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Pediatric humeral fractures can occur in several locations including the proximal humerus, shaft (diaphysis), or the distal humerus (supracondylar ridges, medial and lateral epicondyles). Of these, supracondylar fractures are the most common[1] followed by lateral humeral condylar fractures.^[2] These fractures can result from a direct hit or a fall onto an outstretched hand (FOOSH).^[1] In addition, these injuries occur predominantly in the younger population because their bodies are still in development.^[1]

(Photos Courtesy of The Radiology Assistant)

Epidemiology/Etiology

Upper extremity fractures are more common than lower extremity fractures in children.^[1]

Proximal humeral fractures should be the first diagnosis considered in children between 9 and 15 years of age that sustained a shoulder injury.^[1] Additionly, this fracture can occur in newborns due to a birth-related injury.^[1]

Humeral shaft fractures are uncommon in children. If this injury occurs without a major trauma, it should increase the suspicion for a possible non-accidental trauma (child abuse).^[1]

Lateral humeral condylar fractures account for 12-20% of all pediatric elbow fractures and occurs mostly in children about 6 years of age.^[2]

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.^[3]

Supracondylar fractures comprise 65-75% of all elbow fractures in children.^[4] These injuries are the most challenging and have the highest complication rate.^[1]

Supracondylar fractures mostly occur between the ages of 5 and 10^[5] with the peak incidence occurring between 5-8 years of age (after this, dislocations become more frequent).^[4] This injury occurs during this time period due to greater likelihood of falls, general ligamentous laxity, weak bone structure at the supracondylar region,^[1] and a joint position of hyperextension.^[6] Supracondylar fractures are more common in males and on the non-dominant side.^[4]

Mechanism of injury:

Proximal humeral fractures

• Fall or direct hit to the proximal humerus (most common)^[1]

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^[2]

Supracondylar fractures

• Hyperextension occurs during a 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.^[4]
• Children younger than 3 years usually incur this injury from falling from a height of less than 3 feet^[5]
• Older children sustain fractures from falls from greater heights off of playground equipment^[5]
• If the hand is in a supinated position, then a posterolateral displacement occurs.^[4]
• If the hand is pronated, then a posteromedial displacement occurs (more common).^[4]
• Direct trauma or a fall onto a flexed elbow seldom occurs resulting in a ‘flexion’ type injury (5%) with anterior displacement.^[4]

                                                                         Hyperextension Injury

                                                                               Extreme Valgus

(Photos Courtesy of The Radiology Assistant)

Characteristics/Clinical Presentation

Appropriate age and mechanism of injury are highly suggestive factors when diagnosing a pediatric humeral fracture. Upon presentation, physicians should screen for neurovascular compromise and always be mindful of non-accidental injuries.

Supracondylar fractures

• Swollen, painful elbow with decreased range of motion
• Gentle passive range of motion will be overtly painful^[4]
• Child typically presents to the ER holding arm straight in pronation and refusing to flex the elbow secondary to pain.^[7]

Lateral Condyle Fractures

• Point tenderness over proximal humerus
• Pain with shoulder abduction and rotation
• Swelling and ecchymosis at the fracture site^[1]
• S-Shaped Deformity
• “Pucker” Sign
• Rotation Producing Angulation^[6]

Differential Diagnosis

• Radial head subluxation or nursemaid’s elbow: Patient presentation is similar to supracondylar fracture. The history of traction mechanism with nursemaid’s elbow as opposed to a compression mechanism associated with fractures can help with the diagnosis.^[7]
• Normal ossification centers at capitellum, radius, medial epicondyle, trochlea, olecranon and lateral epicondyle approximately appear at 1, 3, 5, 7, 9, and 11 years of age respectively. It is important to know this sequence to be able to distinguish a fracture from a normal finding. The ages may vary and ossification centers often appear earlier in females.^[1]

(Photos Courtesy of The Radiology Assistant)

Outcome Measures

Currently, there is no standard scale or functional measure used to assess the effectiveness of treatment in pediatric patients with a humeral fracture. Numeric pain rating scale (NPRS), girth measurements, and range of motion (ROM) measurements should be included in the examination and can be used as outcome measures. The Mayo Elbow Performance Scale (MEPS) is a commonly used physician-based elbow rating scale that has been utilized in studies investigating pediatric humeral fractures.^[8]

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:^[9][4]

• When did the injury occur?
• Does the history involve a fall from a height
• 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 of child abuse:

• Inconsistent/contradictory accounts of the incident
• Delayed presentation
• Mechanism not consistent with findings
• Fractures of different ages
• If child abuse is suspected, a referral to the appropriate health care provider is warranted.^[9]

Observation:

• Localized swelling, ecchymosis, deformity, and other skin changes at the fracture site.^[1][4]
• 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^[1]

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:

