,²⁵⁸ and later expanded by Goss.²⁰¹
Type I fractures are isolated glenoid rim fractures, with Ia involving
the anterior rim and Ib involving the posterior rim. Type II, III, and
IV fractures are glenoid fractures with fracture lines exiting through
lateral, superior, and medial aspects of the scapula, respectively.
Type V fractures are various combinations of type II, III, and IV
fractures. Type Va, for example, is a combination of types II and IV.
Type Vb is a combination of types III and IV, whereas type Vc is a
combination of types II, III, and IV. Type VI fractures are comminuted
fractures of the glenoid fossa. These various types of glenoid
fractures are associated with distinct patterns of morbidity and
treatment options.

Scapulothoracic dissociation occurs when all attachments
or articulations between the thorax and the scapula are completely
severed. When there is an ipsilateral neurovascular injury, it is
sometimes referred to as a forequarter amputation. This is in contrast
to scapulothoracic dislocation, where only the inferior scapulothoracic
articulation is displaced.¹⁵⁰ Although intrathoracic dissociations have been reported,⁴⁰⁶
scapulothoracic dissociations are typically laterally displaced. These
injuries are categorized as open or closed with intact or compromised
neurovascular status.

Complications of scapular fractures are rare. The
concomitant injuries frequently associated with scapular fractures were
discussed throughout this section.¹¹,²⁶¹,⁴⁷¹,⁵⁴⁰
Due to their proximity, the axillary and the suprascapular nerves may
be injured in association with glenoid and coracoid fractures,
respectively.³⁷⁶,⁴⁰²
In addition, the energy required to create scapular fractures likely
results in other injuries, such as rib fractures, pneumothorax, and
vascular avulsions. All or portions of the lower brachial plexus are
susceptible to injury with scapulothoracic dissociations.¹⁵⁰,⁴²⁸,⁴⁸³ This devastating injury also has been associated with the development of compartment syndrome in the upper arm.⁵⁸⁸
The presence of a complete brachial plexus avulsion is predictive of a
poor functional outcome with a scapulothoracic dissociation.⁵⁹⁷

Late complications associated with scapular fractures
generally involve improper functioning of the upper extremity.
Displaced fractures of the scapular body and spine, for example,
infrequently result in upper extremity weakness and pain with movement.⁴
Similarly, fractures of the acromion can result in pain and decreased
range of upper extremity motion secondary to subacromial impingement.³⁰⁵
Displaced intra-articular fractures of the glenoid are associated with
glenohumeral subluxation or dislocation, as well as early progression
of degenerative arthritis.¹³⁴,²¹⁴,²⁰²,²²¹

Symptomatic nonunion of scapula body fractures has been reported.¹⁶³,²⁸²
Most problems related to injuries of the scapula are not necessarily
related to treatment but are more often related to failure to
accurately evaluate associated major systems injuries.

Traumatic Dislocations. Significant evidence of trauma
should be present to assign patients to this group, whereas patients
who dislocate with relatively minor trauma should be assigned to the
atraumatic group. The vast majority of traumatic dislocations are
anterior. The mechanism of injury is similar to that observed in the
adult. Typically, a force applied to the outstretched hand forces the
arm and shoulder into a maximally abducted, externally rotated
position. At this point, the humeral head is levered out of the glenoid
process anteriorly, with the head lodging against the anterior neck of
the glenoid. This occurs commonly in contact sports, falls, fights, and
motor vehicle accidents.⁵¹,²⁴⁷,³⁹²
A labral tear (Bankart lesion) and/or capsular stretch injury occurs,
potentially with a compression injury to the humeral head (Hill-Sachs
lesion).

Posterior dislocations are rare. In reported series of
all age groups, posterior dislocations represent only 2% to 4% of all
traumatic dislocations. The history for posterior dislocations is one
of violent trauma with the arm in a position of flexion, internal
rotation, and adduction. This can occur in falls and in motor vehicle
accidents as the arm braces the body against impact. Other common
mechanisms that produce posterior dislocations include convulsions and
electroshock. In these cases, the shoulder is dislocated posteriorly by
the violent contraction of the shoulder internal rotators, which
normally are stronger than the shoulder external rotators. The history
of the mechanism of injury and a high index of suspicion are necessary
to avoid missing a posterior dislocation.¹³⁸,¹⁴²,²²⁵,⁴¹⁴,⁵⁵⁷

In neonates, pseudodislocation of the shoulder can occur.²¹⁸
This problem represents traumatic epiphyseal separation of the proximal
humerus, which is certainly much more common than a true traumatic
dislocation of the shoulder in this age group. Most true traumatic
dislocations of the shoulder in the neonatal period occur in babies
with underlying birth trauma to the brachial plexus or central nervous
system.

Laskin and Sedlin³²⁰
reported on a 3-month-old infant with Erb-Duchenne palsy who sustained
a traumatic luxatio erecta of the shoulder during a planned shoulder
manipulation. Posterior dislocation of the shoulder also can occur as a
secondary traumatic phenomenon in unrecognized brachial plexus injuries
of the upper trunk at delivery.²³,³³⁹,⁵⁸¹,⁵⁸² Green and Wheelhouse²⁰⁵
reported a dislocation in a 7.5-month-old infant that was secondary to
a septic brain injury. Progressive posterior dislocation and
glenohumeral deformity is extremely common in infants and children with
chronic birth brachial plexopathy.

Atraumatic Dislocations. Atraumatic shoulder instability
is common in children and adolescents. The child who presents with
shoulder dislocation without a clear history of trauma should arouse
suspicion that atraumatic instability may be present. These patients
have inherent joint laxity that allows the shoulder to be dislocated
either voluntarily or involuntarily as the result of a minimal
traumatic event (Fig. 17-11).⁸⁷
For example, throwing, hitting an overhead tennis shot, or pushing the
body up when in bed would not constitute significant trauma. These
patients have multidirectional instability. In the individual who
dislocates voluntarily, conscious selective firing of muscles while
antagonists are inhibited, combined with arm positioning, allows the
shoulder to dislocate. A key to the diagnosis is that atraumatic
instability, whether voluntary or involuntary, is not associated with
much pain. Even if reduction is necessary, the pain usually disappears
rapidly. In most instances, spontaneous reduction occurs without
manipulation.⁴⁶⁰ In these cases, the use of conscious sedation or general anesthesia will often lead to reduction without manipulation.

Other causes of atraumatic shoulder instability, in
addition to multidirectional joint laxity, include Ehlers-Danlos and
Marfan’s syndrome, congenital glenoid and/or humeral deformities, and
emotional and psychiatric instability. True congenital dislocations of
the shoulder are most commonly associated with developmental defects
and multiple congenital abnormalities.⁹⁹,¹¹⁴,¹⁸⁷,²⁰⁸,⁴³⁶
Arthrogryposis, neglected septic arthritis, and neurologic defects also
have been implicated in atraumatic dislocations in the young child.²³,¹⁹⁷,²⁰⁵,²³²,⁵²⁸,⁵⁸¹

Traumatic Dislocations. The patient with a traumatic
anterior dislocation presents with a painful, swollen shoulder. Obvious
deformity is present with a prominent acromion and flattening of the
contour of the lateral upper arm. The arm is often supported by the
contralateral hand and held in a slightly abducted and externally
rotated position. Despite swelling, the humeral head can usually be
palpated in a position anterior to the glenoid.

Careful examination of the neurologic and vascular
status should be performed. The axillary nerve is the most commonly
injured with anterior dislocation, and special attention to its
function should be included in the physical examination.⁵³
The sensory distribution of the axillary nerve is along the upper
lateral arm, and motor innervation is to the deltoid and teres minor
muscles. Light touch is adequate for sensory testing in the upper arm
region. A convenient way to test deltoid function is to support the
involved elbow in one of the examiner’s hands while using the
examiner’s opposite hand to palpate the muscle belly of the deltoid.
The patient is asked to abduct the arm against resistance for about 1
inch so that deltoid firing is initiated. This examination confirms the
motor function of the axillary nerve (Fig. 17-12).

In recurrent anterior dislocation or subluxation that
has spontaneously reduced, the arm is well located with an overall
normal appearance of the shoulder. The shoulder demonstrates a full
range of motion, although the patient avoids the cocking position in
abduction, external rotation. The apprehension test

with
the arm abducted above 90 degrees is positive. A positive apprehension
test, along with a suggestive history, is a very diagnostic physical
sign for recurrent anterior instability.

For the much less common traumatic posterior
dislocation, an affected patient presents with flattening of the
anterior aspect of the shoulder and posterior fullness. The arm is held
at the side with the forearm internally rotated across the chest. A
Putti sign with superior scapular winging is present. The patient
resists any attempt at motion. Although difficult to elicit in the
acute situation because of pain, hallmark findings of posterior
dislocation are lack of shoulder external rotation and inability to
supinate the forearm. It is advantageous to examine the shoulder with
the patient seated so that the examiner can visualize the shoulders
from above. From this perspective, posterior fullness and anterior
flattening can be better visualized. As for anterior dislocations, the
neurovascular status should be evaluated meticulously. A history of
convulsion or electrical shock should raise the index of suspicion for
posterior dislocation.

In neonates, traumatic separation of the upper humeral
physis, the so-called pseudodislocation of the shoulder, can mimic an
anterior dislocation. As is the case for true dislocations, the child
is irritable and holds the affected arm abducted and externally
rotated. There is resistance to any type of motion.

Atraumatic Dislocations. The most notable finding in
patients with atraumatic shoulder instability is the relative lack of
pain associated with the subluxation or dislocation.¹⁵,¹²⁸,²⁸⁸,³²¹,³⁶²,⁴⁷³,⁵¹¹
Even in cases of involuntary atraumatic dislocation, the minor pain
associated with the dislocation itself subsides rapidly after
reduction. Episodes of atraumatic subluxation and dislocation

occur much more frequently than traumatic dislocations, and in almost all cases spontaneous reduction is the rule.

