A 16-year-old male football player fell awkwardly from a jump, landing on his right arm and shoulder. He experienced immediate pain in his arm and shoulder and was not able to continue. When he was seen in clinic later that day he was in obvious distress, his shoulder appeared swollen and there was a loss of both active and passive shoulder movements. He had a normal neurovascular examination.
There is an undisplaced, oblique fracture through the proximal humeral metaphysis. The fracture involves the lateral aspect of the proximal humeral growth plate (Salter Harris II). A large amount of soft tissue swelling around the right shoulder can also be seen. The alignment and appearances of the right glenohumeral and AC joints is normal. A follow-up x-ray taken six weeks after the initial injury (image three) shows that there has been healing with an increase in sclerosis and periosteal new bone formation at the fracture site. The fracture alignment is unchanged.
This player was managed with a short period of immobilisation. He was seen again at the six week mark. At this stage his pain had largely settled but his shoulder remained very stiff. He was unable to abduct beyond 120 degrees and had a global restriction in his range of motion. The stiffness improved over the following six weeks with physiotherapy and range of motion exercises. He was able to return to normal play three months post injury with only mild residual stiffness (and no other symptoms).
Among paediatric patients, fractures of the proximal humerus are 3-4 times more likely to occur in boys than girls and have a peak incidence around the age of 15 years. They are most frequently caused by a fall onto the shoulder (as seen in this case) or from a direct blow. The proximal humeral physis remains open until approximately 16-19 years of age (it closes earlier in girls). Approximately 80% of humerus growth comes from the proximal physis and because of this these fractures generally heal well with non-surgical treatment, as there is a high remodelling potential.
Nonoperative is effective in the vast majority of these fractures in young children and adolescents. The amount of acceptable angulation depends on the age of the patient. Almost any angulation can be accepted in patients who are less than 10 years of age, up to 60-75° of angulation can be accepted in those who are 10-12 years of age while up to 45° of angulation or 2/3 displacement can be accepted in those who are aged over 12 years. Open and closed approaches can be used in cases where the fracture is more displaced, is unstable or when the patient is older (and there is less remodelling potential).
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