Chapter 21: Humeral Shaft and Proximal Humerus, Shoulder Dislocation

Donald S. Bae

Chapter Outline

Introduction to Shoulder Dislocation

Historically, glenohumeral joint dislocations in skeletally immature patients were thought to be a rare occurrence.171,179,256,443 Rowe's classic series of 500 glenohumeral joint dislocations from 1956 contained only eight patients under 10 years of age, though 99 patients were reportedly between 10 and 20 years old.360 Other published series similarly have documented shoulder instability in adolescents without specific reference to physeal status.148,276,282,318,356 Prior studies in collegiate athletes have documented the incidence of shoulder instability to be approximately 1 per 10,000 athlete-exposures, and the incidence of dislocations has been reported to be 1.69 per 1,000 person-years in young adult military personnel.325,326 Although these demographic data cannot be directly extrapolated to the pediatric or adolescent population, they do provide some insight into the expected range of glenohumeral joint instability rates in young, active people. 
While the exact incidence of traumatic glenohumeral joint instability in skeletally immature patients remains unknown, there appears to be a rising frequency with which these injuries are occurring in older children and adolescents. Potential etiologies for this trend include increasing participation in higher-demand and higher-energy activities, younger age at first sports participation, and greater awareness among patients, families, and care providers. It is important to remember, however, that ligamentous laxity and shoulder subluxation may be a normal, nonpathologic finding in otherwise asymptomatic children and adolescents.54 Indeed, there is published information to suggest that physical examination signs of glenohumeral joint instability may be seen in up to 50% of otherwise asymptomatic adolescents.120 

Assessment of Shoulder Dislocation

Mechanisms of Injury for Shoulder Dislocation

In general, both traumatic and atraumatic glenohumeral joint instability may be seen. In traumatic instability, the predominant direction of humeral head dislocation is anterior. Typically, an anteriorly directed force applied to the abducted and externally rotated shoulder results in anterior dislocation. These injury mechanisms may be seen with sports participation, altercations, motor vehicle collisions, and even simple falls onto an outstretched upper extremity.35,188,300 The spectrum of injury includes an anterior labral tear (Bankart lesion), glenohumeral joint capsular stretch, compression injury to the posterior humeral head (Hill–Sachs lesion), and/or anterior glenoid rim fracture. 
Posterior dislocations are less common, representing 5% or less of all traumatic glenohumeral instability. Typically patients dislocate with the affected shoulder forward flexed, internally rotated, and adducted. More commonly associated with higher-energy injury, posterior instability events may be seen after falls, motor vehicle collisions, seizures, or electroconvulsive therapy. As in adults, the diagnosis of posterior dislocation is often subtle, and a high index of suspicion is needed to avoid untimely or missed diagnosis.105,110,169,315,432 
Atraumatic shoulder instability is common in children and adolescents. These situations are characterized by initially painless glenohumeral dislocation without antecedent or causative trauma, and may be more commonly seen in patients with systemic ligamentous laxity and multidirectional instability.60 Often patients will report instability symptoms of other parts of the body, including the patellofemoral, ankle, and hip joints. Associations with connective tissue disorders may be seen, such as Ehlers–Danlos or Marfan syndrome. Atraumatic instability may be voluntary or involuntary, and both are thought to arise from selective firing of shoulder girdle muscles with inhibition of their antagonists (Fig. 21-1). Spontaneous reduction is common, and if sedation or anesthesia is utilized, the glenohumeral joint typically reduces without need for manipulation.356 
Figure 21-1
Clinical photographs of a preadolescent child with atraumatic multidirectional instability.
 
A: Anterior view demonstrates obvious anteroinferior position of the humeral head. B: View of the lateral aspect depicts inferior humeral head position and the “sulcus” sign.
A: Anterior view demonstrates obvious anteroinferior position of the humeral head. B: View of the lateral aspect depicts inferior humeral head position and the “sulcus” sign.
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Figure 21-1
Clinical photographs of a preadolescent child with atraumatic multidirectional instability.
A: Anterior view demonstrates obvious anteroinferior position of the humeral head. B: View of the lateral aspect depicts inferior humeral head position and the “sulcus” sign.
A: Anterior view demonstrates obvious anteroinferior position of the humeral head. B: View of the lateral aspect depicts inferior humeral head position and the “sulcus” sign.
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Finally, there are some pediatric patients who sustain glenohumeral joint dislocation due to neuromuscular pathology. In cases of arthrogryposis, brachial plexus birth palsy, stroke, or cerebral palsy, muscle imbalance with or without glenohumeral joint dysplasia can lead to atraumatic dislocations, even in neonates or young children.13,77,148,152,411,451,458 These situations must be distinguished from neonatal pseudodislocation, in which a traumatic displaced physeal fracture and radiographically unossified proximal humeral epiphysis may give the radiographic appearance of glenohumeral dislocation. 

Associated Injuries with Shoulder Dislocations

The axillary nerve is commonly injured in association with shoulder dislocations. Because of its circuitous course around the proximal humerus and inferior to the glenohumeral joint, as well as its relative tethering at the quadrilateral space, the axillary nerve is usually stretched at the time of humeral head dislocation. As these are neuropraxic injuries, spontaneous recovery is typically seen, though recovery may take many months. In the event of complete axillary nerve injuries without spontaneous recovery after the expected period of time, the axillary nerve may be explored, repaired, grafted, or neurotized to provide return of deltoid motor function.18,37,79,87,118,268 Similarly, injuries to the axillary artery, though rare, have been reported in association with shoulder dislocation.18,87,301 Prompt fracture reduction with or without arterial reconstitution should be performed in cases of vascular insufficiency and ischemia. 
While less common than in adults, concomitant fractures of the proximal humerus (e.g., lesser tuberosity, greater tuberosity) or scapula (e.g., coracoid process, glenoid) may be seen with shoulder dislocation.76,109,355,436 (Fig. 21-2). Careful inspection of plain radiographs is needed to assess for associated bony injuries. While nondisplaced fractures may be effectively treated nonoperatively, displaced fractures may predispose to recurrent instability.239 
Figure 21-2
Computed tomography (CT) images of a 13-year-old male after traumatic anterior shoulder dislocation.
 
Axial images (A) and three-dimensional reconstruction with subtraction of the humeral head (B) depict an anterior glenoid fracture (bony Bankart lesion).
Axial images (A) and three-dimensional reconstruction with subtraction of the humeral head (B) depict an anterior glenoid fracture (bony Bankart lesion).
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Figure 21-2
Computed tomography (CT) images of a 13-year-old male after traumatic anterior shoulder dislocation.
Axial images (A) and three-dimensional reconstruction with subtraction of the humeral head (B) depict an anterior glenoid fracture (bony Bankart lesion).
Axial images (A) and three-dimensional reconstruction with subtraction of the humeral head (B) depict an anterior glenoid fracture (bony Bankart lesion).
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Signs and Symptoms of Shoulder Dislocations

In cases of traumatic anterior glenohumeral joint dislocations, patients will present with pain, swelling, and limited shoulder motion. Typically the limb is held in slight abduction and external rotation, and often the patient will support the affected extremity with the contralateral hand. Careful inspection will reveal abnormal contour of the shoulder, with a prominent acromion, flattened or concavity to the posterolateral shoulder girdle, and obvious prominence or fullness anteriorly in the area of the dislocated humeral head. Careful and comprehensive physical examination is critical to rule out concomitant neurologic injury. The axillary nerve is most commonly affected; sensation over the lateral aspect of the shoulder and deltoid muscle function is checked to assess axillary nerve function (Fig. 21-3). In cases in which there has been spontaneous reduction after an anterior instability event, the shoulder appears more normal in contour and glenohumeral motion is typically preserved. Patients will be guarded in active motion especially above the shoulder line, resist extremes of abduction and external rotation, and the apprehension test will be positive.122,263,368,427 
Figure 21-3
 
A: Sensory distribution for the axillary nerve important in anterior dislocation. B: Deltoid muscle can be tested in acute anterior dislocation by grabbing the muscle belly with the right hand while supporting the elbow with the left. The patient then can actively contract the deltoid by pushing the elbow against the examiner's hand while the examiner feels the muscle contraction.
A: Sensory distribution for the axillary nerve important in anterior dislocation. B: Deltoid muscle can be tested in acute anterior dislocation by grabbing the muscle belly with the right hand while supporting the elbow with the left. The patient then can actively contract the deltoid by pushing the elbow against the examiner's hand while the examiner feels the muscle contraction.
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Figure 21-3
A: Sensory distribution for the axillary nerve important in anterior dislocation. B: Deltoid muscle can be tested in acute anterior dislocation by grabbing the muscle belly with the right hand while supporting the elbow with the left. The patient then can actively contract the deltoid by pushing the elbow against the examiner's hand while the examiner feels the muscle contraction.
A: Sensory distribution for the axillary nerve important in anterior dislocation. B: Deltoid muscle can be tested in acute anterior dislocation by grabbing the muscle belly with the right hand while supporting the elbow with the left. The patient then can actively contract the deltoid by pushing the elbow against the examiner's hand while the examiner feels the muscle contraction.
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Conversely, patients with traumatic posterior dislocations will present with a painful adducted and internally rotated shoulder. There is often flattening or concavity to the anterior aspect of the shoulder girdle, with palpable fullness posteriorly. Prominence of the superomedial scapular angle (the so-called Putti sign) is often seen, and patients will resist attempts at passive shoulder motion. Inability to passively externally rotate the shoulder or supinate the forearm should alert the examiner to the possibility of a posterior glenohumeral joint dislocation. Again, a comprehensive examination is performed to evaluate for associated neurovascular deficits. 
In neonates and infants, pseudodislocation may similarly present with pain, reluctance to move the affected upper limb, swelling, and asymmetric contour of the shoulder girdle. Occasionally crepitus due to motion at the fracture site may be appreciated with gentle, small arc range of motion. 
Children and adolescents with atraumatic and/or multidirectional instability present quite differently. In addition to the lack of causative or antecedent trauma, these patients may not have pain with joint subluxation or dislocation (Fig. 21-1). Even with discomfort, patients will frequently report rapid resolution of pain after reduction. Examination will often elicit diffuse signs of ligamentous laxity, including hyperextension of the elbow, knee, and metacarpophalangeal joints.307 Abnormally hyperelasticity and striae of the skin may be seen. Focused examination of the shoulder will demonstrate a positive sulcus sign and increased translation with anterior and posterior load-and-shift testing.419 The sulcus sign refers to a concavity or indentation noted of the skin inferior to the acromion with manual longitudinal traction applied to the adducted arm (Fig. 21-4). Anterior and posterior load-and-shift tests are performed with the examiner standing behind or alongside the patient. While stabilizing the scapula with one hand, the humeral head is grasped and translated anteriorly and/or posteriorly with the examiner's other hand; translation of greater than 5 mm from center is thought to be an indicator of multidirectional instability. Though some patients are truly unstable in all directions, posterior-inferior dislocations are most common. This pattern may be elicited with forward flexion and slight adduction, with joint reduction achieved with abduction. Patients with voluntary instability may demonstrate their condition by contracting the anterior deltoid and internal rotators while inhibiting the antagonistic muscles. 
Figure 21-4
Dramatic demonstration of inferior subluxation of the glenohumeral joint in a patient with multidirectional instability.
The clinical correlate is the sulcus sign.
The clinical correlate is the sulcus sign.
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Imaging and Other Diagnostic Studies for Shoulder Dislocation

Radiographic evaluation should include orthogonal views of the shoulder to assess for direction of dislocation, congruency of subsequent joint reduction, and presence of associated bony injuries. Anteroposterior (AP) and axillary views are preferred (Fig. 21-5). In the acutely injured or anxious, uncomfortable child, alternative views including the transthoracic scapular Y, West Point lateral, or apical oblique projections may be performed.69,144,156,400 AP views with the shoulder in internal rotation are not routinely required, but may allow for visualization of Hill–Sachs lesions of the humeral head. 
Figure 21-5
Anterior dislocation of the right shoulder in a 15-year-old girl.
 
A: Note the typical subcoracoid position on the AP film. B: On a true scapular lateral film, note the anterior displacement of the humeral head. C: Postreduction film demonstrates a Hill–Sachs compression fracture in the posterolateral aspect of the humeral head. D: On the postreduction axillary film, note the posterolateral compression fracture of the humeral head.
A: Note the typical subcoracoid position on the AP film. B: On a true scapular lateral film, note the anterior displacement of the humeral head. C: Postreduction film demonstrates a Hill–Sachs compression fracture in the posterolateral aspect of the humeral head. D: On the postreduction axillary film, note the posterolateral compression fracture of the humeral head.
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Figure 21-5
Anterior dislocation of the right shoulder in a 15-year-old girl.
A: Note the typical subcoracoid position on the AP film. B: On a true scapular lateral film, note the anterior displacement of the humeral head. C: Postreduction film demonstrates a Hill–Sachs compression fracture in the posterolateral aspect of the humeral head. D: On the postreduction axillary film, note the posterolateral compression fracture of the humeral head.
A: Note the typical subcoracoid position on the AP film. B: On a true scapular lateral film, note the anterior displacement of the humeral head. C: Postreduction film demonstrates a Hill–Sachs compression fracture in the posterolateral aspect of the humeral head. D: On the postreduction axillary film, note the posterolateral compression fracture of the humeral head.
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In patients with recurrent instability or in whom the extent of injury needs to be assessed after the initial traumatic dislocation, advanced imaging may be performed. Magnetic resonance imaging (MRI) will provide visualization of chondral, labral, capsular, and musculotendinous pathology. The addition of intra-articular contrast improves sensitivity for labral pathology and provides more detailed information regarding capsular patulousness; this is particularly helpful in patients with persistent, functionally limiting multidirectional instability in whom surgical treatment is being considered (Fig. 21-6). While computed tomography (CT) and CT-arthrography are less helpful for soft tissue evaluation, they do provide the best modality to identify and quantify bony defects in the glenoid and humeral head.75,101,227 (Fig. 21-7). In children and adolescents in whom a large portion of the glenoid is incompletely ossified, careful inspection of the glenoid contour is needed to avoid missing bony lesions. Loss of the normal sclerotic margin of the glenoid has been proposed as a sign of bony defects of the anterior glenoid rim.210 
Figure 21-6
MRI arthrogram of the left shoulder in a 14-year-old female with multidirectional instability.
 
Axial (A) and coronal (B) images depict an intact labrum with a patulous capsule.
Axial (A) and coronal (B) images depict an intact labrum with a patulous capsule.
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Figure 21-6
MRI arthrogram of the left shoulder in a 14-year-old female with multidirectional instability.
Axial (A) and coronal (B) images depict an intact labrum with a patulous capsule.
Axial (A) and coronal (B) images depict an intact labrum with a patulous capsule.
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Figure 21-7
Bony glenoid deficiency in the setting of recurrent anterior instability in a 16-year-old male.
 
A: AP radiograph depicts loss of the sclerotic margin of the anterior glenoid. B: Sagittal CT scan demonstrates loss of the anterior-inferior glenoid. C: Three-dimensional reconstruction further highlights the loss of anteroinferior glenoid bone.
A: AP radiograph depicts loss of the sclerotic margin of the anterior glenoid. B: Sagittal CT scan demonstrates loss of the anterior-inferior glenoid. C: Three-dimensional reconstruction further highlights the loss of anteroinferior glenoid bone.
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Figure 21-7
Bony glenoid deficiency in the setting of recurrent anterior instability in a 16-year-old male.
A: AP radiograph depicts loss of the sclerotic margin of the anterior glenoid. B: Sagittal CT scan demonstrates loss of the anterior-inferior glenoid. C: Three-dimensional reconstruction further highlights the loss of anteroinferior glenoid bone.
A: AP radiograph depicts loss of the sclerotic margin of the anterior glenoid. B: Sagittal CT scan demonstrates loss of the anterior-inferior glenoid. C: Three-dimensional reconstruction further highlights the loss of anteroinferior glenoid bone.
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Radiographic evaluation of patients with atraumatic multidirectional instability is similar, though a few points deserve mention. Though plain radiographs are typically normal, patients with congenital glenoid hypoplasia will have subtle rounding or convexity to the glenoid fossa, with or without scapular neck dysplasia.77,85,88,334 As cited above, MRI-arthrography is a useful tool in assessing the capsular laxity and presence of pathologic lesions of the labrum in these patients. 

Classification of Shoulder Dislocations

In general, shoulder dislocations in children and adolescents are described according to the association with trauma, direction of instability, chronicity, and presence of underlying local or systemic disorders (Table 21-1). Characterizing shoulder dislocations according to these categories is important and influences treatment decision making.11 
 
Table 21-1
Classification of Shoulder Instability
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Table 21-1
Classification of Shoulder Instability
Mechanism Direction Chronicity Associated Conditions
Classification Traumatic
Atraumatic
Anterior
Posterior
Inferior
Multidirectional
Acute
Recurrent
Chronic
None
Neuromuscular
Connective tissue
X
As noted in Table 21-1, shoulder dislocations may be traumatic or atraumatic in etiology. Direction of humeral instability may be anterior, posterior, inferior (luxatio erecta), or multidirectional. As in adults, perhaps 90% of traumatic dislocations in children and adults is anterior, with posterior dislocations occurring much less commonly and luxatio erecta described in case reports.44,130,132,179,246,283,286,356 Furthermore, pathologic instability may include both subluxation or true dislocation. Dislocation refers to situations in which the humeral head moves completely out of the glenoid fossa, with no articular contact and often with locking of the humeral head on the anterior or medial rim of the glenoid. Subluxation is defined as an incomplete dislocation characterized by pain, a feel of “looseness” or “slipping,” and/or a “dead” feeling to the affected limb. Even traumatic subluxations have been associated with structural injury to the glenoid labrum and Hill–Sachs lesions of the humeral head.327 These conditions must be distinguished from ligamentous laxity, which is typically asymptomatic. 
Chronicity is generally classified as being acute, recurrent, or chronic. While a single episode of dislocation denotes acute instability, recurrent instability refers to multiple episodes. Chronic instability refers to unrecognized or untreated shoulder dislocations in which the humeral head is not reduced, and may be seen with congenital or neuromuscular conditions in children. 
The presence or absence of associated systemic conditions—including collagen disorders such as Ehlers–Danlos syndrome, or congenital/neuromuscular syndromes such as cerebral palsy—is also a key consideration in diagnosis and management. 

Pathoanatomy and Applied Anatomy Relating to Shoulder Dislocation

The anatomic development, structure, and growth of the proximal humerus are described in the section on proximal humerus fracture. The glenoid is a shallow, concave fossa with which the humeral head articulates. The radius of curvature of the humeral head is approximately three times that of the glenoid. As the glenohumeral articulation lacks substantial bony constraint, the shoulder is afforded near global range of motion, facilitating placement of the hand in space and upper limb function. 
Given the relatively unconstrained bony architecture, the glenohumeral joint relies primarily on soft tissue capsuloligamentous structures for stability. The cartilaginous labrum runs along the rim of the glenoid, deepening the concavity and conferring stability. The glenohumeral ligaments are confluent with the labrum and are thickenings of the joint capsule. The inferior glenohumeral ligament has both anterior and posterior components. The anteroinferior glenohumeral ligament is taught and biomechanically contributes most stability in shoulder abduction and external rotation. Disruptions of the anteroinferior glenohumeral ligament or anteroinferior labrum (Bankart lesion) are most commonly seen with anterior traumatic instability (Fig. 21-8). Furthermore, traumatic instability may also cause elevation of the anterior labrum with the periosteum of the anterior glenoid neck, resulting in the so-called anterior labroligamentous periosteal sleeve avulsion (ALPSA).309 The middle glenohumeral ligament is primarily responsible for stability in midabduction and external rotation, whereas the superior glenohumeral ligament resists inferior translation of the humeral head. 
Figure 21-8
 
A: The tight anteroinferior glenohumeral ligament complex with the arm abducted and externally rotated. This ligament sling is the primary restraint against anterior instability of the shoulder. B: A cross section in the transverse plane through the glenohumeral joint demonstrates the common lesions associated with anterior instability of the shoulder: Hill–Sachs lesion, Perthes–Bankart lesion, and redundant anteroinferior glenohumeral ligaments.
 