On clinical examination, multidirectional laxity or instability of the contralateral shoulder is usually present.⁴¹⁶,⁴⁶⁰,⁴⁶¹ In addition, there is evidence of laxity of multiple joints.⁴⁰³
Characteristics of multiple joint laxity include hyperextension at the
elbows, knees, and metacarpophalangeal joints along with pes planus.
Striae of the skin can be present. Skin hyperelasticity is a noted
characteristic of Ehlers-Danlos syndrome.

Multidirectional laxity of the shoulder is characterized
by a positive sulcus sign and significant translation on an anterior
and posterior drawer test. The sulcus sign is a dimpling of the skin
below the acromion when manual longitudinal traction is applied to the
arm (Fig. 17-13). This produces an inferior
subluxation of the humeral head away from the acromion that enlarges
the subacromial space and causes dimpling of the skin. The drawer or
shift and load test is performed with the examiner seated behind the
patient. The scapula is stabilized with one hand and forearm while the
humeral head is manually translated anteriorly and posteriorly by the
examiner’s opposite hand (Fig. 17-14). Although
some translation within the glenohumeral joint is expected in all
patients, those with multidirectional laxity demonstrate translation of
greater than 5 mm anteriorly and posteriorly from a neutral position.

In atraumatic dislocation, the shoulder often dislocates
anteriorly, posteriorly, or inferiorly. The most common direction of
dislocation in voluntary instability is posterior or inferior. The
patient who can voluntarily dislocate the shoulder can force the
humeral head posteriorly by contracting the anterior deltoid and
internal rotators while inhibiting the antagonistic muscles (Fig. 17-15).
The elbow is positioned in horizontal adduction, and the head is
dislocated. The arm can then be abducted, and the shoulder reduces,
often with an audible clunk.

Although any of the nerves that traverse the axilla may
be injured at the time of a shoulder dislocation, the axillary nerve is
the most common associated nerve injury. Fortunately, most axillary
nerve injuries associated with dislocations are neurapraxic and recover
spontaneously with time and observation. In the event of complete,
unresolved axillary nerve palsy, significant disability can result due
to the lack of deltoid function.³⁵,⁵³,¹⁰⁵,¹¹⁶,¹⁵³,³⁵³

Vascular injuries are rare, but either the axillary artery or vein can be traumatized. Morrison and Egan³⁹³
reported an axillary artery and a brachial plexus injury in a luxatio
erecta dislocation in an 11-year-old child. The artery was repaired
with a vein graft and the brachial plexus injury fully recovered.

Radiographic Studies. Children and adolescents with open
growth plates have a low incidence of true traumatic dislocation of the
shoulder. Traumatic lesions on plain radiographs are similar to those
found in adults (Fig. 17-16). On the AP or
internally rotated views of the proximal humerus, the Hill-Sachs
compression lesion on the posterolateral aspect of the humeral head is
commonly found. This injury to the proximal humerus occurs as the
humeral head is impacted against the anterior rim of the glenoid during
a dislocation (Fig. 17-17). Bony injury to the
anterior glenoid rim can occur with dislocation as well. Injury to the
glenoid ranges from small avulsion-type fractures to substantial bony
fractures. Anterior glenoid rim injuries are best seen as a double
density on the AP view of the shoulder or as a separate fragment on the
axillary and West Point lateral views. The West Point lateral view
projects the anteroinferior glenoid rim and most clearly shows this
lesion when it is present. In traumatic posterior dislocation, the
reverse Hill-Sachs lesion can be seen on the anterior part of the
humeral head and in some cases will be seen in conjunction with
fracture of the posterior rim of the glenoid.

In cases of traumatic subluxation of the shoulder in
which the diagnosis may be unclear clinically, an arthrogram with CT
scan can sometimes better delineate the extent of capsular stripping
from the anterior glenoid rim. More recently, saline arthrograms and
contrast MRI scans have enhanced our ability to define the degree of
injury to the labrum, capsule, and articular surfaces.²¹⁰,⁴⁶¹ CT scanning and MRI are useful for analyzing the significance of fractures of the glenoid rim (Figs. 17-18 and 17-19).
In addition, the size of the reverse Hill-Sachs lesion of the humeral
head in posterior dislocations is best analyzed with a CT scan.³⁰⁹,⁵⁷⁸

With atraumatic dislocations in patients who do not have
congenital or developmental defects, radiographs are usually normal.
Among patients who do have congenital defects, the most common
abnormality seen on radiographs is hypoplasia or aplasia of the
glenoid. In patients with multidirectional laxity and atraumatic
dislocation, stress radiographs can usually show instability in
anterior, posterior, and inferior directions. The inferior component of
multidirectional instability can be demonstrated by applying weights to
the arm in an AP film. If laxity is present, this stress view will show
the humeral head subluxating inferiorly in its relation to the glenoid.²⁶⁹
In diagnostic dilemmas, contrast-injected MRI scans can define the
presence of labral pathology which will aid in surgical decisions.

Classification. The following scheme is useful for the classification of shoulder dislocation based on etiology:

The above etiologic classification is commonly used in
adults, but no consensus exists as to a classification scheme in
children and adolescents.

Shoulder instability can be classified as to direction,
degree, and chronicity. Two basic schemes have been used to classify
shoulder dislocations in children and adolescents. The more common of
these is based on the direction or location of the dislocation.
Although this scheme is useful in describing the clinical and
radiographic features of the injury, it does not address the underlying
pathology in children and adolescents.⁴⁶⁰
Therefore, a second classification scheme describing the etiology of
the dislocation is also useful when considering treatment options for
this injury in children. This second system is similar to that used for
adults but takes into account the rare congenital and developmental
problems unique to children. As discussed later in the section on
treatment of this problem, accurate classification is important in
selecting the appropriate conservative versus surgical options.²¹,¹²⁵,⁴²¹

The directional classification has four categories:
anterior, posterior, inferior (luxatio erecta), and multidirectional.
As in adults, anterior dislocation in children and adolescents is the
most common, constituting at least 90% of glenohumeral dislocations (Fig. 17-20).
Several isolated reports of posterior dislocation in children and
adolescents have been documented, but traumatic posterior dislocation
is rare in children, as in adults.⁶⁰,¹⁶⁸,²³⁷,³⁷² Luxatio erecta or an inferior locked dislocation is uncommon but has been reported in children.¹⁷⁴,³²⁰,³⁸⁰ Multidirectional luxatio of the shoulder has been well described as a distinct clinical entity by Burkhead and Rockwood,⁸⁰ O’Driscoll and Evans,⁴¹⁶ and Rockwood.⁴⁶⁰,⁴⁶¹

The degree of instability can be classified as a
subluxation or a dislocation. A subluxation is an incomplete
dislocation characterized by pain, a feeling of slipping, or a dead
feeling in the arm. A complete dislocation of the humeral head out of
the glenoid fossa is characterized by a displacement and locking of the
head on the rim of the glenoid.

The chronicity of instability can be classified as
acute, recurrent, or chronic. A single episode of instability can be
described as an acute injury. As in the skeletally mature patient, an
acute injury can lead to a recurrent instability, depending on the
damage to the labral, capsule and ligaments, and bony restraints of the
joint. A chronic instability exists when an acute dislocation

is not reduced, and in children, is usually associated with congenital or neuropathic dislocations.

The literature on the specific treatment of shoulder instability in skeletally immature children is limited.²¹,¹⁰⁴,⁴⁵³,⁵³⁷ Most clinicians make the same treatment recommendations based on the sustained injury, regardless of the patient’s age.¹,¹⁸,³⁶,⁵¹,¹³⁶,²⁸⁴
The majority of treatment recommendations presented in this section are
extrapolated from the adult and adolescent literature, as well as from
the experience of Dameron and Rockwood.¹²⁵

Patients with acute dislocations of the shoulder should
undergo closed reduction by one of the standard techniques. For
anterior dislocation, many reduction techniques have been described.
Most clinicians prefer light sedation with intravenous or intramuscular
injection. The traction/countertraction method is believed to be the
most gentle. A bed sheet placed in the axilla of the affected shoulder
passes above and below the patient so that countertraction can be
applied to the body while longitudinal traction in line with the
deformity is applied to the arm. Steady, continuous traction fatigues
the muscles that lock the dislocation, and eventually reduction is
accomplished by disimpacting the humerus from the glenoid.

The Stimson maneuver is equally effective. In this
technique, the patient is placed prone on the examination table. A
weight is applied to the affected arm. As the shoulder girdle muscles
relax, reduction is achieved atraumatically (Fig. 17-22).³⁸⁹ Another less-often-practiced technique is scapular manipulation. Kothari and Dronen³⁰¹ and McNamara³⁷⁹ report that this latter technique is a safe, effective way to reduce glenohumeral dislocations.

Postreduction immobilization remains a subject for
debate. The adult literature suggests that the period of immobilization
may not be truly important in predicting recurrent dislocation. A sling
or a sling-and-swathe with the arm internally rotated is the most
common method of immobilization.¹⁸,¹³⁵
However, a recent randomized trial noted that immobilization in
external rotation may decrease the risk of recurrence when compared to
immobilization in internal rotation.²⁶⁵

Closed reduction for acute posterior dislocations is
somewhat similar to that for anterior dislocations.
Traction/countertraction is the most effective method. Traction is
applied in line with the deformity, and the humeral head is gently
lifted back into its normal relationship with the glenoid. Most
clinicians agree that immobilization should be with the arm in neutral
rotation or slight external rotation at the shoulder. This may require
the use of a spica cast or modified shoulder spica cast, as described
by Dameron and Rockwood.¹²⁵

