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Paediatric Orthopaedic Pathways
Paediatric Orthopaedic Pathways

Proximal humerus fractures

ED Management | Outpatient/Fracture Clinic Management | Operative Management 


ED Management

The following information is for use by medical practitioners and trainees in the Emergency Department  

1.   Treatment Pathway  
2.   What are likely findings on history?
3.   What specific information from the patient history should be documented?
4.   What are likely findings on clinical exam?
5.   What specific findings on the physical exam are important to document?
6.   What X-rays should be ordered?
7.   What specific features are found on X-ray?
8.   How should this fracture be treated in the emergency department?
9.   Should this patient be referred urgently to the nearest orthopaedic surgery service on call?
10. Where should this patient be seen for follow-up care?
11. What discharge prescriptions and instructions should be provided?
12. What potential complications could result from this injury or its management?

1. Treatment Pathway

Uncomplicated Proximal Humerus Fracture§ 

ED management

Follow-up care

• Girl under 10 years old
• Boy under 12 years old   

 

  • Analgesia
  • No reduction needed
  • Immobilize arm in broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Provide SickKids Parent Information sheet- Proximal humerus fracture (PDF)

 

  • Follow up in Fracture Clinic in 1 week
  • No repeat X-rays needed
  • Removal of sling at home in 4 weeks and begin range of motion exercises
  • Avoid high-risk activities for 3 months following injury

• Girl over 10 years old with ≤ 50% displacement
• Boy over 12 years old with ≤ 50% displacement

 

     

  • Analgesia
  • No reduction needed
  • Immobilize arm in broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Provide SickKids Parent Information sheet- Proximal humerus fracture (PDF)
  • Follow up in Fracture clinic within 1 week with AP and lateral X-rays of the affected shoulder
  • Removal of sling at home in 4 weeks and begin range of motion exercises
  •  Avoid high-risk activities for 3 months following injury

• Girl over 10 years old with > 50% displacement
• Boy over 12 years old with > 50% displacement

 

  • Analgesia
  • Keep NPO
  • Urgent referral to nearest orthopaedic surgeon on call for possible closed reduction and percutaneous pinning
  • To be determined by treating orthopaedic surgeon

Fractures through bone cyst or pathologic lesion

 

  • Analgesia
  • No reduction needed
  • Immobilize arm in broad arm sling
  • Ibuprofen for post-discharge analgesia
  • Referral to nearest orthopaedic surgeon on call to determine individualized follow-up plan
  • To be determined by treating orthopaedic surgeon

§ Uncomplicated fracture implies the absence of open fracture, skin tenting, neurovascular compromise or fractures in the setting of polytrauma.

2. What are likely findings on history?

Mechanism of injury is usually a fall with direct or indirect trauma to the shoulder.

3. What specific information from the patient history should be documented?

    • Document the date and time of injury.
    • Document the time of the last oral intake (all patients should be kept fasting until a decision has been made regarding the need and timing of orthopaedic intervention).

4. What are likely findings on clinical exam?

    • Pain, swelling and ecchymosis at the shoulder
    • The arm is often held in adduction at the patient’s side and the patient is reluctant to move the shoulder
    • Nerve palsies and vascular injuries are rare with uncomplicated fractures but may be present in the presence of polytrauma or ipsilateral clavicle fractures

5. What specific findings on the physical exam are important to document?

    • The presence of skin tenting or fracture blisters
    • The presence of an open fracture (splints placed at outside institutions should be taken down if there is any suspicion of an open fracture to allow adequate inspection of the overlying skin)
    • The presence of a peripheral nerve injury using the SickKids Peripheral Neurovascular Checklist (PDF)
    • The presence of an arterial injury or limb ischemia using the SickKids Peripheral Neurovascular Checklist (PDF)
    • The presence of signs or symptoms of compartment syndrome
    • The presence of an injury to the joints or bones above and below the injury (two-level injuries are at increased risk of having a brachial plexus palsy)

6. What X-rays should be ordered?

    • AP and lateral radiographs of the shoulder
    • Fracture-dislocations of the proximal humerus are rare with uncomplicated fractures therefore routine axillary or Valpeau views are almost never indicated
    • If there are concerns of adjacent injuries, additional radiographs may be warranted  

7. What specific features are found on X-rays?

If you are unfamiliar with interpreting shoulder radiographs, or need a refresher, click here.