(HH, humeral head; P, posterior.)
A: The tight anteroinferior glenohumeral ligament complex with the arm abducted and externally rotated. This ligament sling is the primary restraint against anterior instability of the shoulder. B: A cross section in the transverse plane through the glenohumeral joint demonstrates the common lesions associated with anterior instability of the shoulder: Hill–Sachs lesion, Perthes–Bankart lesion, and redundant anteroinferior glenohumeral ligaments.
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Figure 21-8
A: The tight anteroinferior glenohumeral ligament complex with the arm abducted and externally rotated. This ligament sling is the primary restraint against anterior instability of the shoulder. B: A cross section in the transverse plane through the glenohumeral joint demonstrates the common lesions associated with anterior instability of the shoulder: Hill–Sachs lesion, Perthes–Bankart lesion, and redundant anteroinferior glenohumeral ligaments.
(HH, humeral head; P, posterior.)
A: The tight anteroinferior glenohumeral ligament complex with the arm abducted and externally rotated. This ligament sling is the primary restraint against anterior instability of the shoulder. B: A cross section in the transverse plane through the glenohumeral joint demonstrates the common lesions associated with anterior instability of the shoulder: Hill–Sachs lesion, Perthes–Bankart lesion, and redundant anteroinferior glenohumeral ligaments.
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On the humeral side, the joint capsule inserts along the anatomic neck of the humerus, except for medially where the insertion lies more inferiorly along the proximal humeral metaphysis. Thus the proximal humeral physis is predominantly extracapsular, with exception of the very medial extent. Shoulder dislocation may result in detachment of the capsule from its humeral insertion, resulting in the so-called humeral avulsion of the glenohumeral ligament (HAGL) lesions.463 Failure of recognition and repair of these HAGL lesions is a common cause of recurrent instability after surgical treatment.341 
The glenohumeral joint is surrounded by the rotator cuff muscles, comprising the supraspinatus, infraspinatus, teres minor, and subscapularis. While rotator cuff tears are uncommon in children, these musculotendinous units form a force couple with the larger surrounding shoulder girdle muscles (deltoid, pectoralis major, teres major, and latissimus dorsi) and serve as important dynamic secondary stabilizers of the shoulder. The dynamic stabilizing effects of the rotator cuff muscles are largely the focus of nonoperative rehabilitative programs for young patients with glenohumeral instability.52 

Treatment Options for Shoulder Dislocations

Nonoperative Treatment of Shoulder Dislocations

Indications/Contraindications

Treatment options continue to evolve for shoulder instability in children and adolescents, though remain based upon the classification system and considerations described above. Nonoperative treatment is typically recommended for acute traumatic dislocations as well as atraumatic multidirectional instability. 
Closed reduction is performed for acute traumatic dislocations, and a host of reduction maneuvers have been described. Adequate analgesia and relaxation facilitates closed reduction, and both conscious sedation and intra-articular anesthetic injection have been advocated. Multiple reports have suggested that intra-articular lidocaine injection is as safe and effective as intravenous sedation, with less cost and shorter length of stays.73,281,295,299,444 The method of traction–countertraction is advocated by many (Fig. 21-9). In this method, a bedsheet is looped around the axilla of the affected shoulder and passed superiorly and laterally to the contralateral shoulder. Longitudinal traction is applied to the affected upper extremity in line with the deformity, with countertraction provided by pull of the bedsheet. Steady, continuous traction will ultimately overcome the spasm of the shoulder girdle muscles, and the humeral head may be disimpacted and reduced. Others advocate modifications of the Milch maneuver.96,292,293,317,399 In this technique, the patient is positioned supine and the affected limb supported. Gradual abduction and external rotation is used to achieve glenohumeral reduction. As this technique does not employ traction to overcome muscle spasm, it may be successfully performed without sedation.237,366 Still others utilize the Stimson technique of reduction (Fig. 21-10).413 With the patient in prone position and the affected limb hanging free over the edge of the stretcher, longitudinal traction is applied to the extremity by means of a weight attached to the wrist. As the spasm of the shoulder girdle muscles fatigues and is overcome, reduction is achieved spontaneously and relatively atraumatically. Additional scapular mobilization may assist with reduction using the Stimson technique 231,285 
Figure 21-9
Techniques for closed shoulder reduction.
 
A modification of the Hippocratic method uses a handheld sheet around the thorax to provide countertraction.
A modification of the Hippocratic method uses a handheld sheet around the thorax to provide countertraction.
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Figure 21-9
Techniques for closed shoulder reduction.
A modification of the Hippocratic method uses a handheld sheet around the thorax to provide countertraction.
A modification of the Hippocratic method uses a handheld sheet around the thorax to provide countertraction.
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Figure 21-10
The Stimson technique for closed shoulder reduction.
 
With the patient in prone position, weight is hung from the wrist to distract the shoulder joint. Eventually, with sufficient fatigue in the shoulder musculature, the joint can be easily reduced.
With the patient in prone position, weight is hung from the wrist to distract the shoulder joint. Eventually, with sufficient fatigue in the shoulder musculature, the joint can be easily reduced.
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Figure 21-10
The Stimson technique for closed shoulder reduction.
With the patient in prone position, weight is hung from the wrist to distract the shoulder joint. Eventually, with sufficient fatigue in the shoulder musculature, the joint can be easily reduced.
With the patient in prone position, weight is hung from the wrist to distract the shoulder joint. Eventually, with sufficient fatigue in the shoulder musculature, the joint can be easily reduced.
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Posterior dislocations may be similarly reduced with traction–countertraction maneuvers. Furthermore, the addition of a laterally directed force on the proximal humeral diaphysis may assist in achieving reduction.297 In the rare inferior dislocations (or luxatio erecta), a two-step closed reduction maneuver has been advocated.310 An anterior-directed force is applied to the humeral shaft, converting the inferior dislocation to an anterior one. Subsequent external rotation will then achieve glenohumeral reduction. Closed reduction is the definitive management of luxatio erecta in the majority of cases.329 

Outcomes

Following closed reduction, patients are typically immobilized with a sling for comfort. There is no evidence that longer duration of sling immobilization with the shoulder in internal rotation reduces the risk of recurrent instability.330 Recent work, however, has raised the question of whether immobilization with the shoulder in adduction and external rotation is preferred. Anatomically, 30 degrees or more of external rotation of the shoulder may tension the anterior soft tissues and “reduce” the torn anterior capsulolabral structures to a more anatomic position on the glenoid.206,294 Dynamic MRI have demonstrated improved position of the displaced labrum with external rotation.207,378,384,398 Subsequent clinical studies have demonstrated up to a 40% reduction in recurrent instability rates when external rotation bracing was utilized for 4 or more weeks.204,205,418 These findings have not been universally reproducible; however, other investigators have failed to demonstrate reduction in recurrent instability with external rotation immobilization.126,255,259,330,417 Regardless of the type or time of immobilization after reduction of acute dislocation, physical therapy is typically recommended to improve the dynamic stability conferred by the rotator cuff and adjacent shoulder girdle muscles.52 
Despite successful closed reduction and subsequent rehabilitation, there is a high risk of recurrent instability, particularly in young, active patients.284 The available literature, however, is limited in quantifying the true recurrent dislocation rates in children and adolescents. Much of the previously published information consists of retrospective case series of both adult and pediatric patients with limited follow-up. 
Rowe361 previously reported recurrent anterior instability in 100% of children less than 10 years of age and 94% of patients between 11 and 20 years. Marans et al.276 similarly reported universal recurrent instability in their series of 21 children following traumatic dislocations. Wagner and Lyne443 reported an 80% recurrence in 10 patients with open physes. In a series of nine patients who sustained traumatic instability at a mean age of 12.3 years, Elbaum et al.118 similarly reported recurrent instability in 71%. In their review of 154 traumatic dislocations, Vermeiren et al.435 found a 68% recurrence rate in patients less than 20 years of age. Higher rates of recurrent instability have been reported in higher-energy injuries as well as those associated with bony glenoid injuries.291,349,354 Younger patients involved in overhead or contact sports have similarly been noted to have higher recurrent instability rates.367 
Other reports, however, cite lower recurrence rates in younger patients. Rockwood356 documented a 50% recurrence rate in patients between 13.8 and 15.8 years of age. Cordischi et al.83 published their study of 14 patients between 10.9 and 13.1 years of age and reported that only three patients (21%) went on to surgical treatment for recurrent instability. In perhaps the largest study with the longest follow-up, Hovelius et al.189 reported 25-year follow-up on 229 shoulder in 227 patients who sustained their first traumatic dislocation between 12 and 40 years of age. Of the 58 patients who sustained their primary dislocation between 12 and 19 years of age, 26% reported a single recurrence, and an additional 16% of shoulders stabilized over time (defined as no instability events in the last 10 years). Only 43% of patients underwent surgical stabilization procedures. Additional case reports and small case series exist of young patients without recurrent instability at midterm follow-up (Table 21-2).121,171 
Table 21-2
Classification of Non-operative treatment for shoulder instability
Nonoperative Treatment
Indications Relative Contraindications
Primary dislocation in patients willing to undergo physical therapy and accept risks of recurrent instability Large bony glenoid fracture
Multidirectional instability in setting of ligamentous laxity
X

Operative Treatment of Shoulder Dislocations: Arthroscopic Bankart Repair

Indications/Contraindications

Surgical treatment is considered in patients with functionally limiting recurrent instability as well as in high-demand, overhead or contact athletes in whom the risk of recurrent instability after their primary event is unacceptably high. In general, patients considered for surgery should have failed attempts at physical therapy and rehabilitation. In patients with traumatic anterior shoulder dislocations, recurrent instability is due to injury to the anterior-inferior labrum and adjacent glenohumeral joint capsule and ligaments. Surgical treatment is focused on repairing the torn labrum to its anatomic location on the glenoid rim. 

Surgical Procedure

Preoperative Planning
Presently, arthroscopic labral repair is the standard treatment for posttraumatic shoulder instability. Preoperative imaging should include plain radiographs of the affected shoulder to rule out associated bony lesions (e.g., glenoid fractures, Hill–Sachs lesions). MRI, with or without intra-articular contrast, is also helpful in determining the extent of labral injury and assessing for concomitant soft tissue injuries. Typical equipment required includes a standard 4-mm 30-degree arthroscope, arthroscopic cannulae, and surgical instruments used to mobilize and prepare the capsulolabral tissue (e.g., arthroscopic shavers, elevators, rasps, and suture passing devices). While a host of commercially available instruments are available, all provide the same fundamental arthroscopic capabilities. Suture anchors are also invaluable for arthroscopic labral repairs, and increasing the standard is to use bioabsorbable suture anchors for intra-articular procedures (Table 21-3). 
 
Table 21-3
Bankart Repair for Shoulder Instability
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Table 21-3
Bankart Repair for Shoulder Instability
Preoperative Planning Checklist
  •  
    OR Table: Standard table
  •  
    Position/positioning aids: Bean bag and distraction apparatus for lateral decubitus positioning; bean bag and arm holder for beach chair positioning
  •  
    Fluoroscopy location: N/A
  •  
    Equipment: 4-mm 30-degree arthroscope, arthroscopic cannulae, arthroscopic shaver, arthroscopic instruments to prepare tissue and pass sutures, bioabsorbable suture anchors, shoulder immobilizer
  •  
    Tourniquet (sterile/nonsterile): N/A
X
Positioning
In general arthroscopic stabilization may be performed in either the beach chair or lateral decubitus position (Fig. 21-11). Advantages of lateral decubitus position include ease of longitudinal and lateral distraction to assist in visualization and access to the axillary recess of the glenohumeral joint. Patients are placed with the unaffected shoulder down, allowing the thorax to fall posteriorly about 10 degrees, which will place the glenoid parallel to the ground. Care is taken to place an axillary roll and pad all bony prominences (e.g., contralateral fibular head) to avoid excessive or prolonged compression of the peripheral nerves. The entire affected limb and shoulder girdle are prepped and draped into the surgical field. The limb is placed in balanced suspension with about 40 degrees of abduction and 10 to 20 degrees of forward flexion, typically with 7 to 10 lb of longitudinal and lateral distraction with the assistance of a limb holder. This allows for circumferential access to the shoulder girdle. Furthermore, additional abduction–adduction and internal–external rotation may be employed during surgery for selective access and tensioning of soft tissues. 
Figure 21-11
Patient positioning for surgical procedures.
 
A, B: Beach chair positioning allows for near circumferential access to the shoulder girdle. C: Lateral decubitus positioning with assistance of a bean bag. D: Use of longitudinal and/or lateral distraction will facilitate arthroscopic visualization.
A, B: Beach chair positioning allows for near circumferential access to the shoulder girdle. C: Lateral decubitus positioning with assistance of a bean bag. D: Use of longitudinal and/or lateral distraction will facilitate arthroscopic visualization.
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Figure 21-11
Patient positioning for surgical procedures.
A, B: Beach chair positioning allows for near circumferential access to the shoulder girdle. C: Lateral decubitus positioning with assistance of a bean bag. D: Use of longitudinal and/or lateral distraction will facilitate arthroscopic visualization.
A, B: Beach chair positioning allows for near circumferential access to the shoulder girdle. C: Lateral decubitus positioning with assistance of a bean bag. D: Use of longitudinal and/or lateral distraction will facilitate arthroscopic visualization.
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X
The modified beach chair position is also effective and commonly utilized. After placement of a roll or bump behind the patient between the scapulae, patients may be positioned with the affected limb and shoulder girdle off the edge of the table to allow circumferential access. The use of commercially available beach chairs, limb holders, and/or bean bags will assist with positioning. 
Surgical Approach(es)
The procedure begins with examination under anesthesia to assess pathologic instability anteriorly, posteriorly, and inferiorly. After glenohumeral joint is insufflated with sterile saline solution, a standard posterosuperior, anterosuperior, and anteroinferior arthroscopy portals are established. Viewing is traditionally performed from the posterosuperior portal, but moving the camera to the anterosuperior portal will allow for improved visualization of the anterior glenoid neck and anterior soft tissues, particularly in cases of long-standing instability where the labral and capsule have scarred in a more medial position. 
Technique
Arthroscopic survey is performed to assess the extent of labral, capsular, and/or bony injury (Fig. 21-12). After confirmation of labral pathology, the capsulolabral complex is mobilized from its typical medial position using arthroscopic elevators. The glenoid rim and medial glenoid neck in the region of the labral tear is similarly prepared with arthroscopic rasps or shavers in efforts to debride fibrinous tissue and prepare a bleeding bony bed for biologic healing. In a sequential fashion, arthroscopic suture anchors are placed from inferior to superior and sutures are shuttled through the capsulolabral complex.346,385,431 Knots are tied in a sequential fashion, reapproximating the labrum to its anatomic location and retensioning the soft tissues. While a host of commercially available devices and techniques may be utilized, all conform to the standard principles of soft tissue mobilization, glenoid preparation, and repair of the soft tissue to the glenoid rim, thus tensioning the anteroinferior capsule (Table 21-4). 
Figure 21-12
Arthroscopic Bankart repair.
 
A: Arthroscopic image of an anterior labral tear in the right shoulder of a 16-year-old male. The patient is positioned in the lateral decubitus position. B: Arthroscopic appearance after anterior labral repair, demonstrating reapproximation of the labral tissue to the glenoid rim.
A: Arthroscopic image of an anterior labral tear in the right shoulder of a 16-year-old male. The patient is positioned in the lateral decubitus position. B: Arthroscopic appearance after anterior labral repair, demonstrating reapproximation of the labral tissue to the glenoid rim.
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Figure 21-12
Arthroscopic Bankart repair.
A: Arthroscopic image of an anterior labral tear in the right shoulder of a 16-year-old male. The patient is positioned in the lateral decubitus position. B: Arthroscopic appearance after anterior labral repair, demonstrating reapproximation of the labral tissue to the glenoid rim.
A: Arthroscopic image of an anterior labral tear in the right shoulder of a 16-year-old male. The patient is positioned in the lateral decubitus position. B: Arthroscopic appearance after anterior labral repair, demonstrating reapproximation of the labral tissue to the glenoid rim.
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Table 21-4
Bankart Repair for Shoulder Instability
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Table 21-4
Bankart Repair for Shoulder Instability
Surgical Steps
  •  
    Examination under anesthesia
  •  
    Establish arthroscopic portals
  •  
    Arthroscopic survey
  •  
    Mobilization of torn labrum and associated capsule
  •  
    Preparation of glenoid rim and glenoid neck
  •  
    Suture anchor placement in most inferior position of labral tear, just onto the chondral face of the glenoid
    •  
      Shuttle sutures through the adjacent capsulolabral tissue, effectuating an inferior-to-superior and medial-to-lateral shift
  •  
    Tie arthroscopic knot
  •  
    Repeat anchor placement, suture passage, and knot tying sequentially in more superior positions along the glenoid
  •  
    Minimum of three anchors are utilized
  •  
    Skin closure of portals with simple sutures
  •  
    Application of sling-and-swathe
X

Operative Treatment of Shoulder Dislocations: Latarjet Reconstruction

Indications/Contraindications

In patients with traumatic anterior shoulder dislocations, recurrent instability may also be due to bony fracture or bony insufficiency of the anteroinferior glenoid.291,354 In these cases, soft tissue procedures alone may not address the underlying pathoanatomy and are prone to failure. Surgical treatment in these situations typically involves restoring or augmenting the bony deficit of the glenoid. While several techniques have been advocated, transferring the coracoid process with its soft tissue attachments to the glenoid (the so-called Latarjet procedure) has increasingly become the standard of care.331,336 Bony reconstructions such as the Latarjet procedure have also been advocated in patients with recurrent instability after prior failed soft tissue reconstruction. 
In addition to providing additional bony support for the articulating humeral head, the Latarjet procedure also stabilizes the glenohumeral joint by virtue of the fact that the conjoined tendon remains attached to the tip of the coracoid during transfer. These soft tissues act as a “sling” and provide additional anteroinferior stability. Stability is further conferred by preservation of the musculotendinous fibers of the subscapularis. This “triple effect” has been touted by Patte and Debeyre.99,331,445 

Surgical Procedure

Preoperative Planning
Though MRI is helpful in identifying and qualitatively assessing the extent of labral injury, Latarjet reconstructions are typically reserved for recurrent posttraumatic instability with associated glenoid loss; or, in those patients who have failed prior soft tissue stabilizations. In these situations, assessment of glenoid bone loss and possible engaging Hill–Sachs lesions is best done with CT with three-dimensional reconstructions (Fig. 21-7). 
Most Latarjet reconstructions are performed via open deltopectoral approaches. Aside from the standard instruments and retractors used for open shoulder surgery, a few additional items are useful. A 90-degree oscillating saw blade will facilitate accurate and efficient coracoid osteotomy. Appropriate-sized cannulated screws—typically 4 mm in diameter and 34 to 40 mm in length—are used for fixation of the coracoid process to the anterior glenoid (Table 21-5). 
 
Table 21-5
Latarjet Reconstruction for Shoulder Instability
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Table 21-5
Latarjet Reconstruction for Shoulder Instability
Preoperative Planning Checklist
  •  
    OR Table: Standard table
  •  
    Position/positioning aids: Modified beach chair position
  •  
    Fluoroscopy location: N/A
  •  
    Equipment: 90-degree oscillating saw, 3.5- or 4-mm cannulated screws
  •  
    Tourniquet (sterile/nonsterile): N/A
X
Positioning
The modified beach chair position is effective and commonly utilized. A roll or bump is placed behind the patient between the scapulae, to allow for scapular positioning and improved access to the glenoid neck. Patients are positioned with the affected limb and shoulder girdle off the edge of the table to allow circumferential access. The use of commercially available beach chairs, limb holders, and/or bean bags assist with positioning. 
Surgical Approach(es)
A standard deltopectoral approach is utilized. The incision is placed slightly more medial and superior than traditional deltopectoral approaches to the shoulder, because of the need to expose the coracoid and medial glenoid neck. A vertical incision in Langer skin lines will maximize the aesthetics of the resultant scar. Superficial dissection will allow visualization of the deltopectoral interval, which is developed taking the cephalic vein laterally with the deltoid. Deep dissection will allow visualization of the coracoid process, conjoined tendon, clavipectoral fascia, and subscapularis muscles. 
Technique
After initial dissection is performed, a spike Hohmann retractor is placed superiorly over the coracoid process, with its tip just anterior to the origin of the coracoclavicular (CC) ligaments. The shoulder is abducted and externally rotated, placing the coracoacromial (CA) ligament under tension. The CA ligament is then divided approximately 1 to 2 cm from the coracoid, leaving a cuff of tissue which will be used later for capsular reconstruction. The shoulder is then adducted and internally rotated. The pectoralis minor insertion is then released off the coracoid process, being careful to protect the brachial plexus which lies deep to the pectoralis minor. Following this, the coracoid is osteotomized at its flexure, or “knee,” from medial to lateral. The use of commercially available 90-degree microsagittal saws will facilitate coracoid osteotomy. The coracoid is then freed from the remaining surrounding soft tissue attachments, including the deep coracohumeral ligament, and mobilized while protecting the origin of the conjoined tendon. The undersurface of the coracoid is decorticated to expose bleeding cancellous bone. Two drill holes (typically 3.5 to 4 mm) are made in the coracoid to facilitate subsequent screw placement. Overzealous mobilization or retraction of the freed coracoid process is avoided, as the musculocutaneous nerve enters the coracobrachialis approximately 4 to 5 cm distal. 
Direction is then turned to glenoid preparation. With the shoulder in adduction and external rotation, the subscapularis is split in line with its muscle fibers between the superior two-thirds and inferior one-third. This muscle splitting technique preserves subscapularis integrity, contributing stability and minimizing iatrogenic injury to the axillary nerve. The plane between the subscapularis and underlying capsule is developed bluntly, and the glenohumeral joint line is identified. With the shoulder in neutral rotation, a vertical capsulotomy is made in the glenohumeral joint; this may be extended with a medial horizontal incision (in the shape of a sideways “T”) for improved exposure of the anterior-inferior glenoid. With the shoulder internally rotated, a Fukuda or humeral head retractor is then placed into the glenohumeral joint. Exposure of the anterior-inferior glenoid neck is then performed via subperiosteal elevation or debridement of the scar tissue and prior bony Bankart fragments. The recipient bed on the glenoid is then decorticated until punctate bleeding is seen. 
The coracoid process is then passed through the subscapularis split and its previously decorticated deep surface is approximated to the anterior-inferior glenoid neck. Care is made to position the coracoid bone block precisely; lateral overhang may result in joint incongruity and subsequent degenerative arthrosis or pain. After the coracoid is positioned, the previously placed drill holes are identified. Through these holes, the glenoid neck is drilled anterior to posteriorly in the path of anticipated screw passage. Measurements are taken, and screw fixation of the coracoid process to the glenoid is achieved with 3.5- or 4-mm screws (Fig. 21-13). Screws are typically 34 to 36 mm in older adolescents, though the size will vary according from patient to patient. The lateral portion of the glenohumeral capsule is then reapproximated to the cuff of prior CA ligament still attached to the coracoid, completing a capsular reconstruction. Wound closure is performed in layers including pectoralis major repair, though the subscapularis split need not be closed. Patients are placed in a sling and swathe postoperatively (Table 21-6). 
Figure 21-13
Intraoperative fluoroscopy images of the left shoulder following Latarjet reconstruction.
 
