What is the treatment for a possible transverse fracture of the proximal humerus in a 10-year-old?

Treatment of Transverse Proximal Humerus Fracture in a 10-Year-Old

For a 10-year-old with a transverse proximal humerus fracture, treatment depends critically on the degree of displacement: nondisplaced or minimally displaced fractures should be treated with immobilization in a posterior splint, while severely displaced fractures (≥20° angulation or significant translation) require surgical fixation, preferably with elastic stable intramedullary nailing (ESIN). 1

Initial Assessment and Classification

• Obtain quality radiographs to assess displacement and angulation accurately 1
• Perform careful neurovascular examination at presentation and throughout treatment, as vascular compromise can lead to long-term nerve and muscle dysfunction 2
• Classify the fracture severity: minimally displaced versus severely displaced (≥20° angulation or significant translation) 1

Treatment Algorithm Based on Displacement

For Nondisplaced or Minimally Displaced Fractures

• Immobilize with a posterior splint (back-slab) rather than a collar-and-cuff, as this provides superior pain relief and maintains fracture alignment 2
• The posterior splint provides significantly better pain control within the first 2 weeks compared to collar-and-cuff immobilization 2
• Maintain immobilization for approximately 3-4 weeks 2
• Begin rehabilitation immediately after the immobilization period to avoid harmful effects of prolonged immobilization 3

For Severely Displaced Fractures (≥20° Angulation)

• Surgical fixation with elastic stable intramedullary nailing (ESIN) is the treatment of choice, achieving a 98% success rate compared to 82% for conservative treatment in severely displaced fractures 1
• ESIN demonstrates superior outcomes compared to K-wire fixation or conservative treatment, with better radiological results (96% without residual deformity) and lower limb length discrepancy rates (4% vs 9% conservative, 19% K-wires) 1
• Use a two-nail ESIN technique rather than single-nail, as this significantly reduces complication rates 1
• K-wire fixation is an acceptable alternative (95% success rate) but has higher complication rates (9%) and limb length discrepancies (19%) compared to ESIN 1

Important Clinical Considerations

Age-Specific Factors at 10 Years Old

• At age 10, the proximal humerus has tremendous remodeling potential, but this decreases as skeletal maturity approaches 4
• The mean age in studies of surgically treated proximal humerus fractures was 14.3 years, suggesting that at age 10, there is still excellent remodeling capacity 4
• However, severely displaced fractures still require surgical intervention regardless of remodeling potential 1

Potential Barriers to Closed Reduction

If closed reduction fails and open reduction becomes necessary, common impediments include:

• Periosteum interposition (90% of cases) 4
• Biceps tendon interposition (90% of cases) 4
• Deltoid muscle interposition (70% of cases) 4
• Comminuted bone fragments (10% of cases) 4

Rehabilitation Protocol

• Begin rehabilitation immediately after the immobilization period to avoid harmful effects of prolonged immobilization 3
• Focus on advice, exercise, and mobilization to restore upper limb function 3
• Place controlled stresses throughout the fracture site at an early stage to optimize bone repair without increasing complication rates 3
• Electrotherapy and hydrotherapy do not enhance recovery and should not be routinely used 3

Expected Outcomes

• Radiographic union typically occurs at a mean of 4 weeks 4
• Patients should achieve non-painful full shoulder range of motion and rotator cuff strength by final follow-up 4
• Return to pre-injury sporting activities is expected with appropriate treatment 4
• Overall success rate (good/excellent outcome) for appropriately treated fractures is 93%, with ESIN achieving 98% success in severely displaced fractures 1

Critical Pitfalls to Avoid

• Do not use collar-and-cuff immobilization as first-line treatment, as it provides inferior pain control and fracture stability 2
• Do not delay surgical intervention for severely displaced fractures based solely on age and remodeling potential 1
• Do not use single-nail ESIN technique; always use two-nail technique to reduce complications 1
• Do not immobilize for longer than 3-4 weeks, as prolonged immobilization causes harmful effects without additional benefit 2, 3