Rockwood & Wilkins’ Fractures in Children
6th Edition

Chapter 17
Proximal Humerus, Scapula, and Clavicle
John F. Sarwark
Erik C. King
Scott J. Luhmann
Fractures of the proximal humerus are relatively uncommon injuries of childhood, with an incidence of 1.2 to 4.4 per 1,000 per year (1,2,3), fewer than 5% of all pediatric fractures (2,4,5,6,7). Fractures in this region have enormous potential to heal and remodel, perhaps more so than anywhere else in the body, mainly due to the thick periosteum at the proximal humerus and the proximity to the physis. Thus, proximal humeral fractures in children can be expected to heal without significant residual functional or cosmetic deficits in most cases.
Principles of Management
Mechanism of Injury
Fractures of the proximal humerus can be a common birth-related injury (8,9). As an infant is passing through the birth canal, the arm may be placed in a variety of abnormal positions that can result in a separation through the physis of the proximal humerus (8,9,10,11,12,13,14). These fractures are generally believed to result from hyperextension and/shor rotation of the arm during the passage through the birth canal (Fig. 17-1) (8,9,10,11,12,13,14). As might be expected, obstetric proximal humeral fractures occur most frequently during vaginal deliveries of infants with larger size or breech presentation (9,15,16,17). Prenatal size and presentation, however, have not been accurate predictive factors for these fractures, because proximal humeral fractures can and do occur during vaginal deliveries of infants of all sizes and weights; hence, other infant and maternal factors play a role (15,16,17).
In older children, the predominant cause of fractures in the proximal humerus is trauma, both direct and indirect. In this age group, these fractures can involve the metaphysis, the physis, or both. The trauma can be a direct blow to the shoulder area, especially to the posterior aspect (10,18,19), or indirect, as in a fall onto an outstretched hand that transmits the force through the arm to the proximal humerus (17,20,21). Indirect trauma can result in forced or nonphysiologic positioning of the upper extremity, which in turn may cause a fracture of the proximal humerus. Specifically, six potential mechanisms of upper extremity positioning have been proposed to explain the resulting proximal humeral fractures: forced extension, forced flexion, forced extension with lateral or medial rotation, and forced flexion with lateral or medial rotation (22). Although trauma has been acknowledged as the most common mechanism of pediatric proximal humeral fractures, it is still controversial whether a fall or a direct blow is the more common etiology of the fracture.
FIGURE 17-1 Hyperextension or rotation of the ipsilateral arm may result in a proximal humeral or physeal injury during birth.
FIGURE 17-2 Motor vehicle crashes may result in proximal humeral fracture due to blunt trauma to the shoulder region.
Proximal humeral fractures are typically moderate- to higher-energy injuries and are frequently seen in motor vehicle crashes and sporting activities (Figs. 17-2 and 17-3) (23,24). Approximately 50% of shoulder girdle fractures in children have

been reported to be associated with sports and play activities (25). Athletic activities associated with proximal humeral fractures include contact sports (football, hockey), horseback riding (fall from horses), gymnastics (upper extremity impact and weight bearing), and baseball (repetitive throwing) (6,26,27,28,29).
FIGURE 17-3 Blunt trauma from contact sports may result in fracture of the proximal humerus in children.
Less often, pediatric proximal humeral fractures result from other conditions such as malignant or benign tumors and pituitary gigantism (30,31,32,33). They also can be a complication of radiation therapy to the shoulder region (34). In addition, shoulder joint neuropathy secondary to Arnold-Chiari malformation, myelomeningocele, or syringomyelia has been implicated as an etiologic factor in proximal humeral fractures (23,35). An unknown percentage of pediatric proximal humeral fractures are part of the injuries associated with child abuse (Fig. 17-4) (36). Because no clear fracture pattern in the proximal humerus is suggestive of abuse, an index of suspicion must remain high when evaluating infants or young children with humeral fractures (37).
Signs and Symptoms
Clinical features of proximal humeral fractures in newborns may be subtle and not readily identified. For example, the infant may be irritable when handled by caregivers or when there is movement of the upper extremity. The infant may refuse to move the arm, giving the appearance of paralysis, called “pseudoparalysis.” Infants exhibiting upper extremity paralysis also may be suffering from posterior humeral head dislocation (38).
Older children typically report a history consistent with a proximal humeral fracture: a traumatic injury with the immediate development of moderate to severe global shoulder pain exacerbated by motion of the arm. They often present with an obvious deformity, or fullness, in the anterior shoulder region, with the overall contour of the shoulder altered in comparison with the contralateral uninjured shoulder. The arm is internally rotated against the abdomen and the patient usually refuses to use the involved arm. Pain, swelling, and ecchymosis are invariably present to some degree.
FIGURE 17-4 Although the exact mechanism of injury may vary in child abuse, fracture of the proximal humerus may result from twisting at the elbow or forearm.
The internally rotated position of the injured extremity is due to the pull of the pectoralis major muscle on the distal fragment. With posterior fracture dislocations, children demonstrate limited and extremely painful external rotation. Some children with fractures of the greater tuberosity have an unusual presentation of luxatio erecta where the involved shoulder is positioned in extreme abduction (39). This position reduces the displacement across the fracture as the greater tuberosity is pulled superiorly by the supraspinatus muscle. The elbow is typically flexed in luxatio erecta, allowing the hand to be near or above the head (39,40). Fractures of the lesser tuberosity affect the function of the inserting subscapularis muscle; hence, abduction and external rotation of the shoulder will be limited and painful (41,42,43).
Associated Injuries
In high-energy trauma, fractures of the proximal humerus may be associated with concomitant dislocations of the glenohumeral joint. The direction of the dislocation may be anterior, posterior, or inferior (36,39,40,44,45,46,47). Neurologic injury to the brachial plexus can result from fractures and fracture–dislocations of the proximal humerus (39,47,48,49,50). Typically these nerve deficits are transient, and full function typically returns in less than 6 months (51,52). Fractures of the proximal humerus in children also can be associated with other injuries, including rib fractures and pneumothorax (33).
Diagnosis and Classification
The proximal humeral epiphysis is not visible on plain x-rays until about 6 months of age (51,52,53), and plain x-rays are of limited value in evaluation of proximal humeral fractures in infants. On an anteroposterior (AP) x-ray, a change in the positional relationship between the proximal humeral metaphysis and the scapula and acromion often is visible. A comparison with the uninjured contralateral shoulder may reveal this alteration more clearly. A “vanishing epiphysis” sign also has been reported to describe posteriorly displaced physeal fractures of the proximal humerus (Fig. 17-5) (54,55). On an AP x-ray the epiphysis appears to vanish when it is displaced posteriorly. For complete evaluation of proximal humeral fractures in newborns and infants, ultrasonographic studies can be diagnostic and informative (56,57,58,59). Computed tomography (CT) also may be useful, especially for complex fractures with posterior dislocations (60). In addition to proximal humeral fractures, the differential diagnosis for such “paralysis” in infants includes brachial plexus injury, septic shoulder, and clavicular fractures.
For evaluation of proximal humeral fractures in older children, two x-rays in perpendicular views can be diagnostic (61). Ideally, a true AP view of the shoulder and an axillary lateral view provide the most information about the fracture. Because some lesser tuberosity fractures may be visible only on an axillary lateral view, this x-ray should be included whenever possible (62). Often, however, an axillary lateral view is difficult to

obtain in a child with an acutely fractured proximal humerus. In these instances, transthoracic axillary view or scapular-Y views can be obtained. In addition, an apical oblique view, an AP x-ray with the x-ray beam at 45 degrees of caudal tilt, also can provide significant information about the proximal humerus (63). In fact, some authors report that most shoulder trauma can be evaluated with AP and apical oblique x-rays and that a lateral view (axillary lateral or scapular-Y view) can be obtained if a humeral fracture is suspected (64).
FIGURE 17-5 Vanishing epiphysis sign.
When adequate x-rays cannot be obtained, CT is useful in evaluating proximal humeral fractures. CT may be especially useful in characterizing posterior fracture–dislocations (43,45). If the child continues to report shoulder pain despite negative radiographic and CT results, an occult fracture must be ruled out. For this purpose, magnetic resonance imaging (MRI) can be diagnostic, due to its ability to identify the intramedullary signal change of edema and the fracture plane (1,65,66). A bone scan may also be useful in equivocal cases. However, due to the normally increased radionuclide uptake at the physis of the proximal humerus, additional uptake due to a fracture may be difficult to interpret.
Fractures of the proximal humerus in the pediatric population are broadly categorized by their anatomic location. The fractures may involve the physis, the metaphysis, the lesser tuberosity, or the greater tuberosity. In addition, the degree of fracture deformity (angulation and translation) plays an important role in the overall treatment option. Other fracture characteristics that must be evaluated include the presence or absence of open fractures, concomitant glenohumeral dislocations, and fracture stability.
Fractures involving the physis are classified according to the Salter-Harris classification (Fig. 17-6) (67). Salter-Harris type I injuries with fractures through the physis occur mostly in patients under 5 years of age (10,68). After 11 years of age, most fractures of the proximal humerus are Salter-Harris type II injuries, with the fracture line exiting through the metaphysis (10,57,68,69), and they occasionally are associated with an additional anterolateral bony fragment (69). Salter-Harris type III injuries with the fracture line exiting through the epiphysis rarely occur in the proximal humerus of children (10,68) and have been reported with and without concomitant glenohumeral dislocation (44,45,70,71,72). Salter-Harris type IV injuries involving both the metaphysis and the epiphysis of the proximal humerus have not been reported in children.
Fractures of the metaphysis occur mostly in children 5 to 12 years of age (Fig. 17-7) and are categorized by their anatomic location and degree of displacement (10). This rather unexpected finding has been attributed to the rapid metaphyseal growth that occurs during this age, which in turn results in a relative structural weakness of the metaphysis (10). The anatomic location is described in relation to the major deforming forces in the region, namely the insertions of the pectoralis major and the deltoid muscles. Presence or absence of other fractures in the ipsilateral upper extremity also must be documented, because segmental fractures may require alternative treatments (73,74,75). Other isolated fractures of the proximal humerus may include the greater and the lesser tuberosities (39,40,41,42,76).
FIGURE 17-6 Physeal fractures of the proximal humerus. A. Salter-Harris I.B. Salter-Harris II.C. Salter-Harris III. Salter-Harris IV.
FIGURE 17-7 Healing undisplaced fracture of the proximal humerus in a 5-year-old child. Note the absence of a physeal injury.

The degree of displacement in proximal humerus fractures is classified with respect to the shaft diameter of the humerus (18). In grade I injuries, there is up to 5 mm of displacement. In grade II and III injuries, fractures are displaced by up to one third and two thirds of the humeral shaft diameter, respectively. Displacement of greater than two thirds of the shaft diameter is classified as a grade IV injury. In addition to degree of displacement, fractures in this region typically demonstrate concomitant angular deformities.
Surgical and Applied Anatomy
The proximal humeral ossification center cannot be seen on plain x-rays until about 6 months of age (51,52,53). In addition to the proximal humerus, both the greater and lesser tuberosities contain their own separate ossification centers. The ossification center for the greater tuberosity appears ataround 1 to 3 years of age, while the ossification center for the lesser tuberosity takes form at 4 to 5 years of age (53,77). The two tuberosities typically coalesce between 5and 7 years of age and subsequently fuse with the humeral head at 7 to 13 years of age (53,77).
The proximal physis of the humerus continues to be active well into the teenage years and is ultimately responsible for approximately 80% ofSthe overall humeral growth (78,79,80,81). Interestingly, longitudinal growth at the proximal humeral physis changes during development, such that it is responsible for only 75% of humeral growth before age 2 but up to 90% of growth after age 11 (78,79,80). For girls, this growth continues until around 14 years of age, with subsequent fusionof the epiphysis to the shaft at 14 to 17 years of age (78,81,82). For boys, growth continues until about age 16, when closure of the physis begins (78,79,80).
FIGURE 17-8 The anatomy of the proximal humerus.
For most boys, the proximal humeral physis is closed by about 18 years of age (82). The extracapsular location of the proximal humeral physis makes this structure susceptible to injury. Physeal fractures are thought to occur through the zone of hypertrophy and provisionalcalcification while relatively sparing the cells in the resting and proliferative zones (67). Salter-Harris type I or II fractures in children have high remodeling potential and rarely result in growtharrest (10,83).
The articular surface of the proximal humerus covers most of the medial aspect of the epiphysis as well as the proximal medial corner of the metaphysis (Fig. 17-8). The glenohumeral joint capsule surrounds the articular surface such that most of the medial epiphysis and theproximal medial corner of the metaphysis are intraarticular (Fig. 17-9). Conversely, a predominant

proportion of the physis is extracapsular and remains susceptible to injury. Most fractures of the pediatric proximal humerus involve the physis (10,68,69). The periosteum is quite strong in the posteromedial aspect of the proximal humerus, but the periosteum in the anterolateral aspect is relatively weak, occasionally allowing the fractured fragment to penetrate and prevent reduction (10).
FIGURE 17-9 Glenohumeral joint capsule.
The proximal humerus is the site of insertion for a number of different muscles that can influence the pattern of fracture displacement. These muscles and their attachments form early during development and are grossly similar to those of an adult shoulder by the time of birth. The four muscles of the rotator cuff insert onto the epiphysis. The subscapularis muscle inserts on the anterior aspect of the epiphysis on the lesser tuberosity, whereas the teres minor, the infraspinatus, and the supraspinatus muscles insertonto the superior and posterior aspect of the epiphysis near the greater tuberosity (Fig. 17-10). In addition to the rotator cuff muscles, the deltoid and pectoralis major muscles can also affectfracture displacement. The deltoid muscle attaches in the lateral aspect ofthe humeral shaft, whereas the pectoralis major muscle attaches to the anteromedial aspect of the metaphysis.
The muscular attachments to the proximal humerus contribute to the degree and the overall pattern of fracture displacement. With fractures of the physis (Salter-Harris types I, II, and III) and metaphyseal fractures proximal to the insertion of the pectoralis major muscle, the rotator cuff muscles displace the epiphysis into abduction, flexion, and slight external rotation. The distal fragment is displaced proximally by the deltoid muscle, whereas the pectoralis major muscle displaces the fragment anteriorly and medially. If the metaphyseal fracture occurs between the insertions of the deltoid and the pectoralis major muscles, the proximal fragment is adducted by the pull of the pectoralis major muscle, and the distal fragment is pulled proximally and abducted by the deltoid muscle. If the fracture occurs distal to the deltoid muscle insertion, the proximal fragment is abducted by the deltoid muscle and displaced anteriorly by the pectoralis major muscle. The distal fragment is pulled proximally and medially by the biceps and the triceps muscles (84).
The vascular supply to the proximal humerus arises from the axillary artery. Distal to the pectoralis minor muscle, three different arterial branches arise from the axillary artery before it becomes the brachial artery to supply the upper extremity. One of these branches is the subscapular artery, which runs with the subscapular nerve to supply the rotator cuff muscles. The remaining two branches, the anterior and the posterior humeral circumflex arteries, supply the proximal humerus. Most of the humeral head vascularity is from the arcuate artery, which in turn is from the ascending branch of the anterior humeral circumflex artery (85,86). The posterior humeral circumflex artery is a less dominant vascular supplier of the proximal humerus because it supplies a small portion of the greater tuberosity and posteroinferior portion of the humeral head (Fig. 17-11) (85).
FIGURE 17-10 Origins and insertions of the cuff muscles in a child: subscapularis, teres minor, infraspinatus, and supraspinatus.
FIGURE 17-11 The arterial anatomy of the shoulder region.

