Management of Non-Displaced Proximal Humerus Fracture in a 5-Year-Old
For a non-displaced proximal humerus fracture in a 5-year-old child, immobilize with a posterior splint (back-slab) for superior pain control, follow clinically and radiographically to ensure the fracture remains stable, and expect excellent outcomes with complete remodeling given the tremendous growth potential at this age. 1
Initial Immobilization
Use a posterior splint rather than a collar and cuff for immobilization. 2, 1
The American Academy of Orthopaedic Surgeons (AAOS) provides moderate-strength evidence that posterior splinting provides significantly better pain relief within the first 2 weeks compared to collar and cuff immobilization for non-displaced pediatric proximal humerus fractures. 2
This recommendation is based on two moderate-quality prospective studies (one RCT with 50 patients and one double-cohort study with 40 patients) that both demonstrated superior pain control with posterior splinting. 2
The posterior splint should allow inspection of the injured limb while providing adequate stabilization. 1
Follow-Up Protocol
Monitor the fracture with serial clinical examinations and radiographs to ensure it remains non-displaced during healing. 1
Regular follow-up is essential because the primary concern is detecting any displacement that might occur during the healing process. 1
If the fracture becomes displaced during treatment, surgical intervention with closed reduction and pin fixation would then be indicated. 1
Duration of Immobilization
Use clinical judgment guided by radiographic healing and symptom resolution to determine when to remove immobilization, as there is insufficient evidence for specific timeframes. 1
The AAOS acknowledges there is no evidence-based guideline for optimal timing of immobilization removal or return to unrestricted activity. 1
Base your decision on radiographic evidence of healing combined with the child's clinical symptoms and functional recovery. 1
Expected Outcomes
Expect excellent functional recovery with complete remodeling in this age group. 3, 4, 5
At age 5, the proximal humeral growth plate has tremendous remodeling capacity, with studies showing full remodeling even in severely displaced fractures treated conservatively. 3
A 9-year follow-up study of 64 conservatively treated pediatric proximal humerus fractures showed full remodeling in all cases with displaced fractures, with 89% of patients completely asymptomatic and only 11% having minor sequelae (transient pain or minor motion restriction). 4
Conservative treatment of non-displaced fractures leads to good outcomes in 80-90% of patients. 6
Rehabilitation Considerations
Do not routinely refer for supervised physical or occupational therapy, but use clinical judgment based on the child's recovery of motion and function. 1
The AAOS cannot recommend for or against routine supervised therapy due to insufficient evidence. 1
Most children with non-displaced fractures recover full function without formal therapy. 4, 5
Critical Pitfall to Avoid
Avoid unnecessary surgical intervention. 3, 4
Given the exceptional remodeling capacity of the proximal humerus in young children, even severely displaced fractures can be treated conservatively with excellent outcomes. 3
Surgery should only be considered if the fracture becomes displaced during treatment or if there is gross instability between the humeral shaft and head. 1, 6