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M.KARIMIAN.MD

Proximal humerus fractures

Relatively uncommon ( <3% ) ,most commonly in adolescents

Almost exclusively salter-harris type I or II

In general heal & remodel because : thick periosteom ,universal motion,great growth of region ( 80% )

Mechanism of injury

Birth fracture Direct trauma ( outstretched hand ) Direct blow to the lateral aspect of

the shoulder Child abuse Less common: malignant or benign

tumor,pituitary gigantism,joint neuropathy

Sign & symptom

Infant : irritable,pseudoparalysis

Older children: pain, swelling,deformity

Displaced fx => epiphysis abd & ext. rot

distal fragment ant.medial rot

Undisplaced fx=> arm ininternal rotation

Radiographic study Not useful < 6month sonography & CT Comprision xray & vanishing sign In older children: AP axillary lateral view (difficult) transthorasic axillary view or Y view apical oblique view(AP Xray with 45” caudal tilt) CT scan (R/O dislocation) MRI (R/O occult fx) Bone scan( R/O occult fx but difficult to interpret )

Classification Salter- harris: type I : infants & small children

type II: adolescent

type III & IV : rare because universal motion or combind with dislocation

Neer-Horwitz: grade I: < 5 mm displacement

grade II: 5mm to 1/3 diameter of shaft

grade III: 1/3 to 2/3 diameter

grade IV: more

Stress fx of metaphysis or slipped epiphysis due to chronic or repetitive trauma such as throwing ,gymnastic, localised radiation therapy

treatment Nearly all proximal humeral fx can be traeted

nonoperatively regardless age & grade Grade I & II: treated symptomaticlly without

attempt at reduction Grade III & IV: controversial - all agree <6month treated symptomatically -closed reduction (traction abductionforward

flextionexternal rotation (under fluoroscopic guidance )imobilization 2 to 3 weeks

occasionally reduction is lost or we cannot obtain adequate closed reduction existing deformity is accepted & managed symptomatically ( family reassurance )

Operative treatment:

-intraarticular fx -open fx -neurovascular injury -polytraumatised

patient

Complication of proximal humerus fx Rare 1- shortening (not important): more

after surgury or pathologic fx UBC 2-varus –valgus deformity 3-AVN 4-brachial & axillary nerve

injury(typically transient & return in< 6month ,if >3month EMG )

5-brachial artery disruption 6- hypertrophic scarring ( after

deltopectoral aproach axillary or ant.axillary incision better )

Little league shoulder Also called proximal humeral epiphysiolysis,

osteochondrosis or traction apophysitis Is overuse injury most commonly in pitchers &

occasionally other overhead athletes. Nonspecific shoulderpain,often at beginningof the

season or after a significant change in training protocol

Tendernes along P.H physis ,painful or limited ROM Due to rotary torque Xray : normal or widening Of PHP /stress fx my be

present with methaphyseal lucency & periosteal new bon formation

Almost always respond to rest

Clavicle

The first bone to ossify & the last physis to closed (medial )often not untile the 3rd decade

Clavicle fx is 8% to 15% of all pediatric fx

Most fx in middle third (76% to 85%)

Mechanisem of fx Newbornduring delivery

Children & adolescents 1-fall on outstretched hand or side of

shoulder 2-direct blow ( most the lateral end

fx )

Sign & symptom

Newborn infants: -pseudoparalysis (mistakan for brachial plexsus inj.) -head turn toward fx ( to reduce pull of SCM) -asymetric moro reflex -edema

Older children: -

pain,tenderness,ecchymosis,edema,deformity,decreas motion,turninig head (attention to atlantoaxial subluxation)

Radiographic evaluation

Xray : -AP -serendipity view (40 degree cephalic tilt) for

medial clavicle injuy -stress view : for lateral end

CT scan :evaluation of medial clavicl inj. Or lateral

Sonography : dislocation of medial end in new born

Classification of clavicle fx Type I : middele part (lateral to SCM

,medial to coracoclavicular lig.)