The true incidence of recurrent dislocation after
traumatic shoulder dislocation in children is understandably poorly
defined, given the rarity of reports in the pediatric orthopaedic
literature.¹⁸⁷,²⁴⁹ In 1963, Rowe⁴⁷⁰
reported a 100% incidence of recurrence in children 1 to 10 years of
age with anterior dislocation. He also reported a 94% incidence of
recurrence in adolescents and young adults (ages 11 to 20).⁴⁷⁰ Elbaum et al.¹⁵³
reported a recurrence rate of 71% in 9 pediatric patients with
traumatic anterior dislocations. The average age was 9 years. After
reduction, they were immobilized for 3 weeks and then were treated with
rehabilitation. However, Rockwood⁴⁶⁰ reported a recurrence rate of only 50% in a series of adolescents and young adults 13.8 to 15.8 years of age. Hovelius et al.²⁴⁹
reported a 47% recurrence rate in patients less than 20 years of age.
In the 25 years following, it was found that half of the primary
dislocations that had been treated nonoperatively in patients from 12
to 25 years old had not recurred or had surgical stabilization.²⁴⁸,²⁵⁰
Furthermore, recurrent dislocation necessitating operative treatment
had developed in 38% of shoulders in patients who were 12 to 25 years
of age at the time of initial dislocation, compared with 18% in
patients who were 26 to 40 years old. The type and duration of the
initial treatment had no effect on the rate of recurrence. Vermeiren et
al.⁵⁵⁸ reported a recurrence rate of 68% in patients younger than 20 years of

age. Younger patients involved in contact sports or who require
overhead occupational use of the arm are more likely to have a
redislocation when compared to older less active peers.⁴⁷⁷ They reported a better prognosis if the dislocation was associated with a fracture of the joint. Heck²²⁷ reported a case of traumatic anterior dislocation in a 7-year-old boy who remained stable at a 5-year follow-up. Endo et al.¹⁵⁵
reported no recurrence in 2 patients, ages 3 and 9, with traumatic
anterior dislocation. However, the follow-up was only 2 years in the
3-year-old and 1 year in the 9-year-old. Wagner and Lyne⁵⁶⁵ reported an 80% recurrence rate in 10 patients with clearly open proximal humeral epiphyses. Marans et al.³⁶⁵
reported the fate of traumatic anterior dislocations of the shoulder in
21 children (15 boys, 6 girls) in what may be the largest documented
series to date. All the children had one or more documented anterior
dislocation(s) after the initial injury. Some of the children had been
immobilized in a sling-and-swathe for 6 weeks. The literature reflects
that the natural history of shoulder dislocations in adolescents and
young adults demonstrates recurrence rates for dislocation of 50% to
90% despite the treatment program used after the initial dislocation.

Multiple surgical procedures have been described for the
treatment of anterior shoulder instability. Once again, specific
results for procedures such as the Putti-Platt, Bankart, and
Magnuson-Stack have not been documented for children. Barry et al.³⁶
described the effective use of the coracoid transfer for recurrent
anterior instability in adolescents. Capsular procedures that
specifically address the capsular pathology have been described by Neer,⁴⁰³ Jobe,³⁴⁹ and Rockwood et al.,⁴⁶¹ but results in specifically in children’s dislocations were not documented. Goldberg et al.¹⁹⁷ and Jones et al.²⁷⁸
have reported on the use of arthroscopic techniques for capsular repair
in adolescents. A meta-analysis at that time comparing open and
arthroscopic repairs in the treatment of anterior shoulder instability
found a significantly higher risk of recurrent instability, recurrent
dislocation, and reoperation for arthroscopic repairs. However,
arthroscopic repairs appeared to have a better functional result.³²⁶
The keys to any surgical procedure is labral repair and appropriate
capsular tightening. The trend is towards more arthroscopic repairs of
the labrum and capsule.

Treatment of patients with atraumatic dislocations of
the shoulder appears more difficult than treatment for true traumatic
dislocations. Emphasis should be placed on careful diagnosis in these
cases. Specific congenital bony or neurologic deficits should be
recognized. The sequelae of Ehlers-Danlos syndrome or other collagen
deficiency syndromes should be noted.

In patients with multidirectional laxity and voluntary
or involuntary dislocations, a significant history of trauma is usually
lacking. These patients have minimal pain associated with the
dislocation and on clinical examination usually have other signs of
multidirectional laxity of the opposite shoulder. Most of these
dislocations reduce spontaneously and are associated with little pain.
Rowe et al.,⁴⁷³ Neer,⁴⁰³ and Burkhead and Rockwood⁸⁰,⁴⁶⁰,⁴⁶¹
have described the use of a vigorous rehabilitation program involving
strengthening of the rotator cuff as the treatment of choice for these
patients. Most patients who do not have significant emotional and
psychiatric problems are reasonably successful over time in improving
their shoulder stability with a program of scapular stabilization with
dynamic muscle rebalancing and strengthening.

Most clinicians would agree that surgical intervention
is considered only if a strict 6- to 12-month rehabilitation program
fails. Shoulder reconstructions involving subscapularis shortening,
including the Magnuson-Stack and Putti-Platt procedures, or “bone
blocks” such as the Bristow are not sufficient for preventing future
instability, and are rarely performed. Neer⁴⁰³
described the inferior capsular shift reconstruction specifically for
patients with multidirectional laxity of the shoulder with atraumatic
instability. This procedure attempts to eliminate the overall capsular
laxity and is used only after rehabilitation has failed. Huber and
Gerber²⁵⁴ reported on 25 consecutive
children with 36 involved shoulders with voluntary subluxation of the
shoulder. The children managed by “skillful neglect” had a satisfactory
outcome, but only 50% of those treated with an operative procedure to
prevent later degenerative arthritis had good results. They concluded
that voluntary subluxation of the shoulder has a favorable result and
that there is no indication for surgery with this problem in children.

Fractures of the proximal humerus can occur rarely during birth.³²⁵,⁵⁰⁹ As an infant is passing through the birth canal, the

arm may be stressed such that a separation through the physis of the proximal humerus can occur.¹²⁴,²⁰⁹,²¹⁸,²²²,³²⁵,³⁶¹,⁵⁰⁹
These fractures are generally believed to result from hyperextension
and/or rotation of the arm during the passage through the birth canal (Fig. 17-23).¹²⁴,²⁰⁹,²¹⁸,²²²,³²⁵,³⁶¹,⁵⁰⁹
As might be expected, obstetric proximal humeral fractures occur most
frequently during vaginal deliveries of infants with larger size or
breech presentation.⁸³,¹⁷⁷,²⁷¹,⁵⁰⁹
Prenatal size and presentation, however, have not been accurate
predictive factors for these fractures because proximal humeral
fractures may occur during vaginal deliveries of infants of all sizes
and weights. Hence, other infant and maternal factors play a role.⁸³,¹⁷⁷,²⁷¹

In older children, the predominant cause of fractures in
the proximal humerus is trauma, both direct and indirect. In this age
group, these fractures can involve the metaphysis, the physis, or both.
The trauma can be a direct blow to the shoulder area, especially to the
posterior aspect,¹²⁴,⁴⁰⁴,⁵¹⁵ or indirect, as in a fall onto an outstretched hand that transmits the force through the arm to the proximal humerus.⁶,⁶⁷,²⁷¹
Indirect trauma can result in forced or nonphysiologic positioning of
the upper extremity, which in turn may cause a fracture of the proximal
humerus. Specifically, six potential mechanisms of upper extremity
positioning have been proposed to explain the resulting proximal
humeral fractures: forced extension, forced flexion, forced extension
with lateral or medial rotation, and forced flexion with lateral or
medial rotation.⁵⁸⁵ Although trauma
has been acknowledged as the most common mechanism of pediatric
proximal humeral fractures, it is still controversial whether a fall or
a direct blow is the more common etiology of the fracture.

Proximal humeral fractures are typically moderate- to
higher-energy injuries and are frequently seen in motor vehicle crashes
and sporting activities (Figs. 17-24 and 17-25).³⁰,²⁹⁸ Approximately 50% of shoulder girdle fractures in children have been reported to be associated with sports and play activities.⁴¹¹
Athletic activities associated with proximal humeral fractures include
contact sports (football, hockey), horseback riding (fall from horses),
gymnastics (upper extremity impact and weight bearing), and baseball
(repetitive throwing).¹²¹,³¹⁴,³⁴⁵,⁵⁴⁸

Less often, pediatric proximal humeral fractures can be
pathologic and result from other conditions such as malignant or benign
tumors and pituitary gigantism.⁵,³⁰⁸,⁴⁵⁸,⁴⁸⁴ They also can be a complication of radiation therapy to the shoulder region.¹⁵¹
In addition, shoulder joint neuropathy secondary to Arnold-Chiari
malformation, myelomeningocele, or syringomyelia has been implicated as
an etiologic factor in proximal humeral fractures.³⁰,³⁴⁶ An unknown percentage of pediatric proximal humeral fractures are part of the injuries associated with child abuse (Fig. 17-26).¹⁷⁵
Because no clear fracture pattern in the proximal humerus is suggestive
of abuse, an index of suspicion must remain high when evaluating
infants or young children with humeral fractures.⁵⁰⁵

Clinical features of proximal humeral fractures in
newborns may be subtle and not readily identified. For example, the
infant may be irritable when handled by caregivers or when there is
movement of the upper extremity. The infant may refuse to move the arm,
giving the appearance of paralysis, called “pseudoparalysis.” Infants
exhibiting upper extremity paralysis also may be suffering from
posterior humeral head dislocation.⁵⁴⁴

Older children typically report a history consistent
with a proximal humeral fracture: a traumatic injury with the immediate
development of moderate to severe global shoulder pain exacerbated by
motion of the arm. They often present with an obvious deformity, or
fullness, in the anterior shoulder region, with the overall contour of
the shoulder altered in comparison with the contralateral uninjured
shoulder. The arm is internally rotated against the abdomen and the
patient usually refuses to use the involved arm. Pain, swelling, and
ecchymosis are invariably present to some degree.

