Pediatric Humeral Fracture

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Original Editors Ashley Bohanan, Alisha Lopez, Hannah Duncan, Neha Palsule, Brittany Buenteo

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Search Strategy

Databases Searched:  CINAHL, JOSPT, PubMed, Medline with Full Text, PEDro, Health Reference Center

Keyword Searches:  pediatric humeral fractures, pediatric arm fractures, child humeral fractures, pediatric humeral fracture and treatment, management of pediatric humeral fracture

Search Timeline:  September 27, 2011 - November 21, 2011 

Definition/Description

Pediatric humeral fractures can occur in several locations including the proximal humerus, shaft (diaphysis) of the humerus, or the distal humerus (supracondylar ridges, medial and lateral epicondyles). Of these, the supracondylar fracture is the most common followed by lateral humeral condylar fractures. These fractures can result from a direct hit or a fall onto an outstretched hand (FOOSH). In addition, these injuries occur predominantly in the younger population because their bodies are still in development.

Supracondylar fractures are classified based on how much displacement there is.

Epidemiology/Etiology

Upper extremity fractures are more common in children than those that occur in the lower extremity.

For children and adolescents, proximal humeral fractures are very common. This fracture should be the first diagnosis considered in children between 9 and 15 years of age that sustained a shoulder injury. In addition, this type of fracture can occur during a birth-related injury in newborns.

Humeral shaft (diaphysis) fractures are uncommon in children. If this injury occurs without a major trauma (motor vehicle accident or fall from a height), it should increase the suspicion for a possible non-accidental trauma (child abuse).

Lateral humeral condylar fractures account for 12-20% of all pediatric elbow fractures and occurs mostly in children about 6 years of age.

Medial epicondyle fractures make up 11-20% of all injuries of the elbow in children with 30-55% of cases associated with a dislocation of the elbow.

Pediatric supracondylar fractures make up about 65-75% of all elbow fractures in children. These injuries are serious and if they are not diagnosed and treated quickly and effectively, are linked to significant neurovascular complications and deformity. This fracture has the highest complication rate and is one of the most challenging types of elbow fractures that occur in children.

Supracondylar fractures mostly occur between the ages of 5 and 10 with the peak incidence occurring between 5-8 years of age (after this, dislocations become more frequent). The reason that this injury occurs during this time period is due to greater likelihood of falls, general laxity of the ligaments, and weak bone structure at the supracondylar region. In addition, in children the joint is in a position of hyperextension. Furthermore, the ratio of males to females is 3:2, and the non-dominant side is injured more often.

Complications associated with supracondylar fractures are as follows nerve injuries (7.7%) with the radial nerve most frequently involved (41.2%) followed by the median nerve (36.0%) and ulnar nerve (22.8%), anterior interosseous nerve involvement, true Volkmann’s ischaemic contracture (0.5%), brachial artery injury, malunion, cubitus varus (gunstock deformity), and compartment syndrome.

Mechanism of injury:

Proximal humeral fractures

• Fall or a direct hit to the proximal humerus (most common)

Lateral humeral condyle fractures

• A fall onto the hand while in elbow flexion or on the inner posterior part of a flexed elbow, or forceful adduction of the forearm
• The push-off theory suggested by Milch hypothesized that this fracture is due to a force that is “directed upward and outward along the radius”
• The pull-off theory proposes that this fracture is an avulsion fracture
• In a study of pediatric cadaver elbows, Jakob et al stated that this fracture was the consistent result of only adducting the supinated forearm while the elbow was extended. The fracture line began on the lateral part of the condyle, which implies that the condyle was pulled off by the lateral collateral ligament and extensor muscles
• The most probable cause is a combination of the pull-off and push-off methods

Supracondylar fractures

• Hyperextension occurs during a fall onto the outstretched hand (FOOSH) with the elbow in extension, which indirectly puts force on the distal humerus and displaces it posteriorly; this can occur with or without a valgus or varus force. This ‘extension’ type of injury accounts for 95% of the cases.
• Children younger than 3 years usually incur this injury from falling from a height of less than 3 feet (i.e. couch or bed)
• Older children sustain fractures from falls from greater heights off of playground equipment (i.e. swings, monkey bars)
• If the hand is in a supinated position, then a posterolateral displacement occurs.
• If the hand is pronated, then a posteromedial displacement occurs (more common).
• Direct trauma or a fall onto a flexed elbow seldom occurs resulting in a ‘flexion’ type injury (5%) with anterior displacement.
  

Characteristics/Clinical Presentation

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Differential Diagnosis

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Outcome Measures

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Examination

History:

It is essential to obtain a thorough explanation for the fracture in order to distinguish accidental from non-accidental injuries (pathological fractures, child abuse).The following questions should be addressed: (Kraus 2010, Clinical Practice 2011)

• When did the injury occur?
• Does the history involve a fall from a height, e.g. monkey bars, a trampoline, tree climbing?
• Is it a flexion or extension injury?
• Was the hand supinated or pronated?
• What is the child’s hand dominance?
• Any previous injury or surgery to either upper limb?

Common signs that point to child abuse include inconsistent/contradictory accounts of the incident, delayed presentation, mechanism not consistent with findings, and fractures of different ages (i.e shaft fractures in infants who are not yet walking). If child abuse is suspected, a referral to the appropriate health care provider is warranted. (Kraus 2010)

Physical Exam:

A typical physical exam should involve looking, feeling, moving the joint above and below the injury, and assessing neurovascular status. Detailed components of the exam include:

Observation of:

• Localized swelling, ecchymosis, deformity, and other skin changes at the fracture site. (Hart 2006, Clinical Practice 2011)
• Signs and symptoms of compartment syndrome such as intense pain upon mild extension or stretching of the fingers, paresthesia/numbness, diminished pulses, and pallor. –Medical Emergency (Hart 2006)

Palpation:

• Isolated point tenderness over area of humerus that was fractured.
• Lateral supracondylar humeral fractures tend to present with greater deformity than lateral humeral condylar fractures.