The close proximity of the axillary nerve to the proximal humerus makes this neural structure susceptible to injury during fracture and fracture–dislocations of the proximal humerus (39,47,48). The axillary nerve is a branch of the posterior cord of the brachial plexus. It traverses the anterior aspect of the subscapularis muscle before passing inferior to the glenohumeral joint to the posterior aspect of the proximal humerus (Fig. 17-12). The axillary nerve provides innervation to the deltoid muscle as well as cutaneous sensation over the lateral aspect of the shoulder. Documentation of the normal motor and sensory function of this nerve at the initial evaluation and prior to treatment is essential.
FIGURE 17-12 Relationship of the brachial plexus and artery to the proximal humerus and the scapula.
Current Treatment Options
Because of their tremendous potential for healing and remodeling, fractures of the proximal humerus in children infrequently require operative reduction and fixation (Table 17-1). This is especially true for obstetric proximal humeral fractures in infants. If needed, these fractures are amenable to gentle reduction with minimal anesthesia or sedation. If desired, the adequacy of the reduction can be evaluated via ultrasonography, but due to the incredible remodeling capability in this age group this is not routine. With or without anatomic reduction, the affected upper extremity should then be immobilized to the body by using a safety pin to attach the shirt sleeve to the shirt (33). Proximal humeral fractures in this age group heal quite rapidly, typically within 2 to 3 weeks, and result in no residual functional or cosmetic deficits (9,10,12,17,87,88).
Nondisplaced or minimally displaced proximal humeral fractures (Neer grades I and II) in older children and adolescents also should be treated nonoperatively. Initial management of these fractures involves sling-and-swathe immobilization (Fig. 17-13) followed by protected motion. Overall, nonoperative treatment provides excellent long-term results (10,39,89).
The remodeling potential of the fracture in young children is significant but decreases with the increasing age of the child; hence, the degree of acceptable displacement and angulation also changes with the age of the child. Generally, relative greater displacement and angulation can be accepted in younger children. For fractures in children under the age of 11, good to excellent long-term outcomes have been reported regardless of the fracture displacement (10,18,19,90). Various types of shoulder immobilization to maintain reduction have been advocated and include sling-and-swathe, thoracobrachial bandage (Velpeau), hanging arm cast, shoulder spica cast, salute position shoulder spica cast, and “Statue of Liberty” cast (10,12,18,89,90).
Grossly displaced or angulated proximal humeral fractures (Neer grades III and IV) in children over 11 are managed with fracture reduction and sometimes with specialized immobilization (10,18,90,91). Multiple maneuvers exist for the reduction of pediatric proximal humeral fractures. Most fractures can be reduced by applying longitudinal traction to the arm while positioning it in abduction, flexion, and external rotation. If this maneuver does not sufficiently reduce the fracture, better reduction can be obtained by moderate abduction, flexion to 90 degrees, and external rotation (18). Alternatively, the fracture can be reduced by direct manual manipulation of the fragments while the arm is placed in marked abduction (about 135 degrees), slight flexion (about 30 degrees), and longitudinal traction (17,21,88). Despite signifi

cant efforts, however, some fractures cannot be adequately reduced because of a barrier at the fracture site. Anatomic structures that can prevent reduction of proximal humeral fractures include the periosteum, the shoulder joint capsule, and the biceps tendon (87,92,93,94,95,96). In these situations, open reduction through a small deltopectoral incision is needed to remove the obstacles to reduction.
TABLE 17-1 Interventions for Proximal Humerus Fractures
  Immobilization Operative
Reduction & Immobilization
Reduction &
Internal Fixation
Birth fractures X  
Chronic slipped proximal
humeral epiphysis
Metaphyseal fractures X X X
SH I before age 11 years X X X
SH I after age 11 years X   X
FIGURE 17-13 Sling-and-swathe for immobilization of proximal humeral fracture.
In children over 11 years old, some investigators recommend reducing selected Neer grade III and all grade IV fractures and immobilizing in salute-position shoulder spica casts (18). Other investigators suggest gentle reduction of Salter-Harris type I and II fractures with greater than 50% displacement, followed by immobilization with a thoracobrachial bandage (Velpeau) or shoulder spica cast (Fig. 17-14) (10). An acceptable reduction of proximal humeral fractures in children over 11 years of age has been proposed by some to be less than 50% displacement and 20 degrees of angulation (91). Traditional thinking has been that nonoperative treatment of pediatric proximal humeral fractures has produced good to excellent results in all age groups (10,18,90). Because of this, the reported indications for operative treatment of pediatric proximal humeral fractures have been limited to include open fractures, fractures associated with neurovascular injury, fractures associated with multiple trauma, displaced intraarticular fractures (i.e., Salter-Harris type III fractures), irreducible fractures, and significantly displaced fractures in older adolescents (4,23,68,71,95,97,98,99,100,101,102).
Interestingly, the cited literature that has been reported to support nonoperative treatment regimens for all patients actually supports this method for children less than 11 years of age and in fractures with no to minimal displacement (10,18,90). These classic references identified fractures in older children (11 years of age or older) and those with Neer grades III and IV displacements at increased risk for less-than-optimal outcome (10,18,90). Minimal remodeling, specifically angular correction, occurs in the older child and adolescent, which can lead to limitation of glenohumeral motion (abduction) and pain (10,90). Two issues exist in this fracture in children 11 years of age and older: achieving adequate reduction and maintaining the desired alignment during the healing process. Achieving acceptable fracture alignment can typically be accomplished with closed manipulation of the fracture and only infrequently requires an open reduction to remove

obstructions. Immobilization of the reduced fracture comes in two types: specialized casts or splints, or internal fixation. Various types of externalimmobilization have been reported to maintain reduction (10,12,18,89,90). Loss of reduction has been reported to be as high as 50% in one series in which only external immobilization was used (18). Internal fixation with cannulated screws or more commonly Kirschner wires (Fig. 17-15) can be used to stabilize the reduction, which obviates the need for cumbersome immobilization such as a Velpeau bandage or spica cast (23). Intramedullary fixation is also a viable option for stabilizing displaced proximal metaphyseal fractures (Fig. 17-16).
FIGURE 17-14 Salter-Harris I fracture of proximal humerus. Intraoperative pinning through the metaphysis. Postoperative view. Healed physeal fracture.
A stress fracture of the metaphysis or a slipped epiphysis can be produced by chronic or repetitive trauma, such as repetitive throwing, gymnastics with humeral weight bearing, and localized radiation therapy (26,27,28,29,34,103). Because of the tremendous

healing and remodeling potential in the pediatric proximal humerus, these injuries can be successfully treated with conservative nonsurgical therapy.
FIGURE 17-15 AP x-ray of displaced fracture of the proximal humerus metaphysis with shortening with apparent inferior subluxation of the humeral head with respect to the glenoid. Attempted axillary view. Intraoperative film status after percutaneous pinning. Note the apparent inferior subluxation while under general anesthesia.
Pearls and Pitfalls
  • Most fractures of the proximal humeral physis are managed nonoperatively. This includes nondisplaced and most minimally to moderately displaced physeal injuries of the proximal humerus, which are treated with a shoulder sling or immobilizer. Range-of-motion exercises (pendulum) are initiated as soon as tolerated, and the immobilization is discontinued when healing is confirmed by x-rays and clinical examination. The great majority of metaphyseal fractures are also treated nonoperatively, with only a few requiringclosed reduction. Because of the tremendous remodeling potential of metaphyseal fractures in children, up to 1 cm of displacement is acceptable if thefracture is in bayonet apposition.
  • Due to the significant instability after reduction of displaced fractures involving the humeral epiphysis or metaphysis, we prefer to percutaneously pin these fractures, particularly those in children over 11 years of age (see Fig.17-15). The rationale behind reduction and percutaneous pinning of proximal humeral physeal fractures is a more rapid return of normal active and passive range of motion, improved patient comfort, and easier care of the patient. There is a minimally increased, but acceptable, risk of infection. In our opinion, this approach is more acceptable than leaving the fracture unreduced and risking a decrease in shoulder range of motion with secondary shoulder pain. We prefer to place the pin percutaneously through the metaphyseal fragment up into the physis, similar conceptually to the pinning of a slipped capital femoral epiphysis in the hip (see Fig.17-14). One drawback of Kirschner wire fixation is that if the wires are left under the skin, another general anesthetic is needed to remove the implants. In metaphyseal fractures, if the fracture is more distal, it may not be technically feasible to place a percutaneously placed Kirschner wire obliquely into the epiphysis. In this situation, intramedullary

    fixation with flexible nails is an effective method (see Fig.17-16). Occasionally a fracture is irreducible. In older children, open reduction is indicated. Generally the biceps is the offending structure. An anterior deltopectoral exposure is used.
  • Fracture–dislocations of the shoulder require closed reduction of the glenohumeral joint dislocation with appropriate anesthesia. After reduction of the glenohumeral dislocation, radiographic confirmation of the reduction and reevaluation of the physeal or metaphyseal fracture is essential. If the dislocation does not concentrically reduce or the fracture is in unacceptable alignment, open reduction is generally done through a low anterior or axillary approach to the proximal humerus.
  • Displaced fractures of the lesser tuberosity generally are treated with open reduction to restore the subscapularis tendon and anterior capsule. Lag screws or suture anchors are very useful in this region, particularly for injuries with small bony fragments. Fractures of the greater tuberositygenerally are associated with acute dislocations of the shoulder and are typically treated nonoperatively after closed reduction of the shoulder dislocation. Rarely, after closed reduction of the shoulder dislocation, the greater tuberosity fracture reduction is unacceptable, and an open approach torepair the tuberosity fracture along with the rotator cuff is required.
Early Complications
Diagnosis of a proximal humeral fracture can be delayed in a child who is asymptomatic or minimally symptomatic. In children with multiple trauma, the diagnosis can be delayed due to the need to focus on more life- or limb-threatening problems and the absence of any dramatic limb malalignment. Even after the diagnosis of proximal humeral fracture is made, full evaluation and characterization of the fracture pattern can remain incomplete because of inadequate radiographic studies. A high index of suspicion, thorough physical examination, and insistence on high-quality x-rays must all be present to ensure prompt diagnosis and treatment of proximal humeral fractures.
Neurologic injury to the brachial plexus can result from fractures and fracture–dislocations of the proximal humerus (39,47,48,49,50). Most nerve deficits can be diagnosed immediately because the clinical signs are readily apparent. Rarely, however, nerve deficits from proximal humeral fractures can evolve slowly and delay the diagnosis (49). Typically, these nerve deficits are transient, and full function typically returns in less than 6 months (51,52). If the neurologic deficit persists longer than 3 months, further evaluation with electromyography is warranted. If no evidence of nerve recovery or regeneration is present, nerve exploration, repair, and grafting can be considered (48,104). Salvage operations for permanent nerve deficits include proximal humeral osteotomy and muscle or tendon transfers (105,106,107,108,109).
Fractures of the proximal humerus in children also can be associated with other injuries, including rib fractures and pneumothorax (33). In adults, these fractures have been associated with disruptions and thrombosis of the axillary vessels as well (110,111,112,113). Operative fixation of proximal humeral fractureswith pins and wires has been associated with hardware migration, which can be fatal (114,115). Therefore, serial radiographic monitoring of the hardware after shoulder operations is essential.
Late Complications
Humerus varus after trauma is a rare complication that typically affects neonates and children under 5 years of age (116,117,118,119,120). Children with humerus varus have a significant decrease in the humeral neck–shaft angle and shortening of the upper extremity. Although shoulder abduction may be moderately limited, most children with humerus varus have only mild functional deficits and do not require surgical correction of the deformity (116,117,118,120). If, however, active abduction and flexion are severely limited, corrective osteotomy of the proximal humerus can produce good results (119,121).
Hypertrophic scarring can occur after surgical reduction of proximal humeral fractures. When the scarring is present in the anterior shoulder region after an anterior deltopectoral incision, the cosmetic deformity may be significant and psychologically damaging, especially for girls (93,122). Therefore, many investigatorshave argued for the more cosmetically appealing axillary or anterior axillary incision (123,124).
Limb length inequality after proximal humeral fractures occurs more frequently in children treated with surgical intervention than in those treatednonoperatively (10,83,125). This is likely due to the degree of damage to the physis at the time of injury and not iatrogenically induced due the surgical reduction. The inequality is not significantly affected by the quality of initial fracture reduction and may be more pronounced in older children (1 to 3 cm) (18,83). Despite this inequality, however, these children rarely develop any functional deficits to warrant surgical intervention. Full arrest of physeal growth after traumatic proximal humeral fractures is extremely uncommon (10). Although still quite rare, it does occur more frequently in children with pathologic fractures through unicameral bone cysts (126,127,128). If the functional or cosmetic deficit is significant, a limb-lengthening procedure may be of benefit for these children (129).
Osteonecrosis of the humeral head after proximal humeral fractures occurs frequently in adults but is rare in children (130,131). Even after acute disruption of the vascular supply to the proximal humeral epiphysis, subsequent remodeling and revascularization usually occur in children and lead to excellent clinical results (71). Similarly, glenohumeral subluxation after proximal humeral fractures is a rare complication in the pediatric population that typically results in good clinical outcomes (131). These children are best treated with a short period of immobilization followed by early physical therapy and rehabilitation (33).
Controversies and Future Directions
Little controversy exists in the treatment of minimally displaced fractures and fractures in children 11 years old and younger;

the main area of controversy is in the treatment of displaced fractures in the patient older than 11 years old. Two main areas of controversy are the amount of acceptable displacement (angulation and translation), and the optimal method of stabilization. The Neer classification is currently the mostwidely accepted method for the radiographic classification of proximal humeral fractures, but it has not been validated as a guide for treatment (18). This system defines the fractures based on the bony translation at the fracture site but does not integrate fracture angulation into the schema. Multiple published reports document a high percentage of good and excellent outcomes in Neer grade III and IV fractures (10,18,90,91). It is likely that fracture angulation, and not translation, is the more important factor in the overall outcome of these fractures. Unfortunately, due to the anatomy of the proximal humerus and epiphysis, plain radiographic assessment of fracture angulation can be very imprecise, especially in physeal fractures. This makes preoperative and postoperative analysis of the fracture alignment difficult, if not impossible. Further study into the role of fracture angulation, and the ability to quantifyangulation, is likely to shed new light onto this topic by improving treatment algorithms and patient outcomes.
The classic treatment method for stabilization of the reduced proximal humerus fracture has been a specialized cast or splint designed to position the distal fracture fragment in alignment with the proximal fragment. Improvements in intraoperative imaging and equipment have permitted an evolution in pediatric fracture care to more widespread use of percutaneously placed Kirschner wires or cannulated screws. Both methods, external immobilizationand internal fixation, have their advantages and disadvantages in proximal humerus fractures (Table 17-2), but direct comparison of the techniques has not been performed to date.
Injury to the scapula is rare because it is well protected by multiple layers of muscle and other soft tissues. Due to this inherent protection, fractures and dislocations of the scapula are rare: only 1% of all fractures involve the scapula (132,133). However, when scapular injuries occur, they are almost certainly a result of high-energy trauma and may be associated with significant injuries to other major organ systems (134,135,136). Therefore, all children with apparently isolated scapular fractures should be meticulously evaluated on the secondary trauma survey for the presence of potentially life-threatening visceral injuries that require further intervention.
Principles of Management
Mechanism of Injury
Fractures of the glenoid typically occur in a fall onto an upper extremity. This is believed to drive the humeral head into the glenoidfossa, which in turn results in the fracture. Depending on the direction ofthe force, the fracture may injure the rim of the glenoid or the entire glenoid fossa. Less commonly, fractures may result from direct trauma to the glenoid.
Body of Scapula
Fractures to the body of the scapula occur via direct impact or avulsion mechanisms. The direct impact mechanism is typically of high energy and rarely is an isolated injury. As with all other high-energy injuries, child abuse must be excluded as a cause for scapular injury when no clear traumatic cause is evident (137). The avulsion-type fractures may occur at any of the several muscle attachments on the scapula.
TABLE 17-2 Treatment Pros and Cons: Proximal Humerus Fractures
  Pros Cons
No reduction (sling or shoulder immobilizer)
  1. No anesthesia/sedation
  2. Sling/shoulder immobilizer well tolerated
  1. No improvement of fracture alignment
  2. Loss of shoulder range of motion
Reduction and external immobilization
  1. No Improves fracture alignment
  2. No implant concerns (infection, migration, malposition, etc.)
  3. No need for secondary anesthesia for implant removal
  1. Need general anesthesia
  2. Cumbersome cast/splint
  3. No direct rigid fixation of fracture (potential for loss of reduction)
Reduction and internal fixation
  1. Improves fracture alignment
  2. Direct rigid fixation of fracture
  3. Improved patient comfort (due to rigid fracture fixation)
  4. No cumbersome cast or splint
  1. Need general anesthesia
  2. Minimal increased risk of infection
  3. Implant concerns
  4. Possible need for implant removal

Signs and Symptoms
Children with scapular fractures have significant pain and tenderness around the shoulder girdle and resist movementof the affected arm. Localized edema may obscure the overall shoulder contour, which may be more evident by comparison with the contralateral shoulder. The diagnosis of scapularfractures is frequently missed because of the attention required by more significant injuries.
Associated Injuries
Greater than 75% of patients with scapular fractures have associated injuries (135,138,139,140), many of which are life-threatening. In one reported series, the rate of death among patients with scapular fractures exceeded 14% (135).
Because of the proximity of the scapula to the axillary artery and the brachial plexus, fractures of the scapula often are associated with neurovascular injury (see Fig. 17-12) (135). The ipsilateral arm must be carefully examined to document arterial or neurologic deficits before the initiation of treatment. When injury to axillary or distal vasculature is suspected, an angiogram may be performed to examine the integrity of the vessels.
Scapular fractures also are associated with several life-threatening injuries, such as hemothorax, pneumothorax, cardiac contusions, as well as fractures of the spine, clavicle, rib, and humerus (134,135).
Diagnosis and Classification
Scapular fractures typically are discovered during the evaluation of the multiply injured patient. In the rare case where the scapular fracture is the initially identified fracture, a complete trauma evaluation should be undertaken for head, chest, abdominal, and retroperitoneal injuries. If suspicion is high, a general trauma evaluation may be requested. Conversely, scrutiny for fractures of the scapula should be included in the evaluation of the multiply traumatized child.
Imaging Studies
Most scapular injuries are identified initially on the AP chest x-ray from a trauma series. However, AP and lateral x-rays of the scapula will facilitate detection of fractures not evident on the AP chest view, as well as allowing better description of the fracture pattern. In addition to these, other special radiographic views can aid in fracture characterization. The Stryker notch view, for example, better reveals coracoid fractures, whereasthe axillary lateral view is better suited to identify glenoid fractures. The axillary lateral view also is helpful in confirming the location of the humeral head with the glenoid. When available, CT with three-dimensional reconstruction provides the most detailed representation of scapular anatomy.In addition, CT is essential in characterizing intraarticular injuries of the glenoid.
In high-energy trauma, the AP chest x-ray should also be scrutinized forevidence of scapulothoracic dissociation. Scapulothoracic dissociation typically occurs in patients with massive, direct trauma to the chest or proximal upper extremity and is highly associated with ipsilateral neurovascular injury (141,142). This devastating injury should be suspected if the medial border of the scapula is displaced laterally, if there is a clavicular fracture with a large displacement, or if there is a complete acromioclavicular joint separation with large displacement (142,143).
Developmental variations in scapular anatomy may confuse radiographic interpretation. For example, os acromiale is commonly mistaken for an acute fracture. This variation occurs when the centers of ossification in the acromion fail to unite (144). Os acromiale is considered a normal variant, is present in 10% of normal shoulders, and is bilateral in 60% of affected individuals (143,145). Typically, os acromiale is located in the anterior and inferior aspect of the distal acromion and has a smooth and uniform appearance on x-rays. Occasionally os acromiale is symptomatic. If radiographic studies and clinical examination cannot distinguish between a fracture and a developmental variation, further evaluation with a bone scan may be clarify the diagnosis (141). Other variants in scapular anatomy include Sprengel’s anomaly, absent acromion, bipartite or tripartite acromion, bipartite coracoid, and coracoid duplication (144,146,147,148,149).
Multiple classification systems for scapular fractures have been reported. Many are descriptive and based primarily on the anatomic location of fracture. Ada and Miller divided scapular fractures into categories of acromion, spine, coracoid, neck, glenoid, and body (138). In their series, fractures occurred most often in the body (35%), followed by the neck (27%); fractures of the coracoid were least common (7%). Thompson et al classified scapular fractures into three broad anatomic locations: fractures of the glenoid and the glenoid neck, fractures of the acromion and the coracoid, and fractures of the body
The classification described below is also based on the anatomic location of the fracture, with additional subclassifications based on multiple reported studies (see Fig. 17-17 and Table 17-3). However, most of these studies are not specific for pediatric scapular fractures, so application of this classification system and its supportive studies to pediatric scapular fractures should be individualized to each child. The fracture should be adequately evaluated for its anatomic location, displacement, comminution, and articular involvement. In addition, ipsilateral neurovascular status, the overall status of the patient, and other concomitant injuries should be fully characterized.
Fractures of the body and the spine of the scapula, which make up nearly 50% of all scapular fractures, are broadly categorized into those with and without displacement. Although an isolated fracture of the scapular neck is believed to be a stable bony construct, ipsilateral fractures to both the scapular neck and the clavicle may lead to disruption of the suspensory mechanism of the shoulder (132,150). Therefore, fractures of the scapular neck are categorized into those with and without concomitant injury to the clavicle. For similar considerations, fractures

