A Single Retrograde Intramedullary Nail Technique for Treatment of Displaced Proximal Humeral Fractures in Children: Case Series and Review of the Literature

[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]

BACKGROUND

Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature.

METHODOLOGY

As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this.

RESULTS

The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks).

CONCLUSION

Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study

OBJECTIVE

The purpose of this study was to compare the therapeutic effects of Kirschner wire fixation and external fixation in the treatment of proximal humeral fractures in older children and adolescents.

METHODS

A retrospective analysis was performed on the clinical data of older children and adolescents who underwent surgery at our institution for proximal humeral fractures between April 2014 and May 2022. One group (n = 28) underwent fracture reduction and Kirschner wire fixation, and the other group (n = 23) underwent external fixation. During the follow-up, the differences in shoulder joint function between the two groups were compared by analysing Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) and Constant-Murley scores. Postoperative complications were also recorded.

RESULTS

The operation time of the Kirschner wire group was shorter than that of the external fixation group (69.07 ± 11.34 min vs. 77.39 ± 15.74 min, P = 0.33). The time to remove the fixator in the external fixation group was shorter than that in the Kirschner wire group (6.74 ± 1.57 vs. 7.61 ± 1.22, P = 0.032). The Quick DASH score and Constant-Murley score of the patients in the external fixation group were significantly better than those in the Kirschner wire group at 3 months after surgery (5.63 ± 4.33 vs. 8.93 ± 6.40, P = 0.040; 93.78 ± 2.43 vs. 91.75 ± 2.15, P = 0.003). There was no significant difference in the Quick DASH score or Constant-Murley score between the patients in the external fixator group and those in the Kirschner wire group at 9 months after the operation (2.77 ± 3.14 vs. 3.17 ± 3.68, P = 0.683; 97.39 ± 1.80 vs. 96.57 ± 2.15, P = 0.152). The most common complication of the two groups was pin tract infection. The incidence rate of infection was higher in the external fixation group than that in the Kirschner wire group (9 vs. 4, P = 0.043).

CONCLUSION

Both Kirschner wire fixation and external fixation of N-H III and IV proximal humeral fractures in older children and adolescents produce good outcomes. External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized.

Percutaneous Fixation of Pediatric Proximal Humerus Fractures

Proximal humerus fractures can be seen in children and adolescents after a fall or following significant trauma, like motor vehicle accidents. Significant remodeling potential from the proximal humeral physis along with the wide arc of motion of the shoulder allows for good outcomes with nonoperative care for minimally displaced fractures and fractures in younger children. Operative management is reserved for fractures with greater displacement and angulation, particularly in adolescents nearing skeletal maturity. Closed reduction techniques in the operating room can be difficult due to patient size, fracture displacement, interposed tissue, and deforming forces acting on the proximal humerus. Skeletal stabilization after closed reduction can include percutaneous pins, screws, and flexible nails. Here, we describe a technique for percutaneous reduction and fixation of the difficult-to-reduce proximal humerus fracture. Key Concepts•The proximal humeral physis has considerable remodeling potential, allowing for significant tolerance of deformity in skeletally immature children.•Radiographic and age-based indications for reduction and fixation of proximal humerus fractures remain controversial, but multiply injured patients and significantly displaced fractures in those nearing skeletal maturity are most likely to benefit from surgical management.•Percutaneous reduction techniques can aid in improving fracture alignment when closed maneuvers fail without the need for an extensive open approach.•Screw fixation may provide certain advantages in comparison to pin fixation.

Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study

BACKGROUND

The objective of this study is to compare the treatments of pediatric displaced proximal humerus fractures with external-fixation technique using the combination of K-wires and bone-cement versus close reduction and internal fixation technique using elastic stable intramedullary nail.

METHODS

From April 2016 to March 2020, 72 children with proximal humeral fractures were allocated to group A and 44 children with proximal humeral fractures were allocated to group B. Patients in group A were treated with bone-cemented K-wire fixation, and patients in group B were treated with elastic stable intramedullary nailing. The function of the upper limb was assessed using the Shortened Version of the Disabilities of the Arm, Shoulder and Hand questionnaire and Neer score. Patient satisfaction was assessed using the 10-cm visual analogue scale.

