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HUMERAL SHAFT FRACTURE PEDIATRIC

Introduction

Fracture Nomenclature for Pediatric Humeral Shaft fractures

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Pediatric Humeral Shaft Fractures, the historical and specifically named fractures include no fracture eponyms.

Fractures of the humeral shaft are relatively uncommon in children and adolescents, accounting for about 10% of all humerus fractures in this population. These injuries are frequently seen in newborns, where they occur from birth-related trauma, particularly in large infants and those in breech position. There is also a bimodal age distribution for children younger than 3 years and older than 10 years of age. In both age groups, the mechanism of injury is typically either a fall on an outstretched hand or a direct blow to the upper extremity. Sports are often responsible for humeral shaft fractures in adolescents, and these injuries may also occur from high-energy trauma, such as in a motor vehicle collision. Conservative treatment consisting of a period of immobilization is indicated in most cases, while surgery may be indicated for patients that fail conservative treatment and those with open fractures or otherwise severe injuries.1-3

Definitions

  • A pediatric humeral shaft fracture is a disruption of the mechanical integrity of the pediatric humeral shaft.
  • A pediatric humeral shaft fracture produces a discontinuity in the humeral shaft contours that can be complete or incomplete.
  • A pediatric humeral shaft fracture is caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.4-6
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained by with simple splinting or casting. However, most definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put to a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typical unstable pediatric humeral shaft fractures have significant deformity with comminution, displacement, angulation, and/or shortening.

P - Pattern1,7

  • Pediatric humeral shaft fractures are typically classified according to the following features:
    • Anatomic position
      • Distal third
      • Middle third
      • Proximal third
    • Fracture pattern
      • Spiral
      • Transverse
      • Oblique
    • Presence of soft tissue damage
  • Transverse and short oblique fractures generally occur secondary to direct trauma, while spiral and long oblique fractures are usually caused by indirect twisting.7

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open fractures of the pediatric humeral shaft require antibiotics with surgical irrigation and wound debridement.4,8,9

R - Rotation

  • Pediatric humeral shaft fracture deformity can be caused by proximal rotation of the fracture fragment in relation to the distal fracture fragment.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity.

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site
  • The degree of acceptable angulation changes based on the patient’s age. According to one age-based algorithm, 70° of angulation is acceptable for children under 5 years, 40–70° of angulation is acceptable for children aged 5–12 years, and 40° of angulation for children older than 12 years.10

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: ≥1 fracture lines defining one or several fracture fragments; however, the external cortical contours are not significantly disrupted

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with ≥1 of their fracture lines.
  • Pediatric humeral shaft fractures can have fragment involvement at the glenohumeral, radiocapitellar, or ulnohumeral joints.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to post-traumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised, and the risk of post-traumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Related Anatomy11-13

  • The humerus is a long bone that can be divided into a proximal end, a long shaft, and a distal end.
    • The proximal end consists of an anatomic neck, the humeral head, the surgical neck, and the greater and lesser tuberosities at its proximal end. The humeral head articulates with the glenoid fossa of the scapula to form the glenohumeral joint.
    • The humeral shaft extends distally from the proximal border of the pectoralis major insertion to the supracondylar ridge. It is nearly cylindrical in its proximal half and then becomes flattened and triangular towards its distal end. It has 3 major surfaces: the anterolateral, anteromedial, and posterior surfaces.
    • At the distal end, the medial condyle articulates with the ulna to form the ulnohumeral joint and the capitellum articulates with the radial head to form the radiocapitellar joint.
  • The humeral shaft serves as an insertion site for the pectoralis major, deltoid, and coracobrachialis tendons, and is the origin site for the brachialis, triceps, and brachioradialis tendons.
  • Two important regions of the humeral shaft are the deltoid tuberosity and the radial groove.
    • The deltoid tuberosity is an elevation near the middle of the anterolateral surface, which is the insertion point of the deltoid tendon.
    • The radial groove or sulcus starts distal to the attachment of the lateral head of triceps on the posterior surface and runs distal and lateral toward the anterolateral surface. The radial nerve and profunda artery both pass within this groove.
  • The radial nerve is the major nerve of the humeral shaft and is located 14 cm proximal to the lateral epicondyle and 20 cm proximal to the medical epicondyle. Its proximity to the humerus explains why the radial nerve can be injured in humeral shaft fractures.