Evaluation of x-rays should include the amount of displacement (a percentage of the humeral shaft diameter), angulation and whether or not the fracture involves the physis. 

Fractures that involve the physis can be classified by the Salter-Harris classification system.

 


AP and lateral radiographs of an undisplaced fracture through the metaphysis of the proximal humerus.


 

AP and lateral radiographs of a displaced fracture through the physis of the proximal humerus. 


AP radiograph of displaced fracture through the metaphysis of the proximal humerus.


AP radiograph of fracture through cyst in proximal humerus


8. How should this fracture be treated in the emergency department?

  • Girl under 10 years old or Boy under 12 years old:
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
    • Uncomplicated proximal humerus fractures do not routinely need a reduction in the ED
    • Immobilize arm in broad arm sling
  • Girl over 10 years old with  ≤ 50% displacement or Boy over 12 years old with ≤ 50% displacement:
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
    • Uncomplicated proximal humerus fractures do not routinely need a reduction in the ED  
    • Immobilize arm in broad arm sling
  • Girl over 10 years old with > 50% displacement or Boy over 12 years old with > 50% displacement:
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
    • Uncomplicated proximal humerus fractures do not routinely need a reduction in the ED  
    • Immobilize arm in broad arm sling
    • Keep NPO
    • Urgent referral to nearest orthopaedic surgeon on call for possible closed reduction and percutaneous pinning
  • Fractures through bone cyst or pathologic lesion:
    • Analgesia: 
      • Oral:  Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg) every 6 hours as needed, and/or morphine (0.2-0.5mg/kg/dose) every 4 hours as needed. Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Intravenous:  morphine (0.1 mg/kg/dose), ketorolac (0.5 mg/kg/dose)
    • These fractures do not routinely need a reduction in the ED  
    • Immobilize arm in broad arm sling
    • Referral to nearest orthopaedic surgeon on call to determine individualized follow-up plan

9. Should this patient be referred urgently to the nearest orthopaedic surgery service on call?

Indications for emergent (within 1 hour) referral to the nearest orthopaedic surgeon on call include:

    • Loss of radial pulse or a cool, white hand
    • Signs or symptoms of compartment syndrome

Indications for urgent (within 4 hours) referral to the nearest orthopaedic surgeon on call include:

    • Fractures in a girl over 10 years old with > 50% displacement or in a boy over 12 years old with > 50% displacement
    • Associated nerve injuries
    • Open fracture
    • Impending open fracture (e.g. large anterior bruise or skin tenting)
    • Associated injuries to the elbow, forearm or wrist
    • Fractures through a bone cyst or pathologic lesion

Patients awaiting orthopaedic assessment in the emergency department should be kept nil per os (NPO) until a decision about surgery is made.

For open fractures, tetanus immunization status should be assessed and appropriate IV antibiotics provided.

 10. Where should this patient be seen for follow-up care?

    • Girl under 10 years old or Boy under 12 years old:
      • Follow up in Fracture clinic in 1 week (no repeat x-rays needed)
    • Girl over 10 years old with  ≤ 50% displacement or Boy over 12 years old with ≤ 50% displacement:
      • Follow up in Fracture clinic within 1 week with AP and lateral x-rays of the affected shoulder
    • Girl over 10 years old with > 50% displacement or Boy over 12 years old with > 50% displacement:
      • To be determined by orthopaedic surgical service on call
    • Fractures through bone cyst or pathologic lesion:
      • To be determined by orthopaedic surgical service on call

