Pediatric Humeral Fracture

Original Editor - Ashley Bohanan

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Introduction

Paediatric humeral fractures involve the humerus in skeletally immature patients. They occur at the proximal humerus (including the proximal physis), the shaft (diaphysis) and the distal humerus (supracondylar region, lateral condyle, medial epicondyle). Supracondylar fractures are the most common, followed by lateral condylar fractures. Most injuries result from a fall onto an outstretched hand (FOOSH) or a direct blow. The open growth plates and high remodelling capacity of the immature skeleton influence both the injury patterns and their management.

Clinically Relevant Anatomy

The distal humerus flares from a relatively narrow, circular shaft into a flattened condylar region containing both articular and non-articular structures.

• Non-articular: medial epicondyle, lateral epicondyle, coronoid fossa (anterior), olecranon fossa (posterior)
• Articular: capitellum (articulates with the radial head), trochlea (articulates with the ulna)

The brachial artery and median nerve lie anteromedial to the distal humerus, superficial to brachialis, which is why they are at risk in posteriorly displaced supracondylar fractures. The radial nerve passes between brachialis and brachioradialis. The ulnar nerve runs posterior to the medial epicondyle, making it vulnerable in medial epicondyle fractures and flexion-type injuries.

Ossification (CRITOE)

Ossification centres of the elbow appear in a predictable sequence known as CRITOE, which is useful for distinguishing a fracture from a normal ossification centre or apophysis:

Centre	Approx. age of appearance
Capitellum	1 year
Radial head	2-6 years
Internal (medial) epicondyle	2- 8 years
Trochlea	5-11 years
Olecranon	6-11 years
External (lateral) epicondyle	8-13 years

Growth and remodelling

The proximal humeral physis contributes about 80% of the longitudinal growth of the humerus and the distal physis about 20%. Proximal humeral fractures therefore have a high capacity to remodel, particularly in younger children. Distal humeral (elbow) fractures remodel angular and rotational deformity poorly, so more accurate reduction is needed.

Supracondylar region

The supracondylar region is a thin zone of bone between the olecranon fossa posteriorly and the coronoid fossa anteriorly. This makes it vulnerable to fracture in the 5-10 year age group.

Epidemiology

Proximal humeral fractures most commonly occur in adolescents (about 9–15 years), usually physeal injuries, and should be considered after a shoulder injury in this age group. Additionally, this fracture can occur in newborns due to a birth-related injury. Humeral shaft fractures are uncommon in children. A shaft fracture without a history of major trauma should raise suspicion for non-accidental injury (child abuse). Lateral humeral condylar fractures account for 12-20% of all paediatric elbow fractures and occur 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. Supracondylar fractures comprise 65-75% of all elbow fractures in children. These injuries are the most challenging and have the highest complication rate. 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). This injury occurs during this time period due to greater likelihood of falls, general ligamentous laxity, weak bone structure at the supracondylar region, and a joint position of hyperextension. Supracondylar fractures are more common in males and on the non-dominant side.

Mechanism of injury

Proximal humeral fractures

Fall or direct hit to the proximal humerus is the most common mechanism of injury.

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.

Supracondylar fractures

Extension type (95-97% of cases)

FOOSH with the elbow extended. The force is transmitted indirectly to the distal humerus, displacing a distal fragment posteriorly, with or without an associated valgus or varus component. Children under 3 years typically sustain this form of injury from a fall of under 1 metre (3 feet). Older children more often sustain it from falls off playground equipment. A supinated hand position at impact tends to produce posterolateral displacement; a pronated position (more common) tends to produce posteromedial displacement.

Flexion type (3-5% of cases)

A direct trauma or a fall onto a flexed elbow, producing anterior displacement of the distal fragment.

Direction of displacement and associated injury

Posteromedial displacement of the distal fragment is more often associated with radial nerve injury. Posterolateral displacement is more often associated with injury to the median nerve (especially the anterior interosseous branch) and the brachial artery. Flexion-type fractures are more often associated with ulnar nerve injury.