A: Anteroposterior and (B) axillary projections depict screw fixation of the coracoid process, with care made not to lateralize the bone block.
A: Anteroposterior and (B) axillary projections depict screw fixation of the coracoid process, with care made not to lateralize the bone block.
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Figure 21-13
Intraoperative fluoroscopy images of the left shoulder following Latarjet reconstruction.
A: Anteroposterior and (B) axillary projections depict screw fixation of the coracoid process, with care made not to lateralize the bone block.
A: Anteroposterior and (B) axillary projections depict screw fixation of the coracoid process, with care made not to lateralize the bone block.
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Table 21-6
Latarjet Reconstruction for Shoulder Instability
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Table 21-6
Latarjet Reconstruction for Shoulder Instability
Surgical Steps
  •  
    Deltopectoral approach
  •  
    Expose coracoid process
  •  
    Release CA ligament with shoulder in abduction, external rotation
  •  
    Release pectoralis minor with shoulder in adduction, internal rotation
    •  
      Protect neurovascular structures deep to the pectoralis minor
  •  
    Osteotomize coracoid process
  •  
    Prepare undersurface of coracoid bone block and predrill holes
    •  
      Avoid excessive retraction of coracoid to protect musculocutaneous nerve
  •  
    Split subscapularis at superior 2/3–inferior 1/3 interval
  •  
    Make glenohumeral joint arthrotomy
  •  
    Expose and prepare anterior-inferior glenoid neck
  •  
    Approximate coracoid bone block to prepared glenoid neck
  •  
    Avoid lateral overhang
  •  
    Screw fixation of bone block
  •  
    Wound closure in layers
X

Operative Treatment of Shoulder Dislocations: Arthroscopic Capsulorrhaphy

Indications/Contraindications

In patients with multidirectional instability which is painful and/or functionally limiting and has failed nonoperative treatment, arthroscopic capsulorrhaphy may be considered. As cited above, careful patient selection and preoperative counseling is critical, given the risk of recurrent instability and importance of postoperative therapy. Relative contraindications include patients with poorly controlled neuromuscular conditions, or those with cognitive or developmental delays limiting understanding and compliance with postoperative care. 

Surgical Procedure

Preoperative Planning
Preoperative planning and equipment is similar to arthroscopic Bankart repair, as described above. MRI-arthrography is particularly useful, as it may demonstrate areas of capsular redundancy and guide selective capsulorrhaphy (Table 21-7). 
 
Table 21-7
Arthroscopic Capsulorrhaphy for Shoulder Instability
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Table 21-7
Arthroscopic Capsulorrhaphy for Shoulder Instability
Preoperative Planning Checklist
  •  
    OR Table: Standard table
  •  
    Position/positioning aids: Bean bag and distraction apparatus for lateral decubitus positioning; bean bag and arm holder for beach chair positioning
  •  
    Fluoroscopy location: N/A
  •  
    Equipment: 4-mm 30-degree arthroscope, arthroscopic cannulae, arthroscopic shaver, arthroscopic instruments to prepare tissue and pass sutures, bioabsorbable suture anchors, shoulder immobilizer
  •  
    Tourniquet (sterile/nonsterile): N/A
X
Positioning
Arthroscopic capsulorrhaphy may be performed either in the lateral decubitus or modified beach chair positions. Given the need for circumferential access around the glenoid and glenohumeral joint, the addition of laterally directed distraction is useful. This may be facilitated with the use of lateral traction, commercially available arm holders, or placement of a bump beneath the axilla. 
Surgical Approach(es)
Similar to arthroscopic Bankart repairs, the procedure begins with examination under anesthesia to assess pathologic instability anteriorly, posteriorly, and inferiorly. After glenohumeral joint is insufflated with sterile saline solution, standard posterosuperior, anterosuperior, and anteroinferior arthroscopy portals are established. Viewing is traditionally performed from the posterosuperior portal, but moving the camera to the anterosuperior portal and establishing a posterior working portal will allow for improved visualization and circumferential access to the glenohumeral joint capsule. 
Technique
Arthroscopic survey is performed to assess the extent of capsular patulousness and rule out unrecognized labral and/or bony pathology (Fig. 21-14). As plication of the posterior capsule is typically more challenging, direction is first turned to the posterior aspect of the shoulder. The arthroscope is placed in the anterosuperior portal and a working portal established posteriorly. The redundant capsule adjacent to the glenoid rim is prepared using arthroscopic rasps or shavers until punctate bleeding is seen, in efforts to stimulate a healing response; care is made to avoid overzealous tissue preparation, as the tissue is thin and undesirable rents in the capsule may be created. Following this, imbricating sutures may be placed, beginning in the most inferior aspect of the joint. Typically this is performed by passing a suture through capsular tissue approximately 1 cm from the labrum, and then passing the suture a second time from the capsule through the chondrolabral junction. (Prior biomechanical studies have demonstrated that sutures passed through the chondrolabral junction of patients with an intact labrum is as strong as suture anchors).342 This “pinch-tuck” suture will plicate the capsule when tied, reducing overall capsular volume. If knots are tied as the sutures are passed, the reduced capsular volume will often make subsequent suture placement more difficult; for this reason, consideration is made to pass all posterior sutures first before tying. After all posterior sutures are placed, they may be tied in sequential fashion from inferior to superior, completing the posterior capsulorrhaphy. 
Figure 21-14
Arthroscopic capsulorrhaphy for multidirectional instability.
 
A: Arthroscopic images depict redundant capsule (arrows), falling away from the glenoid rim and labrum. B: Tissue preparation may be performed with either rasps, shavers, or other devices to stimulate a bleeding response (C). D: Suture passing devices are used in a “pinch-tuck” fashion to imbricate the redundant tissue. E: Arthroscopic view after posterior plication sutures have been passed. F: After sutures have been tied, note is made of plication of the capsule and loss of the capsular redundancy.
A: Arthroscopic images depict redundant capsule (arrows), falling away from the glenoid rim and labrum. B: Tissue preparation may be performed with either rasps, shavers, or other devices to stimulate a bleeding response (C). D: Suture passing devices are used in a “pinch-tuck” fashion to imbricate the redundant tissue. E: Arthroscopic view after posterior plication sutures have been passed. F: After sutures have been tied, note is made of plication of the capsule and loss of the capsular redundancy.
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A: Arthroscopic images depict redundant capsule (arrows), falling away from the glenoid rim and labrum. B: Tissue preparation may be performed with either rasps, shavers, or other devices to stimulate a bleeding response (C). D: Suture passing devices are used in a “pinch-tuck” fashion to imbricate the redundant tissue. E: Arthroscopic view after posterior plication sutures have been passed. F: After sutures have been tied, note is made of plication of the capsule and loss of the capsular redundancy.
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Figure 21-14
Arthroscopic capsulorrhaphy for multidirectional instability.
A: Arthroscopic images depict redundant capsule (arrows), falling away from the glenoid rim and labrum. B: Tissue preparation may be performed with either rasps, shavers, or other devices to stimulate a bleeding response (C). D: Suture passing devices are used in a “pinch-tuck” fashion to imbricate the redundant tissue. E: Arthroscopic view after posterior plication sutures have been passed. F: After sutures have been tied, note is made of plication of the capsule and loss of the capsular redundancy.
A: Arthroscopic images depict redundant capsule (arrows), falling away from the glenoid rim and labrum. B: Tissue preparation may be performed with either rasps, shavers, or other devices to stimulate a bleeding response (C). D: Suture passing devices are used in a “pinch-tuck” fashion to imbricate the redundant tissue. E: Arthroscopic view after posterior plication sutures have been passed. F: After sutures have been tied, note is made of plication of the capsule and loss of the capsular redundancy.
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A: Arthroscopic images depict redundant capsule (arrows), falling away from the glenoid rim and labrum. B: Tissue preparation may be performed with either rasps, shavers, or other devices to stimulate a bleeding response (C). D: Suture passing devices are used in a “pinch-tuck” fashion to imbricate the redundant tissue. E: Arthroscopic view after posterior plication sutures have been passed. F: After sutures have been tied, note is made of plication of the capsule and loss of the capsular redundancy.
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The arthroscope is then repositioned posteriorly and an accessory portal reestablished anterosuperiorly. The anteroinferior capsule is similarly prepared with rasps, shavers, or other instruments until punctate bleedings is seen. Plicating sutures are again passed in a “pinch-tuck” fashion, imbricating the redundant capsule to the intact glenoid labrum. These may be tied in series, completing the circumferential repair (Table 21-8). 
 
Table 21-8
Arthroscopic Capsulorrhaphy for Shoulder Instability
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Table 21-8
Arthroscopic Capsulorrhaphy for Shoulder Instability
Surgical Steps
  •  
    Examination under anesthesia
  •  
    Establish arthroscopic portals
  •  
    Arthroscopic survey
  •  
    Preparation and imbrication of posterior glenohumeral joint
    •  
      Place arthroscope anterosuperiorly with working portal posteriorly
    •  
      Stimulation of bleeding response in posterior capsule
    •  
      Pass imbricating suture through capsule first, then through chondrolabral junction, beginning in most inferior position
    •  
      May store sutures in anteroinferior portal to ease visualization and subsequent suture management
    •  
      Pass additional plication sutures from inferior to superior
    •  
      After all posterior sutures have been placed, tie in sequential fashion from inferior to superior
  •  
    Preparation and imbrication of anterior glenohumeral joint
    •  
      Place arthroscope posteriorly and establish accessory portal anterosuperiorly
    •  
      Stimulate redundant anterior capsule until bleeding response seen
    •  
      Pass imbricating sutures through capsule and then chondrolabral junction, placating redundant tissue
    •  
      Tie sutures as they are placed, inferiorly to superiorly
  •  
    Skin closure with simple sutures
  •  
    Application of sling-and-swathe
X

Operative Treatment of Shoulder Dislocations: Open Capsulorrhaphy

Indications/Contraindications

Despite advances in arthroscopic surgical techniques, open soft tissue procedures may still be performed. Relative indications for open capsulorrhaphy include failed prior arthroscopic procedures, multidirectional instability in setting of capsular laxity without labral tear, and surgeon preference and/or experience. The principles of these procedures are similar to arthroscopic plication: Stability is conferred by tightening the redundant capsule, thus reducing joint volume and conferring stability. 

Surgical Procedure

Preoperative Planning
Preoperative planning similar to procedures described above (Table 21-9). 
 
Table 21-9
Open Capsulorrhaphy for Shoulder Instability
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Table 21-9
Open Capsulorrhaphy for Shoulder Instability
Preoperative Planning Checklist
  •  
    OR Table: Regular table
  •  
    Position/positioning aids: Modified beach chair position, limb holder if available
  •  
    Fluoroscopy location: N/A
  •  
    Equipment: Shoulder retractors, nonabsorbable braided sutures
  •  
    Tourniquet (sterile/nonsterile): N/A
X
Positioning
The modified beach chair position is utilized. Intraoperative positioning is aided by a limb holder. 
Surgical Approach(es)
A standard deltopectoral approach is utilized, with the skin incision beginning just lateral to the coracoid process and extending within Langer skin lines toward the axillary crease. The cephalic vein is typically retracted laterally with the deltoid. After the clavipectoral fascia is excised, the conjoined tendon is carefully retracted medially to avoid excessive traction to the musculocutaneous nerve. This will allow direct visualization of the subscapularis and underlying glenohumeral joint capsule. 
Technique
After the subscapularis is exposed, the limb is placed in adduction and external rotation. The lesser tuberosity is palpated and identified. A subscapularis tenotomy may then be performed 2 to 3 cm medial to its insertion on the lesser tuberosity, leaving a cuff of tissue laterally to allow for subsequent repair. Traction sutures are placed on the subscapularis tendon, which may then be mobilized and separated from the underlying glenohumeral joint capsule. (In some situations, the upper two-thirds of the subscapularis may be divided, leaving a portion of the inferior musculotendinous unit intact.) Following this, T-shaped capsulotomy is created; a vertical incision is made laterally, with a subsequent transverse extension medially. The superomedial and inferomedial capsular flaps are then mobilized with suture tags. With the limb in the desired position of slight abduction and external rotation, the inferomedial limb is advanced and shifted superolaterally, repaired to the lateral capsule with multiple interrupted nonabsorbable sutures. The superomedial limb is then similarly advanced inferomedially and sewn to the lateral capsule, completing the capsulorrhaphy. Meticulous repair of the subscapularis tenotomy is performed with multiple braided nonabsorbable sutures. The subcutaneous tissues and skin are closed in layers, followed by application of a sling and swathe (Table 21-10). 
 
Table 21-10
Open Capsulorrhaphy for Shoulder Instability
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Table 21-10
Open Capsulorrhaphy for Shoulder Instability
Surgical Steps
  •  
    Deltopectoral approach
  •  
    Excise clavipectoral fascia
  •  
    Gentle retraction of conjoined tendon
  •  
    Subscapularis tenotomy, leaving cuff of tissue on lesser tuberosity for subsequent repair
    •  
      Mobilize subscapularis after placement of traction sutures
  •  
    Perform T-shaped capsulotomy
  •  
    Imbricate capsule, advancing inferomedial capsular flap superolaterally, followed by repair of the superomedial flap inferomedially
    •  
      Position limb in slight abduction and ∼30 degrees external rotation to avoid overtightening
  •  
    Careful repair of subscapularis tenotomy using heavy braided nonabsorbable sutures
  •  
    Layered wound closure
  •  
    Sling-and-swathe immobilization
X

Author's Preferred Treatment of Shoulder Dislocations

Children and adolescents with traumatic, anterior shoulder dislocations are treated with prompt closed reduction and sling immobilization. Radiographs are obtained to confirm adequacy of glenohumeral reduction and evaluate for possible bony glenoid fractures. In the majority of patients with purely soft tissue injuries—likely anterior-inferior labral tears—physical therapy is initiated following brief immobilization. Return to sports is limited until patients have restoration of motion, strength, and proprioception.8 
Early in the post injury period, patients and families are counseled regarding the risk of recurrent instability. In high-risk patients (e.g., contact or overhead athletes) or patients for whom the risk of recurrent instability is judged to be unacceptable, arthroscopic Bankart repair may be performed after primary dislocation. In rare circumstances where patients wish to continue with high-risk activities despite known risk of recurrent instability (e.g., in-season contact athlete), functional bracing with orthoses limiting abduction and external rotation may be utilized. 
Patients with bony Bankart lesions are further assessed with CT, and quantification is made of glenoid deficiency. Given the high risk of recurrent instability in the setting of glenoid bone loss, patients with small marginal lesions are offered arthroscopic repair. Patients with larger bony glenoid lesions are treated with open reduction and internal fixation (ORIF) versus Latarjet reconstruction, depending upon the integrity of the bony fragment. 
Surgical stabilization of adolescents with recurrent unidirectional instability is typically performed via arthroscopic capsulolabral repair. Preoperative imaging with MRI-arthrography will better define the extent of labral injury and rule out unrecognized or attritional glenoid insufficiency. Latarjet reconstructions are performed in cases of glenoid bone loss or recurrent instability failing prior arthroscopic stabilizations. 
Patients with atraumatic multidirectional instability in the setting of ligamentous laxity or other systemic conditions (e.g., hypermobility, Ehlers–Danlos, etc.) are treated with physical therapy, emphasizing strength, proprioception, biofeedback, and neuromuscular retraining of the entire shoulder girdle. In select patients where there is persistent, painful or functionally limiting instability refractory to or precluding physical therapy, surgical treatment is considered. MRI-arthrography is obtained to characterize the extent and magnitude of capsular redundancy. Stabilization is performed via arthroscopic capsulorrhaphy, with appropriate postoperative immobilization and therapy (Fig. 21-15). 
Figure 21-15
Proposed treatment algorithm for shoulder dislocation.
Flynn-ch021-image015.png
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Postoperative Care

Postoperatively, patients are sling immobilized for 4-week postoperatively. During the third and fourth postoperative weeks, patients initiate pendulum exercises only. Formal supervised physical therapy is begun after the fourth postoperative week, limiting forward flexion and lateral abduction in the plane of the scapula to 90 degrees and external rotation to 30 degrees. After the sixth postoperative week, motion and strengthening are advanced as tolerated. Sports participation is generally limited for 6 months postoperatively, provided full motion and strength has been restored. 

Potential Pitfalls and Preventative Measures

Potential pitfalls in the diagnosis and management of shoulder dislocations are described above. In general, early recurrent instability after nonoperative or surgical treatment is generally due to failure to recognize the pertinent pathoanatomy. Careful radiographic evaluation after primary or recurrent instability events is needed to recognize bony glenoid deficiency and guide appropriate management. Early recurrent instability after arthroscopic soft tissue procedures may be due to unrecognized glenoid deficiency, suboptimal mobilization and preparation of the capsulolabral tissue, untreated HAGL lesions, or technical errors in suture passage and knot security. Finally, recurrent instability after capsulorrhaphy for multidirectional instability may be due to unrecognized systemic connective tissue disorders, suboptimal tissue preparation and plication, or inappropriate patient selection (Table 21-11). 
 
Table 21-11
Potential pitfalls and strategies for prevention
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Table 21-11
Potential pitfalls and strategies for prevention
Potential Pitfalls and Preventions
Pitfall Preventions
Failure to identify bony glenoid fractures Careful evaluation of injury and postreduction radiographs including MRI and/or CT imaging
Use of orthogonal radiographic images, including axillary view
Early recurrent instability after arthroscopic stabilization Appropriate recognition of glenoid deficiency or large, engaging Hill–Sachs lesion requiring bony reconstruction
Meticulous preparation, mobilization of capsulolabral tissue, particularly in the setting of an ALPSA lesion
Appropriate suture passage and knot security
Appropriate recognition of HAGL lesions
Early recurrent instability after stabilization for multidirectional instability Comprehensive counseling regarding importance of therapy and nonoperative treatment modalities
Appropriate patient selection
Meticulous soft tissue preparation and plication
X

Treatment-specific Outcomes

As noted above, there is limited published information regarding the results of surgical stabilization for glenohumeral instability in children and adolescents. Much of the current understanding of the treatment outcomes is derived from applications of the adult experiences. A number of general observations may be gleaned from review of the existing retrospective case series. First, there has been an increase in the incidence of glenohumeral instability in younger patients, perhaps because of increasing activities and younger age of first sports participation, with expectation for high recurrence rates with nonoperative treatment alone.100,149,189,420 Second, arthroscopic repairs have become increasingly common and preferred over open stabilization procedures.275,349 Third, surgical stabilization of Bankart lesions safely and effectively improves shoulder stability, with the risk of recurrence reduced to 5% to 20%.1,61,247 Castagna et al.61 reported the results of 65 patients between 13 and 18 years of age, treated with arthroscopic capsulolabral repair, all of whom were overhead or contact athletes. At mean 5-year follow-up, shoulder motion was restored and 81% had returned to their preinjury level of sports participation. Recurrent instability was reported in 21%, and recurrence was associated with choice of sports participation. In a report of 32 arthroscopic stabilizations in 30 patients under 18 years of age, Jones et al.214 similarly reported high functional outcomes, though recurrent instability was noted in 12% to 19% of patients. Finally, bony procedures including the Latarjet coracoid transfer is safe and effective, with low risk of recurrent instability.21,191,193 

Management of Adverse Outcomes and Unexpected Complications Related to Shoulder Dislocations

Adverse outcomes and complications occur infrequently with glenohumeral instability. As noted above, vascular injury is exceedingly rare, and the majority of neurologic injuries associated with traumatic dislocations represent neurapraxic traction injuries to the axillary nerve or brachial plexus, with expectation of spontaneous resolution over time. Nerve repairs or reconstructions are rarely needed and reserved for patients who fail to demonstrate progressive spontaneous recovery. 
Chondrolysis has been increasingly reported in patients undergoing arthroscopic stabilizations for glenohumeral instability. Recent reports suggest that use of intra-articular analgesics (e.g., indwelling intra-articular pain catheters) are associated with chondrolysis, and for this reason are currently contraindicated.377,382,403,457 Similarly, unexpected joint degeneration has been reported after thermal capsulorrhaphy and loose metallic suture anchors, likely related to thermal injury and third body wear of the articular cartilage, respectively.82,107,150,216 Cartilage loss in a young, skeletally immature shoulder is a disastrous and yet unsolved complication. Avoidance of excessive heat and proper placement of bioabsorbable suture anchors may minimize these adverse events. Judicious placement of bone grafts and internal fixation, such as in the Latarjet procedure, is also critically important to minimize risk of early arthrosis (Table 21-12).192 
 
Table 21-12
Shoulder Dislocations
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Table 21-12
Shoulder Dislocations
Common Adverse Outcomes and Complications
Recurrent instability
Neurovascular injury
Chondrolysis
Arthrosis
X

Summary, Controversies, and Future Directions Related to Shoulder Dislocations

In summary, glenohumeral instability is common in children and adolescents. While closed reduction is easily performed after acute dislocations, there is a high risk of recurrent instability. In appropriately selected patients, arthroscopic or open soft tissue and/or bony stabilization procedures are safe and effective. 
There is ongoing debate and controversy surrounding the indications for surgical stabilization after primary traumatic dislocation in the child or adolescent. Proponents of primary surgery point to the safety and efficacy of predominantly arthroscopic procedures in reducing recurrence risk and restoring stability and return of function. Furthermore, there is some evidence suggesting recurrent dislocations may lead to more extensive labral tears, development of glenoid insufficiency, and even arthrosis.190,219 Many argue that surgical stabilization should be performed in higher-risk patients (e.g., young athletes involved in contact sports).67,233 A recent expected-value decision analysis supports primary arthroscopic stabilization if recurrence risk above 32% and utility value of surgical intervention remains above 6.6.33 Further investigation of the natural history of recurrent glenohumeral instability as well as prospective randomized trials of surgical versus nonoperative treatment is needed in the pediatric patient population. 
Finally, as more information regarding the frequency and clinical significance of bony glenoid and humeral head defects becomes available, clarification of the indications for bony augmentation procedures (e.g., coracoid transfer, bone grafting) is needed. This is particularly relevant given the persistent risks of recurrent instability after arthroscopic Bankart repairs and the promising longer-term studies regarding the results of bony procedures.75,191,193,210,227 

Introduction to Proximal Humerus Fractures

Proximal humeral fractures are relatively uncommon injuries, with an estimated annual incidence of 1.2 to 4.4 per 1,000, and representing less than 5% of all childhood fractures.26,182,203,240,241,358,464 Given the metaphyseal location, thick periosteum, and proximity to the proximal humeral physis, there is tremendous healing and remodeling potential of proximal humerus fractures. Furthermore, given the robust, near universal motion about the glenohumeral joint, little functional impairment may be seen even in cases of considerable bony malalignment. For these reasons, most proximal humeral fractures are amenable to nonoperative treatment. 