of the coracoid process are categorized into those with and without concomitant injury to the acromioclavicular joint.
FIGURE 17-17 General classification of scapular/glenoid fractures.
Fractures of the acromion are categorized into those with and without displacement. Displaced fractures are further subclassified based on the presence or absence of subacromial narrowing. Subacromial space narrowing may occur after inferior displacement of the acromion or after superior displacement of an ipsilateral glenoid fracture. When treated conservatively, these fracture patterns often lead to subacromial impingement in adults and result in decreased range of shoulder motion and increased shoulder pain (151). Although its applicability to acromial fractures in younger children is still debated, this finding significantly affects the treatment options for acromial fractures in older children.
Fractures of the glenoid typically occur when the humeral head is driven onto the glenoid fossa. Depending on the direction of the force applied to the humeral head, the fracture may involve the entire fossa or just the rim. If the entire fossa is

involved, the fracture line may then exit in multiple locations about the scapula. Hence, fractures of the glenoid are classified into five distinct groups based on their anatomic location and course of the fracture. This system was initially proposed by Ideberg and later expanded by Goss (152,153,154). Type I fractures are isolated glenoid rim fractures, with Ia involving the anterior rim and Ib involving the posterior rim. Type II, III, and IV fractures are glenoid fractures with fracture lines exiting through lateral, superior, and medial aspects of the scapula, respectively. Type V fractures are various combinations of type II, III, and IV fractures. Type Va, for example, is a combination of types II and IV. Type Vb is a combination of types III and IV, whereas type Vc is a combination of types II, III, and IV. Type VI fractures are comminuted fractures of the glenoid fossa. These various types of glenoid fractures are associated with distinct patterns of morbidity and treatment options.
TABLE 17-3 Interventions for Scapular Fractures
  Immobilization Operative Reduction & Immobilization Operative Reduction & Internal Fixation
Body of scapula X  
Acromion X   X
Glenoid rim/fossa X X
Scapula-thoracic dissociation X X  
Scapulothoracic dissociation occurs when all attachments or articulations between the thorax and the scapula are completely severed. When there is an ipsilateral neurovascular injury, it is sometimes referred to as a forequarter amputation. This is in contrast to scapulothoracic dislocation, where only the inferior scapulothoracic articulation is displaced (141). Although intrathoracic dissociations have been reported (155), scapulothoracic dissociations are typically laterally displaced. These injuries are categorized as open or closed with intact or compromised neurovascular status.
Surgical and Applied Anatomy
During development, the scapula forms in the first trimester of gestation. It first appears near the level of lower cervical spine, C4–C7, and then descends to its final position on the lateral aspect of the upper thorax during development. Most of the scapula is formed by intramembranous ossification. Numerous centers of ossification exist for the scapula: three for the body, two for the coracoid process, two to five for the acromion (144), and one for the glenoid. These ossification centers during childhood are often mistakenly identified as fractures. In some developmental anomalies, distinct ossification centers fail to fuse and persist into adulthood (147). These conditions are also frequently characterized as fractures. With few exceptions, however, a developmental variation and a fracture can be distinguished by clinical history, physical examination, and radiographic appearance.
The scapula is roughly triangular and has a complex three-dimensional structure. It is responsible for linking the upper extremity to the axial skeleton and contains attachments to 17 distinct muscles. The anterior aspect of the scapular body is a relatively flat surface, most of which is covered by the subscapularis muscle. The posterior aspect of the scapula is divided into two fossae by the scapular spine. These superior and inferior scapula fossae are mostly covered by the supraspinatus and the infraspinatus muscles, respectively. The anteromedial border of the scapular body provides attachment to the serratus anterior muscle. The posteromedial border contains the attachment sites of the levator scapulae, rhomboideus major and minor, and latissimus dorsi muscles. The omohyoid muscle attaches to the superior aspect of the scapular body, whereas the teres minor and major muscles and the triceps muscle attach to the lateral border. The scapular spine provides attachments to the trapezius and deltoid muscles, and the long head of the biceps muscle originates from the superior rim of the glenoid. Finally, the pectoralis minor muscle, as well as the conjoined tendon of the coracobrachialis and short head of the biceps muscles, attach to the coracoid process.
In addition to these muscle attachments, the scapula participates in the formation of both glenohumeral and acromioclavicular joints. The glenohumeral joint is stabilized by multiple dynamic and static forces about the joint, which are discussed separately. The acromioclavicular joint is stabilized in part by the presence of two coracoclavicular ligaments that position the distal clavicle immediately medial to the acromion. The two ligaments are the conoid and the trapezoid ligaments, with the conoid being the more medial of the two.
In close proximity to the scapula are a number of neurovascular structures that can be injured during a scapular fracture. Most notable are the brachial plexus and the axillary artery,

which course across the anterosuperior aspect of the scapula. They are immediately posterior and inferior to the tip of the coracoid process. Medial to the base of the coracoid process is the scapular notch with the overlying transverse scapular ligament. The suprascapular nerve and artery pass under and over the ligament, respectively, in the scapular notch and are susceptible to injury with nearby fractures. The axillary nerve travels within an intermuscular interval immediately inferior to the glenoid and is also susceptible to injury with displaced fractures of the glenoid neck (156).
FIGURE 17-18 Classification of fractures of the glenoid neck.
FIGURE 17-19 Relationship between the scapula, clavicle, and sternum.
A traumatic insult may cause fractures in multiple locations about the scapula, with one fracture influencing the stability of another. Goss proposed this and subsequently introduced the concept of a superior shoulder suspensory complex (SSSC) (132). The SSSC is a set of bony struts attached to a circular complex of structures at the lateral end of the scapula (Fig. 17-20). The superior and inferior bony struts are the middle clavicle and the lateral scapula body/shspine, respectively. The circular complex is composed of the acromioclavicular ligament, acromion, glenoid process, coracoid process, coracoclavicular ligament, and distal clavicle. As a whole, the SSSC is responsible for linking the upper extremity to the axial skeleton. Traumatic injury to any single component of the SSSC may result in a minimally displaced fracture, because the inherent stability of the circular complex is still intact. However, when multiple structures of the circular complex are injured, a double disruption to the circle occurs. This, in turn, results in significant instability. Similarly, injury to one of the structures of the ring complex with a concomitant injury to a bony strut also may create an unstable construct. Goss proposed that the treatment decisions for scapular injuries should be based on the maintenance of SSSC integrity (132).
Current Treatment Options
There are few published studies to provide evidence-based recommendations regarding current treatment options for scapular fractures in children. Therefore, most of the following comments are inferred from studies of adult populations.
Isolated fractures of the scapular body do not affect the integrity of the SSSC. In addition, because of the numerous muscle attachments, fractures of the scapular body are quite stable and can be treated conservatively in most cases (see Table 17-3). Several studies have shown that conservative treatment of nondisplaced or minimally displaced scapular body fractures in adults is generally associated with excellent results. Based on these studies, similar treatment is recommended for equivalent fractures in the pediatric population (139,140,157,158). In adults, conservative treatment of scapular body fractures with

significant displacement of more than 10 mm, however, resulted in unfavorable outcomes (157). Since a comparable study of pediatric scapular body fractures has not yet been reported, we can only assume that widely displaced fractures in children would have a similarly poor long-term outcome. The threshold for acceptable displacement has not been described.
FIGURE 17-20 Superior shoulder suspensory complex. A. AP view of the bone–soft tissue ring and superior and inferior bone struts. B. Lateral view of the bone–soft tissue ring.
Nondisplaced or mildly displaced scapular neck fractures without concomitant injury to the clavicle can be treated conservatively (159). However, if there is also ipsilateral clavicular injury, surgical intervention generally is recommended to reestablish the SSSC (138,150,160,161). Whether open reduction and fixation of the clavicle is sufficient to stabilize the fracture (160) or whether the neck fracture also must be reduced in addition to the clavicle (150) is debatable. For patients in whom surgical intervention is not possible, external fixation or traction may be an acceptable option (162).
Fractures of the coracoid process typically occur at the base. Isolated fractures of the coracoid process usually are nondisplaced and can be treated conservatively with a sling and mobilization as tolerated. Displaced coracoid fractures occur with ipsilateral injury to the distal clavicle or the acromioclavicular joint. Most investigators favor open reduction and internal fixation of these fractures to restore the integrity of the SSSC (136,140,163). Displaced coracoid fractures near the suprascapular notch with injury to the suprascapular nerve also have been described, with some investigators advocating early exploration (164).
Isolated fractures of the acromion in children are typically nondisplaced. In adults, acromial fractures with subacromial narrowing are associated with subsequent development of subacromial impingement when treated nonsurgically (151). Therefore, most investigators recommend open reduction and internal fixation for displaced acromial fractures where the subacromial space has been compromised (151), or with another disruption in the SSSC (132).
Fractures of the glenoid neck typically are nondisplaced unless other elements of the SSSC are disrupted. These fractures generally have excellent outcomes with nonsurgical treatment. Significant displacement or angulation, however, may limit glenohumeral motion (157,162). In adults, glenoid neck fractures with more than 10 mm of displacement or 40 degrees of angulation result in poor outcomes when treated without surgical reduction (138). Therefore, it is reasonable to infer that pediatric glenoid neck fractures with significant displacement or angulation also require surgical intervention.
Treatment of glenoid rim fractures (types I and II) is based on the presence or absence of shoulder instability. Closed treatment of asymptomatic glenoid rim fractures rarely results in long-term morbidity (165). For glenoid rim fractures with resulting shoulder subluxation or instability, however, operative reduction and fixation are recommended to prevent permanent or recurrent dislocations (133,162,166). In adults, shoulder instability occurs when the fracture was displaced more than 10 mm or when the fracture involved more than either 25% of the anterior or 33% of the posterior aspects of the glenoid (162). Anterior and posterior approaches to the glenoid generally are recommended for open reduction and internal fixation of anterior and posterior rim fractures, respectively (132).
Nondisplaced glenoid fossa fractures (types III through VI) also can be successfully treated nonsurgically (132). Displaced fractures, on the other hand, are associated with significant morbidity (pain, stiffness, and limited range of motion) when treated without surgical reduction. Patients with intraarticular displacement greater than 5 mm should be considered for surgical reduction

and fixation (162,167,168). In type IV glenoid fractures, where significant comminution is present, acceptable operative reduction and fixation may be difficult to achieve (132,154), and these fractures may be better treated with nonsurgical options (132,154). For open reduction and internal fixation of these fractures, a posterior approach generally provides the most acceptable exposure (132).
Initial treatment of scapulothoracic dissociations generally focuses on stabilization and repair of the neurovascular injury. If the axillary artery and the brachial plexus are not salvageable, an early amputation should be considered (142). Limb salvage is usually attempted if limb viability cannot be determined. Immediate exploration of the brachial plexus is warranted when a concomitant vascular injury requires an operative repair. If a vascular injury is not present, the brachial plexus need not be explored acutely. After a period of 4 to 6 weeks, the extent of the brachial plexus injury should be documented (physical examination, electromyography/nerve conduction velocity, MRI) prior to surgical reconstruction, such as nerve repair or musculotendinous transfer (132,142). Immediate operative stabilization of an ipsilateral clavicular fracture generally is necessary only if the bony instability compromises the integrity of the neurovascular structures.
Pearls and Pitfalls
  • Suspect scapula fractures in patients with multiple trauma, and scrutinize the x-rays.
  • Maintain a high index of suspicion for visceral injuries when a scapula body fracture presents as an isolated injury.
  • Be aware of normal variants in scapular anatomy, such as os acromiale. Review x-rays of the contralateral scapula if necessary.
  • Look for radiographic evidence of scapulothoracic dissociation.
  • Most scapula fractures are managed without surgery.
  • Highly displaced scapula body fractures and glenoid fossa fractures require open reduction and internal fixation.
Early Complications
Complications of scapular fractures are rare. The concomitant injuries frequently associated with scapular fractures were discussed throughout this section (135,139,140,143). Due to their proximity, the axillary and the suprascapular nerves may be injured in association with glenoid and coracoid fractures, respectively (156,164). In addition, the energy required to create scapular fractures likely results in other injuries, such as rib fractures, pneumothorax, and vascular avulsions. All or portions of the lower brachial plexus are susceptible to injury with scapulothoracic dissociations (141,142,149). This devastating injury also has been associated with the development of compartment syndrome in the upper arm (158). The presence of a complete brachial plexus avulsion is predictive of a poor functional outcome with a scapulothoracic dissociation (170).
Late Complications
Late complications associated with scapular fractures generally involve improper functioning of the upper extremity. Displaced fractures of the scapular body and spine, for example, infrequently result in upper extremity weakness and pain with movement (138). Similarly, fractures of the acromion can result in pain and decreased range of upper extremity motion secondary to subacromial impingement (151). Displaced intraarticular fractures of the glenoid are associated with glenohumeral subluxation or dislocation, as well as early progression of degenerative arthritis (132,133,162,166).
Symptomatic nonunion of scapula body fractures has been reported (171,172). Most problems related to injuries of the scapula are not necessarily related to treatment but are more often related to failure to accurately evaluate associated major systems injuries.
The clavicle has the important function of linking, as a strut, the axial skeleton to the upper extremity (see Fig. 17-19). Through its sternoclavicular and the acromioclavicular joints, the clavicle contributes to the overall motion of the upper extremity.

The clavicle can protract and retract (173). It also rotates and elevates to contribute to shoulder abduction (173,174,175). In addition, the clavicle provides the attachment site for the two predominant mobilizers of the upper extremity: the pectoralis major and the deltoid muscles. The integrity of the clavicle, therefore, is crucial to the optimal functioning of the entire upper extremity.
As a result of two factors, the clavicle is one of the most frequently fractured bones in the body. First, the clavicle is subcutaneous throughout most its span, being situated on the anterosuperior aspect of the thorax. Second, nearly all of the forces imparted onto the upper extremity are transmitted through the clavicle to the trunk. The clavicle is the bone most commonly injured during labor and delivery, occurring in 0.5% of all deliveries and accounting for nearly 90% of all obstetrical fractures (176,177,178,179). In older children, clavicular fractures occur frequently, with the reported rates ranging between 8% and 15% of all pediatric fractures (180,181,182).
Principles of Management
Mechanism of Injury
The clavicle is the most common site of all obstetrical fractures, and clavicular fractures occur in 1% to 13% of all births (176,177,178,183,184,185,186,187,188,189). The incidence of obstetrical clavicle fractures is increased for larger-birthweight infants (176,179,186,190). In addition, deliveries requiring the use of instruments or specialized obstetric maneuvers are more likely to result in clavicular fractures (176,185,186,190). Based on these findings, it has been postulated that fractures in these difficult deliveries result from lateral-to-medial pressure on the shoulders during passage through the narrow birth canal. However, despite the above trends, the majority of birth-related clavicular fractures occur in deliveries of average-birthweight infants who receive routine and otherwise uneventful obstetrical care. Thus, on the whole, obstetrical clavicle fractures are sometimes unavoidable consequences of vaginal deliveries for anatomic or physiologic reasons that may not be evident before or even after delivery.
The most common mechanism of clavicular fractures in children is a fall onto the shoulder (182,191,192). Other mechanisms include accidents where the traumatic insult is applied directly to the clavicle (192). Indirect applications of force, typically falling onto an outstretched hand, are much less likely to result in clavicular fractures (192). Clavicular fractures may also occur in children victimized by child abuse, but no pathognomonic pattern for isolated clavicular fractures resulting from child abuse has been described (193,194).
A significant amount of energy can be applied directly to the clavicle during athletic activities such as football or indirectly through athletic activities such as gymnastics. Most commonly, the direct mechanism is responsible for clavicle fractures, acromioclavicular joint injuries, or sternoclavicular joint injuries (180,182). A large proportion of these sports injuries may be preventable with the use of protective equipment and adequate padding (195). Although rare, stress fractures of the clavicle have been reported (174,196).
Signs and Symptoms
Clavicular fractures in newborns may be difficult to identify. The presence of generalized edema may prevent the palpation of normal clavicular margins (197). To minimize pain, newborns with clavicular fractures demonstrate pseudoparalysis of the affected arm, characterized by voluntary splinting or immobilization of the ipsilateral arm (198,199). Frequently this pseudoparalysis is mistaken for brachial plexus injury. To reduce the pull of the sternocleidomastoid muscle across the fracture site, affected infants turn their head toward the side of the fracture. In addition, infants with acute clavicular fractures typically exhibit an asymmetric Moro reflex (200,201). In the absence of radiographic confirmation, the diagnosis of clavicle fracture may be suspected and later confirmed after a mass is noticed in the affected clavicle. This mass represents a healing fracture callus that forms 7 to 10 days after the initial trauma. Often by this point the fracture is sufficiently stabilized by fracture callus that it causes little discomfort to the infant.
Diagnosis of clavicular fractures in older children is usually straightforward. Children have moderate to severe pain around the area of the fracture and voluntarily immobilize and stop using the affected arm. Tenderness, ecchymosis, and edema are invariably present; in fractures with large displacement, a bony prominence or deformity may be noted. Most children with clavicular fractures keep their heads turned to the side of the fracture to relax the sternocleidomastoid muscle (197).
Crepitus and instability may be detected over the affected joints in children with either acromioclavicular or sternoclavicular joint injuries. True dislocations of the acromioclavicular joint or the sternoclavicular joint are rare. Failure usually occurs at the physis before joint dislocation, and injuries to the medial and lateral end of the clavicle in children are commonly physeal fractures.
Associated Injuries
Atlantoaxial (C1-2) rotatory displacement (subluxation) and clavicular fracture occur together on rare occasions. Attributing acute torticollis entirely to the clavicular fracture may delay the diagnosis of atlantoaxial displacement, and delayed diagnosis of atlantoaxial displacement increases the risk of permanent atlantoaxial rotatory fixation (202,203). When present, the child’s head will be laterally bent toward and rotated away from the fractured clavicle. The diagnosis of C1-2 subluxation is best confirmed by dynamic CT.
Posterior dislocations of the sternoclavicular joint or posterior displaced physeal separations of the medial clavicle are particular worrisome for associated injury or compression of the great vessels, the esophagus, or the trachea (204,205). Suspicion of these injuries is further increased in children who have difficulty speaking, breathing, or swallowing. Pulses in the ipsilateral upper extremity may be diminished or absent, and the neck veins may be distended. Obviously, any of these injuries