The internally rotated position of the injured extremity
is due to the pull of the pectoralis major muscle on the distal
fragment. With posterior fracture dislocations, children demonstrate
limited and extremely painful external rotation. Some children with
fractures of the greater tuberosity have an unusual presentation of
luxatio erecta where the involved shoulder is positioned in extreme
abduction.¹⁷⁴ This position reduces
the displacement across the fracture as the greater tuberosity is
pulled superiorly by the supraspinatus muscle. The elbow is typically
flexed in luxatio erecta, allowing the hand to be near or above the
head.¹⁷⁴,³⁰⁰
Fractures of the lesser tuberosity affect the function of the inserting
subscapularis muscle; hence, abduction and external rotation of the
shoulder will be limited and painful.²⁹²,⁴⁶⁸,⁵⁶⁴

In high-energy trauma, fractures of the proximal humerus
may be associated with concomitant dislocations of the glenohumeral
joint. The direction of the dislocation may be anterior, posterior, or
inferior.¹⁰⁷,¹⁷⁴,¹⁷⁵,²⁰⁷,³⁰⁰,⁴¹⁶,⁵⁵⁷ Neurologic injury to the brachial plexus can result from fractures and fracture-dislocations of the proximal humerus.¹⁹,¹⁴⁴,¹⁷⁴,⁵⁵⁷,⁵⁶¹
The fracture can be displaced into the axilla and may have vascular
compromise requiring emergent reduction. Typically, these nerve
deficits are transient, and full function returns in 6 to 12 months.²⁶⁸,³⁰⁶
There may be an associated pain syndrome that lasts for months in these
rare situations of proximal humerus fracture associated with brachial
plexopathy. Fractures of the proximal humerus in children also can be
associated with other injuries, including rib fractures and
pneumothorax.⁴⁸⁴

The proximal humeral epiphysis is not visible on plain radiographs until about 6 months of age,²⁶⁸,³⁰⁶,⁴²⁴
and plain radiographs are of limited value in evaluation of proximal
humeral fractures in infants. On an AP radiograph, a change in the
positional relationship between the proximal humeral metaphysis and the
scapula and acromion often is visible. A comparison with the uninjured
contralateral shoulder may reveal this alteration more clearly. A
“vanishing epiphysis” sign also has been reported to describe
posteriorly displaced physeal fractures of the proximal humerus (Fig. 17-27).²⁹⁴,⁴⁹¹
On an AP radiograph, the epiphysis appears to vanish when it is
displaced posteriorly. For complete evaluation of proximal humeral
fractures in newborns and infants, ultrasonographic studies can be
diagnostic and informative.⁷¹,¹⁶⁴,²⁵¹,⁵⁵³
MRI will reveal the injury pattern clearly but requires conscious
sedation or general anesthesia in infants for accurate analysis. In
addition to proximal humeral fractures, the differential diagnosis for
such “paralysis” in infants includes brachial plexus injury, septic
shoulder, and clavicular fractures.

For evaluation of proximal humeral fractures in older children, two radiographs in perpendicular views can be diagnostic.⁵³⁶
Ideally, a true AP view of the shoulder and an axillary lateral view
provide the most information about the fracture. Because some lesser
tuberosity fractures may be visible only on an axillary lateral view,
this radiograph should be included whenever possible.²⁵²
Ideally, a properly positioned axillary view should position the normal
humeral head between the acromion and the coracoid. Often, however, an
axillary lateral view is difficult to obtain in a child with an acutely
fractured proximal humerus. In these instances, transthoracic axillary
view or scapular-Y views can be obtained. In obese patients,
transthoracic views are difficult to interpret. In addition, an apical
oblique view, an AP radiograph with the x-ray beam at 45 degrees of
caudal tilt, also can provide significant information about the
proximal humerus.⁵¹³ In fact, some
authors report that most shoulder trauma can be evaluated with AP and
apical oblique radiographs and that a lateral view (axillary lateral or
scapular-Y view) can be obtained if a humeral fracture is suspected.⁶¹

When adequate radiographs cannot be obtained, CT is
useful in evaluating proximal humeral fractures. CT may be especially
useful in characterizing posterior fracture-dislocations.²⁰⁷,⁵⁴⁵,⁵⁶⁴
If the child continues to report shoulder pain despite negative
radiographic and CT results, an occult fracture must be ruled out. For
this purpose, MRI can be diagnostic, due to its ability to identify the
intramedullary signal change of edema and the fracture plane.⁴⁵,⁴⁷⁶,⁵⁴¹

Fractures of the proximal humerus in the pediatric
population are broadly categorized by their anatomic location. The
fractures may involve the physis, the metaphysis, the lesser
tuberosity, or the greater tuberosity. In addition, the degree of
fracture deformity (angulation and translation) plays an important role
in the overall treatment option. Other fracture characteristics that
must be evaluated include the presence or absence of open fractures,
concomitant glenohumeral dislocations, and fracture stability.

Fractures involving the physis are classified according to the Salter-Harris classification (Fig. 17-28).⁴⁸¹ Salter-Harris type I injuries with fractures through the physis occur mostly in patients under 5 years of age.¹²⁴,⁴³⁵
After 11 years of age, most fractures of the proximal humerus are
Salter-Harris type II injuries, with the fracture line exiting through
the metaphysis,⁷⁹,¹²⁴,¹⁶⁴,⁴³⁵ and they occasionally are associated with an additional anterolateral bony fragment.⁷⁹
Salter-Harris type III injuries with the fracture line exiting through
the epiphysis rarely occur in the proximal humerus of children¹²⁴,⁴³⁵ and have been reported with and without concomitant glenohumeral dislocation.¹⁰⁷,²⁰⁷,⁵³⁸,⁵⁶⁸,⁵⁸⁹
Salter-Harris type IV injuries involving both the metaphysis and the
epiphysis of the proximal humerus have not been reported in children.

Fractures of the metaphysis occur mostly in children 5 to 12 years of age (Fig. 17-29) and are categorized by their anatomic location and degree of displacement.¹²⁴
This rather unexpected finding has been attributed to the rapid
metaphyseal growth that occurs during this age, which in turn results
in a relative structural weakness of the metaphysis.¹²⁴
The anatomic location is described in relation to the major deforming
forces in the region, namely the insertions of the pectoralis major and
the deltoid muscles. Presence or absence of other fractures in the
ipsilateral upper extremity also must be documented, because segmental
fractures may require alternative treatments.²⁷⁰,³⁵⁷,⁴²⁵ Other isolated fractures of the proximal humerus may include the greater and the lesser tuberosities.¹⁷⁴,²⁹²,³⁰⁰,⁴⁶⁸,⁵⁷⁷

In the Neer classification, the degree of displacement
in proximal humerus fractures is classified with respect to the shaft
diameter of the humerus.⁴⁰⁴ In grade
I injuries, there is up to 5 mm of displacement. In grade II and III
injuries, fractures are displaced by up to one third and two thirds of
the humeral shaft diameter, respectively. Displacement of greater than
two thirds of the shaft diameter is classified as a grade IV injury. In
addition to degree of displacement, fractures in this region typically
demonstrate concomitant angular deformities.

Diagnosis of a proximal humeral fracture can be delayed
in a child who is asymptomatic or minimally symptomatic. This is
usually not a problem as the fracture can heal well and remodel minor
displacement with growth. In children with multiple

trauma,
the diagnosis can be delayed due to the need to focus on more life- or
limb-threatening problems and the absence of any dramatic limb
malalignment. Even after the diagnosis of proximal humeral fracture is
made, full evaluation and characterization of the fracture pattern can
remain incomplete because of inadequate radiographic studies. A high
index of suspicion, thorough physical examination, and insistence on
high-quality radiographs must all be present to ensure prompt diagnosis
and treatment of proximal humeral fractures.

Neurologic injury to the brachial plexus can result from fractures and fracture-dislocations of the proximal humerus.¹⁹,¹⁴⁴,¹⁷⁴,⁵⁵⁷,⁵⁶¹
Most nerve deficits can be diagnosed immediately because the clinical
signs are readily apparent. Often, the distal fracture fragment is
displaced into the axilla, with resulting adduction and valgus
malalignment and nerve compression or traction injury. There may be an
associated vascular compromise that requires emergent reduction of the
fracture to restore blood supply to the distal arm and hand.²⁵⁶ Rarely, however, nerve deficits from proximal humeral fractures can evolve slowly and delay the diagnosis.¹⁴⁴ Typically, these nerve deficits are transient, and full function typically returns in 3 to 12 months.²⁵⁶,²⁶⁸,³⁰⁶
If the neurologic deficit persists longer than 3 to 6 months, further
evaluation with electromyography is warranted. If no evidence of nerve
recovery or regeneration is present, nerve exploration, repair, and
grafting can be considered.¹⁹,¹⁰⁵ Salvage operations for permanent nerve deficits include proximal humeral osteotomy and muscle or tendon transfers.⁷,¹¹³,²⁴¹,²⁹¹,⁴³⁷

Fractures of the proximal humerus in children also can
be associated with other injuries, including rib fractures and
pneumothorax.⁴⁸⁴ These fractures have been associated with disruptions and thrombosis of the axillary vessels as well in children⁵⁷⁵ and adults.³⁴⁴,⁴⁹⁹,⁵³³,⁶⁰²
Operative fixation of proximal humeral fractures with pins and wires
has been associated with hardware migration, which can be fatal.³³⁸,³⁵⁶ Therefore, serial radiographic monitoring of the hardware after shoulder operations is essential.