Assessment of Proximal Humerus Fractures

Mechanisms of Injury for Proximal Humerus Fractures

Proximal humerus fractures occur through a number of characteristic injury mechanisms. Birth-related fractures of the proximal humerus are not uncommon.250,397 In general, hyperextension and/or rotational forces imparted on the upper limb during labor and delivery result in failure through the proximal humeral physis or metaphysis (Fig. 21-16).95,155,163,167,250,272,397 Risk factors include difficult delivery, macrosomia, and breech presentation, but are not entirely predictive.56,136,212,397 Indeed, proximal humerus fractures may occur during vaginal delivery of infants of all weights and sizes, implicating other maternal and perinatal factors. 
Figure 21-16
Hyperextension or rotation of the ipsilateral arm may result in a proximal humeral or physeal injury during birth.
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In older children and adolescents, proximal humerus fractures are typically sustained from traumatic mechanisms, such as sports-related activities or motor vehicle collisions (Fig. 21-17). Direct trauma to the anterior or posterior aspect of the proximal humerus may result in fracture.95,308,402 More commonly, indirect trauma via forces imparted on the upper limb during falls or nonphysiologic positioning may result in a proximal humeral fracture.3,43,402 Indeed, Williams460 postulated six distinct mechanisms by which proximal humerus fractures may be sustained: Forced extension, forced flexion, forced extension with lateral or medial rotation, and forced flexion with lateral or medial rotation. Fractures may occur at the level of the proximal metaphysis or physis. 
Figure 21-17
 
A: Motor vehicle crashes may result in proximal humeral fracture due to blunt trauma to the shoulder region. B: Blunt trauma from contact sports may result in fracture of the proximal humerus in children.
A: Motor vehicle crashes may result in proximal humeral fracture due to blunt trauma to the shoulder region. B: Blunt trauma from contact sports may result in fracture of the proximal humerus in children.
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Figure 21-17
A: Motor vehicle crashes may result in proximal humeral fracture due to blunt trauma to the shoulder region. B: Blunt trauma from contact sports may result in fracture of the proximal humerus in children.
A: Motor vehicle crashes may result in proximal humeral fracture due to blunt trauma to the shoulder region. B: Blunt trauma from contact sports may result in fracture of the proximal humerus in children.
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Furthermore, the proximal humerus is a common location of pathologic fractures in children. Benign—such as unicameral or aneurysmal bone cysts—and much less often malignant lesions (osteogenic sarcoma), commonly involve the proximal humerus and may first present in the setting of pathologic fracture.2,235,323,353 Neuropathic conditions including Arnold–Chiari malformation, myelomeningocele, or syringomyelia have also been implicated in pathologic fractures of the proximal humerus.19,264 Finally, radiation therapy to the shoulder girdle may result in bony abnormalities predisposing to proximal humerus fracture.115 
Finally, proximal humerus fractures may be seen in the setting of nonaccidental trauma and child abuse.133,289,390 For this reason, careful assessment including comprehensive history and physical examinations are needed when assessing infants and young children with proximal humerus fractures. 

Associated Injuries with Proximal Humerus Fractures

Fractures of the proximal humerus may have concomitant dislocations of the glenohumeral joint, particularly with high-energy mechanisms of injury.80,133,154,231,311,316,449,432 Glenohumeral joint dislocation may be anterior, posterior, or inferior, and concomitant intra-articular or apophyseal avulsion fractures may be seen.303,359,404,455 All patients with proximal humerus fractures should be evaluated for concomitant glenohumeral joint reduction with appropriate radiographic imaging. A high index of suspicion is needed to avoid delayed or missed diagnosis. Ipsilateral fractures of the upper limb have also been reported, emphasizing the importance of a comprehensive physical examination and imaging of the entire humerus or upper limb as appropriate.159,209,269,322 
Given the proximity to the brachial plexus and axillary vessels, proximal humerus fractures may be associated with neurovascular injury. Axillary nerve, radial nerve, and total brachial plexus palsies have been reported in the setting of displaced proximal humerus fractures.10,112,199,432,438 These are typically seen in valgus injuries, in which the distal diaphyseal segment displaces medially and proximally into the region of the brachial plexus. While spontaneous neurologic recovery is seen in the majority of patients within 9 to 12 months, patients may develop a profound neurogenic pain syndrome.199 Proximal humerus fractures associated with arterial injury and vascular insufficiency require emergent reduction and/or stabilization and vascular repair.168,453 Associated injuries to the thorax, including rib fractures and pneumothorax, have also been reported. 

Signs and Symptoms of Proximal Humerus Fractures

In neonates, the signs and symptoms of proximal humerus fractures may be subtle. Rarely will ecchymosis, swelling, or deformity be clinically apparent. Care providers will often report irritability or “fussiness” with handling or motion of the affected extremity. Often the absence of spontaneous movement of the upper limb—so-called “pseudoparalysis”—will alert the examiner to an underlying fracture. 
In older children and adolescents, the clinical diagnosis is more obvious. Patients will present with pain, swelling, ecchymosis, and/or limited shoulder motion after traumatic injury. The limb is typically held against the body in adduction and internal rotation, and patients will guard against passive or active movement. Inspection will reveal asymmetry in the contour of the shoulder girdle compared with the contralateral, uninjured extremity. Subtle skin puckering may be seen, suggestive of soft tissue interposition in severely displaced fractures.97 Careful evaluation of neurovascular status is critical to rule out concomitant nerve or vessel injury. Even in patients with considerable pain and guarding, axillary nerve function (sensation over the lateral deltoid, abduction of the shoulder) may be adequately assessed. Similarly brachial plexus integrity may be assessed by distal motor sensory function without moving the injured limb. 
Patients with associated posterior glenohumeral joint dislocation will posture with internal rotation and have limited or extremely painful passive external rotation. Associated fracture-dislocations involving the greater tuberosity and luxation erecta will present with extreme abduction of the shoulder and elbow flexion.132,230 Fractures of the lesser tuberosity and/or subscapularis disruption may be more subtle in presentation, though patients will have weak internal rotation, a positive lift-off sign, and often increased passive external rotation.254,359,396,436,442 

Imaging and Other Diagnostic Studies for Proximal Humerus Fractures

The proximal humeral epiphysis is not radiographically apparent until approximately 6 months of age, limiting the diagnostic utility of plain radiographs in the evaluation of neonates and infants.234,321 In these very young patients, ultrasonography may provide meaningful diagnostic information.46,127,194 MRI may also help distinguish between proximal humeral fracture and other potential causes of pseudoparalysis, such as osteomyelitis, septic arthritis, or glenohumeral joint instability in the setting of brachial plexus birth palsy, though MRI requires conscious sedation or general anesthesia. 
Subtle signs of proximal humerus fracture in infants include asymmetric positioning of the proximal humeral metaphysis in relationship to the scapula and acromion, particularly when compared to images of the contralateral shoulder. In patients with posteriorly displaced physeal fractures, the so-called “vanishing epiphysis” sign has been used to describe the apparent absence of the small epiphyseal ossification center, which lies behind the proximal metaphysis (Fig. 21-18).224,376 
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Figure 21-18
Vanishing epiphysis sign.
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In older patients and adolescents, plain radiographs will confirm the diagnosis and characterize fracture pattern and displacement. Orthogonal views are necessary, and ideally AP and axillary views are obtained to assess for concomitant lesser tuberosity fracture or glenohumeral joint dislocation.416,436 In appropriate axillary images, the humeral head normally resides between the acromion and coracoid process, concentrically reduced within the glenoid. Given the difficulty in obtaining axillary radiographs in the acutely injured child, a host of alternative radiographic views have been proposed, including the transthoracic scapular Y view, apical oblique view, and other variations.144,400 In unusual situations in which adequate plain radiographs cannot be obtained, CT or MRI may be utilized. These advanced imaging modalities are particularly useful in cases of posterior glenohumeral fracture-dislocations, intra-articular fractures, or occult fractures.26,154,365,423,424,442 

Classification of Proximal Humerus Fractures

Metaphyseal proximal humerus fractures occur most commonly in children between 5 and 12 years of age, and may be described according to their radiographic displacement and angulation (Fig. 21-19). It has been hypothesized that rapid metaphyseal growth and thus relative porosity of the proximal humeral metaphysis contributes to the predilection to fracture in this age group.95 
Figure 21-19
Proximal humeral metaphyseal fracture in a 5-year-old male.
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Physeal fractures are classified according to the Salter–Harris classification (Fig. 21-20).370 Salter–Harris I injuries denote fractures through the physis and most commonly occur in patients under 5 years of age.95,333 Salter–Harris II fractures exit through the metaphysis, often associated with an anterolateral bony fragment, and are more commonly seen in older children and adolescents.51,95,127,333 Salter–Harris III fractures are relatively rare and have been associated with concomitant glenohumeral dislocation. Salter–Harris IV fractures have not been reported in children. 
Figure 21-20
Physeal fractures of the proximal humerus.
 
A: Salter–Harris type I. B: Salter–Harris type II. C: Salter–Harris type III. D: Salter–Harris type IV.
A: Salter–Harris type I. B: Salter–Harris type II. C: Salter–Harris type III. D: Salter–Harris type IV.
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Figure 21-20
Physeal fractures of the proximal humerus.
A: Salter–Harris type I. B: Salter–Harris type II. C: Salter–Harris type III. D: Salter–Harris type IV.
A: Salter–Harris type I. B: Salter–Harris type II. C: Salter–Harris type III. D: Salter–Harris type IV.
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Neer and Horwitz308 proposed a classification system for pediatric proximal humerus fractures based upon the amount of fracture displacement. In grade I fractures, there is up to 5 mm of displacement. Grade II fractures are displaced up to one-third of the cortical diameter of the humeral diaphysis. Grade III injuries have up to two-third displacement. Grade IV fractures have greater than two-thirds cortical diameter displacement. Angulation and malrotation are not specifically categorized in this classification system. 

Pathoanatomy and Applied Anatomy Relating to Proximal Humerus Fractures

Care of proximal humerus fractures in children and adolescents is challenging for a number of reasons. First, given the robust remodeling potential in skeletally immature patients, there are variations in what is deemed “acceptable” deformity. Fracture reduction is often difficult, owing to the small size and deep location of the humeral head as well as the deforming muscle insertions on both the proximal and distal fracture fragments. Multiple reduction maneuvers and fixation options have been proposed, adding complexity to nonoperative or surgical decision making. Finally, the proximity of the zone of injury to adjacent neurovascular structures results in the potential for associated injuries and surgical risks. All of these considerations must be reconciled with evolving patient and family expectations regarding pain control, healing time, and functional return. For these reasons, understanding of the applied anatomy and pathoanatomy of proximal humerus fractures is critical. 
The proximal humeral epiphysis does not become radiographically apparent until approximately 6 months of age.234,321 Furthermore, the greater and lesser tuberosities have their own distinct secondary centers of ossification, which become visible at 1 to 3 years and 4 to 5 years of age, respectively.321,372 The greater and lesser tuberosities coalesce between 5 and 7 years of age, and subsequently fuse to the rest of the humeral head between 7 and 13 years of age. 
The proximal humeral physis ultimately contributes 80% of the longitudinal growth of the humerus.40,339,340 There is some variation over time, however, as the proximal humeral physis contributes 75% of longitudinal growth of the humerus prior to 2 years of age, but up to 90% of growth after the age of 11 years. Generally, the proximal humeral physis closes at 14 to 17 years of age in females and between 16 and 18 years of age in males.40,339,340,407 
The articular surface of the humeral head encompasses the medial aspect of the epiphysis as well as the proximal medial corner of the metaphysis (Fig. 21-21). The capsule of the glenohumeral joint correspondingly surrounds the articular surface. However, the proximal humeral physis is extracapsular and thus susceptible to injury. Indeed, most fractures of the proximal humerus involve the physis.51,95,333 As with other growth plate injuries, proximal humeral physeal fractures typically occur through the zone of hypertrophy and provisional calcification, sparing the resting and proliferative zones. For these reasons, the typical Salter–Harris I and II injuries have tremendous remodeling potential and have a low risk of subsequent growth disturbance.22,95,370 
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Figure 21-21
The anatomy of the proximal humerus.
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The periosteum is thick and strong along the posteromedial aspect of the proximal humerus, but relatively weak anterolaterally, allowing for fracture fragment displacement. In cases of displaced fractures, interposed periosteum may block reduction attempts.95,111,267 
A number of muscles insert on the proximal humerus, influencing fracture pattern, location, and characteristic displacement. Understanding of these dynamic influences is critical for successful fracture reduction. The subscapularis inserts anteriorly on the lesser tuberosity, whereas the supraspinatus, infraspinatus, and teres minor attach to the greater tuberosity and posterosuperior epiphysis. The deltoid tubercle lies more distally along the lateral aspect of the humeral diaphysis, and the pectoralis major and latissimus dorsi muscles insert along the anteromedial aspect of the metaphysis. In patients with physeal or metaphyseal fractures proximal to the pectoralis major insertion, the humeral head is abducted, flexed, and externally rotated by the action of the rotator cuff muscles, whereas the distal humeral diaphyseal segment is typically displaced proximally, medially, and into internal rotation. In metaphyseal fractures between the pectoralis major and deltoid insertions, the proximal fragment is adducted by the pull of the pectoralis major and the distal segment is pulled proximally and into abduction by the deltoid. For diaphyseal fractures distal to the deltoid insertion, the proximal fracture fragment is abducted by the deltoid and flexed by the pectoralis major, and the distal fragment is displaced proximally and medially by the biceps and triceps. Rarely, the subscapularis muscle may lead to displacement of an isolated fracture of the lesser tuberosity. 
The vascularity of the proximal humerus arises from the axillary artery and its branches. In particular, the anterior and posterior humeral circumflex arteries supply the proximal humerus, whereas the humeral head derives most of its vascular supply from the arcuate artery, a branch of the ascending branch of the anterior humeral circumflex artery.142,238 The posterior humeral circumflex artery supplies only a portion of the greater tuberosity and posteroinferior humeral head.142 
Of the neurologic structures, the axillary nerve is the closest and most at risk in fractures and fracture-dislocations of the proximal humerus.10,432 The axillary nerve arises from the posterior cord of the brachial plexus before it traverses the anterior aspect of the subscapularis muscle and passes just inferior to the glenohumeral joint. From there it passes through the quadrilateral space to innervate the deltoid and teres minor muscles and to supply sensation to the lateral aspect of the shoulder. 

Treatment Options for Proximal Humerus Fractures

Nonoperative Treatment of Proximal Humerus Fractures

Indications/Contraindications

Given their tremendous remodeling potential as well as the robust compensatory motion afforded by the shoulder joint, the vast majority of proximal humerus fractures may be treated by nonoperative means. Birth-related fractures of the proximal humerus may be successfully treated with simple pinning of the sleeve to the body or stockinette sling-and-swathe immobilization. Closed reduction is rarely needed in infants, and while ultrasonography may be utilized to confirm alignment, advanced imaging is almost always unnecessary. In these infants, healing is rapid and robust, typically within 2 to 3 weeks, and there is little concern for long-term aesthetic differences or functional limitations.95,163,212,251,397 
Nondisplaced or minimally displaced fractures (Neer–Horwitz grades I and II) in older children and adolescents may also be treated with simple sling-and-swathe immobilization, with or without additional splinting (Fig. 21-22). After confirmation of radiographic healing, patients may advance to motion and strengthening, with anticipation of excellent long-term results.53,95 Similarly, stress fractures of the metaphysis or physis—such as seen from repetitive overuse sports activities, neurologic conditions, metabolic bone disease, or local radiation therapy—may be successfully treated with rest, activity modification and/or simple sling immobilization.45,93,115,261,425,426 
Figure 21-22
Sling-and-swathe for immobilization of proximal humeral fracture.
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With increasing age and skeletal maturity, remodeling capacity diminishes; therefore, the amount of “acceptable” deformity changes with age. Given the remodeling potential in patients less than 11 years of age, good-to-excellent results have been reported with nonoperative treatment regardless of fracture displacement.95,243,308,402 Immobilization options include sling-and-swathe, Velpeau thoracobrachial bandages, hanging arm casts, and shoulder spica casts in the “saluting” and “Statue of Liberty” positions.53,95,163,243 
There continues to be controversy, however, regarding what constitutes “acceptable” alignment in pediatric proximal humerus fractures, particularly in older children and adolescents. Much of the available information comes from historic retrospective case series, with little or no comparative outcome data available. Traditional recommendations have divided treatment recommendations according to patient age and fracture displacement (Table 21-13).23,111,390,393 In patients less than 5 years of age, up to 70 degrees of angulation and 100% displacement is deemed acceptable. In patients between 5 and 11 years of age, 40 to 70 degrees of angulation and 50% to 100% displacement may be accepted. And in patients greater than 12 years of age with less growth and remodeling potential, less than 40 degrees and 50% translation should be accepted. Though these guidelines are generally accepted, appropriate clinical judgment weighing individual patient and provider factors should be made on a case-by-case basis.23,95,111,243 For example, in overhead athletes requiring maximal shoulder abduction and forward flexion, less varus or apex anterior angulation may be acceptable, given concerns regarding acromial impingement and bony blocks to glenohumeral motion (Fig. 21-23). 
 
Table 21-13
Acceptable Alignment of Proximal Humerus Fractures
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Table 21-13
Acceptable Alignment of Proximal Humerus Fractures
Age Angulation Displacement
<5 y 70 degrees 100%
5–11 y 40–70 degrees 50–100%
>12 y <40 degrees <50%
X
Figure 21-23
 
A: AP radiograph of a minimally displaced right proximal humeral physeal fracture in a 14-year-old male. B: Follow-up radiographs depicting humerus varus, characterized by a decreased neck-shaft angle and high-riding greater tuberosity resulting in limited shoulder abduction and bony impingement. C: Intraoperative image during corrective osteotomy, depicting percutaneous pin placement. D: Converging osteotomies (arrows) are made to create a lateral closing wedge osteotomy. E: Osteotomy fixed using percutaneous pins and a tension-band fixation construction. F: Follow-up radiographs demonstrating bony healing and restoration of more normal proximal humeral alignment.
A: AP radiograph of a minimally displaced right proximal humeral physeal fracture in a 14-year-old male. B: Follow-up radiographs depicting humerus varus, characterized by a decreased neck-shaft angle and high-riding greater tuberosity resulting in limited shoulder abduction and bony impingement. C: Intraoperative image during corrective osteotomy, depicting percutaneous pin placement. D: Converging osteotomies (arrows) are made to create a lateral closing wedge osteotomy. E: Osteotomy fixed using percutaneous pins and a tension-band fixation construction. F: Follow-up radiographs demonstrating bony healing and restoration of more normal proximal humeral alignment.
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Figure 21-23
A: AP radiograph of a minimally displaced right proximal humeral physeal fracture in a 14-year-old male. B: Follow-up radiographs depicting humerus varus, characterized by a decreased neck-shaft angle and high-riding greater tuberosity resulting in limited shoulder abduction and bony impingement. C: Intraoperative image during corrective osteotomy, depicting percutaneous pin placement. D: Converging osteotomies (arrows) are made to create a lateral closing wedge osteotomy. E: Osteotomy fixed using percutaneous pins and a tension-band fixation construction. F: Follow-up radiographs demonstrating bony healing and restoration of more normal proximal humeral alignment.
A: AP radiograph of a minimally displaced right proximal humeral physeal fracture in a 14-year-old male. B: Follow-up radiographs depicting humerus varus, characterized by a decreased neck-shaft angle and high-riding greater tuberosity resulting in limited shoulder abduction and bony impingement. C: Intraoperative image during corrective osteotomy, depicting percutaneous pin placement. D: Converging osteotomies (arrows) are made to create a lateral closing wedge osteotomy. E: Osteotomy fixed using percutaneous pins and a tension-band fixation construction. F: Follow-up radiographs demonstrating bony healing and restoration of more normal proximal humeral alignment.
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In patients older than 11 years, fracture reduction and immobilization is recommended for Neer–Horwitz grade III and IV injuries with unacceptable alignment.23,95,243,308,393 While a host of reduction maneuvers have been described, all adhere to the fundamental principles of reversing the deformity and counteracting the deforming forces. Most fractures may be reducing by applying longitudinal traction to the distal brachium, followed by abduction, flexion, and external rotation; this technique essentially brings the distal diaphyseal segment to the displaced humeral head. Often, initial adduction and internal rotation to relax the pectoralis major, followed by posteriorly directed pressure on the humeral diaphysis to correct the apex anterior angulation, will facilitate reduction.208 Alternatively, reduction may be achieved by abduction, flexion to 90 degrees, and external rotation.308 Still others advocate placing the limb in 135 degrees abduction and slight (30 degrees) flexion, followed by longitudinal traction and manual manipulation of the fracture fragments.43,212 In cases of physeal fractures, gentle manipulation with the assistance of conscious sedation or general anesthesia should be considered to avoid excessively forceful manipulation and minimize the risk of iatrogenic physeal disturbance. After reduction, fracture stability needs to be assessed. Often the intact periosteum will stabilize the reduction and allow for immobilization at the patient's side. Typically, immobilization with sling-and-swathe or Velpeau thoracobrachial bandage is sufficient.95 
Some fractures may not be reducible, because of soft tissue interposition at the fracture site. Potential structural barriers to fracture realignment include the adjacent periosteum, glenohumeral joint capsule, and long head of biceps tendon.23,111,131,208,249,251,267,439 In these situations, open reduction via a limited anterior deltopectoral approach may be needed to obtain appropriate reduction. Even in cases in which the bony alignment is improved to “acceptable” parameters but not anatomic, fracture healing and functional return may be expected; indeed, good functional results have been reported in patients with Neer–Horwitz grade III and IV injuries who were reduced to grade I or II displacement.111,198 
There is additional controversy regarding the optimal management of the older adolescent who undergoes successful fracture reduction. Loss of reduction following initial manipulation has been reported to be as high as 50% in older adolescents, suggesting that internal fixation should be considered when caring for older patients with severely displaced injuries.95,111,308 Again, there is no prospective or comparative data to inform us regarding the utility or cost-effectiveness of internal fixation in these situations (Table 21-14). 
 
