How should a proximal humerus fracture in a pediatric patient be managed, including immobilization method, neurovascular monitoring, and follow‑up?

Management of Pediatric Proximal Humerus Fractures

For pediatric proximal humerus fractures, use a posterior splint (back-slab) for immobilization rather than a collar-and-cuff sling, as it provides superior pain relief in the first two weeks after injury 1.

Initial Assessment and Immobilization

Fracture Classification and Treatment Algorithm

The management approach depends critically on fracture displacement and patient age:

Nondisplaced or Minimally Displaced Fractures (Gartland Type I):

• Immobilize with a posterior splint/back-slab in preference to collar-and-cuff 1
• This is a Moderate-strength recommendation from AAOS guidelines based on Level II evidence showing significantly better pain control within the first 2 weeks
• The posterior splint allows better limb inspection while providing adequate immobilization

Displaced Fractures:

• Recent evidence challenges traditional approaches: a 2024 multicenter prospective study found that immobilization without reduction (INR) achieved similar radiographic and clinical outcomes compared to closed reduction in adolescents aged 10-16 years 2
• This questions the necessity of performing closed reduction under conscious sedation in the emergency department for displaced fractures
• The proximal humeral physis accounts for 80% of humeral growth, providing extraordinary remodeling potential 3, 4

Critical Neurovascular Monitoring

Vascular compromise is the most serious complication that can lead to long-term loss of nerve and muscle function 1. Monitor specifically for:

• Pulse status at the radial and ulnar arteries
• Hand perfusion: color, temperature, capillary refill
• Nerve function: median, radial, and ulnar nerve distributions

Vascular Compromise Protocol

If vascular compromise is present:

1. Absent pulses with perfused hand (pink hand): The evidence is inconclusive on whether to explore the antecubital fossa 1
2. Absent pulses with underperfused hand (pale, cold hand): Perform immediate open exploration of the antecubital fossa after reduction and pinning 1 - this is a Consensus recommendation despite limited evidence, given the catastrophic risk of limb loss

Age-Specific Remodeling Capacity

The decision to accept displacement depends heavily on remaining growth:

• Young children: Can accept severe displacement (even 80-90 degrees of angulation) with complete remodeling and full functional recovery 4
• Adolescents near skeletal maturity: Have minimal remodeling potential and may require surgical intervention for significantly displaced fractures 3, 5

Follow-Up Protocol

Initial follow-up at 6 weeks and 3 months is standard based on the prospective multicenter data 2:

• Radiographic assessment of alignment
• Range of motion evaluation
• Patient-reported outcomes show significant improvement between 6 weeks and 3 months in both operative and nonoperative groups

Common Pitfalls to Avoid

1. Over-treating young children: The proximal humerus has tremendous remodeling potential - avoid unnecessary surgical intervention in patients with significant growth remaining 4, 5

2. Inadequate immobilization: Using collar-and-cuff when posterior splint would provide better pain control 1

3. Missing vascular compromise: This is the key complication that affects long-term morbidity - serial neurovascular examinations are mandatory 1

4. Unnecessary closed reduction: Recent evidence suggests immobilization without reduction may be sufficient even for displaced fractures in adolescents 2

Surgical Indications

Surgery is uniformly indicated for 3:

• Open fractures
• Ipsilateral elbow or forearm injury
• Associated neurovascular injury requiring exploration
• Polytrauma patients

Consider surgery for older children with minimal growth remaining and fractures exceeding remodeling potential based on degree of impaction, angulation, and patient age 5.