• Assess radial nerve injury with wrist extension and sensation in the dorsal aspect of the first webspace.
• 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)
• Assess ulnar nerve injury with strength testing of intrinsic muscles of the hand and sensation over the palmar tip of the little finger.^[4]

Assessment of joints above and below injury:

• Range of motion in all planes
• Strength
  

Special tests:

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

Circulatory/Vascular:

• Allen’s test: To assess radial and ulnar artery compromise due to close proximity to the epicondyles.^[1]
• If posterolateral displacement of the humerus, be highly suspicious of brachial artery injury.^[4]
• White/pale and/or cool extremities indicate arterial compromise, which requires immediate referral to the emergency department.^[1]

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.^[1]

Medical Management

Radiography

Interpreting radiographs of pediatric humeral fractures is often challenging due to changing epiphyses during childhood^[4] and a child’s cooperation. Standard imaging includes: anteroposterior view with the elbow extended, lateral view with the elbow flexed to 90° and forearm in neutral, oblique views, and images of joints above and below.^[6]

Normal Findings:

Anteroposterior View

• Baumann’s Angle – Angle formed between physeal line and long axis of the humerus. Average = 72°.^[6]
• Olecranon and medial and lateral epicondyles should maintain an equilateral triangular relationship.^[4]

 Lateral View

• Tear Drop – Visible in distal humerus, consists of the anterior line representing the posterior margin of the coronoid fossa and the posterior line representing the anterior margin of the olecranon fossa. Inferior portion is the ossification center of the capitellum.
• Shaft-Condylar Angle – Angulation of the long axis of the humerus and the lateral condyle. Normal = 40°.
• Anterior Humeral Line – Line drawn through the anterior border of distal humeral shaft and passes through middle-third of the ossification center of the capitellum.

Abnormal Findings:

• Fat pad displacement – Displacement of any of the three fat pads may indicate an occult fracture. Displacement of the posterior (olecranon) pad is almost always associated with a fracture; whereas, displacement of the anterior (coronoid) alone can occur without a fracture.
• Posterior displacement of the ossification center of the capitellum in relation to the anterior humeral line is of value in minimal hyperextension of the distal fragment.^[6]

                                              Anterior Humeral Line

Fat pad displacement

(Photos Courtesy of The Radiology Assistant)

Management

Gartland’s 1959 classification^[1][7][6] and its subsequent modification by Wilkins^[6] are the most widely used classification systems. These classifications guide the standard of care for treatment for supracondylar fractures.^[1][8][10] Additional factors such as radiographic displacement, mechanism of injury, and soft tissue status are considered to determine the most appropriate treatment.^[10]

Complications

Lateral humeral condyle fracture

• Secondary displacement, nonunion, malunion and tardy ulnar nerve palsy.^[11][2]

Supracondylar fracture

• Vascular insufficiency: Seen with Type II and Type III fractures. Emergent vascular exploration surgery is indicated in patients without improvement 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.^[5]
• Forearm compartment syndrome: The extensive swelling has the potential to cause permanent neurovascular damage.^[1] Ischemia and infarction if left untreated may progress to development of Volkmann’s ischemic contracture.^[5]
• Nerve injury: Neurological injury can result from traction injury or attempted reduction and stabilization.^[4] Most deficits are transient neuropraxias^[5][1][4] which resolve within 2 to 3 months. If they persist, surgical exploration^[5][1] or neurolysis^[1] 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^[1][5] from 58% to 3%.^[5] Surgical correction for cosmesis or mechanical symptoms^[6] should be delayed until the child has reached or is near skeletal maturity.^[1]
• Myositis ossificans is a rare complication seen after vigorous manipulation.^[4]

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.^[12]  Much of the controversy is partly due to an initial recovery in elbow motion with progressive improvements for up to a year regardless of physical therapy.^[12][13] Physical therapy is not unsuccessful or totally contraindicated. Children who received physical therapy achieved a more rapid return of normal or near normal elbow range of motion.^[12] The primary goals of treatment should focus on pain reduction, healing, rapid recovery of mobility, and avoidance of late complications.^[9] At two weeks post proximal humeral fracture gentle pendulum and passive ROM exercises should be implemented.^[1] For supracondylar and humeral shaft fractures after the cast is removed, passive and active motion, soft tissue stretching techniques, and strengthening exercises should be implemented to maximize functional outcome.^[1][12][4]  Moreover, patient education should focus on instructing parents on how to monitor the child’s neurovascular status, recognize signs of compartment syndrome, and skin care around the cast.^[1]  Recovery is slower in children who are older, immobilized longer, and have a more severe injury.^[13]

Key Research

• Lord B, Sarraf KM. Paediatric supracondylar fractures of the humerus: acute assessment and management. British Journal of Hospital Medicine. 2011;72(1):M8-M11.
• Hart ES, Grottkau BE, Rebello GN, Albright MB. Broken Bones: Common Pediatric Upper Extremity Fractures – Part II. Orthopaedic Nursing. 2006;25(5):311-323.

Resources

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