Table 21-14
Proximal Humerus Fractures
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Table 21-14
Proximal Humerus Fractures
Nonoperative Treatment
Indications Relative Contraindications
Birth-related fractures Open fractures
Younger patients with stable or minimally displaced fractures Fractures with vascular or severe soft tissue injury
Stress fractures Displaced intra-articular fractures
Displaced tuberosity fractures
Irreducible or unstable fractures in older adolescents with unacceptable alignment
X

Operative Treatment of Proximal Humerus Fractures

Indications/Contraindications

Surgical indications include open fractures, fractures associated with vascular injury, fractures in the multitrauma patient, displaced intra-articular fractures, displaced tuberosity fractures, and irreducible or unstable fractures in unacceptable alignment.23,89,111,182,198,249,265,277,333,383,412,449 
A host of surgical treatment options have been advocated in these situations, and in general may be divided according to manner of reduction (closed vs. open) and type of fixation (pin fixation, intramedullary fixation, and plate-and-screw constructs).23,70,71,89,95,111,125,208,308,345,362,381,393,466 

Surgical Procedure: Percutaneous Pin Fixation

Preoperative Planning
Percutaneous pin fixation is a common technique for the treatment of unstable proximal humerus fractures.71,111,198 Appropriate preoperative planning includes orthogonal radiographic views of the proximal humerus—preferably AP and axillary views—to characterize the fracture pattern and displacement. Careful radiographic assessment should be made to identify associated bony lesions, as pathologic fractures due to unicameral bone cysts, aneurysmal bone cysts, and other benign and malignant lesions commonly occur in the proximal humerus. Preoperative evaluation should also include a careful neurovascular examination to rule out concomitant nerve palsy or vascular injury. 
While terminally threaded pins are commonly used in adults, smooth pins are sufficient in pediatric patients given the bone quality, rapid healing, ease of implant removal, and typical simple extra-articular fracture patterns. The appropriate-sized implants should be determined in advance; typically smooth Kirschner (K)-wires between 0.0625 and 3/32 in in diameter are used. Cannulated screw fixation has been advocated by some, citing its minimal invasiveness, improved stability, and avoidance of complications commonly seen with smooth K-wires. However, given the concerns regarding potential physeal disturbance and need for staged implant removal, cannulated screw fixation is not typically utilized or necessary (Table 21-15).71,452 
Table 21-15
Reduction and Percutaneous Pinning of Proximal Humerus Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Modified beach chair vs. supine with bump
  •  
    Fluoroscopy location: From head of table vs. contralateral side
  •  
    Equipment: Smooth K-wires
  •  
    Tourniquet (sterile/nonsterile): Not applicable
X
Positioning
Patient positioning should be predicated upon access to the shoulder girdle and upper limb and ease of fluoroscopic imaging. Use of the modified beach chair position will allow for easy manipulation, implant placement, and intraoperative imaging. In these cases, the fluoroscopy unit may be brought in from the head of the bed, allowing the surgeon to stand in the axilla or lateral to the affected shoulder and facilitating both AP and axillary views of the proximal humerus (Fig. 21-24). Alternatively, patients may be positioned supine on a radiolucent table with a bump placed under the ipsilateral pelvis or between the scapulae. With supine positioning, the fluoroscopy unit may be brought in from the ipsilateral or contralateral side of the table. 
Figure 21-24
Intraoperative fluoroscopic visualization in the beach chair position.
 
A: Anteroposterior and (B) axillary views may be obtained.
A: Anteroposterior and (B) axillary views may be obtained.
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Figure 21-24
Intraoperative fluoroscopic visualization in the beach chair position.
A: Anteroposterior and (B) axillary views may be obtained.
A: Anteroposterior and (B) axillary views may be obtained.
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X
Surgical Approach(es)
After adequate induction of general anesthesia, closed reduction is performed. Adequate muscle relaxation will facilitate fracture manipulation. In cases where closed reduction does not allow for adequate bony alignment, open reduction may be performed via a deltopectoral approach. As most physeal and metaphyseal fractures are extracapsular, the incision and deep dissection should be biased more inferiorly than standard approaches to the glenohumeral joint. 
Technique
After appropriate positioning, the shoulder girdle and ipsilateral upper limb is prepped and draped into the surgical field. Care is made to provide circumferential access to the shoulder region. Closed reduction maneuvers are performed, as described above. For most injuries, initial adduction and internal rotation will relax the deforming forces of the pectoralis major muscle, and subsequent posterior translation of the diaphyseal fragment will correct the apex anterior angulation. Following this, longitudinal traction and increasing abduction and flexion will reduce the angulation and displacement (Fig. 21-25). In cases of marked fracture instability, the reduction achieved may be lost when the arm is brought into an adducted and internally rotated position. In these situations, it may be advantageous to preplace the pins into the distal humeral fracture fragment first, then perform the appropriate reduction maneuver. Once the fracture is realigned, the pins may be simply passed across the fracture site into the proximal fragment, even with the shoulder abducted, external rotated, and/or flexed. 
Figure 21-25
Percutaneous pin fixation.
 
Injury AP (A) and views (B) of a proximal humerus fracture in a 12-year-old female. Note is made of excessive apex anterior angulation. Intraoperatively, the fracture is closed reduced with traction, abduction (C) and correction of the apex anterior angulation (D). E: Postoperative alignment after percutaneous pinning. F: Follow-up radiograph demonstrates improved alignment and bony healing.
Injury AP (A) and views (B) of a proximal humerus fracture in a 12-year-old female. Note is made of excessive apex anterior angulation. Intraoperatively, the fracture is closed reduced with traction, abduction (C) and correction of the apex anterior angulation (D). E: Postoperative alignment after percutaneous pinning. F: Follow-up radiograph demonstrates improved alignment and bony healing.
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Injury AP (A) and views (B) of a proximal humerus fracture in a 12-year-old female. Note is made of excessive apex anterior angulation. Intraoperatively, the fracture is closed reduced with traction, abduction (C) and correction of the apex anterior angulation (D). E: Postoperative alignment after percutaneous pinning. F: Follow-up radiograph demonstrates improved alignment and bony healing.
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Figure 21-25
Percutaneous pin fixation.
Injury AP (A) and views (B) of a proximal humerus fracture in a 12-year-old female. Note is made of excessive apex anterior angulation. Intraoperatively, the fracture is closed reduced with traction, abduction (C) and correction of the apex anterior angulation (D). E: Postoperative alignment after percutaneous pinning. F: Follow-up radiograph demonstrates improved alignment and bony healing.
Injury AP (A) and views (B) of a proximal humerus fracture in a 12-year-old female. Note is made of excessive apex anterior angulation. Intraoperatively, the fracture is closed reduced with traction, abduction (C) and correction of the apex anterior angulation (D). E: Postoperative alignment after percutaneous pinning. F: Follow-up radiograph demonstrates improved alignment and bony healing.
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Injury AP (A) and views (B) of a proximal humerus fracture in a 12-year-old female. Note is made of excessive apex anterior angulation. Intraoperatively, the fracture is closed reduced with traction, abduction (C) and correction of the apex anterior angulation (D). E: Postoperative alignment after percutaneous pinning. F: Follow-up radiograph demonstrates improved alignment and bony healing.
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Once an adequate closed reduction has been achieved, the fracture is fixed with percutaneous smooth K-wires. Small stab incisions are made at or just proximal to the level of the deltoid tubercle, and careful blunt dissection is performed down to the lateral cortex of the humerus using a hemostat or narrow dissecting scissors. Injury to the axillary nerve may be avoided by placing the entry points for percutaneous pinning two times the height of the articular surface distal to the most proximal edge of the humerus.362 Data from computer modeling studies of pediatric proximal humerus fractures suggest that pins entering laterally 4.4 and 8 cm distal to the superior aspect of the humeral head at a coronal angle of 21 degrees allow for optimal pin placement.288 
After the first pin is placed, multiplanar fluoroscopic views are obtained to confirm appropriate alignment and implant placement. Following this one or two additional pins are placed, again in a distal-lateral to proximal-medial direction. Care is made not to violate the subchondral surface of the humeral head and enter the glenohumeral joint. A drill hole at the entry site may make pin adjustment and placement easier and avoid inadvertent joint and/or adjacent soft tissue (brachial plexus) penetration. Once the desired alignment, depth, and stability is achieved, the pins are bent and cut either below the skin or outside the skin.198 The limb is placed in a sling-and-swathe. Implants may be removed after radiographic evidence of healing is confirmed, typically 4 weeks after surgery. 
Occasionally, additional fixation or assistance with closed reduction is needed. An antegrade pin entering the greater tuberosity and directed distally and medially may be considered, though is rarely necessary. These pins should be placed with the limb in external rotation and directed to a point at least 2 cm inferior to the most medial aspect of the articular surface.362 As cited earlier, if closed reduction is not successful, open reduction via a deltopectoral approach may be utilized, with pinning techniques performed in a similar fashion (Table 21-16). 
Table 21-16
Reduction and Percutaneous Pinning of Proximal Humerus Fractures
Surgical Steps
  •  
    Closed reduction
  •  
    Skin incisions at or proximal to deltoid tubercle
  •  
    Spreading through subcutaneous tissues to lateral humeral cortex
  •  
    Smooth K-wire fixation
  •  
    Fluoroscopic confirmation of alignment and implant placement
  •  
    Placement of additional K-wire(s)
  •  
    Final fluoroscopic evaluation
  •  
    Bent and cut pins beneath or outside the skin
  •  
    Sling-and-swathe immobilization
X

Surgical Procedure: Intramedullary Fixation

Preoperative Planning
Intramedullary nailing is a common technique in the treatment of pediatric proximal humerus fractures.70,71,345,381,466 Unlike adults, in whom solid reamed antegrade nails have been used, intramedullary fixation in children and adolescents typically involves retrograde passage of multiple flexible titanium elastic nails, Rush rods, or Enders nails. Adequate AP and lateral radiographs of the proximal humerus should be reviewed to assess fracture location, pattern, and displacement. Again, careful preoperative evaluation should be made to document neurovascular status, given the known risks of associate nerve injury. Appropriately sized flexible stainless steel or titanium intramedullary nails should be available. Similar to intramedullary fixation techniques of pediatric femur fractures, the selected nail diameter should be approximately 40% of the intramedullary canal dimension (Table 21-17). 
 
Table 21-17
Intramedullary Fixation of Proximal Humerus Fractures
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Table 21-17
Intramedullary Fixation of Proximal Humerus Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent
  •  
    Position/positioning aids: Modified beach chair vs. supine
  •  
    Fluoroscopy location: From head of bed vs. contralateral side
  •  
    Equipment: Appropriate-sized intramedullary nails
  •  
    Tourniquet (sterile/nonsterile): Not applicable
X
Positioning
Patient positioning should be predicated upon access to the shoulder girdle and upper limb and ease of fluoroscopic imaging. Use of the modified beach chair position will allow for easy manipulation, implant placement, and intraoperative imaging. In these cases, the fluoroscopy unit may be brought in from the head of the bed, allowing the surgeon to stand in the axilla or lateral to the affected shoulder and facilitating both AP and axillary views of the proximal humerus. Alternatively, patients may be positioned supine on a radiolucent table with a bump placed under the ipsilateral pelvis or between the scapulae. With supine positioning, the fluoroscopy unit may be brought in from the ipsilateral or contralateral side of the table. 
Surgical Approach(es)
Again, closed reduction of the proximal humerus fracture is performed using the maneuvers described above. If inadequate realignment is achieved, open reduction may be performed via a limited deltopectoral approach. 
Technique
Following fracture reduction, a longitudinal incision is made along the lateral column of the distal humerus at the level of the superior aspect of the olecranon fossa. Alternatively, medial column or posterior approaches may be utilized, splitting the triceps in the latter situation to gain access to the distal humerus and intramedullary canal above the olecranon fossa. Blunt dissection is performed through the subcutaneous tissues to the level of the distal humeral cortex (Fig. 21-26). Using a drill guide to protect the adjacent soft tissues, a 3.2- or 4.5-mm drill bit is used to create a cortical window in the lateral column; care is made to create this starting hole obliquely from distal-lateral to proximal-medial to facilitate subsequent nail passage. Appropriately sized intramedullary nails (typically 3 to 4 mm in diameter) are then prebent; if both nails are to be passed via a lateral entry point, one nail is bent in the shape of a gentle “C” and the other in the shape of a lazy “S” to allow for some divergence of the nail ends in the proximal fracture fragment. Nails are then passed into the lateral column entry site, through the intramedullary canal of the humerus, across the fracture site, and into the proximal fracture fragment. Typically, the nails must be gently impacted into the proximal humerus, with care to avoid distraction or further displacement at the fracture site. Fracture translation or angulation may be further corrected with nail rotation once the proximal fragment is engaged. Intraoperative fluoroscopy is utilized to confirm fracture alignment, stability, and implant placement. Nails are then cut beneath the skin with the distal ends flush against the metaphyseal flare to allow for subsequent removal but lessen the risk of nail irritation during fracture healing. Wound(s) are then closed, the dressing applied, and the upper extremity placed in sling-and-swathe immobilization (Table 21-18). 
Figure 21-26
Intramedullary fixation.
 
A: Displaced proximal humerus fracture in an adolescent female. B: Blunt spreading is performed via a lateral incision along the distal humeral metaphysis. C: Precontoured flexible intramedullary nails are passed into the medullary canal. D: The implants traverse the fracture site and engage the humeral head. E: Rotation of the nails may be used to improve translation or angulation. F: Implants are cut beneath the skin.
A: Displaced proximal humerus fracture in an adolescent female. B: Blunt spreading is performed via a lateral incision along the distal humeral metaphysis. C: Precontoured flexible intramedullary nails are passed into the medullary canal. D: The implants traverse the fracture site and engage the humeral head. E: Rotation of the nails may be used to improve translation or angulation. F: Implants are cut beneath the skin.
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A: Displaced proximal humerus fracture in an adolescent female. B: Blunt spreading is performed via a lateral incision along the distal humeral metaphysis. C: Precontoured flexible intramedullary nails are passed into the medullary canal. D: The implants traverse the fracture site and engage the humeral head. E: Rotation of the nails may be used to improve translation or angulation. F: Implants are cut beneath the skin.
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Figure 21-26
Intramedullary fixation.
A: Displaced proximal humerus fracture in an adolescent female. B: Blunt spreading is performed via a lateral incision along the distal humeral metaphysis. C: Precontoured flexible intramedullary nails are passed into the medullary canal. D: The implants traverse the fracture site and engage the humeral head. E: Rotation of the nails may be used to improve translation or angulation. F: Implants are cut beneath the skin.
A: Displaced proximal humerus fracture in an adolescent female. B: Blunt spreading is performed via a lateral incision along the distal humeral metaphysis. C: Precontoured flexible intramedullary nails are passed into the medullary canal. D: The implants traverse the fracture site and engage the humeral head. E: Rotation of the nails may be used to improve translation or angulation. F: Implants are cut beneath the skin.
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A: Displaced proximal humerus fracture in an adolescent female. B: Blunt spreading is performed via a lateral incision along the distal humeral metaphysis. C: Precontoured flexible intramedullary nails are passed into the medullary canal. D: The implants traverse the fracture site and engage the humeral head. E: Rotation of the nails may be used to improve translation or angulation. F: Implants are cut beneath the skin.
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X
 
Table 21-18
Intramedullary Fixation of Proximal Humerus Fractures
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Table 21-18
Intramedullary Fixation of Proximal Humerus Fractures
Surgical Steps
  •  
    Closed (or open) fracture reduction
  •  
    Incision along lateral column of distal humerus, at or proximal to olecranon fossa
  •  
    Alternatively, may use additional medial or posterior incisions and entry sites
  •  
    Blunt dissection to lateral humeral cortex
  •  
    Create cortical entry site with drill bit
  •  
    Precontour intramedullary nails
  •  
    Pass nails into intramedullary canal, across fracture site, and into proximal humeral fracture fragment
  •  
    Nail rotation to effectuate additional correction of translation/displacement
  •  
    Fluoroscopic confirmation of alignment and implant placement
  •  
    Bend and cut nails, leaving 2–3 cm flush along metaphyseal flare to allow subsequent removal
  •  
    Sling-and-swathe immobilization
X

Surgical Procedure: Open Reduction Internal Fixation

Preoperative Planning
Open reduction and plate fixation is rarely necessary in the pediatric population, and typically reserved for cases of intra-articular extension, extensive fracture comminution, pathologic injuries, or severely displaced fractures in skeletally mature adolescents. Surgical principles follow established tenets of fracture fixation, with particular attention to preservation of the vascularity to the humeral head and avoidance of iatrogenic neurologic injury. Though a host of anatomically precontoured plates are available, these commercially available implants do not often fit the adolescent patient, and standard small fragment plate-and-screw constructs will suffice. 
Appropriate preoperative planning includes orthogonal radiographic views of the proximal humerus—preferably AP and axillary views—to characterize the fracture pattern and displacement. A careful neurovascular examination to rule out concomitant nerve palsy or vascular injury is imperative (Table 21-19). 
 
Table 21-19
Reduction and Fixation of Proximal Humerus Fractures
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Table 21-19
Reduction and Fixation of Proximal Humerus Fractures
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Modified beach chair position
  •  
    Fluoroscopy location: From head of table
  •  
    Equipment: Appropriately sized small fragment implants or site-specific implants; shoulder retractors if desired
  •  
    Tourniquet (sterile/nonsterile): Not applicable
X
Positioning
Similar to the procedures described above, patient positioning should allow near circumferential access to the shoulder girdle and ease of fluoroscopic imaging. Use of the modified beach chair position will allow for easy manipulation, implant placement, and intraoperative imaging. This semirecumbent position will also facilitate venous drainage and visualization. In these cases, the fluoroscopy unit may be brought in from the head of the bed, allowing the surgeon to stand in the axilla or lateral to the affected shoulder and facilitating both AP and axillary views of the proximal humerus. 
Surgical Approach(es)
A standard deltopectoral approach is typically used, as described above. As this procedure targets the proximal humeral metaphysis and diaphysis, rather than the glenohumeral joint, the incision is often biased distally. The approach is extensile and may be carried distally into an anterolateral or Henry approach to the proximal and middle humerus. Careful subperiosteal elevation of the deltoid and pectoralis major insertions will allow for adequate exposure of the metadiaphyseal humerus. Overzealous lateral retraction is avoided to prevent iatrogenic axillary neurapraxis. Great care should be taken to protect the ascending branch of the anterior humeral circumflex artery, which runs just lateral to the long head of biceps tendon. 
Technique
After appropriate exposure is obtained, the fracture site is identified and cleared of fracture hematoma or any interposed soft tissue. Unlike adults, adolescent proximal humerus fractures tend not to be comminuted, and osteopenia is rare. The biceps tendon is a useful anatomic landmark, as the greater and lesser tuberosities lie lateral and medial to the biceps tendon, respectively. Anatomic fracture reduction may be achieved, and if needed provisional fracture fixation using smooth K-wires or fracture reduction clamps may be obtained. Following fracture realignment, internal fixation using appropriate plate-and-screw constructs is achieved. Careful intraoperative imaging will assist in proper screw placement within the humeral head and avoidance of intra-articular implant penetration. Typically six cortices of fixation into the distal fracture fragment are sufficient. After direct and fluoroscopic confirmation of appropriate alignment and stability, the wound is closed in layers and the affected limb placed in a sling. 
As noted above, avulsion fractures of the lesser tuberosity may occur in adolescents. ORIF is recommended in patients with displaced injuries.140,166,223,436 Similar patient positioning and surgical deltopectoral approach may be utilized. In general, the lesser tuberosity fracture fragment is easily identified, and the attachment of the subscapularis tendon and muscle are preserved. Once fracture site on the proximal humerus is defined and debrided, bioabsorbable suture anchors may be placed in the donor site. Heavy, nonabsorbable sutures are then passed through the undersurface of the lesser tuberosity fracture fragment, exiting superficially. The fracture is then reduced, and the previously passed sutures are tied down completing the repair (Table 21-20). 
 
Table 21-20
Open Reduction and Fixation of Proximal Humerus Fractures
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Table 21-20
Open Reduction and Fixation of Proximal Humerus Fractures
Surgical Steps
  •  
    Exposure via a deltopectoral approach
    •  
      Identification of the biceps tendon
    •  
      Protection of the ascending branch of the anterior humeral circumflex artery and axillary nerve
  •  
    Identify fracture fragments
    •  
      Preserve soft tissue attachments
  •  
    Reduce fracture
    •  
      In cases of intra-articular extension, reduce and fix humeral head fragment first
  •  
    Provisional fixation with K-wires
  •  
    Apply plate-and-screw fixation
  •  
    Layered wound closure
  •  
    Sling immobilization
X

Author's Preferred Treatment of Proximal Humerus Fractures

The majority of proximal humerus fractures in children and adolescents may be successfully treated nonoperatively. In infants with birth-related fractures, immobilization with a stockinette or pinning of the sleeve to the trunk is simple and effective. Radiographic assessment of healing is performed at 4 to 6 weeks of age; immobilization is discontinued with evidence of clinical and radiographic healing. 
In children and adolescents with closed proximal humerus fractures in acceptable deformity (Table 21-13), simple sling immobilization is utilized. Serial radiographs are obtained to confirm adequate alignment. Bony union is typically obtained in 4 to 6 weeks, though clinically improvement and pain relief typically precedes radiographic healing. After confirmation of clinical and radiographic healing, range of motion and strengthening is advanced as tolerated. 
In older children and adolescents with unacceptable radiographic alignment, initial closed reduction is performed with conscious sedation or general anesthesia. Careful radiographic evaluation of bony alignment and assessment of fracture stability is performed. Given the data suggesting that late displacement is a frequent occurrence following closed manipulation alone of severely displaced proximal humerus fractures in adolescents, a low threshold exists for fracture stabilization. For unstable injuries with deformity beyond what is anticipated to remodel with continued skeletal growth, fracture fixation is performed. Physeal fractures are treated with closed reduction and percutaneous smooth pin fixation; typically two retrograde pins will suffice. Pins may be bent and cut outside the skin, which facilitates subsequent removal and obviates the need for additional anesthesia. If pins are left outside the skin, patients are immobilized with sling-and-swathe to prevent pin migration or pin-tract complications. In patients with metaphyseal fractures—in which there is still some metaphyseal bone on the proximal fracture fragment—intramedullary nailing is preferred (Fig. 21-27). Using the technique described above, appropriate flexible titanium intramedullary implants are prebent and inserted via a lateral entry point. Intramedullary nails are cut and left beneath the skin; attention to the trajectory and location of nail entry will allow the ends of the nails to lie flush against the metaphyseal flare of the distal humerus, avoiding unnecessary soft tissue irritation. Patients are placed in sling-and-swathe immobilization. 
Figure 21-27
Intramedullary fixation of a proximal humeral metaphyseal fracture.
 
