Humerus Fractures

A seven-month-old child "fell over" while crawling, and now presents with a swollen leg. At age one month, the infant has multiple fractures in various states of healing (right clavicle, right humerus, right radius). At age seven months, the infant has a fracture of a bowed femur, secondary to minor trauma (see x-ray below). The bones are thin, have few trabecula, and thin cortices. A careful family history ruled out nonaccidental trauma (child abuse) as a cause of the bone fractures. The child is most likely to have a defect in ... 

Her x-ray series revealed generalized under-mineralization throughout the bony structures. Her ribs were thin, and the spine showed the presence of multiple compression fractures at the thoracolumbar level. There was marked bowing of all extremities with evidence of old fractures in femurs, humerus, and left ulna. A bone mineral density study of the lumbar vertebral bodies (L1-L4) performed at 5 years of age revealed a value of 6.57 standard deviations below the mean for children of the same age. 

Fracture/trauma is the next most common problem addressed by shoulder replacement. Snyder reports the rate as 9% (1996), Torchia and associates as 12% (1997), Neer and colleagues as 23% (1982), Sojbjerg and colleagues as 30% (1999), and Rahme and associates as 35% (2001). In fact, repair of the humerus after fracture was the driving reason for the development of the first modem shoulder replacement component (Neer, II 2003) and the first reported series of modern shoulder replacements were done to correct problems caused by humeral fractures (Neer, II1974). 

Aequalis and Aequalis Fracture contemporary shoulder prosthesis system components. The noncemented humeral component is shown in (A). An underside view of an indexing offset head, and the proximal stem angle adaptors are shown in (B). An Aequalis fracture prosthesis in a fracture jig to aid in component positioning and reconstruction of the proximal humerus is shown in (C) (images courtesy of Tornier, Stafford, TX). 

Boileau R, C. Trojani, G. Walch, et al. 2001. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal humerus. / Shoulder Elbow Surg 10 299-308. 

In cases of suspected supracondylar fracture careful handling of the joint is required. An older child may be less distressed if the lateral elbow is imaged in the same position as shown above for an erect lateral projection of the humerus. 

Fractures in the region of the elbow can be particularly difficult to diagnose and delineate accurately. Ultrasound has been shown to be a useful adjunct to plain radiography, particularly if clinical suspicion is high and radiographs are indeterminate (Davidson et al. 1994 Markowitz et al. 1992 Vocke-Hell and Schmid 2001). With supracondylar fractures of the humerus, ultrasound may demonstrate the fracture line in association with a joint effusion and elevation of the fat pads (Figs. 4.5,4.6). 

Vocke-Hell AK, Schmid A (2001) Sonographic differentiation of stable and unstable lateral condyle fractures of the humerus in children. J Pediatr Orthop B 10 138-141 Williams GA, Cowell HR (1981) Kohler s disease of the tarsal navicular. Clin Orthop Relat Res (158) 53 -58 Williamson D, Watura R, Cobby M (2000) Ultrasound imaging of forearm fractures in children a viable alternative J Accid Emerg Med 17 22-24... 

Fig. 5.11. Oblique spoiled gradient echo image of the distal humerus showing a fracture extending across the physeal growth plate and through the unossified cartilage...

The proximal humeral epiphysis arises from two, sometimes three separate ossification centres (Fig. 7.12). The first ossification centre develops medially at about 2 weeks of age and the second ossification centre develops in the greater tuberosity between 6-12 months of age. When the arm is internally rotated, the first appearing medial ossification centre is rotated into a lateral position and can give the false impression of shoulder joint disruption. The rare third centre occurs in the lesser tuberosity in the third year of life, and when visualised on the axillary shoulder view, may be mistaken for a fracture. This ossification centre fuses with the shaft of the humerus at 6-7 years of age. The radiolucent proximal physis of the humerus is tented and in various oblique positions can be mistaken for a fracture (Fig. 7.13). The normal bicipital groove in the proximal humerus may simulate periosteal new bone formation (Fig. 7.14). 

Fig. 7.13a,b. AP (a) and axial (b) views of the proximal humerus showing the normal lucent proximal humeral epiphysis, sometimes mistaken for a fracture (arrows)... 

Fig. 8.12. Oblique fracture of the humerus 3 weeks post-injury. Extensive callus is visible and outlining the stripped periosteum...

Fig. 9.14. Fractures at the junction of the mid and distal third of the humerus can unite in a varus position which is not cosmetically acceptable. The radial nerve is also in close proximity at this level and its function must be carefully assessed in such cases...

Type IV This is a vertically orientated fracture, involving both the epiphysis and the metaphysis, crossing the growth plate (Fig. 10.8). This is most commonly seen in the distal humerus and tibia. As type III and IV fractures pass across the articular cartilage into the joint space, there is a higher incidence of degenerative joint disease if the fracture is not anatomically reduced. 

Clavicular fractures are by far the most frequent and maybe discovered incidentally on a chest radiograph or clinically with the development of the hard lump of callus. The humerus is the commonest long bone to be fractured at birth. In Cumming s series of 23 birth related fractures the sites were clavicle, humerus and... 

Fractures of the proximal humerus are uncommon - those involving the physis represent about 3% of physeal injuries (Schwendenwein et al. 2004). In children under 10 the fracture is typically metaphyseal, whilst in adolescence it is a Salter-Harris type 11 fracture. Salter-Harris type 111 fractures have been described in association with dislocation of the shoulder (Wang et al. 1997). 