11. What discharge prescriptions and instructions should be provided?

    • Girl under 10 years old or Boy under 12 years old:
      • Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed, acetaminophen (15mg/kg/dose, max. 1000mg), and/or morphine (0.2-0.5mg/kg/dose). Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Provide SickKids Parent Information Sheet- Proximal humerus fracture  (PDF)
      • Activities that may result in re-injuring the shoulder should be avoided for approximately 12 weeks from the date of injury
    • Girl over 10 years old with  ≤ 50% displacement or Boy over 12 years old with ≤ 50% displacement:
      • Ibuprofen (10 mg/kg/dose, max. 600 mg) every 6 hours as needed is, acetaminophen (15mg/kg/dose, max. 1000mg) and/or morphine (0.2-0.5mg/kg/dose). Ibuprofen is as effective as morphine in children with non-operative upper extremity fractures.
      • Provide SickKids Parent Information Sheet- Proximal humerus fracture  (PDF)
      • Activities that may result in re-injuring the shoulder should be avoided for approximately 12 weeks from the date of injury
    • Girl over 10 years old with > 50% displacement or Boy over 12 years old with > 50% displacement:
      •  To be determined by orthopaedic surgical service on call
    • Fractures through bone cyst or pathologic lesion:
      • To be determined by orthopaedic surgical service on call

12. What potential complications could result from this injury or its management? 

  • Due to the remodeling potential of this region, the outcome from this fracture is usually excellent.  
  • Neurovascular complications are rare and usually due to associated soft tissue and neurological injuries, i.e. brachial plexus.
  • Mild shortening of the humerus and mild angular malunion on are not noticeable cosmetically, and diminished shoulder range of motion is a rare consequence usually seen in adolescents nearing skeletal maturity and therefore limited remodeling potential.
  • Physeal injuries in adolescents are typically Salter-Harris type I and II with very low subsequent growth arrest rates.
  • By limiting return to high risk activities for 3 months, re-fracture is extremely rare.
  • Nonunion is extremely rare.

 

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Outpatient/Fracture Clinic Management

The following information is for use by medical practitioners and trainees in Fracture clinics or Outpatient clinics.

1. When should this patient be seen in fracture clinic/outpatient clinic?
2. What should be reviewed at each clinic visit?
3. What are common reasons to deviate from the treatment pathway?
4. Does this patient require long-term follow-up?
5. Instructions for parents and SickKids Parent Information Sheets  

1. When should this patient be seen in fracture clinic/outpatient clinic?

  • Girl under 10 years old or Boy under 12 years old  
    • Follow-up in Fracture Clinic in 1 week
      • No repeat X-rays needed
    • Subsequent Follow-up
      • No further follow up usually needed
      • Removal of sling at home in 4 weeks and begin range of motion exercises
      • Avoid high-risk activities for 3 months following injury
  • Girl over 10 years old with  ≤ 50% displacement or Boy over 12 years old with ≤ 50% displacement:
    • Follow up in Fracture clinic within 7 days with:
      • AP and lateral X-rays of the affected shoulder
      • Clinical and radiographic review to determine if patient meets indications for operative management
    • Subsequent Follow-up
      • No further follow up usually needed
      • Removal of sling at home in 4 weeks and begin range of motion exercises
      • Avoid high-risk activities for 3 months following injury
  • Girl over 10 years old with > 50% displacement or Boy over 12 years old with > 50% displacement:
    • If orthopaedic surgeon did not recommended operative management at initial presentation then follow up in Fracture clinic within 7 days with:
      • AP and lateral X-rays of the affected shoulder
      • Clinical and radiographic review to determine if patient meets indications for operative management
    • Subsequent Follow-up
      • If orthopaedic surgeon does not recommend operative management then no further follow up usually needed
      • Removal at sling at home in 4 weeks and begin range of motion exercises
      • Avoid high-risk activities for 3 months following injury.
      • Patient instructed to return to clinic if shoulder range of motion decreased and limiting function
  • Fractures through bone cyst or pathologic lesion:
    • Individualized follow-up to be determined by orthopaedic surgeon. However, patients with fractures through simple bone cysts should typically follow-up in Fracture clinic in 1 week with:
      • AP and lateral X-rays of the affected shoulder
      • Clinical and radiographic review
    • Subsequent Follow-up
      • Removal of sling at home in 4 weeks and begin range of motion exercises
      • Follow-up in Fracture clinic at 6 weeks with:
        • AP and lateral X-rays of the affected shoulder
        • Clinical and radiographic review to determine if the cyst has resolved
    • If the cyst has resolved, then the patient should avoid high-risk activities for 3 months following injury and may be discharged from clinic
    • If the cyst persists, then the patient should be referred to a paediatric orthopaedic surgeon for further management and usually seen at 3 months following injury. The patient should avoid high risk activities until assessed by a paediatric orthopaedic surgeon.