                                                                         Hyperextension Injury

                                                                               Extreme Valgus

(Photos Courtesy of The Radiology Assistant)

Clinical Presentation

Age and mechanism of injury are strongly suggestive when a paediatric humeral fracture is suspected. Every child should be screened for neurovascular compromise, and clinicians should remain alert to signs of non-accidental injury.

Supracondylar fractures

• Swollen, painful elbow with reduced range of motion; gentle passive movement is markedly painful. The child typically guards the elbow and resists movement; the arm is often held supported with the other hand, refusing to flex the elbow.
• "S- shaped deformity" and a "pucker sign" (skin dimpling from the proximal fragment tenting the brachialis and skin) may be seen with displaced fractures.
• Watch for signs of compartment syndrome and vascular compromise.

Lateral Condylar Fractures

• Point tenderness over the lateral aspect of the elbow
• Pain with elbow flexion/extension and forearm rotation
• Swelling and ecchymosis at the fracture site to the lateral elbow

Proximal Humeral Fractures

• Point tenderness over the proximal humerus.
• Pain with shoulder abduction and rotation.
• Swelling and ecchymosis at the shoulder.

Medial epicondyle fractures

• Medial elbow pain, swelling and tenderness, often after a valgus stress or an elbow dislocation.
• Valgus instability and ulnar nerve symptoms (tingling or weakness in the ulnar nerve distribution) may be present.
• A fragment trapped in the joint prevents full elbow movement and needs urgent orthopaedic review.

Humeral shaft fractures

• Pain, swelling, deformity and abnormal movement of the arm after a fall or a direct blow.
• Always assess radial nerve function (wrist and finger extension, sensation over the dorsal first web space).
• In an infant or non-ambulant child, treat any shaft fracture without an adequate mechanism as a safeguarding concern until proven otherwise.

Neonates and infants

• A proximal humeral physeal injury or birth fracture may present as a “pseudoparalysis,” with the baby not moving the arm.
• A distal humeral transphyseal separation can mimic an elbow dislocation and is a recognised sign of non-accidental injury in infants.

Differential Diagnosis

• Radial head subluxation (nursemaid’s elbow): Presentation can mimic a supracondylar fracture, but the history typically involves an axial traction mechanism, no swelling or deformity.
• Normal ossification centre mistaken for a fracture fragment: Use the CRITOE sequence above and compare with the contralateral elbow if uncertain.
• Elbow dislocation, and associated forearm fractures (floating elbow).
• Distal humeral transphyseal separation in infants. Pathological fracture through a bone lesion (the proximal humerus is a common site for a unicameral bone cyst).
• Proximal humeral epiphysiolysis (Little League shoulder) in young throwers.
• Septic arthritis or osteomyelitis in a child with pain and refusal to move the arm, especially with fever and no clear injury.

 

(Photos Courtesy of The Radiology Assistant)

Red Flags/Non-Accidental Injury

A thorough, non-leading history should be taken to distinguish accidental from non-accidental injury. Features that should raise suspicion include:

• Inconsistent or changing accounts of the mechanism
• A mechanism inconsistent with the fracture pattern or the child's developmental stage
• Delayed presentation
• Fractures of different ages on imaging
• Any humeral shaft fracture in a non-ambulant child, or without a clear, adequate mechanism
• Unexplained bruising or injuries at other sites.

If non-accidental injury is suspected, refer promptly to the appropriate child protection/safeguarding pathway according to local policy.

Diagnostic Procedures

Radiography

Standard views include an anteroposterior view with the elbow extended, a lateral view with the elbow flexed to 90° and forearm in neutral, oblique views, and imaging of the joints above and below the injury.

