What is the management of a proximal humerus fracture in an 11-year-old patient?

Management of Proximal Humerus Fractures in an 11-Year-Old

For an 11-year-old with a proximal humerus fracture, initial immobilization with a posterior splint for 3-4 weeks is the recommended first-line treatment, with surgical intervention (preferably elastic stable intramedullary nailing) reserved for severely displaced fractures (Neer grade III/IV or angulation ≥20°). 1, 2

Initial Assessment and Classification

The first critical step is determining fracture displacement severity, as this directly dictates treatment:

• Non-displaced or minimally displaced fractures can be managed conservatively 1, 2
• Severely displaced fractures (Neer grade III/IV, angulation ≥20°) benefit significantly from surgical stabilization 2
• Obtain comparison radiographs of both shoulders with internal and external rotation views to assess physeal widening 3

Conservative Management Protocol

Immobilization Technique

• Use a posterior splint rather than collar-and-cuff immobilization - this provides superior pain relief within the first 2 weeks based on moderate-quality prospective evidence 1, 4
• The posterior splint allows inspection of the injured limb while maintaining adequate stabilization 4
• Duration: 4 weeks of immobilization is standard practice 1, 5

Critical Monitoring Requirements

• Obtain radiographic follow-up during the first 3 weeks to confirm the fracture remains non-displaced 1
• Repeat imaging at cessation of immobilization 1
• If displacement occurs during conservative treatment, convert to surgical management 4

Expected Outcomes

Conservative treatment achieves 91% good/excellent outcomes for minimally displaced fractures, but this drops to only 82% for severely displaced fractures 2

Surgical Management Indications

When to Operate

Surgical intervention is indicated for:

• Severely displaced fractures (Neer grade III/IV) 2
• Angulation ≥20° 2
• Fractures that displace during conservative treatment 4

Surgical Technique Selection

Elastic Stable Intramedullary Nailing (ESIN) is the preferred method for this age group with the following evidence:

• 98% success rate (good/excellent outcomes) compared to 95% for K-wires and 82% for conservative treatment in severely displaced fractures 2
• Lower complication rate (7%) compared to K-wires (9%) or conservative treatment (8%) 2
• Superior radiological outcomes with 96% showing no residual deformity at follow-up versus 88% with K-wires 2
• Lowest rate of limb length discrepancies (4%) compared to 19% with K-wires and 9% with conservative treatment 2

Critical technical point: Use a two-nail ESIN technique rather than single-nail, as this significantly reduces complication rates 2

Special Consideration: Little League Shoulder

If this is an overuse injury (proximal humeral epiphysiolysis) rather than acute trauma:

• This typically occurs in 11-year-old baseball pitchers 3
• Presents with progressive upper arm pain with throwing and tenderness over the proximal humerus 3
• Radiographs show physeal widening on comparison views 3
• Treatment requires complete throwing cessation for minimum 6 weeks, followed by 6 additional weeks of strengthening (total 3 months rest from throwing) 3
• Implement rotator cuff, periscapular, and core strengthening with capsular flexibility exercises 3

Rehabilitation Approach

• Begin early mobilization immediately after the immobilization period to avoid harmful effects of prolonged immobilization 6
• There is insufficient evidence to recommend routine supervised physical therapy, so clinical judgment guides this decision based on recovery of motion and function 4
• Controlled early stresses through the fracture site optimize bone repair without increasing complications 6

Common Pitfalls to Avoid

• Do not underestimate severely displaced fractures - the 11-point difference in success rates (82% vs 98%) between conservative and ESIN treatment is clinically significant 2
• Avoid single-nail ESIN technique - always use two nails to reduce complications 2
• Do not delay radiographic follow-up - displacement can occur within the first 3 weeks requiring conversion to surgery 1
• Avoid prolonged immobilization beyond 4 weeks - this increases stiffness without improving outcomes 6