Neurological exam:

Neurological exam should include both the assessment of motor and sensory nerves.

• Assess radial nerve injury with wrist extension and sensation in the dorsal aspect of the first webspace. (clinical practice 2011)
• Assess median nerve injury with the patient’s ability to make the ok sign and sensation over the palmar tip of the index finger (autonomous area of the median nerve) (Clinical practice 2011)
• Assess ulnar nerve injury with strength testing of intrinsic muscles of the hand and sensation over the palmar tip of the little finger. (Clinical Practice 2011)

Range of motion assessment in all planes and joints above and below the injury

Strength assessment of surrounding musculature above and below injury:

• With lateral humeral condylar fractures, expect increase in pain with forced wrist flexion (Tejwani)

Special tests:

• Elbow extension test (Sensitivity: 96.8%, Specificity: 45.8%)

Circulatory/Vascular:

• Allen’s test: To assess radial and ulnar artery compromise due to close proximity to the epicondyles. (Hart 2006)
• If posterolateral displacement of the humerus, be highly suspicious of brachial artery. (Clinical Practice 2011)
• White/pale and/or cool extremities indicate arterial compromise. If arterial compromise is found, the patient needs to be referred to the emergency department. (Hart 2006)

Examination procedures should be performed with caution as the child will experience intense pain and fear during the exam. Reassurance and comfort to the patient and their parent/guardian is important. (Hart 2006)

Medical Management

Complications
Lateral humeral condyle fractures

• Secondary displacement, nonunion, deformities, epiphysiodesis of the distal extremity of the humerus and tardy ulnar nerve palsy. (Marcheiz) (Tejwani)

Supracondylar fractures

• Vascular insufficiency: Seen with type II and Type III fractures. The brachial artery is most frequently injured in posterolaterally displaced fractures. (BJOM, Ryan) Emergent vascular exploration surgery is indicated in patients without improvement in pulse or Doppler pulse after orthopedic care, especially if perfusion is compromised or if the patient complains of intractable pain suggestive of ischemia. Delayed release of brachial artery obstruction can lead to ischemic contractions of hand and/or forearm muscles or nerve injury.(Ryan)
  
• Forearm compartment syndrome resulting in Volkmann's ischemic contracture: Volkmann’s ischemia was more common when displaced fractures were treated nonoperatively with a cast in hyperflexion. The extensive swelling has the potential to cause permanent neurovascular damage. (Hart) Ischemia and infarction if left untreated may progress to development of Volkmann's ischemic contracture which is characterized by fixed flexion of the elbow, pronation of the forearm, flexion at the wrist, and joint extension of the metacarpal-phalangeal joints (Ryan)
  
• Nerve injury: Neurological injury can result from traction injury or attempted reduction and stabilization.(BJOM) Posterolateral displacement of distal fracture fragment with medial displacement of proximal fracture fragment can injure the median nerve and anterior interosseous nerve. (BJOM, Ryan) Posteromedial displacement of distal fracture fragment with lateral displacement of proximal fracture fragment can impinge the radial nerve (BJOM, Ryan).Flexion type fractures can injure the Ulnar nerve (Babal).Most deficits are transient neuropraxias (Ryan, Hart, BJOM) which resolve within 2 to 3 months. If they persist, surgical exploration (Ryan, Hart) or neurolysis (Hart) is considered.
  
• Cubitus varus deformity: Angular deformity or "gunstock" deformity is a long term complication and is mainly cosmetic.Modern surgical techniques have decreased its occurrence (Hart, Ryan)form 58% to 3%. (Ryan)Surgical correction for cosmesis or mechanical symptoms (Marquis) should be delayed until the child has reached or is near skeletal maturity. (Hart)
  
• Myositis ossificans is a rare complication seen after vigorous manipulation (BJOM)

Physical Therapy Management

The indications for physical therapy after supracondylar humeral fractures in children are not clear in the literature, even in the presence of an active or passive limitation of elbow joint motion. (Keppler 2005)Much of the controversy is impart due to an initial recovery in elbow motion with progressive improvements for up to a year regardless if physical therapy is implemented. (Keppler 2005, Bernthal 2011) Physical therapy is not unsuccessful or totally contraindicated. Keppler et al. found that children who receive physical therapy achieved a more rapid return of normal or near normal elbow range of motion.(Keppler 2005)The primary goals of treatment should focus on pain reduction, healing, rapid recovery of mobility, and avoidance of late complications (i.e restriction of range of motion or growth disorders of the fractured bone). (Kraus 2010) Gentle pendulum exercises and passive range of motion can be implemented in week two while wearing the sling. (Hart 2006) Once the cast is removed, passive and active motion, soft tissue stretching techniques, and strengthening exercises should be implemented to maximize functional outcome. (Hart 2006, Keppler 2005, Clinical practice 2011)Moreover, patient education should focus on instructing parents on how to monitor the child’s neurovascular status, recognizing signs of compartment syndrome, and skin care around the cast. (Hart 2006)Recovery is slower in children who are older, immobilized longer, and have a more severe injury. (Bernthal 2011)

Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

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