Normal radiographic landmarks:

• Baumann’s Angle (humerocapitellar angle): Baumann’s angle (humerocapitellar angle): measured on the AP view between the long axis of the humeral shaft and the line of the capitellar physis. In 114 normal children aged 2-13 years the mean angle was 72° (SD 4°), and 95% of normal elbows measured 64°-81°. An increased angle indicates varus malalignment. Because of individual variation, compare with the uninjured side; a difference of more than 5° is considered abnormal. Inter- and intra-observer reliability is good.
• Anterior humeral line: a line along the anterior humeral cortex should pass through the middle third of the capitellar ossification centre on the lateral view. Posterior displacement of the capitellum relative to this line suggests an extension- type fracture; anterior displacement suggests a flexion - type fracture.
• Fat pad displacement: Displacement of the posterior (olecranon) fat pad is strongly associated with an occult fracture; displacement of the anterior (coronoid) fat pad alone can be a normal finding but should still raise suspicion when trauma is present.
• The olecranon and medial/lateral epicondyles should form an Hueter’s triangle on the AP view in the absence of fracture.
  

Outcome Measures

The following outcome measures are the most widely reported for paediatric humeral fracture:

There is no single mandated outcome measure. Choose according to the child’s age, the injury and the goal of the assessment.

Measure	What it assesses	Notes for children
Faces Pain Scale - Revised	Pain Intensity	Preferred for children under about 8 years
Numeric pain rating scale (NPRS)	Pain Intensity	Reliable from about 8 years
Goniometric ROM (flexion, extension, pronation, supination) and carrying angle	Impairment	Compare with the uninjured side
Girth (circumference) measurements	Swelling	Compare with the uninjured side
Flynn’s criteria	Cosmetic (carrying angle loss) and functional (motion loss) result after supracondylar fracture	Clinician-rated: excellent 0-5°, good 6-10°, fair 11-15°, poor >15°
Activities Scale for Kids – performance (ASK-p)	Self-reported activity limitation	Validated in children
QuickDASH	Upper limb function	Older children and adolescents
Mayo Elbow Performance Score	Clinician-rated elbow function	Developed in adults. Not validated in children, so interpret with caution

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:

• Time and mechanism of injury (fall from height, flexion vs extension mechanism, hand position- supinated or pronated)
• Hand dominance
• Any previous injury or surgery to either upper limb
• Screen for factors suggestive of non-accidental injury (Red flags - above)

Observation

• Localised swelling, ecchymosis, deformity, and other skin puckering at the fracture site.
• Signs of compartment syndrome -in young children this may present atypically as the "3 As": Anxiety, Agitation, and increasing Analgesia requirement, in addition to the classical adult signs of pain out of proportion, paraesthesia, pallor, pulselessness, and paralysis. This is a medical emergency requiring immediate escalation.

Palpation

• Isolated point tenderness over area of humerus that was fractured.
• Supracondylar fractures usually present with greater visible deformity than lateral condylar fractures, which often present with localised lateral swelling and tenderness.

Neurological Examination

Nerve injury occurs in up to 12% of paediatric supracondylar fractures, and most children recover fully without intervention. In a systematic review, recovery took on average about 19.5 weeks, and exploration should be considered if there is no recovery within about four months, or earlier for radial nerve palsy. In extension-type fractures the anterior interosseous branch is most often injured, while ulnar nerve injury predominates in flexion-type fractures. Up to 4% of children who have cross pinning develop an iatrogenic ulnar nerve palsy.

Nerve Injury Assessment

Nerve	How to assess
Radial Nerve (posterior interosseous branch)	Thumb interphalangeal extension ("thumbs up") and finger/wrist extension; sensation over the dorsal first web space
Median Nerve (anterior interosseous branch - most commonly affected in posterolaterally displaced supracondylar fractures)	Ability to form an "OK sign" (isolated pincer tip-to-tip pinch, flexor pollicis longus/flexor digitorum profundus function); sensation over the palmar tip of the index finger
Ulnar Nerve	Strength of the hand's intrinsic muscles; sensation over the palmar tip of the little finger

Assessment of Adjacent joints

• Range of motion and Strength of the joints above and below injury
  

Special tests

• Elbow extension test: the child, seated with the shoulders flexed to 90°, tries to extend both elbows fully, and the injured side is compared with the uninjured side. In a multicentre study, the inability to extend fully had a sensitivity of 94.6% and a specificity of 49.5% for fracture in children. A child with a normal test still had about a 4% chance of fracture, and the authors caution against using the test alone in children. A restricted extension test should therefore increase suspicion, but a normal test does not remove the need for radiography in a child.