2. What should be reviewed at each clinic visit?

  • At first clinic:  
    • Perform and document peripheral neurovascular examination using the SickKids Peripheral Neurovascular Checklist (PDF)
      • If radiographs have been ordered, measure displacement and angulation to help determine if patient meets indications for operative management
      • Assess analgesic requirements
    • Review range of motion exercises to be initiated at 4 weeks with aim for full function by 12 weeks.
  • Subsequent clinics:
      • If fracture was through bone cyst, then review new radiographs to determine resolution or persistence of cyst.

3. What are common reasons to deviate from the treatment pathway?

Common reasons to deviate from the treatment pathway include:

  • Angulation or displacement beyond acceptable limits for continued closed management
    • May require more frequent follow-up, additional investigations or referral to subspecialist for operative management
  • Patient underwent treatment in the operating room
    • These patients should be followed up by their treating surgeon
  • Established neurovascular injury
    • May require more frequent follow-up, additional investigations or referral to subspecialist
  • Fractures through bone cyst or pathologic lesion
    • May require evaluation by a paediatric orthopaedic surgeon regarding the need for further work-up and operative management

4. Does this patient require long-term follow-up?

  • The vast majority of patients with proximal humerus fractures do not require long-term follow-up
  • Fractures that involved the physis rarely result in a growth arrest and, as such, do not routinely require long term follow-up.
  • Fractures through persistent bone cysts warrant long-term follow-up provided by a paediatric orthopaedic surgeon.
  • Patients that experience diminished range of motion or shoulder impingement should return to clinic for a clinical evaluation and may warrant long-term follow-up provided by a paediatric orthopaedic surgeon.

5. Instructions for parents and SickKids Parent Information Sheets

  • Contact sports and high-risk activities should be avoided for approximately 12 weeks from the date of injury to prevent refracture.
  • Instruct patient to return to clinic if they continue to have pain in the shoulder 6 weeks after the injury.
  • Instruct patient to return to clinic if full shoulder range of motion has not returned by 6 months. 
        • SickKids Parent Information Sheet- Proximal humerus fracture (PDF)

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Operative Management

Content under development

 

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References

  1. Beringer, D. C., et al. (1998). "Severely displaced proximal humeral epiphyseal fractures: a follow-up study." J Pediatr Orthop 18(1): 31-37. Beringer, D. C., et al. (1998). "Severely displaced proximal humeral epiphyseal fractures: a follow-up study." J Pediatr Orthop 18(1): 31-37.
  2. Chaus, G. W., et al. (2015). "Operative versus nonoperative treatment of displaced proximal humeral physeal fractures: a matched cohort." J Pediatr Orthop 35(3): 234-239.
  3. David, S., et al. (2006). "[Fracture of the proximal humerus in children and adolescents. The most overtreated fracture]." Chirurg 77(9): 827-834.
  4. Dobbs, M. B., et al. (2003). "Severely displaced proximal humeral epiphyseal fractures." J Pediatr Orthop 23(2): 208-215.
  5. Hutchinson, P. H., et al. (2011). "Intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: a comparison of complications and early radiographic results." J Pediatr Orthop 31(6): 617-622.
  6. Kohler, R. and J. M. Trillaud (1983). "Fracture and fracture separation of the proximal humerus in children: report of 136 cases." J Pediatr Orthop 3(3): 326-332.
  7. Pahlavan, S., et al. (2011). "Proximal humerus fractures in the pediatric population: a systematic review." J Child Orthop 5(3): 187-194.
  8. Popkin, C. A., et al. (2015). "Evaluation and Management of Pediatric Proximal Humerus Fractures." J Am Acad Orthop Surg 23(2): 77-86.

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Content developed by Dr. Arahon Gladstein and approved by the SKPOP Committee on September 1st 2015.
To provide feedback, please email mark.camp@sickkids.ca