Incidence

  • Humeral shaft fractures account for about 1–5% of all pediatric fractures and about 10% of all pediatric humerus fractures.2,14,15
  • These injuries occur most commonly at two peaks: in toddlers younger than 3 years and children older than 10 years of age.2,14
  • Most common pediatric humeral shaft fractures occur in either the middle or distal third of the humerus. Concomitant radial nerve injuries occur frequently in midshaft fractures due to the close proximity of the nerve to the fracture site.3

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ICD-10 Codes

  • HUMERAL SHAFT FRACTURE - PEDIATRIC

    Diagnostic Guide Name

    HUMERAL SHAFT FRACTURE - PEDIATRIC

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (If Available)
    HUMERAL SHAFT FRACTURE - PEDIATRIC    
    TORUS FRACTURE LOWER HUMERUS    
    - DISPLACED S42.482_S42.481_ 
    - NONDISPLACED S42.435_S42.434_ 
    GREENSTICK S42.312_S42.311_ 
    TRANSVERSE    
    - DISPLACED S42.322_S42.321_ 
    - NONDISPLACED S42.325_S42.324_ 
    OBLIQUE    
    - DISPLACED S42.331_S42.332_ 
    - NONDISPLACED S42.335_S42.334_ 
    SPIRAL    
    - DISPLACED S42.432_S42.431_ 
    - NONDISPLACED S42.345_S42.344_ 
    COMMINUTED    
    - DISPLACED S42.352_S42.351_ 
    - NONDISPLACED S42.355_S42.354_ 
    SEGMENTAL    
    - DISPLACED S42.362_S42.361_ 
    - NONDISPLACED S42.365_S42.364_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S42
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain
Fracture deformity
Swelling, ecchymosis & tenderness
Abrasion
Typical History

The typical patient is a 12-year-old girl who was injured in a lacrosse game. The girl was moving downfield with possession of the ball when an opposing player coming from behind attempted to knock the ball free from her lacrosse stick. The opposing player missed the girl’s stick and instead contacted the middle of her humerus. The force of the hit caused a transverse fracture at the middle third of the humeral shaft, and the injured girl quickly noticed something was wrong when she was unable to move her arm due to pain. After being assessed by the team physician, the girl was then sent to the emergency department to be evaluated.