Vascular Assessment

• Palpate radial and ulnar pulses; assess capillary refill, skin colour, and temperature of the hand.
• A "pink pulseless hand" (well-perfused with an absent radial pulse) is usually due to arterial spasm or compression rather than transection and, with prompt reduction, often normalises; a white, cool, or pulseless hand indicates arterial compromise and requires emergency referral.
• Posterolateral displacement of the distal fragment carries a higher risk of brachial artery injury.

Examination should be conducted gently, as these injuries are acutely painful; reassurance for the child and caregiver is an important part of the assessment.

Medical Management and Classification

Management of paediatric humeral fractures depends on the fracture site, the degree and direction of displacement, and the presence of neurovascular compromise, with classification systems guiding the choice between non-operative treatment and surgical fixation.

Supracondylar fractures

Classified by direction of displacement (extension or flexion type) and by the Modified Gartland System:

Type	Description	Typical Management
I	Non- displaced or minimally displaced (<2mm); anterior humeral line intact	Long - arm cast/ splint immobilisation, - 3 weeks
II	Displaced with an intact, hinged posterior cortex; no rotational deformity	Closed reduction and percutaneous pinning generally preferred over closed reduction with casting alone, given lower complication rates
III	Displaced with loss of cortical contact; significant soft tissue/ periosteal disruption; neurovascular injury more common	Closed reduction and percutaneous pinning treatment of choice ; open reduction if closed reduction fails, there is soft- tissue entrapment, perfusion is not restored
IV	Multidirectional instability with a circumferentially disrupted periosteal hinge	Operative stabilisation

Lateral condylar fracture

managed according to displacement (e.g., Jakob or Milch classification); minimally displaced fracture may be treated with immobilisation and closed radiographic follow-up given the risk of late displacement, while displaced fractures generally require closed or open reduction with pinning.

Medial epicondyle fracture

management depends on displacement and whether the fragment is incarcerated in the joint (associated with elbow dislocation); displacement thresholds for surgical fixation vary in the literature (commonly cited around >5 mm, with some advocating fixation at lower thresholds, particularly in throwing athletes or when instability is present).

Humeral shaft fractures

Most paediatric humeral shaft fractures are managed non-operatively with immobilisation (collar and cuff, sling, splint or hanging cast). Surgery is mainly considered for displaced fractures, open fractures or children with multiple injuries.

Proximal humeral fractures

The majority remodel well with conservative management (sling immobilisation and early progressive motion), particularly in younger children with more growth remaining; operative management is reserved for severely displaced fractures, especially in older adolescents nearing skeletal maturity.

Complications

Lateral humeral condyle fracture

• Secondary displacement, non-union, malunion and tardy ulnar nerve palsy.

Supracondylar fracture

• Vascular insufficiency: most associated with Type II and Type III fractures. Emergency vascular exploration is indicated if perfusion does not improve after reduction/ fixation, or if there is pain suggestive of ischaemia. Delayed treatment of brachial artery obstruction can lead to ischaemic contracture or nerve injury.
• Forearm compartment syndrome: can progress to Volkmann's ischaemic contracture if untreated; monitor closely for the signs above.
• Nerve injury: Most are transient neuropraxias resolving within 19-20 weeks; persistent deficits may warrant surgical exploration or neurolysis.
• Cubitus varus ("gunstock") deformity: a malunion, not a growth-arrest problem. It is mainly a cosmetic concern but can be associated with tardy ulnar nerve palsy, posterolateral rotatory instability and an increased risk of lateral condylar fracture. Modern fixation has reduced its incidence substantially (from about 58% to about 3%). Corrective osteotomy, when needed, is planned by the treating surgeon according to symptoms, deformity and growth remaining.
• Myositis ossificans: rare, associated with vigorous or repeated manipulation.
• Pin-tract infection after percutaneous pinning, which is usually minor. Teach families what to watch for (redness, discharge, fever).
• Iatrogenic ulnar nerve injury from medial pin placement. This is why lateral-entry pinning is usually preferred.
• Stiffness, especially after open reduction or prolonged immobilisation.
• Lateral condyle: cubitus valgus, “fishtail” deformity, non-union, avascular necrosis of the trochlea.
• Proximal humerus: growth disturbance, which is rare, and shoulder stiffness after prolonged immobilisation.
• Safe positioning: avoid immobilising the elbow in more than about 90° flexion, because hyperflexion raises forearm compartment pressures.

