Proximal humerus fracture represents <5% of all paediatric fractures.

Physeal injuries are more common in late childhood and adolescence, while metaphyseal injuries like buckle injuries are more common in younger children.

Proximal humerus fractures may occur either through the physis (growth plate) or in the metaphysis.

Infantile proximal humerus injuries are usually transphyseal separation incurred during the birth process.

Otherwise, proximal humerus fractures are due to fall on an outstretched hand and occasionally a fracture can occur through a benign bone cyst in childhood.

Infantile injuries are presented with complaints of not using the arm.

Older children present after a defined injury with pain and loss of movement around the shoulder.

The primary clinical sign is a reluctance to move the shoulder and pain.

All fractures should be assessed using the Advanced Trauma Life Support (ATLS) principles to ensure associated and potentially significant injuries are identified.

Standard anteroposterior and axillary lateral radiographs of the shoulder should be obtained.

The appearance will depend on the degree of angulation and/or displacement of the shaft relative to the humeral head.

Buckle injuries may appear as a simple bump usually on the medial cortical margin of the metaphysics.

Proximal humerus fracture should be described displacement i.e. the percentage of the humerus shaft diameter and angulation of neck-shaft i.e. varus (decreased) or valgus (increased).

The proximal humeral physis contributes 80% of the length of the humerus. Due to the enormous remodelling potential, most of these injuries do not require reduction.

The older child with greater deformity may be treated with closed reduction.

Approximate indications:

5-12 years – accept 60 degrees of angulation and 50% of displacement

> 12 years – accept 30 degrees of angulation and 30% of displacement

Closed treatment includes immobilization in plaster cast or sling, depending on the soft tissue swelling and displacement of the fracture.

Operative interventions are indicated in the following situations –

Isolated greater tuberosity fractures with displacement in the adolescent

Open fractures

Neurovascular injury with fracture

Pathological fracture (simple bone cyst, Aneurysmal bone cyst)

Due to the remodelling potential of this region, the outcome of this fracture is usually excellent.

Non-union is rare and shoulder function usually returns to normal even if there is a residual deformity on the x-ray.

Mild shortening of the humerus and mild angular malunion is not noticeable cosmetically and function is unaffected.

Complications are rare and usually due to associated soft tissue and neurological injuries, i.e. brachial plexus.

Mild malunion can occur but is not a functional problem

Non-union are rare.