Positive Tests, Exams or Signs
Work-up Options
Treatment Options
Treatment Goals
  • When treating closed pediatric humeral shaft fractures, the treating surgeon has 4 basic goals:4,9
    1. A humerus with a normal appearance. The X-ray may not need to be perfect, but the humerus should have no obvious deformity (i.e., the humerus looks normal!)
    2. Avoid shoulder and elbow stiffness by maintaining a normal functional ROM (i.e., the shoulder and elbow work!)
    3. The humerus is not painful (i.e., the humerus does not hurt!)
    4. Congruent joint surface with none-to-minimal joint surface irregularities (i.e., the shoulder and elbow do not develop early post-traumatic arthritis!)
  • One additional goal is mandatory for open fractures:
    1. Fracture care should minimize the risk for infection and osteomyelitis.
Conservative
  • Most pediatric humeral shaft fractures can be treated conservatively with immobilization, including fractures that are minimally to moderately displaced.1,2,17,16
    • According to an age-based algorithm for displacement and angulation that can help dictate treatment decisions, 70° of angulation and total displacement is acceptable for children under 5 years, 40–70° of angulation is acceptable for children aged 5–12 years, and 40° of angulation and 50% apposition is acceptable for children older than 12 years. Thus, all fractures that fit these criteria can be treated conservatively.10
  • Immobilization may include a hanging arm cast, sling, coaptation splint, or functional brace.2
    • When coaptation splints are used, the arm is kept immobilized for approximately 2 weeks. For truly minimally displaced fractures, the child is subsequently placed in a clamshell brace for another 4 weeks or until adequate callous formation is seen.1
    • Fractures with acceptable angulation but with some shortening are often treated with a hanging arm cast until adequate healing occurs.1
  • Obstetric fractures in neonates are always treated with simple immobilization in which a swath holds the infant’s arms to the chest for 3–4 weeks.1
Operative
  • Surgical treatment of pediatric humeral shaft fractures must always be an individualized therapeutic decision.1-3,7,14  However, surgical pediatric humeral shaft fracture care is most frequently recommended when:
    1. Closed reduction fails or the simple splint or cast immobilization does not maintain the reduction (i.e., >25° in proximal diaphyseal fractures and 15° in distal fractures). For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced pediatric humeral shaft fracture involving the glenohumeral, radiocapitellar, and/or ulnohumeral joint (i.e., displacement >15° at the mid-diaphysis or >20° near the physis).
    3. Open pediatric humeral shaft fractures. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • Additional indications for surgery in this population include pathological fractures, bilateral fractures, and fractures associated with multiple trauma, compartment syndrome, or substantial nerve injury. Surgical intervention is also more likely to benefit older children and adolescents due to the reduced potential for remodeling and the tendency of such injuries to displace.2,7
  • Open reduction and internal fixation (ORIF)
    • Typically reserved only for open fractures.
    • Plating techniques are frequently used in these cases, but flexible titanium nails are another good choice for open fractures and patients with polytrauma.
  • Elastic stable intramedullary nailing (ESIN)
    • Can be performed in either antegrade or retrograde direction, but retrograde is usually preferred because it avoids damaging the rotator cuff.
    • Familiar to orthopaedic surgeons because it is frequently used for other long-bone fractures.
  • External fixation
    • May be needed for patients with severe soft tissue loss or severe bone loss, in which distraction osteogenesis may be the preferred mode of reconstruction.
  • Closed reduction and percutaneous pinning (CRPP)

Post-treatment Management

  • The care and precautions related to immobilization devices for the pediatric humeral shaft fracture must be carefully reviewed with the patient. Patients should be educated regarding care and precautions. Patients should know that pain, especially increasing pain, numbness, tingling, skin irritation, splint loosening, or excessive tightness are red flags and should be reported to the surgeon or his team.
  • Pain should be managed with properly fitting splints and casts, reassurance, elevation, ice in the initial post-fracture period, and mild pain medications. Patients should be encouraged to discontinue pain medication as soon as possible. Opioid use should be kept to a minimum.
  • Joints that are splinted for closed stable fractures are usually immobilized.
  • Fractures that require internal fixation can usually be mobilized after 4 weeks.
  • ROM exercises should typically begin about 4 weeks post-injury.1
Complications
  • Radial nerve palsy
    • Not nearly as common in pediatrics as it is in adults, but may still occur due to the proximity of the radial nerve to the humeral shaft.1
  • Stiffness
  • Aseptic necrosis
  • Avascular necrosis
  • Malunion
  • Loss of elbow or shoulder ROM
  • Heterotopic ossification
  • Hardware failure
  • Non-union
  • Post-traumatic arthritis
Outcomes
  • The prognosis for healing and remodeling in pediatric humeral shaft fractures is excellent, particularly in younger patients and fractures in the proximal one-third of the humerus. Most pediatric patients who are treated conservatively will experience good outcomes.2,7
    • In one study of 65 pediatric patients with humeral shaft fractures treated with immobilization, most experienced positive outcomes with minimal complications over 20 years.15
  • In another study of children and adolescents with closed isolated humeral shaft fractures treated surgically with ESIN, most patients experienced good clinical and functional outcomes, even in the presence of mild residual frontal and sagittal plane deformity. However, researchers cautioned that conservative treatment should still be considered the treatment of choice for these injuries in most cases.14
  • Neonates with obstetric fractures typically heal very quickly and with abundant callous formation in a very short time.1
Key Educational Points
  • Although the rate of surgery for pediatric humeral shaft fractures has increased over the past 15 years as an alternative to conservative treatment, there have been no significant changes in the characteristics of patients or their fractures over that period to explain this trend. Thus, the increased rate of surgery may be related only to a lower threshold for surgical intervention.3
  • Many of the practices currently used to manage pediatric patients with humeral shaft fractures are based on medical literature in adults. As such, there is debate regarding the optimal management of radial nerve palsy in pediatrics, as is the case in adults.15
  • For patients between the ages of 3–10 who present with humeral shaft fractures, the treating clinician should suspect child abuse as a potential cause.7
  • Anteroposterior (AP) and lateral views of the humerus are sufficient in most cases of suspected pediatric humeral shaft fracture.1 The elbow and shoulder should also be adequately visualized with these radiographs, but if they cannot be clearly seen with humerus views, dedicated shoulder and elbow series should be obtained.1
  • Magnetic resonance imaging - MRI without contrast may be needed for fractures that cannot be visualized on plain radiography.7
  • Radiology studies - Computerized tomography (CT) scanning may be needed for fractures that cannot be visualized on plain radiography.7
References