associated with posterior sternoclavicular joint dislocations can be life-threatening, and precautionary diagnostic and treatment steps should be taken at the onset of treatment. If available, a thoracic or vascular surgeon should be consulted or notified prior to reduction attempts.
Diagnosis and Classification
Imaging Studies
An AP x-ray of the clavicle is the standard study with which a clavicular fracture is initially evaluated. In addition, ultrasonography is been a valuable supplement in establishing the diagnosis of clavicular fractures in neonates (206,207,208). Ultrasonography is particularly useful in detecting occult clavicular fractures as well as sternoclavicular joint dislocations in this young group (206,209). Bone healing may be detected on ultrasound 1 week before on x-rays.
For older children, other radiographic studies may be necessary to supplement the AP x-ray in evaluating the clavicular fracture. For fractures in the middle third of the clavicle, several views may be beneficial: the cephalad-directed views, the apical oblique view, and the apical lordotic view. The cephalad-directed views are helpful in illustrating the degree of fracture displacement. These views are taken with the x-ray beam 20 to 40 degrees cephalad to the clavicle (Fig. 17-21A). The apical oblique view is taken with the x-ray beam 45 degrees lateral to the axial axis of the body and 20 degrees cephalad to the clavicle. This view is better suited to identify fractures in the middle third of the clavicle, where significant curvature is present in the bone (210). The apical lordotic view is a perpendicular view of the AP x-ray. It is taken laterally with the shoulder abducted more than 130 degrees (see Fig.17-21B). This degree of shoulder abduction, however, can cause significant discomfort in children with acute clavicular fractures. Therefore, this radiographic view may be better suited for evaluating the healing of the clavicular fracture rather than for the initial assessment of the fracture (211).
Fractures in the lateral aspect of the clavicle may require additional radiographic views for full assessment. In addition to the views mentioned above, an axillary lateral view is helpful in evaluating the fracture and its displacement. If the injury in this portion of the clavicle or the acromioclavicular joint is not obvious on the obtained x-rays, a radiographic stress view may provide more useful information. A radiographic stress view is an AP x-ray of the lateral clavicle with distraction on the ipsilateral upper extremity. Distraction can be achieved by asking the child to hold 5 to 10 pounds of weight with his or her hand or by simply having an assistant gently pull on the arm downward. The stress view may show subtle injuries to the distal clavicle or the acromioclavicular joint. If enhanced evaluation of the acromioclavicular joint is desired, a CT scan should be performed.
Additional radiographic views are usually necessary to characterize fractures of the medial third of the clavicle and sternoclavicular injuries. The “serendipity” view, where a broad x-ray beam with 40 degrees of cephalic tilt projects both clavicles on the same film, is helpful for evaluating fractures in this portion of the clavicle (Fig. 17-22) (212). By comparing with the uninjured contralateral side, the location of injury and the degree of displacement often can be determined. Currently, CT is highly effective for evaluating injuries in the medial third of the clavicle. CT provides detailed information about the morphology of the medial clavicle, the medial physis, the degree of displacement, and possible injury to the underlying intrathoracic structures (Fig. 17-23). Virtually every acute injury of the medial end of the clavicle should be evaluated with CT, and it also is useful for follow-up of chronic injuries. Nonetheless, the technique for serendipity views continues to be useful for intraoperative radiography.
FIGURE 17-21 A. Cephalad-directed views. B. Apical lordotic view.
FIGURE 17-22 Serendipity view of the medial clavicle.

Because of differences in the mechanism and rate of injury, prognosis, and treatment options, clavicular fractures are broadly categorized by their anatomic location: medial third, middle third, and distal third (Fig. 17-24). Most clavicular fractures occur at the middle third, with the reported rates ranging from 76% to 85% (182,213). The second most common site of clavicular injury is the distal third, with the reported rates between 10% and 21% (182,213,214,215). Fractures in the medial third of the clavicle are relatively uncommon and represent only 3% to 5% of all clavicular fractures (182,215).
The widely used classification for clavicular fracture is based on the anatomic location of the fracture (216) (see Fig. 17-24). Type I fractures occur in the middle third of the clavicle and generally include all fractures lateral to the sternocleidomastoid muscle and medial to the coracoclavicular ligament. Type II fractures are in the distal clavicle, including and lateral to the coracoclavicular ligament. Type III fractures are medial to the sternocleidomastoid muscle. Type III fractures are relatively uncommon. Within this general framework, further classifications exist for injuries to the distal and medial ends of the clavicle.
Distal Clavicular Injuries
Distal clavicular injuries lateral to the coracoclavicular ligament and injuries to the acromioclavicular joint are categorized by a system proposed by Dameron and Rockwood (Fig. 17-25) (198). Although similar to the system for adult distal clavicular injuries, this classification system incorporates the observation that the distal clavicle displaces through a disruption in its periosteal sleeve rather than by true disruption of the coracoclavicular ligaments. Also, true acromioclavicular dislocations rarely occur in children. Most fractures in this region are either metaphyseal or physeal fractures (217,218). However, because distal clavicular epiphyseal ossification does not occur until age 18 or 19, these injuries may have the radiographic appearance of an acromioclavicular dislocation rather than a fracture (pseudodislocation) (217,218,219).
Type I acromial clavicular injuries are caused by low-energy trauma and are characterized by mild strains of the ligaments. No gross changes are seen on x-rays. Type II injury includes complete disruption of the acromioclavicular ligaments, with mild damage to the superolateral aspect of the periosteal sleeve. Mild instability of the distal clavicle results from this type of injury, and minimal widening of the acromioclavicular joint may be seen on an x-ray. In type III injury, complete disruption of the acromioclavicular ligaments occurs in addition to a large disruption in the periosteal sleeve. Noticeable superior displacement of the distal clavicle is seen on an AP x-ray, and the coracoid–clavicle interval is 25% to 100% greater than on the contralateral uninjured side (220,221). Similar soft tissue disruptions are seen in type IV injuries. The distal clavicle, however, is displaced posteriorly and is often embedded in the trapezius muscle (222). Minimal changes may be noted on an AP x-ray, and an axillary lateral x-ray may be required to identify the posterior clavicular displacement. Type V injuries are similar to type III injuries; the difference lies in the fact that the superior aspect of the periosteal sleeve is completely disrupted in type V injuries. This allows displacement of the distal clavicle into the subcutaneous tissues, occasionally splitting the deltoid and the trapezius muscles. On an AP x-ray, the coracoid–clavicle interval is more than 100% greater than on the contralateral uninjured side. In type VI injuries, the distal clavicle is displaced inferiorly, with its distal end located inferior to the coracoid process (223).
Medial Clavicular Injuries
The medial physis of the clavicle is the last physis in the body to close, and the fusion of this epiphysis to the shaft occurs as late as 23 to 25 years of age (224,225). The sternoclavicular ligaments attach primarily to the epiphysis, leaving the physis unprotected outside the capsule (194). Because of its unique anatomy, traumatic insults to the medial end of the clavicle in children typically result in fractures through the physis rather than dislocations through the sternoclavicular joint. Therefore, these injuries are categorized most appropriately in the Salter-Harris classification system (226). Most fractures at the medial end of the clavicle are Salter-Harris type I or II fractures. These fractures are further subdivided by the direction of the clavicular displacement, either anterior or posterior. Although anterior displacement of the clavicle occurs more frequently, more attention is given to fractures with posterior displacement due

to the possibility of concomitant mediastinal injuries requiring emergent intervention.
FIGURE 17-23 A. CT image of the clavicle showing posterior retrosternal dislocation of the medial end of the clavicle. B. Three-dimensional reconstruction of image shown in A.
Surgical and Applied Anatomy
The clavicle is an S-shaped bone whose medial end is connected to the axial skeleton through the sternoclavicular joint. The medial two thirds of the bone is tubular, whereas the lateral end is flatter and is stabilized in its position by the two coracoclavicular ligaments. The clavicle appears early during embryonic development. By the 5th or 6th week of gestation, it begins ossification at two separate centers, medial and lateral (173,227,228). By the 7th or 8th week of gestation, its overall

contour and shape are already formed (227). During childhood, approximately 80% of clavicular growth and longitudinal growth occur at the medial physis (229). Despite this early ossification and growth, complete growth of the clavicle does not occur until early adulthood. The lateral physis continues to proliferate until 18 to 19 years of age, and the medial physis does not close until 23 to 25 years of age (219,224,225).
FIGURE 17-24 A. Fracture of the medial third of the clavicle. B. Fracture of the middle third of the clavicle. C. Fracture of the lateral third of the clavicle.
FIGURE 17-25 Dameron and Rockwood classification of distal/shlateral fractures.
The distal clavicle articulates with the scapula through the acromioclavicular joint, a joint that lacks inherent structural stability. It is held together in part by the acromioclavicular ligaments, which are relatively weak secondary stabilizers. The primary stabilizers of the joint are the two coracoclavicular ligaments, the conoid and the trapezoid, which place the lateral end of the clavicle immediately next to the acromion. Although the distal clavicle and the coracoid process usually do not articulate, a coracoclavicular joint has been reported in adults (230). In children, the distal clavicle and the acromion are surrounded by thick periosteum that forms a protective tube around the bony structures. The coracoclavicular ligaments are attached to the periosteum on the inferior surface of the distal clavicle. Because these ligament attachments are stronger than the periosteum, displacement of the distal clavicle occurs through a disruption in the periosteum rather than by detachment of the ligaments. In fact, displacement of the distal clavicle through this periosteum in children has been likened to having “a banana being peeled out of its skin.” As mentioned above, the distal clavicular physis does not ossify until early adulthood (219). Therefore, fractures through the distal clavicular physis or metaphysis may be mistakenly identified as acromioclavicular joint dislocations.
Medially, the clavicle articulates with the sternum and the first rib through the sternoclavicular joint. Similar to the acromioclavicular joint, this joint also lacks inherent structural stability. It is held together by a series of strong ligaments, including the intraarticular disc ligament, the anterior and posterior capsular ligaments, the interclavicular ligament, and the costoclavicular ligament (231). In children, the medial physis of the clavicle is still open, and the capsular ligaments attach primarily to the epiphysis (224,225,231). Therefore, injuries to the medial clavicle typically result in physeal fractures with the epiphysis attached to the sternum.
The clavicle also serves as attachment sites for a number of different muscles. On its superior surface, the clavicular head of the sternocleidomastoid muscle is attached. On the posterior surface, the trapezius muscle is attached, whereas the pectoralis major and the deltoid muscles are attached on the anterior surface. Inferiorly, the clavicle provides attachment sites for the subclavius muscle as well as the clavipectoral fascia.
The clavicle provides protection for the subclavian vessels and the brachial plexus. These vital structures are located posterior to the clavicle, crossing the clavicle at the junction between the medial two thirds and lateral one third of the bone (see Fig. 17-12). Due to this close proximity, the neurovascular status of the ipsilateral upper extremity may be jeopardized in children with displaced clavicular shaft fractures. In addition, as discussed above, posterior dislocation of the sternoclavicular joint can lead to compression or injuries of the great vessels within the mediastinum. Therefore, the neurovascular status of the ipsilateral upper extremity must be documented before the initiation of treatment for any clavicular injury.
The clavicle contributes significantly to the overall motion and optimal function of the upper extremity. In the anterior to posterior direction, the clavicle can protract and retract approximately 35 degrees (173). Laterally, it can rotate and elevate to contribute approximately 30 degrees to shoulder abduction (173,175). The clavicle also provides the attachment sites for the major mobilizers of the upper arm, the pectoralis major and the deltoid muscles. Finally, together with the scapula, the distal clavicle forms the SSSC (described in the scapula section). As proposed by Goss, the SSSC provides a scaffold from which the upper extremity suspends and articulates in order to function (232).
Current Treatment Options
Treatment options are listed in Tables 17-4 and as well as in the following text.
TABLE 17-4 Interventions for Clavicle Fractures
  Immobilization Closed Reduction & Immobilization Operative Reduction & Internal Fixation
Middle third X   Rare
Distal third X Rare
Medial third X  
SC dislocation, anterior   X
SC dislocation, posterior X—Emergency Rare—see text

Middle-Third Fractures
Treatment of the obstetrical clavicle fracture is nonoperative. For most birth-related clavicular fractures, minimal or no treatment is required. If the infant appears to be in significant discomfort, the affected arm can be immobilized to the body for a short period of time, typically less than 2 weeks. Immobilization of the affected arm can be easily and effectively accomplished by using a safety pin to attach the long shirt sleeve to the shirt (233,234,235). The parents should be warned not to disturb the upper extremity by unnecessary excessive movements in the acute period. In addition, they should be informed that the infant will develop a noticeable mass over the fracture site that will typically resolve within 6 months (200).
Good to excellent results also can be expected from nonoperative treatment of most clavicle fractures in older children. A figure-of-eight splint is an acceptable method of nonoperative treatment and has been widely used with successful outcomes (200,236,237,238). It can be applied directly or after an attempt at closed reduction with retraction of the shoulders (239). In general, younger children do not require reduction of the fracture because their potential for remodeling is greater (239). A sling to support the weight of the arm is sufficient treatment in most cases.
The figure-of-eight splint, unfortunately, can be uncomfortable for some children. In addition, inappropriate use of the splint, on rare occasions, can lead to a number of complications, including edema, compression of the axillary vessels, and brachial plexopathy (237,240,241). Use of a sling, on the other hand, is typically well tolerated by children and is not associated with any of these complications. Treatment of both nondisplaced and displaced clavicular fractures with a sling has shown remarkably good results. In fact, in comparison with a figure-of-eight splint, treatment of clavicular fractures with a sling resulted in similar final outcomes (236,242,243). Therefore, it appears that nonoperative treatment of middle-third clavicular fractures with a simple sling can result in excellent outcomes without compromising the child’s comfort.
Reported indications for operative treatment of middle-third