Type II : distal end ( lateral to CC lig.)

Type III : medial end (medial to SCM)

Type II

Type III

Epiphysis of medial supported with SC lig. & capsul physis unprotectedtrauma in children typically result in fx trough physis rather than dx of SCj in adult (salter fx type I or II)

This type classified : 1- ant (more frequent)

2- post (more serious)

Treatment Neonate: asymptomatic: benign neglected symptomatic: sling & swatch 1-2weeks Children & adolescents: midshaft fx :- rarely need to reduction -bump of callus remodel within 6-

9month - comfortable 8 bandag or sling 1 to

4 (bandag not immobilize fx , comfort patient by holding shoulder back) -reduction only skin in jeopardy - open reduction: neurovasculr jnj. or open inj.

that is unstable following irrigation & debridment

treatment of Medial physeal separation

Because a significant remodeling conservative treatment is the rule

If significant cosmatic deformity ,may attempt a closed reduction & often this inj. Are quiet stable after reduction , if lost we accept it

If posterior displacement is with airway, esophgeal or neurovascular impingment closed reduction or open reduction

Treatment of lateral end All type I ,II,III can manag be

managed symptomticlly ( sling & harness)

Type IV,V,VI usually requier open reduction,often by repairing the periosteal sleeve ,( avoiding percutanous pins)

Scapula fracture Scapular body fx are often comminuted

with multi direction line Infra spinatus portion is more more

frequntly fx Abundant muscleprevent displacement Scapular neck fx:if C.Clig & clavicle

intactdisplacement is minimal /// If this lig. Torn or if fx is lateral to coracoid process articular fragment displaced downward & inward bythe weight of limb

Mechanism of scapular fx Most commonly direct trauma High energy trauma result in significant injury to adjacent structres

DIAGNOSIS: often delayed or missed Shuold be considered in upper thorasic or

arm trauma True AP xray is necessary CTscan is helpfull

Treatment Vast majority of scapular fx managed

conservatively, directed toward patient comfort ( sling ,sling&swath,shoulder immobilizer)

Open reduction : 1- significantly displaced intra-articular fx

2-glenoid rim fx associated with subluxation of humeral head

3-unstabl fx through scapular neck including ipsilateral fx of neck & clavicle////displaced fx involving both the scapular spine & neck

Fracture of proximal metaphysis & shaft of humerus More common inchildren than

adolescents

Less common in children than adult ,but as in adults ,are frequently associated with radial nerve injury

Are the second most common birth fracture

61% of all new fx in child abuse

Mechanism of fx Proximal metaphysis: -usually high-energy direct trauma - minimal trauma suspicion of

pathologic fx (UBC & other benign tumor)

Shaft: -most direct force : like fall on the side

of arm (usually transvers or comminuted)

-indirect force : fall on outstretched hand (oblique or spiral fx)

diagnosis

Obvious deformity ,localized swelling,pain clinical diagnosis straightforward

classificationLocation: proximal ,middle,distalPatteren:spiral ,short oblique ,transverseAnatomically:proximal to the pectoralis

major ,between it & deltoid ,below deltoid insertion

Ao –ASIF:interobserver variability

Treatment

Infants with obstetric fx : imoblization 1-3 weeks /// effort to control aligment are not necessary (remodelling potential is great)/// follow-up only for brachial plexus

Proximal humral fx :remodeling potential is great these fx rarely require more than symptomatic treatment (sling)

- occasionally percutaneous fixation (polytraumatized patient or open fx)

Treatment

Humeral shaft: -generally managed with closed technique -initially placed in a coaption splint 2-3weeks then

managed in sling or hanging arm cast -end to end aligment not necessary (overriding 1 to

1.5 cm can be easily accepted) -angulation more than 15-20 degree in either plan

is not desirable -rotational aligment should be maintain -clinical appearance is more important than

radiographic alligment -open reduction: polytraumatised patient or open fx