Cited Articles

  1. Shrader MW. Proximal humerus and humeral shaft fractures in children. Hand Clin 2007;23(4):431-435. PMID: 18054670
  2. Canavese F, Marengo L, Cravino M, Giacometti V, Pereira B, et al. Outcome of Conservative Versus Surgical Treatment of Humeral Shaft Fracture in Children and Adolescents: Comparison Between Nonoperative Treatment (Desault's Bandage), External Fixation and Elastic Stable Intramedullary Nailing. J Pediatr Orthop 2017;37(3):e156-e163. PMID: 27479190
  3. Hannonen J, Sassi E, Hyvonen H, Sinikumpu JJ. A Shift From Non-operative Care to Surgical Fixation of Pediatric Humeral Shaft Fractures Even Though Their Severity Has Not Changed. Front Pediatr 2020;8:580272. PMID: 33240832
  4. Cheah AE, Yao J. Hand Fractures: Indications, the Tried and True and New Innovations. J Hand Surg Am 2016;41(6):712-722. PMID: 27113910
  5. Nesbitt KS, Failla JM, Les C. Assessment of instability factors in adult distal radius fractures. J Hand Surg Am 2004;29(6):1128-1138. PMID: 15576227
  6. Walenkamp MM, Vos LM, Strackee SD, Goslings JC, Schep NW. The Unstable Distal Radius Fracture-How Do We Define It? A Systematic Review. J Wrist Surg 2015;4(4):307-316. PMID: 26649263
  7. Caviglia H, Garrido CP, Palazzi FF, Meana NV. Pediatric fractures of the humerus. Clin Orthop Relat Res 2005(432):49-56. PMID: 15738803
  8. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y) 2017;12(2):119-126. PMID: 28344521
  9. Meals C, Meals R. Hand fractures: a review of current treatment strategies. J Hand Surg Am 2013;38(5):1021-1031. PMID: 23618458
  10. Beaty JH. Fractures of the proximal humerus and shaft in children. Instr Course Lect 1992;41:369-372. PMID: 1588080
  11. Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ. Management of humeral shaft fractures. J Am Acad Orthop Surg 2012;20(7):423-433. PMID: 22751161
  12. Updegrove GF, Mourad W, Abboud JA. Humeral shaft fractures. J Shoulder Elbow Surg 2018;27(4):e87-e97. PMID: 29292035
  13. Attum B, Thompson JH. Humerus Fractures Overview. In: StatPearls. Treasure Island (FL) 2021. PMID: 29489190
  14. Marengo L, Rousset M, Paonessa M, Vanni S, Dimeglio A, et al. Displaced humeral shaft fractures in children and adolescents: results and adverse effects in patients treated by elastic stable intramedullary nailing. Eur J Orthop Surg Traumatol 2016;26(5):453-459. PMID: 26988699
  15. O'Shaughnessy MA, Parry JA, Liu H, Stans AA, Larson AN, et al. Management of paediatric humeral shaft fractures and associated nerve palsy. J Child Orthop 2019;13(5):508-515. PMID: 31695818
  16. Omid R, Choi PD, Skaggs DL. Supracondylar humeral fractures in children. J Bone Joint Surg Am 2008;90(5):1121-1132. PMID: 18451407
  17. Saeed W, Waseem M. Elbow Fractures Overview. In: StatPearls. Treasure Island (FL) 2021. PMID: 28723005
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