Injury to the proximal humerus can be either a metaphyseal fracture or more typically a Salter-Harris type 1 physeal separation. This will not be evident on the plain film as the proximal humeral physis does not start to ossify until 3-6 months of age. The radiological finding of widening of the joint space occurs in physeal separation, dislocation, brachial plexus palsy and septic arthritis. Ultrasound maybe indicated to clarify the diagnosis (Zieger et al. 1987). However, since healing is rapid at this age periosteal new bone will often be apparent within 10-14 days. 

Levine B, Pereira D, Rosen J (2005) Avulsion fractures of the lesser tuberosity of the humerus in adolescents review of the literature and case report. J Orthop Trauma 19 349-352... 

Schwendenwein E, Hajdu S, Gaebler C, Stengg K, Vecsei V (2004) Displaced fractures of the proximal humerus in children require open/closed reduction and internal fixation. Eur J Pediatr Surg 14 51-55... 

Wang P Jr, Koval KJ, Lehman W, Strongwater A, Grant A, Zuckerman JD (1997) Salter-Harris type 111 fracture-dislocation of the proximal humerus. J Pediatr Orthop... 

Approximately 65%-75% of fractures in children occur in the upper limh, principally due to their tendency to fall on an outstretched hand. Most fractures occur at the distal radius with less than 10% of them occurring at the elbow. Of the elbow injuries, the vast majority are at the distal end of the humerus with the supracondylar fracture being the commonest, followed by lateral condyle fractures. 

Avulsion fractures of the medial epicondyle are seen between the ages of 9 and 15, after the apophysis becomes a separate ossification nucleus from the epiphysis of the distal humerus and before it fuses with the distal humerus. The medial epicondyle is a traction apophysis for the flexor group of forearm muscles, and also serves as an attachment for the ulnar collateral ligaments and the joint capsule. This injury accounts for up to 10% of elbow fractures. 

In a flexed elbow, a direct blow to the posterior aspect of the ulna, just anterior to the distal humerus, can cause a shear stress on the olecranon metaphysis, breaching the anterior cortex and with the radius and distal ulnar fragment displaced anteriorly by the pull of the brachialis and biceps. This may occur with the elbow either flexed or extended, leading to either a transverse or oblique fracture pattern (Table 18.2). 

Foster DE, Sullivan JA, Gross RH (1985) Lateral humeral condylar fractures in children. J Pediatr Orthop 5 16-22 Gartland JJ (1959) Management of supracondylar fractures of the humerus in children. Surg Gynecol Obstet 109 145-154... 

Karlsson J, Thorstien T, Thorleifsson R, Arnason H (1986) Entrapment of the median nerve and brachial artery after supracondylar fractures of the humerus in children. Arch Orthop Trauma Surg 104 389-391... 

Kilfoyle RM (1965) Fractures of the medial condyle and epi-condyle of the elbow in children. Clin Orthop 41 43-47 Lee SS, Mahar AT, Miesen D, Newton PO (2002) Displaced pediatric supracondylar humerus fractures biomechanical analysis of percutaneous pinning techniques. J Pediatr Orthop 22 440-443... 

Leet AI, Young C, Hoffer MM (2002) Medial condyle fractures of the humerus in children. J Pediatr Orthop 22 2-7 Lyons JP, Edwin A, Hoffer MM (1998) Ulnar nerve palsies after percutaneous cross-pinning of supracondylar fractures in children s elbows. J Pediatr Orthop 18 43-45 Lyons ST, Quinn M, Stanitski CL (2000) Neurovascular injuries in type III humeral supracondylar fractures in children. Clin Orthop 376 62-67... 

Milch H (1964) Fractures and fracture dislocations of humeral condyles. J Trauma 4 592-607 Mirsky EC, Karas EH, Weiner LS (1997) Lateral condyle fractures in children evaluation of classification and treatment. J Orthop Trauma 11 117-120 Mostafavi HR, Spero C (2000) Crossed pin fixation of displaced supracondylar humerus fractures in children. Clin Orthop 376 56-61... 

O Hara LJ, Barlow JW, Clarke NM (2000) Displaced supracondylar fractures of the humerus in children. Audit changes practice. J Bone Joint Surg Br 82 204-210 Prathapkumar KR, Garg NK, Bruce CE (2006) Elastic stable intramedullary nail fixation for severely displaced fractures of the neck of the radius in children. J Bone Joint Surg Br 88 358-361... 

Rogers LF, Malave S Jr, White H, Tachdjian MO (1978) Plastic bowing, torus and greenstick supracondylar fractures of the humerus radiographic clues to obscure fractures of the elbow in children. Radiology 128 145-150 Roposch A, Reis M, Molina M, Davids J, Stanley E, Wilkins K, Chambers HG (2002) Supracondylar fractures of the humerus associated with ipsilateral forearm fractures in children a report of forty-seven cases. J Pediatr Orthop 21 307-312... 

Fig. 21.8a,b. Aneurysmal bone cyst. Pathological fracture through the ABC in the proximal humerus in the active phase. The axial T2-weighted MR image shows multiple fluid-fluid levels... 

Fig. 21.21. Gaucher disease. Progression of fracture proximal humerus ending in malunion at 18 months...

---