clavicular fractures include severely displaced and irreducible fractures that threaten skin integrity, concomitant vascular injury requiring repair, irreducible compression of the subclavian vessels, compromise of the brachial plexus, and open fractures (244,245,246,247,248). In addition, as discussed separately in this chapter, concomitant displaced fractures in various regions of the scapula, including the acromion, the coracoid, and the scapular neck, may compromise the SSSC and require operative repair (232). For the rare surgical case, either plating or intramedullary fixation can be performed. Intramedullary stabilization with elastic nails is increasingly popular because it is a safe, minimally invasive procedure (249,250).
TABLE 17-5 Treatment Pros and Cons: Clavicle Fractures
  Pros Cons
No reduction (sling or shoulder immobilizer)
  1. No anesthesia/sedation
  2. Sling/shoulder immobilizer well tolerated
  1. No improvement of fracture alignment
  2. Functional loss of shoulder range of motion (rare)
Reduction and internal fixation (rare)
  1. Improves fracture alignment
  2. Direct rigid fixation of fracture
  3. Improved patient comfort (due to rigid fracture fixation)
  4. No cumbersome cast or splint
  1. General anesthesia
  2. Minimal increased risk of infection
  3. Significant implant concerns
  4. Implant removal
Distal-Third Fractures
Injuries to the distal clavicle in the pediatric population typically are pseudodislocations of the acromioclavicular joint, with fractures through the metaphysis or the physis (218,251). The acromioclavicular joint and the coracoclavicular ligaments usually are undamaged, and most of the periosteal sleeve is intact. Therefore, exceptional potential for growth and remodeling exists for these fractures, allowing successful nonoperative treatment for most injuries to the distal clavicle.
Most investigators agree that undisplaced or minimally displaced injuries of the distal clavicle (types I, II, and III) are treated without surgery (198,218,252,253,254). These injuries are managed with a sling or a figure-of-eight splint immobilization followed by early rehabilitation with range-of-motion exercises. Most children treated with nonoperative management have no significant long-term functional or cosmetic deficits.
The treatment of displaced types IV, V, and VI distal clavicle fractures remains controversial. Some investigators report that most children experience no functional deficits regardless of the method of treatment (252,253). Others report that distal clavicular injuries with either fixed or gross displacement should be treated with open reduction and internal fixation to prevent permanent deformity (198,217,218,220,253,255,256,257). One report suggested that although displaced distal clavicular injuries in children under 13 years of age may be amenable to nonoperative treatment, those in children over 13 years of age should be treated with open reduction and internal fixation (251).
Although no clear consensus exists for the treatment of grossly displaced distal clavicular fractures in children, as long as the integrity of the SSSC is maintained, it appears that neither nonoperative nor operative management results in long-term deficit in the normal function of the shoulder. Treatment options, therefore, should be individualized for each child and his or her family based on compliance as well as acceptance of the possible cosmetic deformity.
Medial-Third Clavicular Injuries
Most pediatric injuries in the medial clavicle are fractures through thephysis. Similar to distal clavicular injuries, these fractures have vast potential for healing in an acceptable position, and subsequent remodeling and nonoperative management is appropriate.
Nondisplaced fractures of the medial physis do not require active intervention. Symptomatic treatment is all that is required for these stable fractures. In fact, nondisplaced fractures often are missed during initial examination and are only discovered after a mass or bump is noted over the medial clavicle. The parents should be warned that the mass is a healing callus surrounding the fracture and that it should remodel and disappear in 4 to 8 months.
Anterior displaced medial clavicular fractures and sternoclavicular dislocations can be safely reduced in the emergency department or operating room. Longitudinal traction is applied to the ipsilateral upper extremity while the shoulder is abducted to 90 degrees (235). Gentle posterior pressure also should be applied over the fracture to encourage reduction. After the reduction is accomplished, the clavicle should be immobilized with a figure-of-eight splint (235).
Posteriorly displaced medial clavicular fractures and sternoclavicular dislocations require immediate evaluation for the presence of concomitant injuries of the airway and/shor great vessels. Minimally displaced fractures and dislocations can be treated without reduction. These mildly displaced injuries can be expected to remodel without significant residual deformity or pain. For fractures and dislocations with significant posterior displacement or those associated with compromise of the airway or great vessels, urgent reduction should be performed. Under general anesthesia, closed reduction is attempted, followed by open reduction if necessary. Before beginning closed reduction in the operating room, appropriate instruments should be prepared for a possible open reduction. It is advisable to notify a thoracic surgeon before beginning reduction maneuvers in case an associated airway or vascular injury becomes apparent.
Technique of Reduction
After induction of general anesthesia, a bolster is placed in the midline between the scapulae with the patient in the supine position. This positioning alone may cause reduction. Gentle longitudinal traction through the ipsilateral arm is then applied if necessary. If these reduction maneuvers are unsuccessful, direct reduction using a sterile towel clip is then attempted. After sterile preparation of the skin, the surgeon pierces the skin with the towel clip and grasps the medial end of the clavicle while an assistant applies longitudinal traction to the ipsilateral upper arm. The clavicle is then manipulated into a reduced position (235). If the above reduction techniques are unsuccessful or in the case of open injuries, open reduction is performed with the repair of the interposed ligaments.
Once these fractures or dislocations are reduced, they are often stable and require no internal fixation. If loss of reduction occurs intraoperatively, suture or wire stabilization can be performed for physeal fractures, or ligament repair for true sternoclavicular joint dislocations (258). A figure-of-eight harness is used for postoperative immobilization for 3 to 6 weeks, or until the injury is nontender. Internal fixation with metal implants is

contraindicated because of the possibility of implant migration, with resulting fatal consequences (259)
Pearls and Pitfalls
  • Every newborn with a delivery-related clavicle fracture should be evaluated for concurrent brachial plexus palsy.
  • Obtain a CT scan for posterior displaced medial clavicle fractures and posterior displaced sternoclavicular dislocations.
  • When performing reduction of posterior displaced clavicles with a towel clip, grasp the clavicle in the central portion of the middle third. This enables better mobilization than grasping near the medial end.
Early Complications
Serious vascular injuries also have been described in association with clavicular fractures, including subclavian and axillary artery disruption, subclavian vessel compression, and arteriovenous fistula (244,260,261,262,263). In addition, displaced fractures of the medial clavicle may result in compression or injury of the great vessels within the mediastinum (204,205). Occasionally, these compressions can be relieved nonoperatively by reducing the fracture and eliminating the excessive pressure on the vessels (244,262). However, if nonoperative treatment does not alleviate the compression, operative reduction of the fracture and possible vascular repair may be required. Certainly, if the structural integrity of the vessels is compromised, operative repair by an experienced vascular or thoracic surgeon is necessary.
In addition to the compression of the great vessels, displaced medial clavicular fractures can result in compression of the trachea and esophagus, causing difficulty with the airway or with swallowing (204,205). Clavicular fractures resulting from severe trauma can be associated with pneumothorax (264,265). Rarely, a pneumothorax results from obstetrical clavicular fractures (266).
Neurologic deficits of the brachial plexus have been reported in association with clavicular fractures. Brachial plexus palsy may present early or late after the traumatic insult and occasionally requires operative reduction of the fracture (244,260,267,268,269). Rarely, such nerve deficits can result from inappro-priate

use of the figure-of-eight splints (237,241). Although permanent nerve deficits have been reported, most brachial plexus injuries resolve spontaneously (269,270).
Failure to recognize and treat associated atlantoaxial rotatory displacement promptly can lead to fixed C1-2 deformity (203). Displacement recognized in the first 3 weeks of injury can be successfully treated without surgery. Fixed deformity can result if the diagnosis and treatment is delayed 6 weeks or longer. Once fixed deformity is established, limited cervical fusion will be necessary.
Late Complications
Implants and internal fixation devices for clavicular fractures have been associated with numerous complications, including hardware migration, infection, and nonunion (199,259,271,272,273,274,275). Although most of these complications can be adequately treated, some can have fatal results (259). Therefore, whenever possible, fixation of pediatric clavicular fractures should use minimal or no hardware.
Malunions are common after initial fracture healing, but most children experience no long-term deformities because of their tremendous potential for remodeling. Rare cases of clavicular reduplication and cleidoscapular synostosis have been reported (218,276). These unusual complications may require additional intervention.
Nonunions following traumatic clavicular fractures should be distinguished from congenital pseudarthrosis and pseudarthrosis secondary to other pathologic processes (214,273,277,278,279,280,281). Operative indications for posttraumatic clavicle fracture pseudarthroses are unacceptable cosmetic deformity and pain (278,281,282,283). However, operative repair with grafting and internal fixation of the pseudarthroses can be associated with additional iatrogenic complications, such as pneumothorax, subclavian vessel damage, air embolism, and brachial plexus deficit (284).
Controversies and Future Directions
Whether internal fixation of clavicle fractures with titanium elastic nails (TEN) will take hold for severely displaced fractures remains to be seen. In any event, management of this fracture remains nonproblematic on the whole.
Dislocation of the glenohumeral joint in children is rare. None of the ancient writings of Hippocrates (460–375 B.C.), Galen (A.D. 131–201), and Paul of Aegena (A.D. 625–690) made specific mention of this injury in children (285). Most textbooks that address children’s shoulder problems do not even discuss dislocations of the glenohumeral joint, and others merely touch on the subject (286,287,288,289,290,291). A review of the literature would suggest that glenohumeral dislocations in children less than 12 years of age are rare. Although several case reports have been presented, no large series of this entity are available (292,293,294,295). In Rowe’s review of 500 dislocated shoulders (296), only 8 patients were under 10 years of age. In this same series, 99 patients were 10 to 20 years of age, but no details on skeletal maturity were given (296,297). Rockwood reported a series of 44 patients with shoulder dislocations, predominantly adolescents (285). Many articles have been published on adolescent patients without discussing their skeletal maturity (298,299,300,301). As the child reaches adolescence, the incidence of shoulder instability increases, but in the skeletally immature patient, this injury can still be considered rare. Marans et al (302) in 1992 presented a series of 21 patients with open physes from two major trauma centers.
Principles of Management
Mechanism of Injury
Traumatic Dislocations
Significant evidence of trauma should be present to assign patients to thisgroup, whereas patients who dislocate with relatively minor trauma should be assigned to the atraumatic group. The vast majority of traumatic dislocations are anterior. The mechanism of injury is similar to that observed in the adult. Typically, a force applied to the outstretched hand forces the arm and shoulder into a maximally abducted, externally rotated position. At this point, the humeral head is levered out of the glenoid process anteriorly, with the head lodging against the anterior neck of the glenoid. This occurs commonly in contact sports, falls, fights, and motor vehicle accidents (303,304,305).
Posterior dislocations are rare. In reported series of all age groups, posterior dislocations represent only 2% to 4% of all traumatic dislocations. The history for posterior dislocations is one of violent trauma with the arm in a position of flexion, internal rotation, and adduction. This can occur in falls and in motor vehicle accidents as the arm bracesthe body against impact. The other common mechanisms that produce posteriordislocations include convulsions and electroshock. In these cases, the shoulder is dislocated posteriorly by the violent contraction of the shoulder internal rotators, which normally are stronger than the shoulder external rotators. The history of the mechanism of injury and a high index of suspicion are necessary to avoid missing a posterior dislocation (306,307,308,309,310).
In neonates, pseudodislocation of the shoulder can occur (311). This problem represents traumatic epiphyseal separation of the proximal humerus, which is certainly much more common than a true traumatic dislocation of the shoulder in this age group. Most true traumatic dislocations of the shoulder in the neonatal period occur in babies with underlying birth trauma to the brachial plexus or central nervous system.
Laskin and Sedlin (312) reported on a 3-month-old infant with Erb-Duchenne palsy who sustained a traumatic luxatio erecta of the shoulder during a planned shoulder manipulation. Posterior dislocation of the shoulder also can occur as a secondary traumatic phenomenon in unrecognized brachial plexus in-juries

of the upper trunk at delivery (313,314,315,316). Green and Wheelhouse (317) reported a dislocation in a 7.5-month-old infant that was secondary to a septic brain injury.
Atraumatic Dislocations
Atraumatic shoulder instability is more common in children and adolescents than previously reported. The child who presents with shoulder dislocation without a clear-cut significant history of trauma should arouse suspicion that atraumatic instability may be present. These patients have inherent joint laxity that allows the shoulder to be dislocated either voluntarily or involuntarily as the result of a minimally traumatic event (Fig. 17-27) (318). For example, throwing, hitting an overhead tennis shot, or pushing the body up when in bed would not constitute significant trauma. A high index of suspicion should be maintained with this kind of history. In the individual who dislocatedvoluntarily, conscious selective firing of muscles while antagonists are inhibited, combined with arm positioning, allows the shoulder to dislocate. Akey to the diagnosis is that atraumatic instability, whether voluntary orinvoluntary, is not associated with much pain.
FIGURE 17-27 Congenital laxity of the left shoulder in a 4-year-old boy who is totally asymptomatic and has full range of motion of the left shoulder. A. With abduction and extension, the head subluxates anteriorly and inferiorly. B. An AP x-ray shows some lateral displacement of the humeral head. C. With overhead elevation, the humeral head is noted to displace anteriorly, laterally, and inferiorly. (Courtesy of Don Jones, MD.)

Even if reduction is necessary, the pain usually disappears rapidly. In most instances, spontaneous reduction occurs without manipulation (285).
Other causes of atraumatic shoulder instability, in addition to multidirectional joint laxity, include Ehlers-Danlos syndrome, congenital absence of the glenoid, deformities of the proximal end of the humerus, and emotional and psychiatric instability. True congenital dislocations of the shoulder are most commonly associated with developmental defects and multiple congenital abnormalities (319,320,321,322,323). Arthrogryposis, neglected septic arthritis, and neurologic defects also have been implicated in atraumatic dislocations in the young child (299,313,315,317,324,325).
Signs and Symptoms
Traumatic Dislocations
The patient with a traumatic anterior dislocation presents with a painful, swollen shoulder. Obvious deformity is present with a prominent acromion and flattening of the contour of the lateral upper arm. The arm is often supported by the contralateral hand and held in an abducted and externally rotated position. Despite swelling, the humeral head can usually be palpated in a position anterior to the glenoid.
Careful examination of the neurologic and vascular status should be performed. The axillary nerve is the most commonly injured with anterior dislocation, and special attention to its function should be included in the physical examination (326). The sensory distribution of the axillary nerve is along the upper lateral arm, and motor innervation is to the deltoid and teres minor muscles. Light touch is adequate for sensory testing in the upper arm region. A convenient way to test deltoid function is to support the involved elbow in one of the examiner’s hand while using the examiner’s opposite hand to grab the muscle belly of the deltoid. The patient is asked to abduct the arm against resistance for about 1 inch so that deltoid firing is initiated. This examination confirms the status of the axillary nerve (Fig. 17-28).
In recurrent anterior dislocation or subluxation, the arm is well located with an overall normal appearance of the shoulder. The shoulder demonstrates a full range of motion, although the patient avoids the cocking position. The apprehension test with the arm abducted above 90 degrees is positive. A positive apprehension test, along with a suggestive history, is a very diagnostic physical sign for recurrent anterior instability.
For the much less common traumatic posterior dislocation, an affected patient presents with flattening of the anterior aspect of the shoulder and posterior fullness. The arm is held at the side with the forearm internally rotated across the chest. The patient resists any attempt at motion. Although difficult to elicit in the acute situation because of pain, hallmark findings of posterior dislocation are lack of shoulder external rotation and inability to supinate the forearm. It is advantageous to examine the shoulder with the patient seated so that the examiner can visualize the shoulders from above. From this perspective, posterior fullness and anterior flattening can be better visualized. As for anterior dislocations, the neurovascular status should be evaluated meticulously. A history of convulsion or electrical shock should raise the index of suspicion for posterior dislocation.
In neonates, traumatic separation of the upper humeral physis, the so-called pseudodislocation of the shoulder, can mimic an anterior dislocation. As is the case for true dislocations, the child is irritable and holds the affected arm abducted and externally

rotated. There is resistance to any type of motion. Deformity in dislocation or pseudodislocation in the neonate is not apparent or subtle.
FIGURE 17-28 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.
FIGURE 17-29 Dramatic demonstration of inferior subluxation of the glenohumeral joint in a patient with multidirectional instability. The clinical correlate is the sulcus sign.
Atraumatic Dislocations
The most notable finding in patients with atraumatic shoulder instability is the relative lack of pain associated with the subluxation or dislocation (327,328,329,330,331,332,333). Even in cases of involuntary atraumatic dislocation, the minor pain associated with the dislocation itself subsides rapidly after reduction. Episodes of atraumatic subluxation and dislocation occur much more frequentlythan traumatic dislocations, and in almost all cases spontaneous reduction is the rule.
On clinical examination, multidirectional laxity or instability of the contralateral shoulder is usually present (285,298,334,335). In addition, there is evidence of laxity of multiple joints (336). Characteristics of multiple joint laxity include hyperextension at the elbows, knees, and metacarpophalangeal joints. Not uncommonly, striae of the skin are present. Skin hyperelasticity is a noted characteristic of Ehlers-Danlos syndrome.
Multidirectional laxity of the shoulder is characterized by a positive sulcus sign and significant translation on an anterior and posterior drawer test. The sulcus sign is a dimpling of the skin below the acromion when manual longitudinal traction is applied to the arm (Fig. 17-29). This produces an inferior subluxation of the humeral head away from the acromion that enlarges the subacromial space and causes dimpling of the skin. The drawer or shift and load test is performed with the examiner seated behind the patient. The scapula is stabilized with one hand and forearm while the humeral head is manually translated anteriorly and posteriorly by the examiner’s opposite hand (Fig. 17-30). Although some translation within the glenohumeral joint is expected in all patients, those with multidirectional laxity demonstrate translation of greater than 5 mm anteriorly and posteriorly from a neutral position.
In atraumatic dislocation, the shoulder often dislocates anteriorly, posteriorly, or inferiorly. The most common direction of dislocation in voluntary instability is posterior or inferior. The patient who can voluntarily dislocate the shoulder can force the humeral head posteriorly by contracting the anterior deltoid and internal rotators while inhibiting the antagonistic muscles