A: Preoperative radiograph depicting displacement and shortening. B: Postoperative radiographs depict bony healing. C: Radiograph after staged implant removal.
A: Preoperative radiograph depicting displacement and shortening. B: Postoperative radiographs depict bony healing. C: Radiograph after staged implant removal.
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A: Preoperative radiograph depicting displacement and shortening. B: Postoperative radiographs depict bony healing. C: Radiograph after staged implant removal.
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Figure 21-27
Intramedullary fixation of a proximal humeral metaphyseal fracture.
A: Preoperative radiograph depicting displacement and shortening. B: Postoperative radiographs depict bony healing. C: Radiograph after staged implant removal.
A: Preoperative radiograph depicting displacement and shortening. B: Postoperative radiographs depict bony healing. C: Radiograph after staged implant removal.
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A: Preoperative radiograph depicting displacement and shortening. B: Postoperative radiographs depict bony healing. C: Radiograph after staged implant removal.
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X
In cases of open fractures with adequate soft tissue coverage, open reduction and either pin or intramedullary nail fixation is performed after thorough irrigation and debridement of the open wound. In cases associated with excessive fracture comminution, vascular insufficiency, or severe soft tissue loss, internal fixation with plate-and-screw constructs are considered. Open reduction is similarly performed in closed injuries in which an acceptable reduction may not be achieved with manipulation, typically because of interposed soft tissue (Fig. 21-28).16,89,111,251,439 
Figure 21-28
Proposed treatment algorithm for humeral shaft fracture.
Flynn-ch021-image028.png
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Postoperative Care

Patients receiving nonoperative treatment of proximal humeral fractures are followed weekly with radiographs to ensure confirm maintenance of alignment. Once there is evidence of clinical and radiographic healing, gentle shoulder pendulum and elbow range-of-motion exercises are begun. Immobilization is typically discontinued after 4 to 6 weeks. Sports participation is restricted until there is return of motion and strength, and patients/families are counseled regarding the risk of refracture. 
Following surgical reduction and stabilization, sling immobilization is usually sufficient and continued until radiographic healing. With plate fixation, gentle pendulum and elbow range-of-motion exercises may be initiated once adequate comfort is achieved. In cases of intramedullary nail fixation, implants are typically removed at 6 months postoperatively. 

Potential Pitfalls and Preventative Measures

While the principles of treatment are seemingly straightforward, proximal humerus fractures present a number of challenges and potential pitfalls, particularly in the adolescent with severe displacement. First, assessment of what constitutes “acceptable deformity” can be challenging in the older pediatric patient population. Though guidelines exist on what constitutes adequate bony alignment, these recommendations are based upon historical retrospective case series and expert opinion. The decision-making process is further challenged by changing patient functional demands and evolving parent/family expectations. Careful characterization of radiographic alignment in the context of patient demands is needed to ensure optimal outcomes. For example, less than 40 degrees of varus may be deemed permissible, but might lead to limitations in abduction unacceptable to an overhead athlete. As in all pediatric orthopedics, care should be individualized to account for these considerations. 
Second, when indicated, closed reduction of severely displaced proximal humerus fractures is challenging. Awareness of the deforming muscular forces, adequate analgesia or anesthesia, and appropriate fluoroscopic imaging will facilitate successful closed manipulations. In cases where acceptable reduction cannot be achieved, open reduction should be pursued, and any interposed periosteum or soft tissue extricated from the fracture site. 
In addition, loss of reduction and further fracture displacement is common in older adolescents with severely displaced injuries. Careful assessment of fracture stability at the time of reduction and with serial radiographs is recommended. A low threshold should exist for percutaneous pin fixation or intramedullary nailing of severely displaced fractures to maintain bony alignment. 
Furthermore, there are a number of potential pitfalls commonly encountered during surgical stabilization. Judicious percutaneous pin placement is imperative to avoid iatrogenic axillary nerve injury or inadvertent intra-articular penetration of the glenohumeral joint. Given the frequency with which pins cause soft tissue or infectious complications, adequate immobilization of the affected limb and timely pin removal are needed. Conversely, if intramedullary devices are used, appropriate entry point(s) and trajectory will prevent soft tissue irritation or migration of the implants (Table 21-21). 
 
Table 21-21
Proximal Humerus Fractures
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Table 21-21
Proximal Humerus Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Failure to recognize fracture pattern Appropriate orthogonal imaging
Avoid varus and apex anterior angulation
Individualized treatment
Difficulty with closed reduction Understand, reverse deforming muscle actions
Adequate analgesia/anesthesia
Orthogonal fluoroscopic imaging
Transition to open reduction if interposed soft tissue
Loss of alignment after reduction Routine fracture fixation after closed reduction of severely displaced injuries in adolescents
Preset pins into the distal fracture fragment first, then perform the reduction, then pass the pins across the fracture site with the shoulder abducted and/or externally rotated
Implant-related complications Correct insertion of percutaneous pins
Sling-and-swathe immobilization if percutaneous pins left out of skin
X

Treatment-specific Outcomes

Multiple published reports have suggested that surgical reduction and stabilization of displaced proximal humerus fractures is safe and effective in obtaining radiographic healing with improved bony alignment and minimal complications.28,70,111,229 In patients with Neer–Horwitz grade III and IV injuries, improvement to grade I and II displacement may be expected.111,198 
Kohler and Trillaud229 have previously reported the clinical and radiographic outcomes of 52 patients at a mean of 5 years following proximal humerus fractures. Clinical results were “good” or “very good” in all cases, with little correlation to longer-term radiographic parameters. While the authors suggest that surgical intervention offers no advantages over nonoperative treatment, it should be noted that all surgical patients in their series underwent formal ORIF, with fixation including staples, pins, screws, and plate-and-screw constructs. 
Beringer et al.28 similarly advocated a nonoperative approach in their report of 48 patients with displaced proximal humerus fractures. All patients with longer-term follow-up reported no activity restrictions or limitations, and functional results did not correlate with radiographic findings. As three of the nine patients treated surgically had complications, the authors recommended nonsurgical treatment in the majority of cases. 
Dobbs et al.111 published their series of 29 patients treated for Neer–Horwitz grade III and IV fractures, of which 25 were treated with closed versus open reduction and pin or screw fixation. The majority of patients were greater than 15 years of age. Postoperatively, all patients improved to a grade I or II deformity, and there were no surgical complications. At a mean follow-up of 4 years, normal or near-normal motion and strength was seen in all patients. These findings support the efficacy and safety of surgical intervention for severely displaced injuries in older patients. 
Chee et al.70 presented their series of 14 patients, mean age 13 years, treated with single intramedullary flexible nail fixation for displaced proximal humerus fractures. All patients had full range of shoulder motion at final follow-up, supporting the authors' assertion that intramedullary fixation is effective in select patients. 
To date, however, much of the available data comes from retrospective case series or limited comparative cohort studies, heavily weighted toward radiographic and/or physician-derived results. Little patient-derived functional outcomes data is available, and future prospective investigation assessing long-term results using validated outcomes instruments is needed to provide better insight into optimal management and potential adverse sequelae. 

Management of Expected Adverse Outcomes and Unexpected Complications Related to Proximal Humerus Fractures

While uncommon, complications of proximal humerus fractures may have considerable effect on shoulder girdle and upper limb function. Neurologic injury of the brachial plexus or peripheral nerves may be seen, particularly in severely displaced valgus injuries and the rare fracture-dislocation.10,112,199,432,438 Most nerve palsies are diagnosed at the time of injury and represent neurapraxic injuries rather than true nerve transections. In general, these neurologic deficits will resolve spontaneously over 6 to 12 months but may be associated with neurogenic pain in the affected limb during recovery.199 In patients with persistent nerve deficits without clinical signs of spontaneous recovery in the expected period of time, electrodiagnostic studies (electromyography and nerve conduction velocities) may be considered to characterize the location and severity of neurologic deficit. In rare situations, exploration with neurolysis, nerve repair, nerve grafting, or nerve transfers (i.e., radial motor branch of long head of triceps to axillary motor) may be necessary.10,79 In chronic or late-presenting situations, salvage procedures such as tendon transfers or proximal humeral osteotomies may be considered to improve shoulder and upper limb function.84,181,222,335 
Vascular insufficiency is a rare but potentially devastating complication of proximal humerus fractures. Treatment is predicated on prompt reduction, fracture stabilization, and reassessment of vascularity. In cases of persistent distal ischemia, appropriate exploration and vascular repair or reconstruction is needed.199 
Humerus varus is another potential complication of proximal humerus fractures in children and adolescents. Humerus varus is characterized by a humeral neck-shaft angle of less than 140 degrees, a greater tuberosity cephalad to the superior aspect of the humeral head, and a reduced distance between the articular surface of the humeral head and the lateral cortex of the humerus.228 The resultant varus angulation and prominent greater tuberosity leads to limitations in shoulder forward flexion and lateral abduction. Potential etiologies include varus malunion as well as partial physeal arrest following proximal humeral physeal fracture. In cases of functionally limiting humerus varus, corrective osteotomy to restore more anatomic proximal humeral morphology may be performed (Fig. 21-23).119,146,242,268,404,428 
Upper limb length discrepancy may similarly be seen as a late sequela of physeal fractures.22,95,369 Though more commonly reported in patients following operative reduction, physeal disturbance is likely due to the trauma associated with the initial injury rather than surgical intervention. Furthermore, prior reports have suggested that limb length discrepancy is not correlated with the quality of initial fracture reduction.22,308 Limb length inequality has similarly been reported in patients with pathologic fractures of the proximal humerus through unicameral bone cysts.180,298,314 In patients with functional limitations or predicted upper limb length discrepancies of greater than 6 cm at skeletal maturity, limb-lengthening procedures may be considered.187,248,332 
Osteonecrosis of the humeral head is much less common in children than adults.278 In setting of confirmed osteonecrosis, revascularization and humeral head remodeling may be seen in skeletally immature patients, leading to satisfactory clinical outcomes.449 
Finally, hypertrophic scar formation is commonly seen after surgical treatment of proximal humerus fractures, particularly following open reduction via a deltopectoral approach. Prior investigation has suggested this aesthetic difference may be psychologically troubling to adolescent patients.131,145 For this reason, alternative, more aesthetic incisions in the axilla have been proposed.157 Patients and families should be counseled about the possibility of hypertrophic scar formation from deltopectoral incisions or percutaneous pin sites prior to surgical intervention (Table 21-22). 
 
Table 21-22
Proximal Humerus Fractures
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Table 21-22
Proximal Humerus Fractures
Common Adverse Outcomes and Complications
Neurovascular injury
Malunion/humerus varus
Upper limb length discrepancy
Osteonecrosis
Hypertrophic scar formation
X

Summary, Controversies, and Future Directions Related to Proximal Humerus Fractures

In summary, the majority of proximal humeral fractures may be effectively treated nonoperatively. In older adolescent patients with greater angulation and displacement, reduction and surgical stabilization is safe and effective in restoring radiographic alignment and shoulder motion. Future prospective, comparative investigation is needed to determine the criteria for reduction and fixation in older children and adolescents and characterize the patient-derived functional outcomes of these injuries in the long term. 

Introduction to Humerus Shaft Fractures

The humeral diaphysis is the location of 20% or less of all pediatric humerus fractures and 5% or less of all childhood skeletal injuries.72,257,358 The incidence is estimated to be between 12 and 30 per 100,000 per year, and more recent epidemiologic information from the United States suggests that this incidence has remained relatively constant despite population changes.221,240,464 There is a bimodal distribution of ages of children who sustain humeral diaphyseal fractures, with the greatest frequency seen in infants and adolescents.23 

Assessment of Humerus Shaft Fractures

Mechanisms of Injury for Humerus Shaft Fractures

Humeral shaft fractures may be due to a variety of injury mechanisms, each with its own set of clinical considerations. 
Birth-related trauma is a frequent cause of humeral diaphyseal injury, with a reported incidence between 0.035% and 0.34%.56,272 Macrosomia, breech presentation, and/or difficult delivery are thought to be potential risk factors. The humerus is at particular risk in situations where the upper limb is abducted above the newborn's head and must be delivered inferiorly after version and extraction.272 Similarly, humerus fractures may occur in cases of shoulder dystocia with rotational maneuvers or posterior arm delivery.253 Cesarean section delivery is not necessarily protective, and any forceful extraction may impart enough energy to cause a humerus fracture.29,57,351 
Nonaccidental trauma may also manifest as humerus fracture in a child. Indeed, 12% of all fractures and up to 60% of new fractures stemming from nonaccidental trauma affect the humerus.266,390 While child abuse must be considered within the differential diagnosis of humeral diaphyseal fractures—particularly in children less than 3 years of age—only a minority of humeral shaft injuries in children are due to nonaccidental trauma.390 
The most common mechanism of injury is direct or indirect force imparted upon the upper limb in the older child or adolescent. Direct blows to the brachium, falls onto an outstretched upper limb, motor vehicle collisions, and sports-related trauma may all result in diaphyseal fractures. Indeed, humeral shaft fractures have even been noted from throwing and other overuse activities, because of the rotational forces imparted upon the humerus during the throwing motion.4,141,153,177,260,320,454 

Associated Injuries with Humerus Shaft Fractures

Radial nerve palsies are commonly associated with humeral diaphyseal fractures and raise a number of treatment considerations and controversies.5,23,68,90,94,117,138,172,184,270,273,328,338,357,391,429 Owing to the anatomic proximity of the radial nerve to the mid- and distal humerus, the nerve may be contused, stretched, kinked, or rarely transected with the initial injury and/or fracture displacement.433 Furthermore, a delayed palsy may occur due to compression secondary to scar tissue, fracture callus, and even bone formation. It has been estimated that up to 20% of adult and 5% of pediatric humeral diaphyseal fractures will have associated radial nerve palsies.36,138,270,280,337,386,440 
Clinically, radial nerve palsies may be categorized into the time of presentation. Primary radial nerve palsies occur at the time of injury and are clinically apparent at first evaluation. Secondary radial nerve palsies refer to deficits presumably sustained at the time of fracture reduction or manipulation, in patients in whom radial nerve function was initially intact. 
Most published information suggests that the potential for spontaneous nerve recovery is high, with 78% to 100% of patients regaining radial nerve function with observation alone.6,36,41,42,50,108,117,138,147,262,328,337,338,371,386,440 Indeed, in cases in which the primary radial nerve palsies were treated with immediate or early exploration, the vast majority of the time the nerve is found to be intact, though contused or tented over the displaced fracture fragments (Fig. 21-29).151,270,328,386,388,405,440 In children, it has been hypothesized that the thicker periosteum may confer a protective effect on the radial nerve, reducing the risk of traumatic laceration or incarceration within the fracture site. 
Figure 21-29
 
A: AP radiograph of a 15-year-old female with an open humeral diaphyseal fracture and radial nerve palsy. B: Intraoperative radiograph depicting exposure via a lateral approach. The kinked and contused radial nerve (long arrow) displaced by the proximal fracture fragment (short arrow). C: After irrigation, debridement, and plate fixation of the fracture, the nerve can be seen decompressed overlying the implant. D: Postoperative radiograph depicting bony healing and implant placement.
A: AP radiograph of a 15-year-old female with an open humeral diaphyseal fracture and radial nerve palsy. B: Intraoperative radiograph depicting exposure via a lateral approach. The kinked and contused radial nerve (long arrow) displaced by the proximal fracture fragment (short arrow). C: After irrigation, debridement, and plate fixation of the fracture, the nerve can be seen decompressed overlying the implant. D: Postoperative radiograph depicting bony healing and implant placement.
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A: AP radiograph of a 15-year-old female with an open humeral diaphyseal fracture and radial nerve palsy. B: Intraoperative radiograph depicting exposure via a lateral approach. The kinked and contused radial nerve (long arrow) displaced by the proximal fracture fragment (short arrow). C: After irrigation, debridement, and plate fixation of the fracture, the nerve can be seen decompressed overlying the implant. D: Postoperative radiograph depicting bony healing and implant placement.
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Figure 21-29
A: AP radiograph of a 15-year-old female with an open humeral diaphyseal fracture and radial nerve palsy. B: Intraoperative radiograph depicting exposure via a lateral approach. The kinked and contused radial nerve (long arrow) displaced by the proximal fracture fragment (short arrow). C: After irrigation, debridement, and plate fixation of the fracture, the nerve can be seen decompressed overlying the implant. D: Postoperative radiograph depicting bony healing and implant placement.
A: AP radiograph of a 15-year-old female with an open humeral diaphyseal fracture and radial nerve palsy. B: Intraoperative radiograph depicting exposure via a lateral approach. The kinked and contused radial nerve (long arrow) displaced by the proximal fracture fragment (short arrow). C: After irrigation, debridement, and plate fixation of the fracture, the nerve can be seen decompressed overlying the implant. D: Postoperative radiograph depicting bony healing and implant placement.
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A: AP radiograph of a 15-year-old female with an open humeral diaphyseal fracture and radial nerve palsy. B: Intraoperative radiograph depicting exposure via a lateral approach. The kinked and contused radial nerve (long arrow) displaced by the proximal fracture fragment (short arrow). C: After irrigation, debridement, and plate fixation of the fracture, the nerve can be seen decompressed overlying the implant. D: Postoperative radiograph depicting bony healing and implant placement.
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Radial nerve exploration should be performed in instances of open humeral diaphyseal fractures in which surgical debridement and stabilization is to be performed. If a true radial nerve laceration is encountered, options include tagging the nerve ends for subsequent identification and repair versus immediate primary neurorrhaphy.129,415,422 Given the distance to reinnervation from a high radial nerve palsy, earlier repair allows for the best anatomic and functional potential.31 
In cases of primary radial nerve palsy, recommendations have been made for observation and exploration at 8 weeks to 6 months if there is failure of adequate recovery.5,6,94,108,186,280,337,338,391 While these time-based guidelines are helpful, each patient must be considered individually, adhering to fundamental principles.32 In general, if there is failure of adequate recovery after the anticipated time—based upon the distance from the injury to distal points of reinnervation—surgical exploration should be considered. Prior physiologic studies have determined that following wallerian degeneration, nerve growth will occur at a rate on an average of 1 mm per day.379,380,414,415 For high radial nerve palsies, spontaneous resolution should entail an advancing Tinel sign, with sequential return of radial wrist extensors, central wrist extensors, digital extensors, and thumb extensors. In cases of late exploration where radial nerve lacerations are encountered, sural nerve grafting may be performed, with anticipation of functional return.31,128,319,434 
There continues to be controversy regarding the optimal management of secondary radial nerve palsy. If nerve function is lost after fracture manipulation, observation alone is still supported by published data suggesting that spontaneous recovery will occur in the majority of patients.36,42,108,138,236,386 Others advocate early exploration because of liability concerns and late extraction from fracture callus is much more difficult than early decompression. If radial nerve function is lost during the later period of fracture healing, careful consideration should be made regarding whether the nerve is entrapped within scar tissue, fracture callus, or bone.116,468 Radiographs may depict an oval lucency corresponding to the bony foramen through which the nerve is running, the so-called Matev sign.113,196,441 In these situations, surgical exploration and decompression should be performed. 

Signs and Symptoms of Humerus Shaft Fractures

Clinical signs and symptoms will vary considerably depending upon the patient age and mechanism of injury. 
In infants in whom a birth-related humerus fracture is suspected, a careful pre- and perinatal history should be obtained, specifically evaluating for macrosomia, prolonged or difficult labor and delivery, and history of shoulder dystocia. Additional historical information—such as whether the newborn will nurse from each breast—may guide the care provider to the correct diagnosis. Clinically, these infants will exhibit pseudoparalysis of the affected limb, holding or splinting the arm against the side. As distal neurologic function is intact, the infant will spontaneously grasp and move the digits and wrist. There will be reproducible tenderness, motion, and crepitus at the fracture site, though often little swelling or ecchymosis. 
In older children who sustain traumatic or sports-related fractures, a careful history will provide insight into the mechanism of injury and any associated trauma. Details regarding the position of the upper limb, direction of forces imparted, and energy of injury will aid in clinical diagnosis. Patients will typically present with pain, swelling, ecchymosis, and guarding of the affected limb, with or without obvious deformity. The arm is typically held tightly against the body as the patient guards and protects the injured limb. Physical examination should include careful inspection of the overlying skin to assess for open wounds, ecchymosis, and skin tenting or dimpling. A thorough neurovascular examination is critical, particularly to assess potential injury of the radial nerve.41,42,184,312,319,337 

Imaging and Other Diagnostic Studies for Humerus Shaft Fractures

Plain radiographs of the humerus will confirm the diagnosis and should be performed in all cases of suspected humeral diaphyseal fractures (Figs. 21-30 and 21-31). Orthogonal views should be obtained, as nondisplaced or incomplete greenstick fractures may occur in children. Appropriate lateral radiographs will demonstrate overlap or superimposition of the posterior supracondylar ridges of the medial and lateral epicondyles.151 
Figure 21-30
 
A, B: Radiographs depicting a humeral diaphyseal fracture in a 4-day-old infant with displacement and angulation. C, D: By 3 months of age, there is excellent bony healing and early remodeling.
A, B: Radiographs depicting a humeral diaphyseal fracture in a 4-day-old infant with displacement and angulation. C, D: By 3 months of age, there is excellent bony healing and early remodeling.
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Figure 21-30
A, B: Radiographs depicting a humeral diaphyseal fracture in a 4-day-old infant with displacement and angulation. C, D: By 3 months of age, there is excellent bony healing and early remodeling.
A, B: Radiographs depicting a humeral diaphyseal fracture in a 4-day-old infant with displacement and angulation. C, D: By 3 months of age, there is excellent bony healing and early remodeling.
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Figure 21-31
 
A: AP radiograph of a minimally displaced humeral diaphyseal fracture in a 13-year-old male. B: Radiograph in fracture brace, demonstrating maintenance of alignment.
A: AP radiograph of a minimally displaced humeral diaphyseal fracture in a 13-year-old male. B: Radiograph in fracture brace, demonstrating maintenance of alignment.
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Figure 21-31
A: AP radiograph of a minimally displaced humeral diaphyseal fracture in a 13-year-old male. B: Radiograph in fracture brace, demonstrating maintenance of alignment.
A: AP radiograph of a minimally displaced humeral diaphyseal fracture in a 13-year-old male. B: Radiograph in fracture brace, demonstrating maintenance of alignment.
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In addition to confirming the diagnosis and characterizing its anatomic location and pattern, radiographs should be inspected for associated lesions to evaluate for possible pathologic fractures.323,410,421 The humerus is a common site for both benign and malignant lesions in skeletally immature patients, and care should be taken to identify an associated condition. 
“Floating elbow” injuries may occur, particularly in the setting of higher-energy mechanisms.409 In patients with ipsilateral wrist or forearm pain or swelling, radiographic evaluation of the elbow and forearm will allow for diagnosis of these associated injuries. 
Finally, in cases of suspected nonaccidental trauma, a skeletal survey and bone scan may be performed to evaluate for the presence of other fractures at various stages of healing. 

