From the Guidelines
The best way to immobilize a proximal humeral fracture in a pediatric patient is with a sling and swathe, as it provides adequate stability while being comfortable enough for children to tolerate. This approach involves using a standard arm sling to support the weight of the arm, combined with a swathe (bandage) wrapped around the child's body to secure the arm against the torso, limiting shoulder movement. For most pediatric proximal humeral fractures, this immobilization method is sufficient as these fractures typically heal well with conservative management due to children's remarkable remodeling potential 1. The immobilization should be maintained for 3-4 weeks, depending on the child's age and fracture severity.
Some key points to consider when immobilizing a proximal humeral fracture in a pediatric patient include:
- Maintaining proper alignment to ensure optimal healing
- Providing adequate pain relief, which can be achieved with the sling and swathe method or potentially with a posterior splint/back-slab method, as suggested by studies on supracondylar fractures 1
- Allowing for gentle pendulum exercises after 2-3 weeks to promote range of motion
- Gradually introducing more active range of motion after immobilization is discontinued
It's worth noting that more rigid immobilization methods like spica casts are rarely necessary and may cause more discomfort without providing significant clinical benefit. The focus should be on finding a balance between providing adequate stability for the fracture to heal and minimizing discomfort for the child. By prioritizing the child's comfort and using a sling and swathe for immobilization, healthcare providers can help ensure the best possible outcome in terms of morbidity, mortality, and quality of life.
From the Research
Immobilization Methods for Proximal Humeral Fractures in Pediatric Patients
- The best way to immobilize a proximal humeral fracture in a pediatric patient can vary depending on the age of the patient, the severity of the fracture, and the patient's overall health status 2, 3.
- For most pediatric patients with proximal humeral fractures, treatment with a sling or hanging arm cast is sufficient, although older children with decreased remodeling capacity may require surgery 2.
- A study comparing the use of a simple sling (SS) and a neutral-rotation brace (NRB) for immobilization of proximal humerus fractures found that the NRB group had better outcomes in terms of range of motion and subjective shoulder value 4.
- Nonoperative management is often successful in younger patients or less displaced fractures, while operative management is usually considered in older patients with more displaced fractures 3.
- Early mobilization has been shown to be safe and effective in quickly restoring physical capability and performance of the injured arm, compared to conventional immobilization followed by physiotherapy 5.
Considerations for Immobilization
- The choice of immobilization method should take into account the patient's age, fracture severity, and overall health status 2, 3, 6.
- Special considerations should be taken for management of proximal humerus fractures that occur in the context of Little League shoulder, lesser tuberosity avulsion fractures, fracture-dislocations, birth fractures, and fractures associated with cysts 2.
- Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential 3.