Humerus varus after trauma is a rare complication that typically affects neonates and children under 5 years of age.¹⁵⁴,³¹⁷,³⁵²,⁵¹⁷,⁵⁴⁶
Children with humerus varus have a significant decrease in the humeral
neck-shaft angle and shortening of the upper extremity. Although
shoulder abduction may be moderately limited, most children with
humerus varus have only mild functional deficits and do not require
surgical correction of the deformity.¹⁵⁴,³¹⁷,³⁵²,⁵⁴⁶
If, however, active abduction and flexion are severely limited and
corrective growth is not possible, corrective osteotomy of the proximal
humerus can produce good results.¹⁹³,⁵¹⁷

Hypertrophic scarring can occur after surgical reduction
of proximal humeral fractures. When the scarring is present in the
anterior shoulder region after an anterior deltopectoral incision, the
cosmetic deformity may be significant and psychologically damaging,
especially for girls.¹⁷³,¹⁹¹ Therefore, many investigators have argued for the more cosmetically appealing axillary or anterior axillary incision.²¹¹,³²⁸

Limb length inequality after proximal humeral fractures
occurs more frequently in children treated with surgical intervention
than in those treated nonoperatively.³⁸,¹²⁴,⁴⁷⁸
This is likely due to the degree of damage to the physis at the time of
injury and not iatrogenically induced due to the surgical reduction.
The inequality is not significantly affected by the quality of initial
fracture reduction and may be more pronounced in older children (1 to 3
cm).³⁸,⁴⁰⁴
Despite this inequality, however, these children rarely develop any
functional deficits to warrant surgical intervention. Full arrest of
physeal growth after traumatic proximal humeral fractures is extremely
uncommon.¹²⁴ Although still quite rare, it does occur more frequently in children with pathologic fractures through unicameral bone cysts.²³⁹,³⁸⁸,⁴¹³ If the functional or cosmetic deficit is significant, a limb-lengthening procedure may be of benefit for these children.⁴⁹²

Osteonecrosis of the humeral head after proximal humeral fractures occurs frequently in adults but is rare in children.³⁶⁸,⁵⁹⁴
Even after acute disruption of the vascular supply to the proximal
humeral epiphysis, subsequent remodeling and revascularization usually
occur in children and lead to excellent clinical results.⁵⁶⁸
Similarly, glenohumeral subluxation after proximal humeral fractures is
a rare complication in the pediatric population that typically results
in good clinical outcomes.⁵⁹⁴ These children are best treated with a short period of immobilization followed by early physical therapy and rehabilitation.⁴⁸⁴

Birth Injuries. Humeral fractures are more common in
breech presentations and with macrosomic infants. The most difficult
position is when the child’s arms have gone above the head with
maneuvers to bring the arm down after version and extraction.³⁶¹

Child Abuse. Humeral fractures in child abuse represent
61% of all new fractures and 12% of all fractures in these unfortunate
children.³⁴⁸,⁵⁰⁵ Shaw et al.,⁵⁰⁵
in a retrospective review of 34 humeral shaft fractures in children
under 3 years of age, found that most occurred accidentally: only 6
were classified as caused by probable abuse. Child abuse must be part
of the differential diagnosis in children with humeral diaphyseal
fractures.⁴²⁶ The fractures may be spiral from a twisting injury or transverse from a direct blow.

Older Children. Older children sustain primarily
transverse fractures from direct blows to the arm, frequently from
falls, pedestrian/vehicle accidents, gunshot wounds, and machinery.
Sports injuries are direct from contact sports or indirect from
throwing. Throwing injuries occur as a stress injury from overuse or
acutely during the throwing cycle from poor mechanics.⁹,⁷⁶,¹⁸⁶,²⁰⁰,²⁰⁶,²³⁵,³⁴³,³²¹,⁵²⁷,⁵⁴⁸,⁵⁷⁶ A stress fracture also has been reported in an adolescent tennis player.⁴⁵⁴
Acute throwing fractures result from a sudden external rotation torque
developed on the distal humerus with concomitant proximal internal
rotation from the pectoralis major between the cocking and acceleration
phases¹⁴¹ as shoulder external
rotation and elbow flexion suddenly changes to shoulder internal
rotation and elbow extension. Humeral fractures may occur from arm
wrestling in older adolescents.³⁹,³⁵¹,³⁹¹
Some humeral fractures are pathologic through benign lesions such as
simple bone cysts or through dysplastic bones from osteogenesis
imperfecta or fibrous dysplasia. Occasionally, pathologic fractures
occur from malignant tumors.

History. The infant who does not move the shoulder poses
a diagnostic challenge. Establishing and evaluating a differential
diagnosis is the first concern. According to the history, was the
delivery normal? When was the problem noticed? Does the child move any
part of the extremity? Was there a history of maternal gestational
diabetes or of fetal macrosomia? Does the child nurse from each breast?
A broad, useful differential diagnosis consists of clavicle fracture,
proximal humeral physeal fracture, humeral shaft fracture, shoulder
dislocation, brachial plexus palsy, septic shoulder, osteomyelitis,
hemiplegia, stroke, and child abuse.

Examination. Initially, the child should be observed for
spontaneous motion of the upper extremity. Is there any hand or elbow
motion? Are there any areas of swelling, ecchymosis, or increased
warmth? Does the child move the ipsilateral lower extremity? The
clinician should carefully palpate each area of the upper extremity,
starting with the clavicle and comparing it carefully with the opposite
side for any change in soft tissue contour or tenderness. The upper
arms and shoulders should then be examined, looking for any tenderness
in the supraclavicular fossa. Lastly, the spine should be examined for
tenderness or swelling.

Birth Fractures of the Humerus. In the newborn, a
humeral fracture can simulate a brachial plexus palsy with
pseudoparalysis and an asymmetric Moro reflex. The fracture site is
tender and may have swelling or ecchymosis. The diagnosis is confirmed
by plain radiography.²⁵³,³⁶¹

Older Children. In older children, the diagnosis is
usually evident with pain, swelling, and unwillingness to move the arm.
The arm is often supported by the opposite hand and is held tightly to
the body (Fig. 17-39). It is essential to
perform a complete neurologic and vascular examination of the extremity
before any treatment except emergency splinting.

Children with torus or greenstick fractures may have
localized tenderness but no deformity. In multiple-trauma victims,
careful evaluation should be made of the arm because the diagnosis can
be missed, especially if the patient is medically unstable.³¹⁶ Humeral fractures should be sought in patients with massive upper extremity trauma.

The simplest classification for humeral diaphyseal
fractures describes the location (proximal third, middle third, or
distal third, or the diaphyseal-metaphyseal junction), the pattern
(spiral, short oblique, or transverse), the direction of displacement,
and any tissue damage. Anatomically, the location is noted as proximal
to the pectoralis major insertion, between the pectoralis major and
deltoid insertions, below the deltoid insertion, or at the distal
metaphyseal-diaphyseal junction.¹²³ Humeral shaft fractures may be segmental, with fractures of the shaft and neck,⁵²⁶,⁵³⁹ or associated with shoulder dislocation.¹⁷,³⁴ If they are associated with fractures of the ipsilateral forearm, they result in the so-called floating elbow.⁶⁹,⁵²³

The Association for the Study of Internal Fixation has a classification for humeral shaft fractures designed for adults,²⁴⁵,³⁹⁷
but it is not as helpful in the evaluation and treatment of most
children’s humeral fractures, and like most classifications, it is
subject to some interobserver variability.¹⁸²,²⁷⁵

Imaging Studies. Radiographs may be needed of the
shoulder, clavicle, humerus, and cervical spine. Often the shoulder,
clavicle, and humerus can be seen on a single AP view of both upper
extremities and the chest. Ultrasonography can be used to identify a
fracture of the clavicle or the proximal humeral epiphysis, a shoulder
dislocation, or a shoulder effusion by a skilled radiologist. A CT and
MRI scan may be necessary to evaluate a pathologic fracture. The
radiographic findings for each fracture are discussed in the particular
anatomic sections.

AP and lateral radiographs are sufficient and complete
in most instances of humeral shaft fractures. In the occasional case
where the diagnosis is suspect but not readily apparent on these views,
oblique views may be useful.

Radiographic Findings. Fractures of the humerus are
usually quite apparent on AP and lateral radiographs of the humerus.
Radiographs should be taken in both the AP and lateral planes to obtain
two films perpendicular to each other to assess displacement. A true
lateral view of the distal humerus is noted by superimposition of the
posterior supracondylar ridges of the medial and lateral epicondyles.²⁰⁴,⁵¹⁸
A supracondylar process of the humerus, when present, is best seen on
an oblique radiograph showing the anterior medial aspect of the distal
humerus.

Displaced fractures above the pectoralis major have
marked abduction of the proximal fragment with external rotation by the
rotator cuff attachment.¹¹⁸,¹²³
The distal fragment is pulled proximally by the deltoid and medially by
the pectoralis major. Displaced fractures between the pectoralis major
and deltoid insertions show adduction of the proximal fragment from the
pectoralis major and shortening by pull of the deltoid on the distal
fragment. Fractures below the deltoid insertion have abduction of the
long proximal fragment by the deltoid, but with shortening and medial
displacement of the distal fragment by the pull of the biceps and
triceps.¹²³

Pathologic bone may be evident.⁵²⁶,⁵³⁹
Simple bone cysts are a common cause of fractures. Periostitis or
periosteal reaction of the humerus necessitates differentiating
osteomyelitis or Ewing sarcoma from a stress fracture; every effort
must be made to identify a cortical fissure using other imaging
techniques.¹⁷,³⁴,⁶⁹,⁵²³

Holstein and Lewis²⁴⁵ described a short oblique fracture of the distal third of the humerus with risk of radial nerve palsy.³⁹⁷ This has been called the Holstein-Lewis fracture.

The end of the embryonic period is marked by vascular
invasion of the humerus at age 8 weeks. During the subsequent fetal
period, the humerus resembles the adult bone in both form and muscular
relationships.¹⁸²,²⁰⁴,²⁷⁵,⁵¹⁸
A bony collar is present very early with subsequent enchondral bone
formation. The secondary ossification centers at the ends are not
generally ossified radiographically until after birth.²⁰⁴,⁵¹⁸

The proximal metaphysis of the humerus is wider than the
thinner, triangular shaft. Distally, this flattens and widens to form
the condylar region of the elbow. The deltoid inserts into a
protuberance midway down the shaft known as the deltoid tuberosity.
Distal to the tuberosity, the muscular spinal groove

wraps
posteriorly around the humerus. The groove gives origin to the
uppermost fibers of the brachialis. The periosteum of the humeral
diaphysis is thick and provides good remodeling potential.¹¹⁸,¹²²
The main vascular foramen is at midshaft, but accessory foramina are
common—most enter the anterior surface usually below the main foramen,
but many are posterior.⁸⁶,²⁰⁴,⁵¹⁸

The radial nerve ordinarily lies close to the inferior lip of the spiral groove but not directly in it.⁵⁸⁰
The profunda artery either accompanies the radial nerve or passes in a
second narrower groove. The nerve is protected from the humerus by a
layer of either the triceps or the brachialis until the lower margin of
the spiral groove near the lateral intermuscular septum.⁵⁸⁰
The ulnar nerve passes from anterior to posterior just distal to the
humeral midshaft. A well-formed arcade (arcade of Struthers) covers the
ulnar nerve as it passes distally.²⁸³
This arcade is always posterior to the medial intermuscular septum and
subsequently joins the medial intermuscular septum proximal to the
medial epicondyle. A few patients with a modified arcade have only
superficial fibers of the triceps medial head passing superficial to
the ulnar nerve and none deep to the nerve, making the nerve very close
to the bone and vulnerable during a fracture.²⁸³