Classification of Humerus Shaft Fractures

Classification of humeral diaphyseal fractures remains largely descriptive. Anatomic location, fracture pattern, direction of displacement and/or angulation, and the presence of associated soft tissue or ipsilateral skeletal injuries are used. While a classification system has been proposed by the Association for Study of Internal Fixation for humeral shaft fractures in adults, this has not been universally applied to the pediatric patient population, and questions persist over its interobserver reliability and clinical utility.213,303 

Pathoanatomy and Applied Anatomy Relating to Humerus Shaft Fractures

While the humerus is a long, tubular bone, a number of anatomic features are worthy of note. First, the middiaphyseal region is triangular in cross section and narrower than the adjacent proximal and distal metaphyseal regions. In children, the humerus is enveloped in thick periosteum and has a rich vascular supply; the primary nutrient artery enters at the middiaphyseal level, though abundant accessory vessels supply the humeral shaft anteriorly and posteriorly.59,139,151 
The deltoid tuberosity serves as the insertion of the deltoid and is located in the middiaphysis. The latissimus dorsi and teres major insert on the proximal aspect of the humerus, just medial to the bicipital groove. Conversely, the pectoralis major inserts along the anterior humerus lateral and distal to the bicipital groove. The coracobrachialis arises from the coracoid process and inserts along the middle third–distal third junction anteromedially. Distal and posterior to the deltoid tuberosity lies the so-called spiral groove, adjacent to which runs the radial nerve and from which the most proximal fibers of the brachialis originate. Similar to fractures of the proximal humerus, awareness of these muscle and soft tissue relationships help explain typical fracture displacement patterns and guide reduction maneuvers. 
The anatomic path of the radial nerve deserves special attention, given the frequency with which the nerve is injured with humeral diaphyseal fractures.456 While much of the published literature is derived from cadaveric data in adults, a few principles may be applied to the pediatric population. First, as the radial nerve arises from the posterior cord of the brachial plexus, it passes through the triangular interval, bounded by the teres major superiorly and the lateral and long heads of the triceps medially and laterally. The radial nerve is typically accompanied by the profunda brachii artery as it passes through the upper arm. The nerve travels along the spiral groove, but is typically not in direct contact with the posterior humeral cortex; instead, it is separated from the bone by muscular fibers.58,456 In general, the radial nerve is located directly posterior to the humeral diaphysis at the level of the deltoid tuberosity, a useful anatomic relationship in cases of surgical fracture treatment. The radial nerve continues distally and laterally, where it pierces the lateral intermuscular septum to enter the anterior compartment. Distally at the elbow, it may be found reliably in the brachialis–brachioradialis intermuscular interval. 
The ulnar nerve runs in the medial aspect of the posterior compartment and does not give off any motor branches above the elbow. The median nerve travels just medial to the brachial artery in the distal half of the brachium. 

Treatment Options for Humerus Shaft Fractures

Nonoperative Treatment of Humerus Shaft Fractures

Indications/Contraindications (Table 21-23)

 
Table 21-23
Humerus Shaft Fractures
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Table 21-23
Humerus Shaft Fractures
Nonoperative Treatment
Indications Relative Contraindications
Birth-related fractures Open fractures
Diaphyseal fractures with acceptable alignment Associated vascular injury
Stress fractures
Benign pathologic fractures
Diaphyseal fractures with unacceptable alignment
X
The vast majority of humeral diaphyseal fractures in children are amenable to nonoperative care.103 As the upper limb is not weight bearing, anatomic alignment of the humerus is not necessary for functional restoration. Furthermore, shoulder motion, elbow flexion–extension, and forearm rotation may effectively compensate for mild-to-moderate humeral deformity. Finally, there is considerable remodeling potential for humeral deformity in skeletally immature patients; indeed, even up to 30 degrees may remodel in the adolescent population.94 For these reasons, up to 20 to 30 degrees of varus, 20 degrees of apex anterior angulation, 15 degrees of internal rotation, and bayonet apposition with 1 to 2 cm of shortening is deemed acceptable.94,225,347 As with all guidelines, these parameters for “acceptable deformity” must be taken into their historical context, and individualized decisions should be made regarding the function demands and treatment goals of each patient. 
Birth-related fractures of the humeral diaphysis heal robustly and demonstrate profound remodeling potential. Indeed, 50% or greater remodeling may be seen within 1 to 2 years.30 For this reason, simple immobilization to maximize comfort is sufficient, and no effort to achieve or maintain anatomic alignment is necessary.183,197,394 A host of different treatment options have been proposed—ranging from sling-and-swathe, splinting, casting, traction, or simply pinning the sleeve of the affected arm to the body.12,183,197,394 Concerns regarding immobilization and bony healing in excessive internal rotation may be addressed by immobilization of the upper extremity with elbow extension. This is particularly relevant in patients with concomitant brachial plexus birth palsies, in whom internal rotation contractures and external rotation weakness of the shoulder are common.162,232,450 
Stress fractures of the humerus do occur and almost universally heal with appropriate rest, time, and activity modification.4,106,141,260,348,454 Failure to allow for symptom-free healing may result in fracture completion and displacement.4 

Techniques

Sling-and-swath immobilization is simple, safe, and effective for incomplete and minimally displaced fractures.347 It may also be utilized for displaced fractures, though does not control apex anterior or varus angulation well, particularly in active and/or obese patients.173,347,406 While the weight of the upper limb may be well supported, some patients find sling-and-swathe immobilization uncomfortable because of persistent motion at the fracture site. 

Techniques: Coaptation Splinting

Coaptation splinting (also referred to as U-plaster or sugartong splinting) has also been advocated in the treatment of humeral diaphyseal fractures.38,471 The application of a coaptation splint is straightforward and is similar to that of sugartong splinting of the forearm (Fig. 21-32). A plaster splint, corresponding to the width of the brachium, is applied in a well-padded fashion from the acromion superolaterally, around the olecranon distally, and back up to the level of the axilla medially. The splint may be gently molded to the upper arm and secured in place with an elastic bandage or wrap. Efforts should be made to advance the superolateral extension of the splint to the level of the neck, in efforts prevent distal migration with gravity.387 Others have recommended application of benzoin to the skin prior to splint placement and the use of a collar-and-cuff to prevent slippage.183 Coaptation splinting has proven effective in children, and is particularly useful in the acute setting as the plaster slab may be molded comfortably to the swollen limb.94,226 However, as the initial swelling subsides, refitting or transitioning to other methods of immobilization may be needed. Furthermore, coaptation splinting is not as effective as other forms of immobilization at effectuating or maintaining reduction in cases of severe initial displacement.39,183 
Figure 21-32
Coaptation splints with collar and cuff.
 
A: The material used for a sugartong arm splint is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same width but 4 in longer than the splint. B: The plaster splint is applied to the arm from the axilla up to the tip of the acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff sling.
A: The material used for a sugartong arm splint is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same width but 4 in longer than the splint. B: The plaster splint is applied to the arm from the axilla up to the tip of the acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff sling.
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A: The material used for a sugartong arm splint is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same width but 4 in longer than the splint. B: The plaster splint is applied to the arm from the axilla up to the tip of the acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff sling.
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Figure 21-32
Coaptation splints with collar and cuff.
A: The material used for a sugartong arm splint is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same width but 4 in longer than the splint. B: The plaster splint is applied to the arm from the axilla up to the tip of the acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff sling.
A: The material used for a sugartong arm splint is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same width but 4 in longer than the splint. B: The plaster splint is applied to the arm from the axilla up to the tip of the acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff sling.
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A: The material used for a sugartong arm splint is two pieces of cast padding rolled out to the length of the plaster-of-paris splint and applied to each side of the splint after it is wet. The splint is then brought into the tubular stockinette of the same width but 4 in longer than the splint. B: The plaster splint is applied to the arm from the axilla up to the tip of the acromion. C: As the plaster is setting, the splint is molded to the arm. An elastic bandage holds the splint in place. D: Stockinette is applied and attached to the wrist to form a collar-and-cuff sling.
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Techniques: Traction

Both overhead and side-arm traction have been described for the treatment of humeral diaphyseal fractures.183,195,437 Skin traction may be applied to the elbow, forearm, or hand. Alternatively, skeletal traction via an olecranon wingnut or transolecranon traction pin may be utilized.15,27 Excessive or prolonged traction includes nonunion and elbow dislocation.174,178 At present, because of patient and family demands, economic pressures, and wealth of alternative treatment options, the use of traction remains primarily of historic importance and is rarely utilized. 

Techniques: Hanging Casting

Hanging arm casts utilize both immobilization and gravity to impart stability and longitudinal traction to humerus fractures.53 Long above-elbow casts are applied to the affected limb and supported by a sling or collar-and-cuff. Adjustments in sling/cuff placement may allow for correction of coronal and sagittal plane deformity, though rotational alignment is poorly controlled. While reported results demonstrate efficacy with this technique, compliance may be limited due to pain and difficulty maintaining an upright position, particularly in very young patients.412,461 Furthermore, concerns regarding shoulder and elbow stiffness and internal rotation contractures persist.14,78,352 

Techniques: Functional Bracing

First described by Sarmiento et al.374 in 1977, functional bracing of humeral diaphyseal fractures has been increasingly used in both children and adults.17,24,65,161,252,306,389,446,447,469 In general, these functional braces confer a number of advantages over other nonoperative treatment options. In addition to providing external support via their clamshell design, when properly applied functional braces may effectuate and maintain fracture reduction due to the hydraulic effect to the surrounding soft tissues (Fig. 21-31). Furthermore, functional braces allow for elbow motion, minimizing the risk of late elbow contractures. While limited comparative information is available, there is data to suggest that functional bracing is superior to coaptation splinting and equally effective as locked intramedullary nailing in appropriately selected patients.389,447 
Prefabricated or custom-fit functional braces are used early in the course of treatment. Many patients will not tolerate functional bracing immediately, and are temporarily supported in a sling-and-swathe or coaptation splint until the initial swelling subsides. Serial clinical visits and radiographic assessment are needed to ensure adequate brace fit and maintenance of radiographic alignment. Functional braces may even be utilized for comminuted extra-articular fractures of the distal third of the humerus, though occasionally brace extensions may need to assist in coronal plane control.211,373 By design, functional braces for humerus fractures are not as effective in controlling apex anterior angulation, nor are they meant to support weight bearing of the affected upper limb. 

Operative Treatment of Humerus Shaft Fractures

Indications/Contraindications

In general, indications for surgical treatment of humeral diaphyseal fractures include open fractures, fractures with vascular injury, floating elbow injuries (Fig. 21-33) and failure to achieve adequate alignment with nonoperative means. In addition, multitrauma and secondary radial nerve palsies (i.e., those occurring after closed fracture manipulation in patients in whom the radial nerve was initially intact) are deemed by many as relative indications for surgical exploration and fracture fixation. A host of options exist for surgical fracture fixation, including ORIF using plate-and-screw constructs, intramedullary nailing, and external fixation.104,175,324 
Figure 21-33
Floating elbow injury.
 
A: AP radiograph depicting an open humeral diaphyseal fracture in a 10-year-old female. B: An ipsilateral radius fracture is also seen, consistent with a floating elbow injury. C: Postoperative radiograph after open irrigation and plate fixation of the humeral fracture. The radius fracture was also stabilized with internal fixation.
A: AP radiograph depicting an open humeral diaphyseal fracture in a 10-year-old female. B: An ipsilateral radius fracture is also seen, consistent with a floating elbow injury. C: Postoperative radiograph after open irrigation and plate fixation of the humeral fracture. The radius fracture was also stabilized with internal fixation.
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Figure 21-33
Floating elbow injury.
A: AP radiograph depicting an open humeral diaphyseal fracture in a 10-year-old female. B: An ipsilateral radius fracture is also seen, consistent with a floating elbow injury. C: Postoperative radiograph after open irrigation and plate fixation of the humeral fracture. The radius fracture was also stabilized with internal fixation.
A: AP radiograph depicting an open humeral diaphyseal fracture in a 10-year-old female. B: An ipsilateral radius fracture is also seen, consistent with a floating elbow injury. C: Postoperative radiograph after open irrigation and plate fixation of the humeral fracture. The radius fracture was also stabilized with internal fixation.
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Surgical Procedure: Open Reduction Internal Fixation

Preoperative Planning
Preoperative planning for open reduction and plate-and-screw fixation includes appropriate AP and lateral radiographs of the humerus to assess fracture location, pattern, and displacement. The appropriate-sized implants should be determined in advance. While broad 4.5-mm dynamic compression plates are commonly utilized in adults, smaller 3.5 mm or semitubular plates are often used and sufficient for fixation of humeral diaphyseal fractures in children and adolescents, given the smaller size of the bone.176,213,363 Furthermore, careful preoperative evaluation should be made to document neurovascular status, given the known risks of traumatic and iatrogenic radial nerve palsy associated with humeral diaphyseal fractures (Table 21-24). 
 
Table 21-24
ORIF of Humerus Shaft Fractures
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Table 21-24
ORIF of Humerus Shaft Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent table or regular table with radiolucent hand table
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: From head of table as needed
  •  
    Equipment: 4.5 mm, 3.5 mm, or semitubular plates and screws
  •  
    Tourniquet (sterile/nonsterile): Sterile, if needed
X
Positioning
Patient positioning is dependent in part on the planned surgical approach. In most instances, supine positioning is sufficient. In older children and adolescents, the affected limb may be placed on a radiolucent hand table to provide adequate access to both the surgeon and fluoroscopy unit. In the very young child, the patient and injured extremity may be supported by a radiolucent fracture table. Even in cases in which a posterior surgical approach is to be utilized, supine positioning may be used with the limb adducted across the body. The fluoroscopy unit may be best positioned coming in from the head of the patient, allowing the surgeon to sit in the axilla and access the limb at all times. 
Surgical Approach(es)
A variety of different surgical approaches may be utilized. For distal humeral fractures, a posterior, triceps-splitting approach may be used.91,185,305,459,473 Prone or lateral decubitus positioning may be helpful for this approach. After a posterior midline incision is made, dissection is performed down to the level of the triceps fascia, through the deep fascia. Skin flaps are elevated, exposing the triceps. The triceps tendon is split longitudinally in the midline, and this may be extended proximally in the interval between the long and lateral heads of the triceps. The deeper, medial head of the triceps may then be split and careful subperiosteal elevation is performed, exposing the humeral cortex. This approach is not extensile, and more proximal exposure is limited by the course of the radial nerve. 
A traditional anterolateral approach is familiar to most surgeons and provides more extensile exposure.25,130,185 In the supine position, a proximal deltopectoral incision is extended distally along the lateral aspect of the biceps. Proximally, the deltopectoral intermuscular interval is developed, retracting the cephalic vein laterally. More distally, the brachialis–brachioradialis interval is developed. Proximally, subperiosteal elevation will allow bony exposure. Distally, the brachialis muscle may be split longitudinally in the distal humeral shaft region, taking advantage of its dual innervation. The brachial artery and median and ulnar nerves are protected within the medial soft tissues. This exposure will not allow visualization or access to the radial nerve, which must be protected from overzealous retractor placement or drill/screw insertion posterior to the humerus.467 
Alternatively, an extensile lateral or posterolateral approach will provide access to most of the humeral diaphysis as well as the radial nerve.58,143,296 In the supine position, a lateral or posterolateral incision is created centered on the fracture site. Dissection is performed down to the level of the deep fascia and subcutaneous flaps elevated. The triceps fascia is incised just posterior to the lateral intermuscular septum, entering the posterior compartment of the brachium. The lateral head of the triceps is then elevated off the lateral intermuscular septum from distal to proximal. The radial nerve may then be identified, often surround by perineural fat, as it passes from the posterior to anterior compartments. Often the posterior antebrachial cutaneous nerve may be identified as it travels from proximal-posterior to distal-anterior more superficially; following this nerve proximally will allow for easy identification of the radial nerve proper. Other anatomic landmarks, including the apex of the triceps aponeurosis, have been utilized for radial nerve identification.9 After the radial nerve is circumferentially dissected free, it may be isolated with a vessel loop and carefully retracted. Subperiosteal dissection will then allow for exposure of the humeral diaphysis. 
Technique
After the diaphysis is exposed and radial nerve identified and retracted, the fracture site is identified. Fracture hematoma is evacuated and the cortical fracture edges defined. Reduction may be performed under direct visualization, with interdigitation of the fracture edges restoring longitudinal alignment and proper rotation. The fracture is then fixed using appropriately sized plates for age and size of patient (3.5-mm compression plates, single or double-stacked semitubular plates), ideally obtaining six cortices of fixation above and below the fracture site using 3.5-mm cortical screws. Intraoperative fluoroscopy may be utilized to confirm anatomic reduction and appropriate implant placement. If the fracture site occurs adjacent to the radial nerve, care must be made to slide the plate beneath the nerve and avoid iatrogenic injury or kinking (Table 21-25). 
 
Table 21-25
ORIF of Humerus Shaft Fractures
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Table 21-25
ORIF of Humerus Shaft Fractures
Surgical Steps
  •  
    Expose humeral diaphysis
  •  
    Identify and retract radial nerve, when applicable
  •  
    Anatomic reduction of humeral fracture
  •  
    Apply lateral plate, with care to protect the radial nerve
  •  
    Six cortices of fixation above and below the fracture site
  •  
    Layered wound closure
  •  
    Splint or cast immobilization
X

Surgical Procedure: Intramedullary Fixation

Preoperative Planning
Preoperative planning for intramedullary nailing includes appropriate AP and lateral radiographs of the humerus to assess fracture location, pattern, and displacement. Again, careful preoperative evaluation should be made to document neurovascular status, given the known risks of traumatic and iatrogenic radial nerve palsy associated with humeral diaphyseal fractures. (In cases of radial nerve palsy, consideration should be given for formal open reduction and plate fixation, given the ability to simultaneously explore and decompress the radial nerve.) Appropriately sized flexible stainless steel or titanium intramedullary nails should be available. Similar to intramedullary fixation techniques of pediatric femur fractures, the selected nail diameter should be approximately 40% of the intramedullary canal dimension (Table 21-26). 
 