Physical Therapy Management

Evidence on the role of physiotherapy after paediatric supracondylar fractures is mixed, and elbow range of motion tends to improve substantially in the first year regardless of formal therapy input. Randomised trials in children treated with casting or closed reduction and percutaneous pinning have found no added benefit of a structured post-immobilisation physiotherapy course over self-directed activity in terms of final range of motion or function. Active, play-based, functional exercise appears preferable to passive stretching or forceful mobilisation.

Physiotherapeutic management is typically required in following circumstances:

• Persistent stiffness or loss of movement beyond the expected recovery.
• Nerve injury, vascular compromise or compartment syndrome sequelae.
• Severe injury patterns (Gartland III–IV, open reduction, multiple fractures).
• Older children and adolescents, who have less remodelling and more risk of stiffness.
• Anxiety or fear of using the arm, or difficulty returning to school or sport.

Phased Programme:

Phase management provides a structured, step‑wise rehabilitation plan that aligns interventions with the child’s healing timeline and functional goals.

Phase	Timing	Aims	Content
Immobilisation	Until cast, splint or pins are removed (usually 3 to 4 weeks)	Protect the fracture, maintain function, educate	Active movement of shoulder, wrist and fingers several times a day. Elevation and swelling control. Cast/pin-site care and warning-sign education for caregivers. Postural advice if a sling is used. The elbow stays still.
Early mobilisation	From removal of immobilisation, with surgeon clearance	Restore pain-free active elbow and forearm movement	Gentle active and active-assisted movement toward full flexion, extension, pronation and supination. Encourage normal use of the arm in dressing, eating and writing. Avoid forceful passive stretching. Avoid lifting, pushing and weight-bearing until healing is confirmed.
Progressive	From about 2 weeks after removal, or per protocol	Restore strength and function	Play-based activity such as throwing and catching a light ball, drawing and climbing. Progressive isometric then resisted strengthening of the arm and forearm. Progress by pain and function, not by a fixed timeline.
Return to activity	Guided by union, ROM and the surgeon	Return to school, play and sport	Non-contact activity is usually allowed first. Contact and high-risk sports are delayed until radiographic healing, near-full pain-free ROM and surgeon clearance.

Precautions and red flags (stop and refer urgently)

Increasing pain out of proportion to the injury, pain with finger movement, new numbness, tingling, pallor, a cold hand or a loss of pulse, or the “3 As” (anxiety, agitation, increasing analgesia need).

Proximal humeral and shaft fractures

Children usually do well with a sling or collar and cuff, then progress from pendulum exercises to active and active-assisted shoulder movement as pain settles. Check the plan with the surgical team. Do not simply apply adult proximal humerus protocols, because children remodel much more and need different restrictions.

Clinical Bottom Line

Paediatric humeral fractures occur at the proximal humerus, shaft and distal humerus. Supracondylar fractures are the most common paediatric elbow fracture, with peak incidence between 5 and 8 years of age and carry the highest risk of neurovascular complications. Assess age, mechanism and neurovascular status in every child, and actively screen for non-accidental injury. Vascular compromise and compartment syndrome are emergencies. Most children recover functional movement without intensive intervention, so physiotherapy is best targeted at children with persistent stiffness, complications or severe injuries, using active, play-based exercise rather than passive stretching.