Several major muscle attachments occur throughout the
metaphyseal and diaphyseal regions of the humerus. The pectoralis major
muscle inserts laterally and distal to the bicipital groove along the
anterior aspect of the humerus. The latissimus dorsi and teres major
insert on the upper medial aspect of the humerus medial to the
bicipital groove. The deltoid originates from the clavicle, acromion,
and scapular spine to insert over a broad area of the deltoid
tuberosity. The coracobrachialis arises from the coracoid process and
inserts on the anterior medial aspect of the humerus at the junction of
the middle and lower thirds. The brachialis originates from the
anterior humerus about midway down the shaft. Knowledge of these
muscles and their orientation is essential to understand fracture
displacement and treatment.¹¹⁸,²⁴³

Neonatal humeral shaft fractures heal and remodel quite well, with 40% to 50% remodeling within 2 years (Fig. 17-40).⁴⁷ Reported treatments include a sling-and-swathe²⁴⁴ or a traction device using the von Rosen splint.²² The primary potential complication

of birth injuries is an internal rotation deformity. Therefore, the
fracture can be stabilized by splinting the arm in extension. The
long-term, resultant angulation of the healed fracture is minimal due
to the child’s tremendous capacity of remodeling. Attempts at anatomic
reduction are not necessary.²⁵⁵
If the parents will be moving the child, the splinted arm can be bound
to the chest with a soft wrap. These fractures usually heal with some
varus and overlap that remodels. Children with arthrogryposis and
brachial plexus palsies are prone to internal rotation contractures of
the shoulder; these can be exacerbated if the birth fracture’s rotation
is not controlled.

Virtually all nondisplaced stress injuries heal well with temporary rest and immobilization.⁹,¹³⁹,¹⁸⁶,²⁰⁰,³⁴³,⁴⁵⁴,⁵²⁷,⁵⁵⁰,⁵⁷⁶ They can displace if athletic participation continues without protected

rest and healing.⁹ Displaced stress fractures should be treated like other humerus fractures.

Because the humerus is not a weight-bearing bone, it
does not require the precise mechanical alignment of the lower
extremity. The marked mobility of the shoulder also allows some axial
and rotational deviation without functional problems. Severe internal
rotation contractures can cause difficulties in some overhead
activities such as ball throwing and facial hygiene. Varus of 20 to 30
degrees is necessary before becoming clinically apparent (Fig. 17-41).¹²³,²⁹⁵,⁴⁵³ Anterior bowing may be apparent with 20 degrees of angulation.²⁹⁵ Functional impairment does not occur with 15 degrees or less of internal rotation deformity.¹²³ Even adolescents can correct up to 30 degrees spontaneously.¹²³ Beaty⁴²
gives guidelines based on the patient’s age: children under 5 years of
age tolerate 70 degrees angulation and total displacement, children 5
to 12 tolerate 40 to 70 degrees angulation, and children over 12
tolerate 40 degrees and 50% apposition. While not based on a study,
these numbers underscore the tremendous remodeling potential of the
humerus and the ability to functionally compensate for angulation.
Bayonet apposition is acceptable,¹⁷¹,³²⁴,⁴²² with 1 to 2 cm of shortening well-tolerated (Fig. 17-42). Clinical appearance is more important than radiographic alignment.

Nonoperative treatment often increases internal rotation by 3 to 12 degrees at the expense of external rotation.¹²³
This rarely is a functional problem. Nonoperative methods include a
sling-and-swathe, the U plaster, a hanging arm cast, a thoracobrachial
cast or dressing, a coaptation splint, functional bracing, and traction.

Sling-and-Swathe. The simplest form of treatment for
fractures is a sling-and-swathe. It is sufficient for patients with
minimally displaced greenstick and torus fractures.²²⁸,⁴⁵³ Although this treatment may yield good results in displaced fractures,⁵²⁰ it can be quite difficult to control anterior angulation,²⁴⁶ varus in an obese patient, and may be uncomfortable.

U Plaster-Sugartong or Coaptation Splint. Böhler⁶³
described a U plaster similar to the sugartong splint used on forearms.
Plaster of appropriate width for the upper arm is formed from over the
shoulder along the lateral aspect of the arm, underneath the olecranon,
and along the medial aspect of the arm to the axilla. Cotton webbing is
placed between the plaster and the skin, and the plaster is secured
using a wrap (Fig. 17-43). Results have been quite good,¹²³ particularly in children.²⁹⁷ Holm²⁴⁴
suggested applying benzoin before the cotton webbing and using a
collar-and-cuff sling about the wrist. To prevent slippage, Shantharam⁵⁰²
suggested applying the splint from the base of the neck, over the
shoulder, and around to the axillary fold, with a strap securing the
proximal end to the chest. The U plaster may not control alignment
satisfactorily in more displaced fractures, which may require a
thoracobrachial cast⁶²,²⁴⁴,⁴⁵³ or internal fixation if better alignment is necessary. Böhler⁶²,⁶⁴ actually abandoned the immediate use of the U plaster for a thoracobrachial cast because of problems with early swelling.

Hanging Arm Cast. The hanging arm cast, described by Caldwell⁸²
as a technique already in use, consists of a long-arm cast with a sling
around the neck tied to the cast along the forearm. The weight of the
cast and arm provides longitudinal traction. The position of the sling
is modified to correct anterior or posterior angulation and varus or
valgus. Rotation is difficult to control. Stewart and Hundley⁵³⁰ suggested not using it in children under age 12 because children cannot keep their arms in a

dependent position during sleep and often keep the arm supported rather
than hanging while awake. However, excellent results are reported in
patients under age 10.⁵⁸⁶
This is probably due to the marked remodeling and potential for good
results regardless of treatment in children. Possible complications of
the hanging cast include inferior shoulder subluxation,¹⁰¹ decreased external rotation,¹⁰¹ and shoulder stiffness,²⁵ but these are rarely significant in children.

Thoracobrachial Immobilization. Severely unstable
fractures uncontrollable in a hanging cast or U plaster may necessitate
extending the cast to the chest as a thoracobrachial cast or splint.⁶²,⁶⁴,²⁴⁴,²⁴⁶,⁴⁵³
Various types of thoracobrachial dressings are often described as a
Velpeau, but technically this is incorrect: Velpeau described a
thoracobrachial bandage with acute elbow flexion. If a thoracobrachial
cast or splint is used for a grossly unstable fracture, usually only a
few degrees of abduction is necessary.²⁴⁴ Distal diaphyseal fractures rarely require extension to the chest.

Functional Bracing. Functional bracing, as described by Sarmiento,⁴⁸⁹ has been quite effective in adults.²⁹,¹⁴⁵,¹⁷⁹,²¹⁷,³²⁹,³⁸⁵,⁴⁰⁰
It may be difficult to use in children because size differences require
a customized brace for each patient or a large supply of braces;
however, modern thermoplastics can keep this economical (Fig. 17-44).⁴³
A prefabricated brace is placed on the initial visit if possible or on
subsequent visits after placement of a U plaster or sling-and-swathe at
the initial evaluation.⁵⁹⁵ The
patient must be followed closely and the splint tightened as needed. It
should not be used in bedridden patients because of loss of gravity
support.²⁹ Sarmiento⁴⁸⁷,⁴⁸⁸,⁴⁸⁹
noted difficulty in controlling anterior angulation and indicated that
patients should not lean on the elbow. The results in adults may be
functionally superior to those of the U plaster.⁵⁰³

Traction. Side-arm and overhead skin and skeletal forms of traction have been described.²⁰,²⁴⁴,⁴⁵³,⁵⁵⁹
If olecranon skeletal traction is used, the AO method of an eye screw
in the olecranon is less likely to produce ulnar nerve irritation than
is a transolecranon pin.²⁷⁵,⁴⁵³ Excessive traction can lead to nonunion in adults²³⁶ and elbow dislocation in children.²²⁹ This technique is rarely utilized now due to economic and family considerations.

There are several surgical alternatives for humeral
diaphyseal fractures: pinning, external fixation, intramedullary
rodding, screw fixation, and compression plating. Biomechanically,
interlocking rods are the stiffest in bending, and dynamic compression
plating is stiffest in torsion. Flexible intramedullary rods are not as
stiff as intact bone.²³³

Open Reduction and Internal Reduction. Open reduction
and internal reduction can be performed through either a posterior
triceps-splitting approach, as advocated by the AO group,²⁷⁵,⁴⁷⁵
or through an anterior lateral approach between the brachialis and
brachioradialis with extension proximally between the deltoid and
pectoralis.⁴⁴,¹⁶⁶
The normal 4.5-mm dynamic compression plate does not provide adequate
stability for the adult humerus shaft. The broad 4.5-mm dynamic
compression plate is designed to allow compact screw placement without
causing excessive stress on the humerus in adults.²⁷⁵
At least six cortices of screw fixation proximal and distal to the
fracture site are needed. In children, smaller plates can be used, such
as small pelvic reconstruction plates and double stacked semitubular
plates depending on the size of the child. With either the
anterolateral or posterior approach, the lateral intermuscular septum
should be split in the distal third to release the tether of the radial
nerve. Interfragmentary lag screws should be used when possible. The
plate should be slipped underneath the radial nerve and vessels and
some muscle placed between the plate and the nerve. Multiple screws in
oblique fractures without a compression plate are unsatisfactory in
adults⁴⁷⁵ but may be sufficient in children. Extensively comminuted fractures may require bone graft.