Table 21-26
IM Nailing of Humerus Shaft Fractures
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Table 21-26
IM Nailing of Humerus Shaft Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent table or regular table with radiolucent hand table extension
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: From head of bed
  •  
    Equipment: Stainless steel or flexible titanium intramedullary nails, ideally 40% of intramedullary canal diameter
  •  
    Tourniquet (sterile/nonsterile): None
X
Positioning
In the majority of cases, supine positioning is sufficient. In older children and adolescents, the affected limb may be placed on a radiolucent hand table to provide adequate access to both the surgeon and fluoroscopy unit. In the very young child, the patient and injured extremity may be supported by a radiolucent fracture table. The fluoroscopy unit may be best positioned coming in from the head of the patient, allowing the surgeon to sit in the axilla and access the limb at all times. 
Surgical Approach(es)
A theoretical advantage of intramedullary nailing of humeral diaphyseal fractures is the ability to achieve stable realignment via closed or indirect fracture reduction and minimally invasive implant placement. Reduction and stabilization may be achieved with efficiently, without need for extensive surgical dissection.81,102,165,392 A host of surgical approaches may be utilized. Intramedullary implants (Enders nails, Rush rods, flexible titanium nails) may be inserted via a posterior approach. Through a small posterior incision and triceps-splitting approach to the posterior humeral cortex just proximal to the olecranon fossa, an oval corticotomy may be made, large enough to accommodate passage of two nails. Nails may then be inserted retrograde through this combined entry point. While two nails may be sufficient, some have advocated the Hackethal or “bouquet” technique, in which the canal is progressively filled with multiple pins to confer additional rigidity (Fig. 21-34).160 This may be particularly useful in cases of segmental, comminuted, or pathologic fractures. 
Figure 21-34
The Hackethal technique involves multiple smooth pins placed up the humeral shaft through a cortical window just above the olecranon fossa.
The pins are placed until the canal is filled.
The pins are placed until the canal is filled.
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Alternatively, intramedullary nails may be placed via the lateral and/or medial columns of the distal humerus258,290 Small incisions may be made overlying the distal lateral and/or medial columns, at or above the level of olecranon fossa. Oval corticotomies are created at the site of nail entry to facilitate implant passage. Others have proposed insertion through the lateral and medial epicondyles via small drill holes. Care is made to retract and protect the posteromedial soft tissues—including the ulnar nerve—if a medial entry point is chosen. Nails may then be passed into the intramedullary canal and in a retrograde fashion to the fracture site. 
Once fracture reduction is achieved, intramedullary nails may be atraumatically passed into the canal of the proximal fragment. Fluoroscopic guidance is helpful, and efforts should be made to avoid repeated false passage of the nails into the adjacent soft tissues. In general, two nails are sufficient, provided they are of appropriate diameter and symmetrically contoured to allow for appropriate angular correction and rotational control.244,245,290 
While the experience in adults is well documented, at present there are limited indications for solid reamed intramedullary nailing of humeral diaphyseal fractures in skeletally immature patients. This is in part because of the risks of physeal disturbance, shoulder impingement, and the relative narrow dimensions of the intramedullary canal in younger patients.86,164,202,279,344,350,357,430 
Technique
Patients are positioned in the supine position. The appropriate-sized intramedullary implants (titanium elastic nails, Enders nails, Rush rods) are placed over the brachium, and fluoroscopy is utilized to determine the anticipated length of the intramedullary nail. The nails are then prebent into a gentle bow, with the apex centered at the level of the fracture site. If lateral column entry site only is to be used, the nails should be contoured into the shape of a “C” and “S” to maximize spread (and thus stability) at the level of the fracture site while still allowing for medial and lateral engagement of the proximal humeral metaphysis. If both medial and lateral column entry sites are planned, each nail will be prebent into the shape of a “C.” 
A longitudinal incision is then created over the palpable lateral (and medial) column, just proximal to the olecranon fossa. Tourniquet control is not typically necessary. While epicondylar entry sites have been described, these have been associated with more frequent nail back-out.165 Dissection is performed down to the level of the cortex. A small periosteal window may be elevated. Drill bits or awls may be used to create a cortical entry point, with care taken to orient the obliquity of the cortical tunnel along the anticipated trajectory of the nail. The intramedullary devices are then passed into the intramedullary canal of the distal fracture fragment to the level of the fracture. Fracture reduction is achieved through gentle closed manipulation, restoring length and correcting the angular deformity in the coronal and sagittal planes. Once fracture reduction is achieved, intramedullary nails may be atraumatically passed into the canal of the proximal fragment. A small bend at the leading tip of the intramedullary implant will facilitate engagement of the proximal fracture fragment. Fluoroscopic guidance is helpful, and efforts should be made to avoid repeated false passage of the nails into the adjacent soft tissues. In general, two nails are sufficient, provided they are of appropriate diameter and symmetrically contoured to allow for appropriate angular correction and rotational control.244,245,290 
The implants are passed proximally into the proximal fragment until they lie 1 to 2 cm from the proximal humeral physis. At this time, the nails may be cut distally, leaving approximately 2 cm of length outside the cortex. If the nails were inserted with appropriate obliquity, the cut distal end of the nail will lie flush against the flare of the distal humeral metaphysis, avoiding symptomatic implant prominence yet still allowing for reliable implant retrieval. The entry wounds are closed in layers, and a long posterior splint, coaptation splint, or simple sling is applied (Table 21-27). 
 
Table 21-27
IM Nailing of Humerus Shaft Fractures
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Table 21-27
IM Nailing of Humerus Shaft Fractures
Surgical Steps
  •  
    Measure anticipated diameter and length of intramedullary nails
  •  
    Precontour intramedullary nails
  •  
    Create entry sites along lateral (and medial) column(s) of distal humerus
  •  
    Create cortical entry points for subsequent nail passage
  •  
    Introduce intramedullary nails and pass proximally to level of fracture site
  •  
    Closed reduction of humerus
    •  
      Fluoroscopic assistance
  •  
    Pass nails into intramedullary canal of proximal fragment, avoiding excessive false passage and trauma to the adjacent soft tissues
  •  
    Pass nails up to 1 to 2 cm distal to the proximal humeral epiphysis
  •  
    Bent and cut intramedullary nails beneath the skin
  •  
    Application of splint or sling after wound closure
X

Surgical Procedure: External Fixation

Preoperative Planning
External fixation remains a treatment option for humeral shaft fractures, particularly in critically ill multitrauma patients or patients with severe open fractures associated with extensive soft tissue injury and/or bone loss.62,98,217,220,343,364,401 Preoperative planning includes appropriate AP and lateral radiographs of the humerus to assess fracture location, pattern, displacement, and/or bone loss. Thorough documentation of preoperative neurovascular status is needed. For the multitrauma patient, communication with other care providers is important for care coordination and prioritization of injury treatment. In cases of severe soft tissue injury, appropriate consultation with plastic surgeons is recommended; this will allow for guidance regarding appropriate pin placement and planning of ultimate soft tissue coverage, if needed. Appropriately sized external fixator pins and bars should be available. While unilateral constructs are sufficient in most situations to provide stability, multiplanar or ring fixators may be employed, particular if there are plans for subsequent lengthening, bone transport, or deformity correction (Table 21-28). 
 
Table 21-28
External Fixation of Humerus Shaft Fractures
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Table 21-28
External Fixation of Humerus Shaft Fractures
Preoperative Planning Checklist
  •  
    OR Table: Radiolucent table
  •  
    Position/positioning aids: Supine
  •  
    Fluoroscopy location: Ipsilateral side of table
  •  
    Equipment: Appropriate-sized external fixation pins, bars, rings
  •  
    Tourniquet (sterile/nonsterile): N/A
X
Positioning
Patients may be positioned supine with the limb supported by a radiolucent table or hand table. Fluoroscopy units may be positioned on the ipsilateral side of the table, coming from the head or foot. Coordination should be made with other care providers in the multitrauma patient to allow adequate access to all anatomic regions necessitating care. 
Surgical Approach(es)
Surgical approaches are dictated by fracture characteristics, concomitant wounds and soft tissue injuries, and plans for future interventions. For a standard unilateral construct, pins may be inserted using percutaneous approaches via small incisions and careful spreading through the underlying soft tissues. Understanding of the cross-sectional anatomy of the brachium is important to avoid potential neurovascular injury. 
Technique
Once the patient is positioned and the fracture location and pattern identified, the configuration of the ultimate external fixator construct is determined. Biomechanically, maximal spread of pins in both the proximal and distal fracture fragments will allow for the most rigid construct. If a unilateral frame is to be applied, preassembly of the bar with pin-to-bar clamps may facilitate coplanar placement of pins; indeed, the pin-to-bar clamps may be utilized as a “drill guide” during pin placement. 
In a sequential fashion, the skin is incised at the site of pin placement and gentle, blunt dissection is performed through the subcutaneous tissues to the level of the humeral cortex. Appropriately sized threaded pins may then be drilled into the humerus, and use of cannulae or drill guides will protect the adjacent soft tissues and minimize the risk of iatrogenic neurovascular injury. This is particularly true for the radial nerve when lateral pins are placed in the mid- to distal diaphysis. 
After pins are placed and connected to the external fixator bar, the fracture may be aligned in the desired position and stabilized. The addition of a second bar, while not always necessary, will improve bending rigidity of the construct (Table 21-29). 
 
Table 21-29
External Fixation of Humerus Shaft Fractures
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Table 21-29
External Fixation of Humerus Shaft Fractures
Surgical Steps
  •  
    Identify fracture location and pattern
  •  
    Preassemble external fixator frame with planned pin-to-bar/ring clamps
  •  
    Small stab incisions made in skin at desired pin sites
  •  
    Blunt dissection through the subcutaneous tissues to level of humeral cortex
  •  
    Insert threaded pins (should be coplanar if unilateral fixator used)
  •  
    Provisionally connect the pins to the bar/ring
  •  
    Reduce or realign fracture
  •  
    Tighten pin-to-bar/ring connections
  •  
    Evaluate final alignment and construct with fluoroscopy or full-length radiographs of the humerus
X

Author's Preferred Treatment of Humerus Shaft Fractures

The majority of humeral shaft fractures in children and adolescents may be successfully treated nonoperatively. In infants with birth-related fractures, immobilization with a stockinette or pinning of the sleeve to the trunk is simple and effective. Radiographic assessment of healing is performed at 4 to 6 weeks of age; immobilization is discontinued after confirmation of clinical and radiographic healing. 
In children and adolescents with closed humeral diaphyseal fractures, stable injuries (e.g., torus or minimally displaced greenstick fractures) may be treated with simple sling immobilization. Patients with displaced fractures typically present with considerable pain, swelling, and ecchymosis. In these situations, gentle fracture realignment of the fracture may be performed with conscious sedation or general anesthesia, followed by application of a well-molded coaptation splint. Patients may be transitioned to a fracture brace at 1 to 2 weeks post injury, after the initial swelling and discomfort has subsided. Serial radiographs are obtained to monitor fracture alignment and bony healing. Bony union is typically obtained by 6 weeks, after which immobilization is discontinued and activities advanced. 
Similar nonoperative treatment is advocated for patients with closed injuries and acceptable alignment who present with radial nerve palsies. Even after bony union is achieved, serial clinical checks are performed monthly to monitor nerve recovery. An advancing Tinel sign and sequential motor recovery, beginning with wrist extension and progressing to digital and thumb extension, portend a favorable prognosis and spontaneous recovery. In general, nerve regeneration progresses 1 mm per day, and calculation of the distance from the fracture site to the sites of distal muscle innervation will allow for prediction of time to motor recovery. Surgical exploration with radial nerve decompression, repair, or reconstruction is considered after 3 to 6 months without evidence of any neurologic recovery. 
Surgical intervention is indicated in cases of open fractures, fractures with vascular or severe soft tissue injury, and fractures in unacceptable alignment. Surgery is also considered for patients with failure of appropriate radial nerve recovery or new radial nerve palsies after fracture manipulation. 
For most humeral diaphyseal fractures proximal to the distal metadiaphysis and without intercondylar extension that are treated surgically, formal open reduction and plate fixation is preferred. An extensile lateral or posterolateral approach is used, as it allows safe access to up to 90% of the humeral diaphysis.143 As surgery is often performed in the setting of radial nerve palsy, the lateral approach confers the additional advantage of allowing identification, mobilization, and/or repair of the radial nerve.58,143,296 
Intramedullary nailing may be considered in patients without preoperative radial nerve palsy and transverse or short oblique (i.e., “length stable”) fracture patterns. While the principles of intramedullary fixation are well established and the results well documented, closed nailing does not allow for visualization or decompression of the radial nerve (Fig. 21-35). 
Figure 21-35
Author's preferred treatment algorithm for humeral shaft fractures.
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Postoperative Care

Patients receiving nonoperative treatment of humeral diaphyseal fractures are followed weekly with radiographs in splint or fracture brace to ensure adequate fit, monitor neurovascular function, and confirm radiographic alignment. In patients with associated radial nerve palsies, evaluation for an advancing Tinel sign and sequential motor recovery is performed. Once there is evidence of clinical and radiographic healing, gentle shoulder pendulum and elbow range-of-motion exercises are begun. Immobilization is typically discontinued after 6 weeks. Sports participation is restricted until there is return of motion and strength, and patients/families are counseled regarding the risk of refracture. 
Following surgical reduction and stabilization, sling immobilization is usually sufficient and continued until radiographic healing. With plate fixation, gentle elbow range-of-motion exercises may be initiated once adequate comfort is achieved. In cases of intramedullary nail fixation, implants are typically removed at 6 months postoperatively. 

Potential Pitfalls and Preventative Measures

While the techniques described above are well established, a number of potential pitfalls may be encountered during the treatment of diaphyseal fractures. First, nonoperative treatment of distal diaphyseal fractures may be challenging, given the anatomic location and relative limited amount of distal humerus that may be incorporated into a fracture brace or splint.124 In these situations, use of medial and lateral extensions of conventional fracture brace may be needed to provide better control of coronal plane and rotational alignment. Alternatively, long arm casts or long posterior splints may be utilized to provide stability and maintain alignment until clinical and radiographic healing occurs. Careful clinical and radiographic monitoring is needed, due to the tendency for varus malalignment and the limited capacity for remodeling of very distal humeral deformity.48 
Similarly, surgical treatment of distal diaphyseal fractures may provide several challenges (Fig. 21-36).124 Closed reduction and percutaneous pinning techniques commonly used for supracondylar humerus fractures may not provide adequate stability, as the more proximal fracture location results in medial and lateral entry pins that cross at the fracture site (Fig. 21-37). This may result in longer operative times, loss of fixation with late deformity, and loss of motion. Alternative treatments include open plating or intramedullary nailing via medial and lateral epicondyle entry sites (Fig. 21-38). With a medial epicondylar entry, the ulnar nerve needs to be identified and protected. When open plate or intramedullary nail fixation is chosen, consideration should be made for stabilization of both the medial and lateral columns to provide maximal control and minimize risk for late instability. In cases where bicolumnar fixation is not possible, supplementation with long arm casts or other external immobilization is suggested. 
Figure 21-36
 
A: Intraoperative image depicting a comminuted, open distal humerus fracture in a 3-year-old male after a motorcycle injury. B: Intraoperative image after lateral column plate fixation, sparing the distal humeral physes. C: Given single column fixation, some loss of fixation is seen. Internal fixation was supplemented with spica cast immobilization. D: Final radiographs demonstrate appropriate bony healing and alignment.
A: Intraoperative image depicting a comminuted, open distal humerus fracture in a 3-year-old male after a motorcycle injury. B: Intraoperative image after lateral column plate fixation, sparing the distal humeral physes. C: Given single column fixation, some loss of fixation is seen. Internal fixation was supplemented with spica cast immobilization. D: Final radiographs demonstrate appropriate bony healing and alignment.
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Figure 21-36
A: Intraoperative image depicting a comminuted, open distal humerus fracture in a 3-year-old male after a motorcycle injury. B: Intraoperative image after lateral column plate fixation, sparing the distal humeral physes. C: Given single column fixation, some loss of fixation is seen. Internal fixation was supplemented with spica cast immobilization. D: Final radiographs demonstrate appropriate bony healing and alignment.
A: Intraoperative image depicting a comminuted, open distal humerus fracture in a 3-year-old male after a motorcycle injury. B: Intraoperative image after lateral column plate fixation, sparing the distal humeral physes. C: Given single column fixation, some loss of fixation is seen. Internal fixation was supplemented with spica cast immobilization. D: Final radiographs demonstrate appropriate bony healing and alignment.
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Figure 21-37
 
A, B: Distal humeral diaphyseal fracture in an 18-month old treated with closed reduction and percutaneous pinning. C: The pins cross at the fracture site with decreased stability and some loss of position. D, E: The ultimate outcome was good.
A, B: Distal humeral diaphyseal fracture in an 18-month old treated with closed reduction and percutaneous pinning. C: The pins cross at the fracture site with decreased stability and some loss of position. D, E: The ultimate outcome was good.
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Figure 21-37
A, B: Distal humeral diaphyseal fracture in an 18-month old treated with closed reduction and percutaneous pinning. C: The pins cross at the fracture site with decreased stability and some loss of position. D, E: The ultimate outcome was good.
A, B: Distal humeral diaphyseal fracture in an 18-month old treated with closed reduction and percutaneous pinning. C: The pins cross at the fracture site with decreased stability and some loss of position. D, E: The ultimate outcome was good.
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Figure 21-38
Ideally, pin fixation for distal humeral diaphyseal–metaphyseal junction fractures involves pins placed in intramedullary fashion up the medial and lateral columns.
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During ORIF via a lateral or posterolateral approach, care of the radial nerve is paramount. Identification of the posterior brachial cutaneous nerve and/or the characteristic fat stripe along the lateral aspect of the triceps will enable radial nerve identification during surgical exposures. Often the radial nerve must be mobilized to allow for implant placement between the humeral cortex below and the radial nerve above. Adequate direct visualization of plate placement and screw insertion is imperative to minimize the risk of iatrogenic nerve injury (Fig. 21-39). 
Figure 21-39
Intraoperative radiograph depicting radial nerve placement beneath a previously applied lateral plate.
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Finally, a few maneuvers may aid in the intramedullary nailing of humeral diaphyseal fractures. Lateral column entry provides easy surgical access and minimizes risk to the ulnar nerve. If this is chosen, nails should be precontoured into the shape of a “C” and “S” to allow for maximal spread at the fracture site and engagement of the proximal humeral fracture fragment. Creating the cortical entry point above the olecranon fossa with the appropriate distal-lateral to proximal-medial vector will allow the nail to sit against the metaphyseal flare of the lateral column when cut; this will facilitate subsequent retrieval and minimize the soft tissue irritation commonly caused by epicondylar entry points (Table 21-30). 
 
Table 21-30
Humerus Shaft Fractures
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Table 21-30
Humerus Shaft Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Malalignment of distal fractures (nonoperative) Extensions of fracture brace
Use of long arm casts/splints
Malalignment of distal fractures (surgical) Avoid percutaneous pinning
Use of plates or IM nails
Bicolumnar fixation
Supplement with cast/splint immobilization
Radial nerve injury during ORIF Careful dissection and mobilization
Position plate beneath nerve
Direct visualization of plate/screws
Complications of IM nailing Lateral entry above olecranon fossa
Appropriate vector for nail insertion
X

Treatment-specific Outcomes

Overall, reported clinical results are good after surgical treatment of humeral diaphyseal fractures using both intramedullary nailing and open plate fixation techniques.25,86,114,165,175,202,304,344,357,412,430,462,470,472 

Management of Expected Adverse Outcomes and Unexpected Complications Related to Humerus Shaft Fractures

Radial nerve palsies are commonly seen with humeral diaphyseal fractures. As discussed above, these nerve injuries may be primary or secondary. Secondary radial nerve injuries may result from a host of mechanisms, including excessive fracture manipulation resulting in neurapraxia, nerve incarceration within the fracture site or subsequent fracture callus, or rarely direct nerve injury or transection during fracture manipulation or implant placement. These inadvertent neurologic complications may be seen with both nonoperative and surgical treatment. There continues to be controversy regarding the initial management of immediate secondary nerve palsies, though it is clear that failure of spontaneous recovery after an appropriate period of observation should prompt surgical exploration, decompression, and/or nerve reconstruction.134,448 In addition to radial nerve injuries, ulnar and median nerve injuries have been reported.218,271,408 
Compartment syndrome of the brachium is relatively rare, in part because of anatomic differences in fascial strength, ability to avoid extreme positioning during fracture immobilization, and fracture characteristics.34,55,135,158,302 Patients with associated ipsilateral upper extremity fractures or vascular injuries are at highest risk. 
Vascular injuries, including brachial artery transection, are uncommon but mandate prompt evaluation and intervention to restore vascularity to the upper limb.47,274,287 In cases in which vascular repair or reconstruction is needed, fracture stability with external or internal fixation is needed to protect and facilitate vascular repair. 
Functionally limiting malunion is uncommon in pediatric humeral diaphyseal fractures. As cited previously, 20 to 30 degrees of varus and 20 degrees of apex anterior angulation may be accepted, with often little aesthetic differences and functional consequence.94,119,225,347,409 Up to 15 degrees of internal rotation is also well tolerated.94 Patients younger than 6 years of age will remodel most angular deformity, and obese patients—though more prone to malunion given the challenges of immobilization—may hide their resultant deformity better.186,313,363 Because of the remodeling potential, compensatory motion at the shoulder, elbow, and forearm, and lack of functional deficits, corrective osteotomies for humeral diaphyseal malunions are rarely necessary. 
While more commonly reported in adults, nonunion of humeral diaphyseal fractures may rarely occur in children and adolescents (Fig. 21-40).74,137 Risk factors may include excessive soft tissue injury, vascular insufficiency, segmental bone defects, or underlying bone abnormalities, such as osteogenesis imperfecta. Treatment principles for humeral nonunion in children have been extrapolated from adult orthopedics.20,66,123,170,184,303,465 In cases of hypertrophic nonunions, treatment is predicated on provision of bony stability, typically with ORIF. In cases of atrophic nonunions, ORIF with debridement of the pseudarthrosis back to bleeding bone and use of autogenous bone grafting is advised.178 Alternatively treatments include external fixation or Ilizarov technique.49,63,200,201,395 In cases of pathologic fractures or systemic bone abnormalities—such as osteogenesis imperfecta—intramedullary implants are preferred.137 In rare situations, a vascularized fibula graft is appropriate to provide bony alignment, stability, and healing.215 
Figure 21-40
Radiograph depicting an atrophic humeral diaphyseal nonunion in a skeletally mature adolescent previously treated with screw and cerclage wire fixation of an open humeral diaphyseal fracture.
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Limb length discrepancy may result from prior humeral diaphyseal fracture, though clinically up to 6 to 8 cm of shortening may be well tolerated without functional loss. As with other long bone fractures, overgrowth may occur following humerus fracture, though the magnitude is often minimal (less than 1 cm).173,375 In cases of considerable limb length discrepancy and functional compromise, humeral lengthening via distraction osteogenesis using unilateral or multiplanar ring fixators may be performed.63,64,92,332 
Finally, while loss of shoulder and/or elbow motion is common with both nonoperative and surgical treatment of humeral diaphyseal fractures in adults, persistent stiffness is uncommon in pediatric patients.7,178 Judicious initiation of early range of motion will aid to minimize the risk of this complication (Table 21-31). 
 
Table 21-31
Humerus Shaft Fractures
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Table 21-31
Humerus Shaft Fractures
Common Adverse Outcomes and Complications
Radial nerve palsy
Malunion
Nonunion
Limb length discrepancy
Stiffness
X

Summary, Controversies, and Future Directions Related to Humerus Shaft Fractures

In summary, the vast majority of humeral diaphyseal fractures may be effectively treated nonoperatively. In older patients with greater deformity, surgical reduction and stabilization will result in reliable bony healing and improved radiographic alignment. Controversy continues regarding the optimal management of secondary radial nerve palsies as well as the relative indications for intramedullary nailing versus open reduction and plate fixation of displaced humeral shaft fractures. Future prospective, comparative investigation is needed to determine the optimal surgical management of these injuries. 

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