RESULTS

Bone healing was achieved in group A and B after a mean time of 6.1 ± 1.2 and 6.4 ± 1.1 weeks, respectively. The mean surgical time of groups was 33 ± 9 and 54 ± 12 minutes, respectively. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score of groups were 0.5 ± 1.4 and 0.7 ± 1.5, respectively. Based on Neer score, we obtained 69 excellent and 3 good results in group A, and 41 excellent and 3 good results in group B. There were significant differences regarding duration of operation, cost of treatment, and postoperative angle at bone healing (P < .05).

CONCLUSIONS

The external cemented K-wire fixation is a useful and reliable alternative technique for the treatment of severely displaced proximal humerus fractures in children. The technique is a minimally invasive procedure with minimal complications.

Management of Pediatric Proximal Humerus Fractures

Proximal humerus fractures have an outstanding potential to remodel due to their proximity to the proximal humeral physis. Fractures in young children can be treated nonoperatively with excellent outcomes. The incidence peaks in adolescent patients and these injuries most commonly occur after a fall or direct trauma. The muscle attachments of the proximal humerus act as deforming forces and anatomic structures such as the periosteum and biceps tendon may act as blocks to reduction. Operative management is uniformly indicated for patients with open fractures, ipsilateral elbow or forearm injury, associated neurovascular injury, or poly-trauma patients. Operative treatment may be further considered in older children with minimal growth remaining and with fractures that are considered significantly displaced by available classification systems. Unfortunately, there are significant challenges in recommending treatment based on displacement and age alone. The purpose of this paper is to review what is known about these injuries and how they can be treated in light of current deficiencies in the literature; this may stimulate further work to refine indications for treatment based upon age and displacement. Key Concepts•The proximal humerus physis is responsible for 80% of the growth of the entire bone, and proximal humerus fractures have tremendous potential to remodel.•Proximal humerus fractures occur most commonly due to a fall or direct trauma but other causes include overuse injury and pathologic lesions.•Treatment indications for pediatric proximal fractures are guided by age of the patient, fracture displacement, and associated injuries; the majority of these injuries may be treated nonoperatively.•Outcomes after operative and nonoperative management of proximal humerus fractures are generally good.

Predictors of outcomes of proximal humerus fractures in children and adolescents: A systematic review

PURPOSE

Minimally displaced pediatric proximal humerus fractures can be reliably managed non-operatively; however, there is considerable debate regarding the appropriate management of severely displaced proximal humerus fractures, particularly in older children and adolescents with limited remodeling potential. The purpose of this study was to perform a systematic review to answer the questions: "What are the functional and quality-of-life outcomes of pediatric proximal humerus fractures?" and "What factors have been associated with a poorer outcome?"

METHODS

A review of Medline and Embase was performed on 4 July 2021 using search terms relevant to proximal humerus fractures, surgery, non-operative management, pediatrics, and outcomes. Studies including ≥10 pediatric patients with proximal humerus fractures, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes.

RESULTS

Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favorable outcome scores were found for patients with minimally displaced fractures, and for children aged less than 10 years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score.

CONCLUSION

An excellent functional outcome can be expected following non-operative management for minimally displaced pediatric proximal humerus fractures. Prospective trials are required to establish a guideline for the management of severely displaced proximal humerus fractures in children and adolescents according to fracture displacement and the degree of skeletal maturity.

LEVEL OF EVIDENCE

level V.

Efficacy of Intramedullary Nailing in the Treatment of Comminuted Proximal Humeral Fractures and Its Influence on Shoulder Joint Function Recovery

In this paper, we have aimed to elucidate the therapeutic effect of intramedullary nailing (IMN) in treating comminuted proximal humeral fractures (CPHFs) and its influence on the recovery of shoulder joint function. For this purpose, 60 cases with CPHFs were selected, particularly from January 2020 to October 2021. In these cases, 28 cases were treated with a locking proximal humeral plate (LPHP) and assigned to the control (Con) group and the remaining 32 patients were treated with IMN and included in the research (Res) group. The therapeutic effect, surgical indicators, total complications, visual analogue scale (VAS) score, and postoperative shoulder joint function score were compared between the two arms. We observed that compared with the Con group, the effective rate in the Res group was higher while the operation time, intraoperative blood loss, and fracture healing time were shorter, the overall complication rate and VAS score were lower, and the postoperative shoulder joint function score was higher, all with statistical significance. The above results indicate that IMN is effective and safe in the treatment of CPHFs, which can validly reduce the discomfort of patients and facilitate the recovery of shoulder joint function.