Generally, the results are good,⁴⁴,²³⁰,²³¹,³⁹⁹,⁵⁸⁷,⁶⁰⁰ and plating is particularly advocated in multiple-trauma patients to facilitate nursing care and management of other injuries.⁴⁴ Potential complications include radial nerve palsy, infection, delayed union, nonunion, and failure of fixation.⁶⁰⁰

Intramedullary Rodding. Several types of intramedullary
rods are available. Currently, there are no indications for reamed
intramedullary nailing in children because of potential proximal
physeal damage and the small diaphyseal diameter. However, they may be
used in skeletally mature adolescents if the canal has sufficient
diameter.⁴⁵⁷ Reamed nailing has been reported in patients as young as 16.¹¹⁵,¹⁴⁹ The results are generally good,¹¹⁵,¹⁴¹,²¹⁹,²⁶²,²⁹⁹,³⁶⁹,⁴⁵⁰,⁴⁶⁵,⁵⁵⁴,⁵⁵⁶,⁵⁹⁶ with a low risk of nonunion and infection.²⁴

Unreamed nails, such as Ender nails, Rush rods, or
flexible titanium rods, have been used most extensively in adults with
multitrauma. Nails or rods can be inserted via a posterior
triceps-splitting approach through a hole just above the olecranon
fossa. This can be useful for rapid management of fractures, including
open fractures in patients with multiple trauma.⁷⁶,⁹³,¹¹⁰,¹³³,²²⁰
Rods should not be inserted through the greater tuberosity in children
(except under extenuating circumstances) because of risk of injury to
the proximal humeral physis and the potential for shoulder impingement.³⁵⁹,⁴⁶⁷,⁵²⁹ Inserting these relatively large rods through the epicondyles results in a high incidence of nail back-out.²²⁰

There are two techniques of using small, flexible, smooth wires. In the Hackethal technique,²¹⁶
fluoroscopy is used with a tourniquet placed on the upper arm. A hole
is made just proximal to the olecranon fossa using a triceps-splitting
approach. Smooth, blunt-tipped Steinmann pins are placed up the canal
of the humerus, progressively filling the canal with smaller and
smaller pins as needed (Fig. 17-45). Results are generally good,⁹²,¹³⁷,¹⁴⁷,²³⁴,³⁸³,⁴³³,⁵⁹⁹
although pin back-out can be a problem and care must be taken not to
distract the fracture site. The rods should be bent 90 degrees at the
cortical window.⁴³³ This technique may be useful for segmental and pathologic fractures.³⁴²

The other technique consists of using small smooth rods or Steinmann pins placed through the epicondyles.³⁴⁰,³⁸⁴
The tips of the rods should be blunt and slightly bent. These are
placed through the lateral epicondyle or through both the medial and
lateral epicondyles. A hole is made in the epicondyle, and a
blunt-tipped Steinmann pin is tapped up the diaphysis using a mallet or
passed by hand, with a drill chuck holding the pin. The bend on the tip
of the rods facilitates crossing the fracture site and manipulating the
fracture reduction. A splint is necessary postoperatively. Alignment
need be only within the tolerances for a closed reduction (Fig. 17-46). The use of flexible intramedullary nailing has also been described with good success in children and adolescents.³¹⁹

External Fixation. Both unilateral and multiplanar
external fixation techniques are occasionally useful for humeral shaft
fractures.²⁰,¹²⁹,²⁸¹,²⁸⁹
External fixators are primarily useful for severe open fractures or as
an alternative to internal fixation. In patients with open fractures,
immediate external fixation with subsequent bone grafting yields good
results.⁴⁴⁹,⁵¹⁴ External fixation can be combined with internal fixation for immediate stability¹¹²
and early rehabilitation. Severe open fractures with bone loss can be
treated with primary shortening followed by callus distraction⁴⁷⁹
to provide early soft tissue coverage and subsequent restoration of
humeral length. Care must be taken during pin placement to avoid radial
nerve injury. If screws are used, limited open screw placement can
prevent this injury.⁴⁴⁹ Ring fixators may be useful for reconstructing the injured humerus.⁷⁸,⁸⁹,⁹⁰,¹⁰²,²⁵⁹,²⁶⁰,⁵⁰⁸,⁵¹⁰

Because most humeral fractures are controllable nonoperatively, there are few surgical indications.⁴⁶
Potential operative indications include open fractures, multiple
trauma, bilateral injuries, arterial injuries, compartment syndromes,
pathologic fractures, significant nerve injuries, inadequate closed
reduction, and ipsilateral upper extremity injuries or paralysis.

Preadolescents can almost always be managed
nonoperatively, except those with severe soft tissue injury. If
fracture reduction cannot obtain less than 30 degrees varus and 20
degrees anterior angulation in older children and adolescents—or more
importantly, if the arm appears deformed—alternatives such as internal
fixation, intramedullary rodding, external fixation, or a
thoracobrachial cast should be considered. Inadequate closed reduction
is most common in obese patients and in thin women with large breasts.⁴⁷⁵ However, obesity tends to hide the deformity of the fracture, and large breasts are seldom encountered in thin children.

Open fractures may require fixation. Small, stable grade
1 wounds can still be managed using coaptation splints or other closed
methods. Unstable open fractures should be stabilized with internal or
external fixation to protect soft tissues.⁹⁸,¹³³,³³¹,³⁵⁸,⁴⁷⁵,⁵⁶⁰

Multiple-trauma victims are often best treated with internal or external fixation for more rapid mobilization.⁴²,⁷⁶,⁴⁴,⁶⁶,³⁴⁷,³⁶⁶
This is particularly true in patients with chest injuries, where
thoracobrachial immobilization would compromise pulmonary care.¹³³,³⁴⁷,³⁵⁸ Excellent results have been reported with external fixation⁹⁸,²⁸¹,⁴⁴⁹,⁵¹⁴; retrograde rodding using titanium, Ender, or Rush rods⁷⁶; and internal fixation.⁴⁴
In older adolescents, more rigid locked or unlocked intramedullary
rodding can be used for patients requiring their upper extremities for
mobility.¹⁶⁶ However, this luxury does not exist for younger children.

Arterial injury and compartment syndromes requiring fasciotomy are potential indications for internal fixation.¹⁷⁸,⁴⁴⁵,⁴⁵⁵,⁵¹⁶ Continued fracture mobility can damage a vascular anastomosis,¹⁸⁰,³⁷⁸,⁴⁵⁵,⁵¹⁶ and fasciotomy can make the fracture less stable.

Temporary vascular shunting before internal fixation allows the
orthopaedist and the vascular surgeon to work under optimal conditions.⁹⁷

Most pathologic fractures in children, including those from malignancy,⁴⁶² fibrous dysplasia,¹⁹⁰,⁵²⁶,⁵³⁹
osteogenesis imperfecta, and simple bone cysts, can be treated
nonoperatively. Simple bone cysts are discussed in the section on
proximal humerus fractures. A report of a 6-year-old with progressive
ossifying fibrodysplasia suggests that internal fixation may prevent
stiffness after fractures in this condition.⁴⁰⁵ In fractures secondary to malignancy, intramedullary rodding is necessary if extensive cortical loss causes instability.¹⁰⁹,¹⁴⁹,³³⁴,⁵²⁹,⁵⁵² Spontaneous fracture in a severely brain-injured or unresponsive cerebral palsy patient is best treated nonoperatively.⁵⁵⁷

Ipsilateral injuries, particularly fractures of the
proximal or distal humerus and of the forearm, can be difficult to
control. In adults with a floating elbow, internal fixation or elastic
nailing of the humeral fracture provides optimal results.⁷⁶,³¹⁵,⁴⁶³ This is also true for supracondylar humeral fractures in children but is not documented in diaphyseal fractures.⁶⁹,⁵²³ The floating elbow is often associated with other organ system injuries; nerve injury occurs in up to 50% of these patients.⁴³⁸

Humeral shaft fractures with ipsilateral brachial plexus palsies in adults heal best with open reduction and internal fixation.⁷⁰ The same is true with spinal cord injuries.¹⁸⁵
Functional bracing is precluded in these patients because the muscles
do not function and sensation is altered. Because of the excellent
healing potential in children, they may be treated nonoperatively if
satisfactory alignment can be maintained. Older adolescents should be
treated like adults.

Radial nerve palsies with humeral shaft fractures have been reported in children (Fig. 17-47).⁹⁴,³⁵⁸
Primary radial nerve palsies occur at the time of the fracture;
secondary radial nerve palsies occur after manipulation of the
fracture. Many clinicians recommend exploration of secondary radial
nerve palsies⁴²,¹²³,¹⁸¹,⁴³¹,⁴⁴⁴,⁵⁰⁶,⁵⁵⁵,⁵⁷¹ and a few do for primary nerve injuries.¹⁰,¹¹⁹,¹⁸¹,²⁴⁵,³⁰⁷,³¹¹,³⁹⁷,⁴³¹,⁴⁴⁴,⁴⁶⁴,⁵⁴² The incidence of concomitant radial nerve palsy with a humeral shaft fracture ranges from 2.4% to 20.6%²⁴,⁵²,¹⁸¹,³⁵⁸,³⁷⁰,⁴⁴¹,⁴⁶⁴,⁵⁰¹,⁵⁶³ and has been reported in 4.4% of children’s humeral shaft fractures.³⁵⁸ Most occur with middle and distal humeral shaft fractures, but they may occur with more proximal fractures as well.³⁷⁰ In explored primary radial nerve palsies, the incidence of complete nerve laceration is small.²⁰⁴,³⁵⁸,⁴³¹,⁵⁰¹,⁵¹⁸,⁵⁶³
Commonly, the nerve is tented over the bone, trapped in the fracture
site, or contused. The natural history is excellent, with recovery
ranging from 78% to 100%.¹²,⁵²,⁶⁵,⁶⁶,¹⁴⁰,¹⁸¹,¹⁹⁵,⁴³¹,⁴⁴¹,⁴⁴⁴,⁴⁸²,⁵⁰¹,⁵⁶³ Therefore, most clinicians recommend observation rather than early exploration.⁵²,¹⁴⁰,¹⁸¹,¹⁹⁵,⁴³¹,⁴⁴¹,⁴⁴⁴,⁴⁸²,⁵⁰¹,⁵⁶³
This is especially true in children where the periosteum can be
protective against entrapment and the nerves can recovery quickly from
contusion and traction ischemia. Open fractures resulting in severe
soft tissue injury requiring débridement should have the radial nerve
identified. If lacerated, exploration and tagging for later repair,⁵³⁵ or preferably, primary repair is performed.¹⁶⁷
More severe open fractures should be stabilized using either
intramedullary rodding, internal or external fixation to provide
stability for soft tissue healing, or radial nerve recovery. Early
repair of the nerve provides the best anatomic results.⁴⁹ Bostman et al.⁶⁶
recommended exploration and internal fixation in patients with bayonet
apposition because the abundant callus may endanger nerve recovery. The
recommended waiting time before radial nerve exploration ranges from 8
weeks to 6 months.¹⁰,¹²,¹²³,¹⁴⁰,²⁴⁶,³⁷⁰,⁴⁴¹,⁴⁴⁴,⁴⁵³,⁵⁰⁶,⁵⁷¹ Nerve grafting up to 18 months after the injury can provide good function.⁴⁹,¹⁶⁵ Ogawa⁴¹⁹ reported a complete radial nerve division which was repaired with a sural nerve graft resulting in full function. Seddon⁴⁹⁵
suggested a physiologic time of allowing 1 mm per day after the 1 to 2
months of Wallerian degeneration and nerve growth through the neuroma.
Nerves grow 1 to 3 mm per day,⁴⁹⁵,⁴⁹⁶,⁵³⁴ and this rate has been used clinically with good success.¹⁹⁹,⁵³⁵
In children, healing is usually faster and signs of spontaneous
recovery are usually present by 3 months. This is noted by an advancing
Tinel sign, radial wrist extension recovery followed by central wrist
extension, digital metacarpophalangeal extension, and then thumb
retropulsion and ipsilateral extension.