(Fig. 17-31). The elbow is positioned in horizontal adduction, and the head is dislocated. The arm can then be abducted, and the shoulder reduces, often with an audible clunk.
FIGURE 17-30 Drawer test. This technique is used to subluxate the shoulder manually both anteriorly and posteriorly to demonstrate multidirectional laxity.
FIGURE 17-31 Voluntary anterior dislocation of the right shoulder in an 8-year-old boy. A. The patient voluntarily has dislocated the right shoulder anteriorly. B. The shoulder voluntarily reduced. The patient explained that he was taught to do this by an older brother who also had voluntary dislocation of the shoulders.
Associated Injuries
Although any of the nerves that traverse the axilla may be injured at the time of a shoulder dislocation, the axillary nerve is the most common associated nerve injury. Fortunately, most axillary nerve injuries associated with dislocations are neurapraxic and recover spontaneously with time and observation. In the event of complete axillary nerve palsy, significant disability can result due to the lack of deltoid function (326,337,338,339,340,341).
Vascular injuries are rare, but either the axillary artery or vein can be traumatized. Morrison and Egan (342) reported an axillary artery and a brachial plexus injury in a luxatio erecta dislocation in an 11-year-old child. The artery was rejoined with a vein graft and the brachial plexus injury fully recovered.
Diagnosis and Classification
Radiographic Studies
Children and adolescents with open growth plates have a low incidence of true traumatic dislocation of the shoulder. Traumatic lesions on plain x-rays are similar to those found in adults (Fig. 17-32). On the AP or internally rotated views of the proximal humerus, the Hill-Sachs compression lesion on the posterolateral aspect of the humeral head is commonly found. This injury to the proximal humerus occurs as the humeral head is impacted against the anterior rim of the glenoid during a dislocation (Fig. 17-33). Bony injury to the anterior glenoid rim can occur with dislocation as well. Injury to the glenoid ranges from small avulsion-type fractures to substantial bony fractures. Anterior glenoid rim injuries are best seen as a double density on the AP view of the shoulder or as a separate fragment on the axillary and West Point lateral views. The West Point lateral view projects the anteroinferior glenoid rim and most clearly shows this lesion when it is present. In traumatic posterior dislocation, the reverse Hill-Sachs lesion can be seen on the anterior part of the humeral head and in some cases will be seen in conjunction with fracture of the posterior rim of the glenoid.
In cases of traumatic subluxation of the shoulder in which the diagnosis may be unclear clinically, an arthrogram with CT scan can sometimes better delineate the extent of capsular stripping from the anterior glenoid rim. More recently, saline arthrograms and MRI have enhanced our ability to define the degree of injury to the labrum, capsule, and articular surfaces (335,343). CT scanning and MRI are useful for analyzing the significance of fractures of the glenoid rim (Fig. 17-34 and Fig. 17-35). In addition, the size of the reverse Hill-Sachs lesion of the humeral head in posterior dislocations is best analyzed with a CT scan (344,345).
With atraumatic dislocations in patients who do not have congenital or developmental defects, x-rays are usually normal. Among patients who do have congenital defects, the most common abnormality seen on x-rays is hypoplasia or aplasia of the glenoid. In patients with multidirectional laxity and atraumatic dislocation, stress x-rays can usually show instability in anterior, posterior, and inferior directions. The inferior component of multidirectional instability can be demonstrated by applying weights to the arm in an AP film. If laxity is present, this stress view will show the humeral head subluxating inferiorly in its relation to the glenoid (346).
The following scheme is useful for the classification of shoulder dislocation based on etiology:
  • Traumatic dislocations.
    • Primary trauma to the shoulder itself
    • Secondary to birth trauma of the brachial plexus or central nervous system
  • Atraumatic dislocations—voluntary or involuntary
    • Congenital abnormalities or deficiencies of bone or soft tissue
    • Hereditary joint laxity problems, such as Ehlers-Danlos syndrome
    • Developmental joint laxity problems
    • Emotional and psychiatric disturbances
The above etiologic classification is commonly used in adults, but no consensus exists as to a classification scheme in children and adolescents.
Shoulder instability can be classified as to direction, degree,

and chronicity. Two basic schemes have been used to classify shoulder dislocations in children and adolescents. The more common of these is based on the direction or location of the dislocation. Although this scheme is useful in describing the clinical and radiographic features of the injury, it does not address the underlying pathology in children (285). Therefore, a second classification scheme describing the etiology of the dislocation is also useful when considering treatment options for this injury in children. This second system is similar to that used for adults but takes into account congenital and developmental problems unique to children. As discussed later in the section on treatment of this problem, accurate classification is important in selecting the appropriate conservative versus surgical options (347,348,349).
FIGURE 17-32 Traumatic anterior dislocation of the right shoulder in a 15-year-old boy. A. On the AP view, note the Hill-Sachs lesion as well as the anteroinferior bony fragment off the glenoid rim. B. Axillary x-ray made with the arm in 90 degrees of abduction demonstrates the anterior subluxation as well as the deficiency of the anterior glenoid rim.
The directional classification has four categories: anterior, posterior, inferior (luxatio erecta), and multidirectional. As in adults, anterior dislocation in children is the most common, constituting at least 90% of glenohumeral dislocations (Fig. 17-36). Several isolated reports of posterior dislocation in children and adolescents have been documented, but posterior dislocation is rare in children, as in adults (293,350,351,352). Luxatio erecta or inferior locked dislocations are uncommon but have been reported in children (312,353,354). Multidirectional luxatio of the shoulder has been well described as a distinct clinical


entity by Burkhead and Rockwood (355), O’Driscoll and Evans (298), and Rockwood (285,335).
FIGURE 17-33 Anterior shoulder dislocation in a skeletally immature adolescent patient. A. AP x-ray shows the common appearance of an anterior dislocation of the shoulder. B. Postreduction AP x-ray of the shoulder shows a large posterolateral compression fracture of the humeral head or Hill-Sachs lesion.
FIGURE 17-34 A. AP x-ray of a 14-year-old boy with recurrent anterior subluxation. Notice the presence of a Hill-Sachs compression fracture on the humeral head and a subtle double density at the anteroinferior glenoid rim. B. CT scan shows this to be an avulsion-type bony injury of the anterior glenoid.
FIGURE 17-35 MRI in a patient with recurrent anterior instability of the shoulder. The arrows demonstrate a calcified bony Bankart’s lesion.
The degree of instability can be classified as a subluxation or a dislocation. A subluxation is an incomplete dislocation characterized by pain, a feeling of slipping, or a dead feeling in the arm. A complete dislocation of the humeral head out of the glenoid fossa is characterized by a displacement and locking of the head on the rim of the glenoid.
The chronicity of instability can be classified as acute, recurrent, or chronic. A single episode of instability can be described as an acute injury. As in the skeletally mature patient, an acute injury can lead to a recurrent instability, depending on the damage to the ligament and bony restraints of the joint. A chronic instability exists when an acute dislocation is not reduced, and it is usually associated with congenital dislocations.
Surgical and Applied Anatomy
Developmental anatomy is discussed previously in the section on fractures of the proximal humerus. The glenohumeral joint consists of the articulation between the large convex humeral head and the relatively flat glenoid fossa. Since there is very little bony constraint inherent to the glenohumeral joint, this joint is anatomically suited to accommodate the wide range of motion necessary to perform upper extremity function. The articular surface area and radius of curvature of the humeral head are about three times that of the relatively flat glenoid surface. Although the glenoid fossa is deepened by the labrum, the mismatch in the surface area and the radius of curvature explains the lack of joint stability.
The primary constraint for the glenohumeral joint is the capsular/shligamentous complex. The capsule on its inner surface is reinforced by thickened areas known as the anterior glenohumeral ligaments. This complex capsular/shligamentous structure must provide stability against abnormal translation while allowing a wide range of motion. With the arm abducted, the inferior capsule is highly redundant. The most important ligament is the anteroinferior glenohumeral ligament, located within the inferior redundant area. It is mechanically designed to tighten as the arm is abducted and externally rotated, much like the effect of wringing out a washcloth. This structure becomes the primary site of pathology in anterior shoulder instability, either when the anteroinferior glenohumeral ligament attachment to the glenoid and labrum is stripped from the anterior neck of the glenoid or as these ligaments are disrupted in substance (Fig. 17-37). Disruption of the capsular labral attachment is known as a Perthes or Bankart lesion.
The humeral attachment of the capsule of the glenohumeral joint is along the anatomic neck of the humerus except medially, where the attachment is more distal along the shaft. The physis, therefore, lies in an extracapsular position except on the medial side. As in most pediatric joint injuries, the strong capsular attachment to the epiphysis makes failure through the physis a much more common injury than true capsular/shligamentous injury (348,356,357). Therefore, fracture through the physis is more common than a dislocation in the skeletally immature patient.
The rotator cuff tendons consist of the subscapularis, supraspinatus, infraspinatus, and teres minor muscles. These muscle–tendon units surround the joint anteriorly, superiorly, and posteriorly. They serve an important function as dynamic secondary stabilizers of the joint by forming a force-couple with the large shoulder muscles (deltoid, pectoralis major, and latissimus dorsi). As the glenohumeral joint moves through its range of motion, the cuff provides a dynamic stabilizing effect, preventing excessive translation of the humeral head on the glenoid. This is important when addressing rehabilitation for the prevention of recurrent glenohumeral dislocation.
Current Treatment Options
Treatment options are listed in Table 17-6 as well as in the following text.
Traumatic Instability
The literature on the specific treatment of shoulder instability in children is limited (288,290,347,358). Most clinicians make the same treatment recommendations based on the sustained injury, regardless of the patient’s age (303,359,360,361,362,363). The majority of treatment recommendations presented in this section are extrapolated from the adult and adolescent literature, as well as from the experience of Dameron and Rockwood (348).
Acute Dislocation
Patients with acute dislocations of the shoulder should undergo closed reduction by one of the standard techniques. For anterior dislocation, many reduction techniques have been described. Most clinicians prefer light sedation with intravenous or intramuscular injection. The traction/shcountertraction method is believed

to be the most gentle. A bed sheet placed in the axilla of the affected shoulder passes above and below the patient so that countertraction can be applied to the body while longitudinal traction in line with the deformity is applied to the arm. Steady, continuous traction fatigues the muscles that lock the dislocation, and eventually reduction is accomplished by disimpacting the humerus from the glenoid.
FIGURE 17-36 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.
The Stimson maneuver is equally effective. In this technique, the patient is placed prone on the examination table. A weight is applied to the affected arm. As the shoulder girdle muscles relax, reduction is achieved atraumatically (301). Another less-often-practiced technique is scapular manipulation. Kothari and Dronen (364) and McNamara (365) report that this latter technique is a safe, effective way to reduce glenohumeral dislocations.
Postreduction immobilization remains a subject for debate. The adult literature suggests that the period of immobilization may not be truly important in predicting recurrent dislocation. A sling or a sling-and-swathe with the arm internally rotated is the most common method of immobilization (360,366).
Closed reduction for acute posterior dislocations is somewhat similar to that for anterior dislocations. Traction–

countertraction is the most effective method. Traction is applied in line with the deformity, and the humeral head is gently lifted back into its normal relationship with the glenoid. Most clinicians agree that immobilization should be with the arm in neutral rotation or slight external rotation at the shoulder. This may require the use of a spica cast or modified shoulder spica cast, as described by Dameron and Rockwood (348).
FIGURE 17-37 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. A, anterior; P, posterior; HH, humeral head.
Recurrent Dislocation
The true incidence of recurrent dislocation after traumatic shoulder dislocation in children is understandably poorly defined, given the rarity of reports in the pediatric orthopaedic literature (321,367). In 1963, Rowe (297) reported a 100% incidence of recurrence in children 1 to 10 years of age with anterior dislocation. He also reported a 94% incidence of recurrence in adolescents and young adults (ages 11 to 20) (297). Elbaum et al (340) reported a recurrence rate of 71% in nine pediatric patients with traumatic anterior dislocations. The average age was 9 years. After reduction, they were immobilized for 3 weeks and then were treated with rehabilitation. However, Rockwood (285) reported a recurrence rate of only 50% in a series of adolescents and young adults 13.8 to 15.8 years of age. Hovelius et al (367) reported a 47% recurrence rate in patients less than 20 years of age. In a 10-year follow-up study, Hovelius et al (368) found that recurrent dislocation necessitating operative treatment had developed in 34% of shoulders in patients who were 12 to 22 years of age at the time of initial dislocation, compared with 28% in patients who were 23 to 29 and 9% in patients who were 30 to 40 years old. The type and duration of the initial treatment had no effect on the rate of recurrence. Vermeiren et al (369) reported a recurrence rate of 68% in patients younger than 20 years of age. They reported a better prognosis if the dislocation was associated with a fracture of the joint. Heck (292) reported a case of traumatic anterior dislocation in a 7-year-old boy who remained stable at a 5-year follow-up (Fig. 17-38). Endo et al (370) reported no recurrence in 2 patients, ages 3 and 9, with traumatic anterior dislocation. However, the follow-up was only 2 years in the 3-year-old and 1 year in the 9-year-old. Wagner and Lyne (295) reported an 80% recurrence rate in 10 patients with clearly


open proximal humeral epiphyses. Marans et al (302) reported the fate of traumatic anterior dislocations of the shoulder in 21 children (15 boys, 6 girls) in what may be the largest documented series to date. All the children had one or more documented anterior dislocations after the initial injury. Some of the children had been immobilized in a sling-and-swathe for 6 weeks. The literature reflects that the natural history of shoulder dislocations in adolescents and young adults demonstrates recurrence rates for dislocation of 50% to 90% despite the treatment program used after the initial dislocation.
TABLE 17-6 Interventions for Glenohumeral Subluxation and Dislocation
  Closed Reduction & Immobilization Closed Reduction & Early Reconstruction
Traumatic—acute, anterior X X (less common)
Traumatic–acute, posterior X  
Atraumatic X
Atraumatic–multidirectional X X–with caution, see text
FIGURE 17-38 Traumatic anterior subluxation of the left shoulder in a 7-year-old boy. A. AP film of the left shoulder does not reveal any striking abnormality. B. An axillary film shows that the humeral head is subluxated away from the glenoid fossa. C. AP film of the left shoulder after manual reduction. (Courtesy of Charles C. Heck.)
Multiple surgical procedures have been described for the treatment of anterior shoulder instability. Once again, specific results for procedures such as the Putti-Platt, Bankart, and Magnuson-Stack have not been documented for children. Barry et al (361) described the effective use of the coracoid transfer for recurrent anterior instability in adolescents. Capsular procedures that specifically address the capsular pathology have been described by Neer and Foster (371), Jobe (372), and Rockwood et al (335), but results in children’s dislocations were not documented. Goldberg et al (299) have reported on the use of arthroscopic techniques for capsular repair in adolescents.
Atraumatic Instability
Treatment of patients with atraumatic dislocations of the shoulder appears more difficult than treatment for true traumatic dislocations. Emphasis should be placed on careful diagnosis in these cases. Specific congenital bony or neurologic deficits should be recognized. The sequelae of Ehlers-Danlos syndrome or other collagen deficiency syndromes should be noted.
In patients with multidirectional laxity and voluntary or involuntary dislocations, a significant history of trauma is usually lacking. These patients have minimal pain associated with the dislocation and on clinical examination usually have other signs of multidirectional laxity of the opposite shoulder. Most of these dislocations reduce spontaneously and are associated with little pain. Rowe et al (332), Neer (336), and Burkhead and Rockwood (285,335,355) have described the use of a vigorous rehabilitation program involving strengthening of the rotator cuff as the treatment of choice for these patients. Most patients who do not have significant emotional and psychiatric problems are successful in improving their shoulder stability with such a program.
Most clinicians would agree that surgical intervention is considered only if a strict 6- to 12-month rehabilitation program fails. Routine shoulder reconstructions involving subscapularis shortening, including the Magnuson-Stack and Putti-Platt procedures, or “bone blocks” such as the Bristow are not sufficient for preventing future instability. Neer and Foster (371) described the inferior capsular shift reconstruction specifically for patients with multidirectional laxity of the shoulder with atraumatic instability. This procedure attempts to eliminate the overall capsular laxity and is used only after rehabilitation has failed. Huber and Gerber (373) reported on 25 consecutive children with 36 involved shoulders with voluntary subluxation of the shoulder. The children managed by “skillful neglect” had a satisfactory outcome, but only 50% of those treated with an operative procedure to prevent later degenerative arthritis had good results. They concluded that voluntary subluxation of the shoulder has a favorable result and that there is no indication for surgery with this problem in children.
Any of the neurologic or vascular injuries can occur at the time of dislocation or during relocation. Although rare, axillary or other nerve neuropraxia that does not spontaneously recover requires neurodiagnostic evaluation and possibly surgical reconstruction. Vascular injury should be evaluated immediately for repair.
Little information is available in the literature about the success or failure rates of surgical reconstruction of the shoulder for recurrent dislocation in children. As discussed, traumatic dislocation in a child or adolescent can progress to recurrent dislocation in 50% to 100% of cases. Rockwood et al have shown that more than 85% of atraumatic dislocators can be managed with a vigorous rehabilitation program and do notrequire surgery (285,335,355). Surgical treatment of these problems in children could be expected to have a success rate at least equal to that in adults. Greater than 90% success in stopping traumatic dislocations would be expected with surgical reconstruction (359,361,363).
Complications of surgical reconstruction of the shoulder include recurrent dislocation, recurrent subluxation, painfully restricted motion, problems with metal impingement or loosening about the shoulder, and neurologic injury. Perhaps the most common problem associated with the standard reconstructions about the shoulder that include subscapularis tendon-shortening procedures (Magnuson-Stack and Putti-Platt) is loss of external rotation. This loss in adults has been associated in some patients with a more rapid progression to glenohumeral arthritis (374,375).
Procedures that use metallic implants about the shoulder, including the Bristow and the DuToit stapling procedures, have been associated with complications of metal impingement on the humeral head or encroachment on the articular surface. Both problems can lead to pain and eventual arthritic change (286,334,376,377).
Controversies and Future Directions
The role of primary capsular repair (Bankart repair) for the acute first-time traumatic dislocator remains to be seen and played out in research of this injury. Initial indications seem to suggest that the procedure has value for the very active individual with a high likelihood of recurrent dislocation.
Fractures of the humeral shaft represent 10% or less of humerus fractures in children (378,379,380) and 2% to 5.4% of all children’s fractures (378,381). They are most common in children under 3 and over 12 years of age (382). The incidence is greater in children with more severe trauma (383). The incidence is 12 to 30 per 100,000 per year (381,384,385). Birth injuries to the humerus have a reported incidence ranging from 0.035% to 0.34% (386,387).
Principles of Management
Mechanisms of Injury
Birth Injuries
Humeral fractures are more common in breech presentations and with macrosomic infants. The most difficult position is when the child’s arms have gone above the head with maneuvers to bring the arm down after version and extraction (387).
Child Abuse
Humeral fractures in child abuse represent 61% of all new fractures and 12% of all fractures (388,389). Shaw et al (389), in a retrospective review of 34 humeral shaft fractures