In secondary radial nerve palsies, the surgeon may feel
compelled to explore the nerve because he or she “caused” the radial
nerve injury. However, natural history studies of observed secondary
radial nerve palsies show recovery rates of 80% to 100% with
nonoperative treatment.⁶⁶,¹⁸¹ Secondary palsies occurring after manipulation may be observed.⁵²,¹⁴⁰,³¹⁰,⁴³²,⁵⁰¹
If the palsy occurs after a considerable time, the nerve is probably
encased in callus and further investigation, including exploration, is
warranted.¹⁴⁸,⁵³¹ Late presentation may result in an osseous foramen containing the nerve and requiring decompression.¹⁴⁸ Again, in children, there should be signs of recovery by 3 months, and no later than 6 months, if natural history is chosen.

Nerve Palsies. Radial nerve palsies were discussed previously. They may occur immediately after operative treatment,¹³⁰ or may be delayed and occur many years after internal fixation.¹⁷⁶ Ulnar nerve paralysis has been reported from entrapment of the nerve in the fracture site.²⁸³
A few people have an abnormal arcade of Struthers in which only
superficial fibers of the triceps medial head pass superficial to the
ulnar nerve and none pass deep to the nerve, making the nerve extremely
close to the bone and vulnerable to an abduction extension mechanism of
fracture, which opens the anterior medial aspect of the humerus.²⁸³
In about 10% of the population, the median nerve crosses posterior to
the brachial artery rather than anterior, placing it closer to the
humerus. Median nerve palsy has been reported from an apex anterior
middiaphyseal fracture.³⁶⁰ After an
easy fracture reduction, the median nerve was caught in the fracture
between the coracobrachialis and brachialis muscles, where the nerve
crossed anteriorly. Anterior interosseous nerve palsies have not been
reported in fractures above the supracondylar region.

Compartment Syndrome. The fascia of the upper arm is not
as strong as it is in the lower arm, making compartment syndrome less
common. Mubarak and Carroll³⁹⁵ reported a dorsal forearm compartment syndrome in a 9-year-old boy with a humerus shaft fracture. Gupta and Sharma²¹²
described an adult with a triceps compartment syndrome from a middle
third minimally displaced fracture; this fracture did not disrupt the
intercompartmental boundaries.

Vascular Injuries. Vascular injuries require a high index of suspicion and rapid treatment.⁷⁴,¹³⁰,³⁶³,³⁸¹ The fracture should be stabilized sufficiently to prevent disruption of the vascular repair.

Infection. Infections have been reported in patients
undergoing surgery. They have not been reported in closed fractures of
the humerus in children, but have been reported in closed fractures
elsewhere.⁸⁵,⁵⁷⁰

Malunion. Malunion is uncommon in children’s humeral diaphyseal fractures. Varus of 20 to 30 degrees can be accepted (see Fig. 17-41),⁶⁹,¹²³,¹⁵⁴,⁴⁵³,⁵²³ but anterior bowing of 20 degrees may be apparent.²⁹⁵ An internal rotation deformity of 15 degrees causes no functional impairment.¹²³ Most patients under 6 years of age grow out of angular deformities.²⁴⁶ Children 6 to 13 years of age may not, although some remodeling is possible even in adolescents.²⁴⁶,⁴⁰⁹ Obese patients are more prone to malunion, but they also hide their deformity better.⁴⁷⁵ Green and Gibbs³³³
noted that the deformity visible on the AP and lateral radiographs is
generally not the maximum deformity, which is the vector sum of the two
deformities. This can be appreciated by obtaining a radiograph
perpendicular to the plane of the deformity, similar to the Stagnara
view for scoliosis.

Nonunion. Primarily a problem in adults and occasionally
in older adolescents, there are few reports of humeral nonunion in
children: one in a child with progeria at age 4,¹⁷² four in children with osteogenesis imperfecta,¹⁸⁰ and three from severe trauma.⁹⁷ In adults, numerous treatments have been used successfully. These include reamed nails¹⁰⁰ and modified flexible nails.²¹³,⁴⁴⁶
However, the best results appear to be from ASIF techniques with the
broad dynamic compression plate and autogenous bone grafting.³³,⁹¹,¹⁶¹,²²⁶,²⁴⁵,³⁹⁷,⁵⁹²
Currently, treatment in children and adolescents must be extrapolated
from adult treatment. In general, the atrophic ends of the nonunion are
taken back to bleeding surfaces and apposed, a compression plate is
applied with fixation of at least six cortical screws proximally and
distally, and bone grafting is performed.²²⁶ The Ilizarov technique also reportedly produces good results.¹⁷,³⁴,⁷⁸,⁸⁹,²⁵⁹,²⁶⁰,⁵⁰⁸ Electrical stimulation also has been used with success.¹¹¹,¹⁵⁶,¹⁵⁸,⁴⁹⁷,⁴⁹⁸,⁵³²
Children with dysplastic bone, such as those with osteogenesis
imperfecta, are best treated with intramedullary rodding and bone
grafting.¹⁸⁰

Loss of Motion. Loss of shoulder and elbow motion is more common in older patients.¹⁴,²⁴⁶ The joint affected is usually the one closest to the fracture site.

Upper Extremity Limb-Length Discrepancy. Overgrowth
after humeral fracture occurs in about 81% of patients but is generally
minimal (<1 cm).²²⁸ Some generalized stimulus to the extremity is evident, with overgrowth of the carpals as well.⁴⁹⁰
Lengthening is rarely indicated as the humerus can tolerate 5 to 8 cm
of shortening without functional loss due to shoulder and truncal
compensation. However, lengthening has been performed in patients with
limb-length discrepancy of 3 cm or more at maturity.¹²⁰,⁴³⁴ Unilateral or ring fixators may be used with Ilizarov’s principles.⁸⁹,⁹⁰

Other Complications. Uncommon complications include reflex sympathetic dystrophy¹⁶⁹ and fat embolism.³⁰³ Late refracture may occur from retained internal fixation.⁶⁸

Most distal humeral diaphyseal fractures are transverse,
spiral, or short oblique. Occasionally, an oblique or spiral fracture
extends distally toward or beyond the epicondyles (Fig. 17-48).
The description must include the direction of displacement, the
neurologic and vascular status, and the degree of comminution. Medial
column comminution predisposes to varus malunion.

Closed treatment usually is possible because acute
flexion of the elbow, with potential vascular compromise, is not
required to maintain reduction. These fractures tend toward varus
malunion (Fig. 17-49),⁷⁵
which may be cosmetically unacceptable, particularly in more distal
fractures. With 20% or less of humeral growth occurring distally,⁵⁶,⁴⁴⁷,⁴⁴⁸
significant remodeling may not occur. Because of the proximity to the
epicondyles with their muscular origins, supination and pronation
affect fracture reduction. If one cortex is open, then the muscles
originating on that side should be tightened to reduce the fracture.¹⁶ Because of the varus tendency, this is usually by pronation.⁶³,⁶⁴,⁵¹⁶ However, this is best checked radiographically (Figs. 17-50 and 17-51).

Unstable fractures may require fixation⁷⁵,⁴⁵³
and possibly open reduction. Closed reduction and percutaneous pinning
should be performed in a similar fashion to supracondylar humerus
fractures. However, because the fracture is more proximal, it is
difficult to get the pins into the diaphysis without crossing them at
the fracture site (Fig. 17-52). The difficulty
in stabilizing these fractures has been demonstrated by a longer
operative time when compared to standard supracondylar fractures.¹⁶²
In addition, transverse fractures in this region have a high incidence
of loss of fixation, reoperation, pin migration, cubitus varus
deformity, and prolonged loss of motion.¹⁶²
Attempts can be made to pass the wires in intramedullary fashion up the
lateral or medial and lateral columns separately to provide stability (Fig. 17-53).⁴⁵³
This can be done by drilling the wires, but it is easier to create a
starting site at the epicondyles and pass blunt-tipped wires up the
columns. Holding the wires with a drill chuck helps, too. Because of
the bony anatomy and the ulnar nerve, lateral wires are easier to
place, particularly in younger children (Fig. 17-54).
However, unilateral intramedullary fixation may lead to bowing.
Alternatively, the fracture can be managed with skeletal traction until
callus forms; then either a U plaster splint or a long-arm cast can be
applied (Fig. 17-55). Brug et al.⁷⁵
reported the best results with flexible intramedullary rodding. If
internal fixation with a plate is chosen, both columns need to be
stabilized.

Supracondyloid process fractures are classified as
displaced or nondisplaced, with notation of median nerve or brachial
artery compromise.