in children under 3 years of age, found that most occurred accidentally: only 6 were classified as caused by probable abuse. Child abuse must be part of the differential diagnosis in children with humeral diaphyseal fractures (390). The fractures may be spiral from a twisting injury or transverse from a direct blow.
Older Children
Older children sustain primarily transverse fractures from direct blows to the arm, frequently from falls, pedestrian/shvehicle accidents, gunshot wounds, and machinery. Sports injuries are direct from contact sports or indirect from throwing. Throwing injuries occur as a stress injury from overuse or acutely during the throwing cycle from poor mechanics (391,392,393,394,395,396,397,398,399,400,401). A stress fracture also has been reported in an adolescent tennis player (402). Acute throwing fractures result from a sudden external rotation torque developed on the distal humerus with concomitant proximal internal rotation from the pectoralis major between the cocking and acceleration phases (403) as the shoulder external rotation and elbow flexion suddenly change to shoulder internal rotation and elbow extension. Humeral fractures may occur from arm wrestling in older adolescents (404,405,406). Many humeral fractures are pathologic through simple bone cysts or through dysplastic bones from osteogenesis imperfecta or fibrous dysplasia. Occasionally, pathologic fractures occur from benign or malignant tumors.
Signs and Symptoms
Evaluation of the Neonatal Shoulder
The infant who does not move the shoulder poses a diagnostic challenge. Establishing and evaluating a differential diagnosis is the first concern. By history, was the delivery normal? When was the problem noticed? Does the child move any part of the extremity? Was there a history of maternal gestational diabetes or of fetal macrosomia? Does the child nurse from each breast? A broad, useful differential diagnosis consists of clavicle fracture, proximal humeral physeal fracture, humeral shaft fracture, shoulder dislocation, brachial plexus palsy, septic shoulder, osteomyelitis, hemiplegia, and child abuse.
Initially, the child should be observed for spontaneous motion of the upper extremity. Is there any hand or elbow motion? Are there any areas of swelling, ecchymosis, or increased warmth? Does the child move the ipsilateral lower extremity? The clinician should carefully palpate each area of the upper extremity, starting with the clavicle and comparing it carefully with the opposite side for any change in soft tissue contour or tenderness. The upper arms and shoulders should then be examined, looking for any tenderness in the supraclavicular fossa. Lastly, the spine should be examined for tenderness or swelling.
Birth Fractures of the Humerus
In the newborn, a humeral fracture can simulate a brachial plexus palsy with pseudoparalysis and an asymmetric Moro reflex. The fracture site is tender and may have swelling or ecchymosis. The diagnosis is confirmed by plain radiography (387,407).
Older Children
In older children, the diagnosis is usually evident with pain, swelling, and unwillingness to move the arm. The arm is often supported by the opposite hand and is held tightly to the body (Fig. 17-39). It is essential to perform a complete neurologic and vascular examination of the extremity before any treatment except emergency splinting.
Children with torus or greenstick fractures may have localized tenderness but no deformity. In multiple-trauma victims, careful evaluation should be made of the arm because the diagnosis can be missed, especially if the patient is medically unstable (408). Humeral fractures should be sought in patients with massive upper extremity trauma.
Diagnosis and Classification
The simplest classification for humeral diaphyseal fractures describes the location (proximal third, middle third, or distal third, or the diaphyseal–metaphyseal junction), the pattern (spiral, short oblique, or transverse), the direction of displacement, and any tissue damage. Anatomically, the location is noted as proximal to the pectoralis major insertion, between the pectoralis

major and deltoid insertions, below the deltoid insertion, or at the distal metaphyseal–diaphyseal junction (409). Humeral shaft fractures may be segmental, with fractures of the shaft and neck (410,411), or associated with shoulder dislocation (412,413). If they are associated with fractures of the ipsilateral forearm, they result in the so-called floating elbow (414,415).
FIGURE 17-39 A young patient with a humeral shaft fracture, holding the arm tightly to his side.
The Association for the Study of Internal Fixation (AO-ASIF) has a classification for humeral shaft fractures (416,417), but it is not helpful in the evaluation and treatment of most children’s humeral fractures, and like most classifications, it is subject to interobserver variability (418,419).
Imaging Studies
X-rays may be needed of the shoulder, clavicle, humerus, and cervical spine. Often the shoulder, clavicle, and humerus can be seen on a single AP view of both upper extremities and the chest. Ultrasonography can be used to identify a fracture of the clavicle or the proximal humeral epiphysis, a shoulder dislocation, or a shoulder effusion. A CT scan or arthrogram may be necessary. The radiographic findings for each fracture are discussed in the particular anatomic sections.
AP and lateral x-rays are sufficient and complete in most instances of humeral shaft fractures. In the occasional case where the diagnosis is suspect but not readily apparent on these views, oblique views may be useful.
Radiographic Findings
Birth fractures of the humerus are usually quite apparent on AP and lateral x-rays of the humerus. In older children, x-rays should be taken in both the AP and lateral planes to obtain two films perpendicular to each other. Most fractures are easily visualized on these x-rays. A true lateral view of the distal humerus is noted by superimposition of the posterior supracondylar ridges of the medial and lateral epicondyles (420,421). A supracondylar process of the humerus, when present, is best seen on an oblique x-ray showing the anterior medial aspect of the distal humerus.
Displaced fractures above the pectoralis major have marked abduction of the proximal fragment with external rotation by the rotator cuff attachment (409,422). The distal fragment is pulled proximally by the deltoid and medially by the pectoralis major. Displaced fractures between the pectoralis major and deltoid insertions show adduction of the proximal fragment from the pectoralis major and shortening by pull of the deltoid on the distal fragment. Fractures below the deltoid insertion have abduction of the long proximal fragment by the deltoid, but with shortening and medial displacement of the distal fragment by the pull of the biceps and triceps (409).
Pathologic bone may be evident (410,411). Simple bone cysts are a common cause of fractures. Periostitis or periosteal reaction of the humerus necessitates differentiating osteomyelitis or Ewing sarcoma from a stress fracture; every effort must be made to identify a cortical fissure using other imaging techniques (412,413,414,415).
Holstein and Lewis described a short oblique fracture of the distal third of the humerus with potential radial nerve palsy after closed reduction (416,417). This has been called the Holstein-Lewis fracture.
Surgical Applied Anatomy
Embryology and Development
The end of the embryonic period is marked by vascular invasion of the humerus at age 8 weeks. During the subsequent fetal period, the humerus resembles the adult bone in both form and muscular relationships (418,419,420,421). A bony collar is present very early with subsequent enchondral bone formation. The secondary ossification centers at the ends are not generally ossified radiographically until after birth (420,421).
The proximal metaphysis of the humerus is wider than the thinner, triangular shaft. Distally, this flattens and widens to form the condylar region of the elbow. The deltoid inserts into a protuberance midway down the shaft known as the deltoid tuberosity. Distal to the tuberosity, the muscular spinal groove wraps posteriorly around the humerus. The groove gives origin to the uppermost fibers of the brachialis. The periosteum of the humeral diaphysis is thick and provides good remodeling potential (422,423). The main vascular foramen is at mid-shaft, but accessory foramina are common=mmost enter the anterior surface usually below the main foramen, but many are posterior (420,421,424).
The radial nerve ordinarily lies close to the inferior lip of the spiral groove but not directly in it (425). The profunda artery either accompanies the radial nerve or passes in a second narrower grove. The nerve is protected from the humerus by a layer of either the triceps or the brachialis until the lower margin of the spiral groove near the lateral intermuscular septum (425). The ulnar nerve passes from anterior to posterior just distal to the humeral mid-shaft. A well-formed arcade and internal brachial ligament may hold the ulnar nerve (426). This ligament is always posterior to the medial intermuscular septum and subsequently joins the medial intermuscular septum proximal to the medial epicondyle. A few patients with a modified arcade have only superficial fibers of the triceps medial head passing superficial to the ulnar nerve and none deep to the nerve, making the nerve very close to the bone and vulnerable during a fracture (426).
Several major muscle attachments occur throughout the metaphyseal and diaphyseal regions of the humerus. The pectoralis major muscle inserts laterally and distal to the bicipital grove along the anterior aspect of the humerus. The latissimus dorsi and teres major insert on the upper medial aspect of the humerus medial to the bicipital groove. The deltoid courses from the

clavicle, acromion, and scapular spine to insert over a broad area of the deltoid tuberosity. The coracobrachialis arises from the coracoid process and inserts on the anterior medial aspect of the humerus at the junction of the middle and lower thirds. The brachialis originates from the anterior humerus about midway down the shaft. Knowledge of these muscles and their directions is essential to understand fracture displacement and treatment (422,427).
TABLE 17-7 Interventions for Fractures of the Humeral Shaft and Distal Humeral Diaphyseal Fractures
  Nonoperative (sling/swathe; U plaster; hanging arm cast) Functional Bracing Operative Reduction & Internal Fixation
Birth fractures, humeral shaft X    
Humeral shaft X X
Distal humeral diaphyseal X X Traction pin and traction (rare)
Current Treatment Options
Treatment options are listed in Tables 17-7 and 17-8 as well as in the following text.
Birth Injuries
Neonatal humeral shaft fractures heal and remodel quite well, with 40% to 50% remodeling within 2 years (Fig. 17-40) (428). Reported treatments include a sling-and-swathe (429) or a traction device using the von Rosen splint (430). The primary potential complication of birth injuries is an internal rotation deformity. Therefore, the fracture is best stabilized by splinting the arm in extension. If the parents will be moving the child, the splinted arm can be bound to the chest with a soft wrap. Children with arthrogryposis and brachial plexus palsies are prone to internal rotation contractures of the shoulder; these can be exacerbated if the birth fracture’s rotation is not controlled.
Stress Fractures
Virtually all nondisplaced stress injuries heal well with temporary rest and immobilization (391,393,394,397,399,401,402,431,432). They can displace if not treated (391). Displaced stress fractures should be treated like other humerus fractures.
TABLE 17-8 Treatment Pros and Cons: Fractures of the Humeral Shaft and Distal Humeral Diaphyseal Fractures
  Pros Cons
No reduction (sling or shoulder immobilizer)
  1. No anesthesia/sedation
  2. Sling/shoulder immobilizer well tolerated
  1. No improvement of fracture alignment
  2. Loss of shoulder range of motion
Reduction and external immobilization
  1. Improves fracture alignment
  2. No implant concerns (infection, migration, malposition, etc)
  3. No need for secondary anesthesia for implant removal
  1. Need general anesthesia
  2. Cumbersome cast/splint
  3. No direct rigid fixation of fracture (potential for loss of reduction)
Reduction and internal fixation
  1. Improves fracture alignment
  2. Direct rigid fixation of fracture
  3. Improved patient comfort (due to rigid fracture fixation)
  4. No cumbersome cast or splint
  1. Need general anesthesia
  2. Minimal increased risk of infection
  3. Implant concerns
  4. Possible need for implant removal
FIGURE 17-40 A. Fracture of the left humerus in a neonate that occurred during a difficult delivery. B. After 2 weeks of immobilization, clinical and radiographic union is evident, but with anterolateral angulation. C. At 2 months after injury, there is considerable remodeling. D, E. At 20 months, there is essentially complete remodeling of the fracture.
FIGURE 17-41 A, B. Radiographic appearance of a malunited humerus fracture showing 20 degrees of varus. C, D. The same patient with no deformity or disability, despite her thin extremities.



Acceptable Alignment
Because the humerus is not a weight-bearing bone, it does not require the precise mechanical alignment of the lower extremity. The marked mobility of the shoulder also allows some axial and rotational deviation without functional problems. Severe internal rotation contractures can cause difficulties in some overhead activities such as ball throwing and facial hygiene. Varus of 20 to 30 degrees is necessary before becoming clinically apparent (Fig. 17-41) (409,433,434). Anterior bowing may be apparent with 20 degrees of angulation (433). Functional impairment does not occur with 15 degrees or less of internal rotation deformity (409). Even adolescents can correct up to 30 degrees spontaneously (409). Beaty (382) gives guidelines based on the patient’s age: children under 5 years of age tolerate 70 degrees angulation and total displacement, children 5 to 12 tolerate 40 to 70 degrees angulation, and children over 12 tolerate 40 degrees and 50% apposition. However, bayonet apposition is acceptable (435–1237), with 1 to 2 cm of shortening well tolerated (Fig. 17-42). Clinical appearance is more important than radiographic alignment.
Nonoperative Treatment
Nonoperative treatment often increases internal rotation by 3 to 12 degrees at the expense of external rotation (409). This rarely is a functional problem. Nonoperative methods include a sling-and-swathe, the U plaster, a hanging arm cast, a thoracobrachial cast or dressing, a coaptation splint or functional bracing, and traction.
The simplest form of treatment for fractures is a sling-and-swathe. It is sufficient for patients with minimally displaced greenstick and torus fractures (434,438). Although this treatment may yield good results in displaced fractures (439), it can be quite difficult to control anterior angulation (440) and may be uncomfortable.
U Plaster-Sugartong
Böhler (435) described a U plaster similar to the sugartong splint used on forearms. Plaster of appropriate width for the upper arm is formed from over the shoulder along the lateral aspect of the arm, underneath the olecranon, and along the medial aspect of the arm to the axilla. Cotton webbing is placed between the plaster and the skin, and the plaster is secured using a wrap (Fig. 17-43). Results have been quite good


(409), particularly in children (441). Holm (429) suggested applying benzoin before the cotton webbing and using a collar-and-cuff sling about the wrist. To prevent slippage, Shantharam (442) suggested applying the splint from the base of the neck, over the shoulder, and around to the axillary fold, with a strap securing the proximal end to the chest. The U plaster may not control alignment satisfactorily in more displaced fractures, which may require a thoracobrachial cast (429,434,436) or internal fixation. Böhler actually abandoned the immediate use of the U plaster for a thoracobrachial cast because of problems with early swelling (436,437).
FIGURE 17-42 A. Humerus fracture allowed to heal in slight varus and bayonet apposition. B, C. The ultimate result, with essentially normal alignment.
FIGURE 17-43 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 inches 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.
Hanging Arm Cast
The hanging arm cast, described by Caldwell as a technique already in use (443), consists of a long-arm cast with a sling around the neck tied to the cast along the forearm. The weight of the cast and arm provides longitudinal traction. The position of the sling is modified to correct anterior or posterior angulation and varus or valgus. Rotation is difficult to control. Stewart and Hundley suggested not using it in children under age 12 because children cannot keep their arms in a dependent position during sleep and often keep the arm supported rather than hanging while awake (444). However, excellent results are reported in patients under age 10 (445). This is probably due to the marked remodeling and potential for good results regardless of treatment in children. Possible complications of the hanging cast include inferior shoulder subluxation (446), decreased external rotation (446), and shoulder stiffness (447), but these are rarely significant in children.
Thoracobrachial Immobilization
Severely unstable fractures uncontrollable in a hanging cast or U plaster may necessitate extending the cast to the chest as a thoracobrachial cast or splint (429,434,436,437,440). Various types of thoracobrachial dressings are often described as a Velpeau, but technically this is incorrect: Velpeau described a thoracobrachial bandage with acute elbow flexion. If a thoracobrachial cast or splint is used for a grossly unstable fracture, usually only a few degrees of abduction is necessary (429). Distal diaphyseal fractures rarely require extension to the chest.
Functional Bracing
Functional bracing, as described by Sarmiento (448), has been quite effective in adults (449,450,451,452,453,454,455,456). It may be difficult to use in children because size differences require a customized brace for each patient or a large supply of braces; however, modern thermoplastics can keep this economical (Fig. 17-44) (457). A prefabricated brace is placed on the initial visit if possible or on subsequent visits after placement of a U plaster or sling-and-swathe at the initial evaluation (458). The patient must be followed closely and the splint tightened as needed. It should not be used in bedridden patients because of loss of gravity support (449). Sarmiento (448,459,460) noted difficulty in controlling anterior angulation and indicated that patients should not lean on the elbow. The results in adults may be functionally superior to those of the U plaster (461).
FIGURE 17-44 Light plastic functional braces are useful to maintain alignment and allow early restoration of motion, particularly in older children and adolescents.
Side-arm and overhead skin and skeletal forms of traction have been described (429,434,462,463). If olecranon skeletal traction is used, the AO method of an eye screw in the olecranon is less likely to produce ulnar nerve irritation than is a transolecranon pin (419,434). Excessive traction can lead to nonunion in adults (464) and elbow dislocation in children (465).
Operative Treatment
There are several surgical alternatives for humeral diaphyseal fractures: pinning, external fixation, intramedullary rodding, screw fixation, and compression plating. Biomechanically, interlocking rods are the stiffest in bending, and dynamic compression plating is stiffest in torsion. Flexible intramedullary rods are not as stiff as intact bone (466).
Open Reduction and Internal Reduction
Open reduction and internal reduction can be performed through either a posterior triceps-splitting approach, as advocated by the AO group (419,467), or through an anterior lateral approach between the brachialis and brachioradialis with extension proximally between the deltoid and pectoralis (468,469). The normal 4.5-mm dynamic compression plate does not provide adequate

stability for the adult humerus shaft. The broad 4.5-mm dynamic compression plate is designed to allow compact screw placement without causing excessive stress on the humerus (419). At least six cortices of screw fixation proximal and distal to the fracture site are needed. With either the anterolateral or posterior approach, the lateral intermuscular septum should be split in the distal third to release the radial nerve’s tether. Interfragmentary lag screws should be used when possible. The plate should be slipped underneath the radial nerve and vessels and some muscle placed between the plate and the nerve. Multiple screws in oblique fractures without a compression plate are unsatisfactory in adults (467) but may be sufficient in children. Extensively comminuted fractures should be grafted with autologous cancellous bone.
Generally, the results are good (468,470,471,472,473,474), and plating is particularly advocated in multiple-trauma patients to facilitate nursing care and management of other injuries (468). Potential complications include radial nerve palsy, infection, delayed union, nonunion, and failure of fixation (474).
Intramedullary Rodding
Several types of intramedullary rods are available. Currently, there are no indications for reamed intramedullary nailing in children because of potential proximal physeal damage and the small diaphyseal diameter. However, they may be used in older adolescents if the risk of physeal arrest is minimal and the canal has sufficient diameter (475). Reamed nailing has been reported in patients as young as 16 (476,477). The results are generally good (403,476,478,479,480,481,482,483,484,485,486), with a low risk of nonunion and infection (487).
Unreamed nails, such as Ender nails, Rush rods, or flexible titanium rods have been used primarily in adults. Nails or rods can be inserted via a posterior triceps-splitting approach through a hole just above the olecranon fossa. This can be useful for rapid management of fractures, including open fractures in patients with multiple trauma (392,488,489,490,491). Rods should not be inserted through the greater tuberosity in children (except under extenuating circumstances) because of the proximal humeral physis and the potential for shoulder impingement (492,493,494). Inserting these relatively large rods through the epicondyles results in a high incidence of nail back-out (491).
There are two techniques of using small, flexible, smooth wires. In the Hackethal technique (495), fluoroscopy is used with a tourniquet placed on the upper arm. A hole is made just proximal to the olecranon fossa using a triceps-splitting approach. Smooth, blunt-tipped Steinmann pins are placed up the canal of the humerus, progressively filling the canal with smaller and smaller pins as needed (Fig. 17-45). Results are generally good (496,497,498,499,500,501,502), although pin back-out can be a problem and care must be taken not to distract the fracture site. The rods should be bent 90 degrees at the cortical window (501). This technique may be useful for segmental and pathologic fractures (503).
The other technique consists of using small smooth rods or Steinmann pins placed through the epicondyles (504,505). The tips of the rods should be blunt and slightly bent. These are placed through the lateral epicondyle or through both the medial and lateral epicondyles. A hole is made in the epicondyle, and a blunt-tipped Steinmann pin is tapped up the diaphysis using a mallet or passed by hand, with a drill chuck holding the pin. The bend on the tip of the rods facilitates crossing the fracture site and manipulating the fracture reduction. A splint is necessary postoperatively. Alignment need be only within the tolerances for a closed reduction (Fig. 17-46).
FIGURE 17-45 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.
External Fixation
Both unilateral and multiplanar external fixation techniques are occasionally useful for humeral shaft fractures (462,506,507,508). External fixators are primarily useful for severe open fractures or as an alternative to internal fixation. In patients with open fractures, immediate external fixation with subsequent bone grafting yields good results (509,510). External fixation can be combined with internal fixation for immediate stability (511) for early rehabilitation. Severe open fractures with bone loss can be treated with primary shortening followed by callus distraction (512) to provide early soft tissue coverage and subsequent restoration of humeral length. Care must be taken during pin placement to avoid radial nerve injury. If screws are used, limited open screw placement can prevent this injury (509). Ring fixators may be useful for reconstructing the injured humerus (513,514,515,516,517,518,519,520).
FIGURE 17-46 A. A segmental fracture difficult to align by nonoperative methods treated with two intramedullary smooth pins. B. Alignment need be only within the same tolerances as closed reduction.

Operative Versus Conservative Treatment
Because most humeral fractures are controllable nonoperatively, there are few surgical indications (521). Potential operative indications include open fractures, multiple trauma, bilateral injuries, arterial injuries, compartment syndromes, pathologic fractures, significant nerve injuries, inadequate closed reduction, and ipsilateral upper extremity injuries or paralysis.
Preadolescents can almost always be managed nonoperatively, except those with severe soft tissue injury. If fracture reduction cannot obtain less than 30 degrees varus and 20 degrees anterior angulation in older children and adolescents=mor more importantly, if the arm appears deformed=malternatives such as internal fixation, intramedullary rodding, external fixation, a thoracobrachial cast, or traction should be considered. Inadequate closed reduction is most common in obese patients and in thin women with large breasts (467). However, obesity tends to hide the deformity of the fracture, and large breasts are seldom encountered in children.
Open fractures may require fixation. Small, stable grade 1 wounds can still be managed using coaptation splints or other closed methods. Unstable open fractures should be stabilized with internal or external fixation to protect soft tissues (467,490,522,523,524,525).
Multiple-trauma victims are often best treated with internal or external fixation for more rapid mobilization (382,392,468,469,526,527). This is particularly true in patients with chest injuries, where thoracobrachial immobilization would compromise pulmonary care (490,524,526). Excellent results have been reported with external fixation (507,509,510,522), retrograde rodding using Ender nails or Rush rods (392), and internal fixation (468). In older adolescents, more rigid locked or unlocked intramedullary rodding can be used for patients requiring their upper extremities for mobility (469). However, this luxury does not exist for younger children.
Arterial injury and compartment syndromes requiring fasciotomy are potential indications for internal fixation (528,529,530,531). Continued fracture mobility can damage a vascular anastomosis (530,531,532,533), and fasciotomy can make the fracture less stable. Temporary vascular shunting before internal fixation allows the orthopaedist and the vascular surgeon to work under optimal conditions (534).
Most pathologic fractures in children, including those from malignancy (535), fibrous dysplasia (410,411,536), osteogenesis imperfecta, and simple bone cysts, can be treated nonoperatively. Simple bone cysts are discussed later in the section on proximal humerus fractures. A report of a 6-year-old with progressive ossifying fibrodysplasia suggests that internal fixation may prevent stiffness after fractures in this condition (537). In fractures secondary to malignancy, intramedullary rodding is necessary if extensive cortical loss causes instability (477,494,538,539,540). Spontaneous fracture in a severely brain-injured or unresponsive cerebral palsy patient is best treated nonoperatively (541).
Ipsilateral injuries, particularly fractures of the proximal or distal humerus and of the forearm, can be difficult to control. In adults with a floating elbow, internal fixation of the humeral fracture provides optimal results (392,542,543). This is also true for supracondylar humeral fractures in children but is not documented in diaphyseal fractures (414,415). The floating elbow is often associated with other organ system injuries; nerve injury occurs in up to 50% of these patients (544).
Humeral shaft fractures with ipsilateral brachial plexus palsies in adults heal best with open reduction and internal fixation (545). The same is true with spinal cord injuries (546). Functional bracing is precluded in these patients because the muscles do not function. Because of the excellent healing potential in children, they may be treated nonoperatively if satisfactory alignment can be maintained. Older adolescents should be treated like adults.
Radial Nerve Palsies
Radial nerve palsies with humeral shaft fractures have been reported in children (Fig. 17-47) (524,547). Primary radial nerve

palsies occur at the time of the fracture; secondary radial nerve palsies occur after manipulation of the fracture. Many clinicians recommend exploration of primary (416,417,548,549,550,551,552,553,554,555,556) and secondary radial nerve palsies (381,382,409,550,553,554,557,558). The incidence of concomitant radial nerve palsy with a humeral shaft fracture ranges from 2.4% to 20.6% (487,524,550,555,559,560,561,562,563) and has been reported in 4.4% of children’s humeral shaft fractures (524). Most occur with middle and distal humeral shaft fractures, but they may occur with more proximal fractures as well (560). In explored primary radial nerve palsies, the incidence of complete nerve laceration is small (420,421,524,553,562,563). Commonly, the nerve is tented over the bone, trapped in the fracture site, or contused. The natural history is excellent, with recovery ranging from 78% to 100% (383,550,553,554,559,561,562,563,564,565,566,567,568). Therefore, many clinicians recommend observation rather than early exploration (383,550,553,554,559,561,562,563,567,568). Open fractures resulting in severe soft tissue injury requiring debridement should have the radial nerve explored and tagged (569) or preferably repaired (570). More severe open fractures should be stabilized using either intramedullary rodding or internal or external fixation to provide good soft tissue for radial nerve recovery. Early repair of the nerve provides the best anatomic results (571). Bostman et al (566) recommended exploration and internal fixation in patients with bayonet apposition because the abundant callus may endanger nerve recovery. The recommended waiting time before radial nerve exploration ranges from 8 weeks to 6 months (381,409,434,440,548,554,557,560,561,564,567). Nerve grafting up to 18 months after the injury can provide good function (571,572). Seddon suggested a physiologic time of allowing 1 mm per day after the 1 to 2 months of Wallerian degeneration and nerve growth through the neuroma (573). Nerves grow 1 to 3 mm per day (573,574,575), and this rate has been used clinically with good success (569,576).
FIGURE 17-47 Radial nerve palsy secondary to a humeral shaft fracture from a low-velocity gunshot wound.
In secondary radial nerve palsies, the surgeon may feel compelled to explore the nerve because he or she “caused” the radial nerve injury. However, natural history studies of observed secondary radial nerve palsies show recovery rates of 80% to 100% with nonoperative treatment (550,566). Secondary palsies occurring after manipulation may be observed (456,559,562,567,577). If the palsy occurs after a considerable time, the nerve is probably encased in callus and further investigation, including exploration, is warranted (578,579). Late presentation may result in an osseous foramen containing the nerve and requiring decompression (578).
Nerve Palsies
Radial nerve palsies were discussed previously. They also may occur immediately after operative treatment (580), or may be delayed and occur many years after internal fixation (581). Ulnar nerve paralysis has been reported from entrapment of the nerve in the fracture site (426). A few people have an abnormal arcade of Struthers in which only superficial fibers of the triceps medial head pass superficial to the ulnar nerve and none pass deep to the nerve, making the nerve extremely close to the bone and vulnerable to an abduction extension mechanism of fracture, which opens the anterior medial aspect of the humerus (426). In about 10% of the population, the median nerve crosses posterior to the brachial artery rather than anterior, placing it closer to the humerus. Median nerve palsy has been reported from an apex anterior mid-diaphyseal fracture (582). After an easy fracture reduction, the median nerve was caught in the fracture between the coracobrachialis and brachialis muscles, where the nerve crossed anteriorly. Anterior interosseous nerve palsies have not been reported in fractures above the supracondylar region.
Compartment Syndrome
The fascia of the upper arm is not as strong as it is in the lower arm, making compartment syndrome less common. Mubarak and Carroll (583) reported a dorsal forearm compartment syndrome in a 9-year-old boy with a humerus shaft fracture. Gupta and Sharma (584) described an adult with a triceps compartment syndrome from a middle-third minimally displaced fracture; this fracture did not disrupt the intercompartmental boundaries.
Vascular Injuries
Vascular injuries require a high index of suspicion and rapid treatment (580,585,586,587). The fracture should be stabilized sufficiently to prevent disruption of the vascular repair.
Infections have been reported in patients undergoing surgery. They have not been reported in closed fractures of the humerus in children, but have been reported in closed fractures elsewhere (588,589).
Malunion is uncommon in children’s humeral diaphyseal fractures. Varus of 20 to 30 degrees can be accepted (see Fig. 17-41) (409,414,415,434,590), but anterior bowing of 20 degrees may be apparent (433). An internal rotation deformity of 15 degrees causes no functional impairment (409). Most patients under 6 years of age grow out of angular deformities (440). Children 6 to 13 years of age may not, although some remodeling is possible even in adolescents (440,591). Obese patients are more prone to malunion, but they also hide their deformity better (467). Green and Gibbs (594) noted that the deformity visible on the AP and lateral x-rays is generally not the maximum deformity, which is the vector sum of the two deformities. This can be appreciated by obtaining an x-ray perpendicular to the plane of the deformity, similar to the Stagnara view for scoliosis.
Primarily a problem in adults and occasionally in older adolescents, there are few reports of humeral nonunion in children=mone in a child with progeria at age 4 (593), four in children with osteogenesis imperfecta (532), and three from severe trauma (534). In adults, numerous treatments have been used successfully. These include reamed nails (595) and modified flexible nails (596,597). However, the best results appear to be from ASIF techniques with the broad dynamic compression plate and autogenous bone grafting (416,417,598,599,600,601,602). Currently, treatment in children and adolescents must be extrapolated from adult treatment. In general, the atrophic ends of the nonunion are taken back to bleeding surfaces and apposed, a compression plate is applied with fixation of at least six cortical screws proximally and distally, and bone grafting is performed (601). The Ilizarov technique also reportedly produces good results (412,413,513,514,517,518,519). Electrical stimulation also has been used with success (603,604,605,606,607,608). Children with dysplastic bone, such as those with osteogenesis imperfecta, are best treated with intramedullary rodding and bone grafting (532).
Loss of Motion
Loss of shoulder and elbow motion is more common in older patients (440,609). The joint affected is usually the one closest to the fracture site.

Upper Extremity Limb Length Discrepancy
Overgrowth after humeral fracture occurs in about 81% of patients but is generally minimal (<1 cm) (438). Some generalized stimulus to the extremity is evident, with overgrowth of the carpals as well (610). In patients with limb length discrepancy of 3 cm or more at maturity, lengthening may be indicated (611,612). Unilateral or ring fixators may be used with Ilizarov’s principles (514,515).
Other Complications
Uncommon complications include reflex sympathetic dystrophy (613) and fat embolism (614). Late refracture may occur from retained internal fixation (615).
Little has been written about distal humeral diaphyseal or metaphyseal–diaphyseal junction fractures, which are much less common than supracondylar humeral fractures. Fractures in this region should not be confused with supracondylar humeral fractures. The distal diaphysis is more triangular and the periosteum is thinner than in the supracondylar region (422,423), making these fractures generally less stable than supracondylar fractures. The cortical bone also heals more slowly than metaphyseal bone, requiring longer immobilization. The mobile wad, anconeus, and flexor pronator mass originate off the epicondyles; the biceps, brachialis, and triceps all insert distally. Therefore, forearm position greatly affects the fracture position. Because the brachial artery is tethered by the lacertus fibrosus, injury to the artery is more likely than with more proximal fractures.
Distal humeral diaphyseal–metaphyseal junction fractures may be caused by transverse or longitudinal loading, torsion, or moments generated by the forearm about the elbow. They are caused by direct blows and twisting more often than ulnar leverage in the olecranon fossa. The diagnosis, made on plain x-rays, must be differentiated from a supracondylar humerus fracture.
Diagnosis and Classification
Most distal humeral diaphyseal fractures are transverse, spiral, or short oblique. Occasionally, an oblique or spiral fracture extends distally toward or beyond the epicondyles (Fig. 17-48).

The description must include the direction of displacement, the neurologic and vascular status, and the degree of comminution. Medial column comminution predisposes to varus malunion.
FIGURE 17-48 Distal humeral diaphyseal fracture extending to the epicondyles. This fracture was treated by casting with the forearm in pronation.
Current Treatment Options
Closed treatment usually is possible because acute flexion of the elbow, with potential vascular compromise, is not required to maintain reduction. These fractures tend toward varus malunion (Fig. 17-49) (616), which may be cosmetically unacceptable, particularly in more distal fractures. With 20% or less of humeral growth occurring distally (617,618,619), significant remodeling may not occur. Because of the proximity to the epicondyles with their muscular origins, supination and pronation affect fracture reduction. If one cortex is open, then the muscles originating on that side should be tightened to reduce the fracture (620). Because of the varus tendency, this is usually by pronation (435,437,531). However, this is best checked radiographically (Figs. 17-50 and 17-51).
Unstable fractures may require fixation (434,616) and possibly open reduction. Closed reduction and percutaneous pinning should be performed in a similar fashion to supracondylar humerus fractures. However, because the fracture is more proximal, it is difficult to get the pins into the diaphysis without crossing them at the fracture site (Fig. 17-52). Attempts should be made to pass the wires in intramedullary fashion up the lateral or medial and lateral columns separately to provide stability (Fig. 17-53) (434). This can be done by drilling the wires, but it is easier to create a starting site at the epicondyles and pass blunt-tipped wires up the columns. Holding the wires with a drill chuck helps, too. Because of the bony anatomy and the ulnar nerve, lateral wires are easier to place, particularly in younger children (Fig. 17-54). Alternatively, the fracture can be managed with skeletal traction until callus forms; then either a U plaster splint or a long-arm cast can be applied (Fig. 17-55). Brug et al reported the best results with flexible intramedullary rodding (616).
FIGURE 17-49 X-rays showing the tendency of distal humeral diaphyseal fractures toward varus malunion. This fracture required remanipulation.
FIGURE 17-50 Influence of forearm rotation. Pronation (A, B) of the forearm produces a valgus angulation at the fracture site (arrows). Supination (C, D) creates a varus angulation (arrows).
FIGURE 17-51 The same patient shown in Figure 17-50. A. The humeral coaptation splint is molded (arrows) with the forearm in neutral. B. A second forearm coaptation splint is added, and the extremity is suspended with a loop. C. X-rays show satisfactory linear alignment. D, E. The fracture healed in bayonet apposition but with satisfactory alignment.
FIGURE 17-52 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.
FIGURE 17-53 Ideally, pin fixation for distal humeral diaphyseal–metaphyseal junction fractures involves pins placed in intramedullary fashion up the medial and lateral columns.




Occasionally, a proboscis-like supracondylar process extends from a few centimeters above the medial epicondyle. The incidence


of this process ranges from 0.1% to 2.7%, with the lower percentages in blacks and the higher percentages in whites (621,622,623). The process extends obliquely downward and may be connected with the medial epicondyle by a tough fibrous band (507,621,622,623,624). Frequently, the foramen formed between the fibrous band and the humerus is traversed by the median nerve and the brachial artery. They may be entrapped by a fracture. Anomalous attachments of the coracobrachialis and the pronator teres may occur on the process (Fig. 17-56) (480,625).
FIGURE 17-54 Segmental distal humeral diaphyseal and supracondylar fracture in a 4-year-old boy. A, B. Both fractures could not be controlled by closed means. C, D. A lateral column pin acting as an internal splint is technically easier than medial column pins.
FIGURE 17-55 A comminuted distal humeral metaphyseal–diaphyseal fracture in a 14-year-old boy. Injury films (A) show multiple fragments in the metaphyseal–diaphyseal area. B. The patient was placed in traction for 2 weeks until callus appeared and then was transferred to a long-arm cast (C).
FIGURE 17-56 Radiographic appearance of a supracondylar process (arrow).
Principles of Management
Supracondylar process fractures are the result of direct blows. There are no reports of avulsion from the anomalous muscle attachments.
Diagnosis and Classification
Supracondylar process fractures are classified as displaced or nondisplaced, with notation of median nerve or brachial artery compromise.
Current Treatment Options
Supracondylar process fractures have been reported in children (480) and usually are caused by direct blows to the distal humeral area. They may be quite painful and result in compression of the brachial artery or median nerve (480,621,622,623,624,625). The process is best seen on oblique views (623). If there are no symptoms of median nerve or brachial artery compression, they are treated by elevation, ice, and temporary immobilization for comfort. However, if a painful nonunion or neurovascular symptoms develop, the fragment should be excised (623). Fractures with neurologic signs or symptoms are treated by fragment excision and nerve and artery decompression.
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