Humerus fractures in children

Proximal and diaphyseal injuries

During closed reduction of the proximal section, traction is applied downward by the healthy shoulder girdle. The tense muscle sheath helps retain the central fragment. After reduction, a plaster cast is applied (e.g., using Gromov's method, where the arm is positioned behind the head). In children under 7 years of age, fixation lasts 20–21 days; in children over 7, it lasts 26–28 days. Surgical treatment (osteosynthesis with Kirschner wires) is indicated only if closed reduction fails and angular displacement exceeds 15–20°.

Diaphyseal fractures in infants are most often the result of birth trauma (affecting the middle third). In older children, oblique, spiral, and comminuted injuries occur. The most critical diagnostic step is a neurological examination, as middle-third fractures are frequently complicated by radial nerve injury.

Conservative treatment of diaphyseal fractures depends on age:

• In newborns: a splint is applied from the hand to the healthy shoulder girdle (with the shoulder abducted at 90°). Displacement in length by 2–3 cm, in width by the full diameter of the bone, and angular displacement up to 30° are acceptable.
• In older children: angular displacement up to 10° and width displacement up to half of the bone diameter are acceptable. Local anesthesia is used for the reduction of oblique fractures (1 ml of 0.25% novocaine solution per year of the child's life).

Functional treatment is practically never used in children: as soon as the pain subsides, patients stop adhering to the strict activity regimen.

Distal fractures: classification and supracondylar injuries

Injuries to the distal end of the humerus are the most frequent and difficult to treat in children. According to G.A. Bairov's classification, they are divided into:

1. Intraarticular: supracondylar, capitellum fractures, trochlea fractures, and obstetric epiphysiolysis.
2. Periarticular: fractures of the epicondyles and their eminences.

Supracondylar fractures are the most common. They must be carefully differentiated from forearm dislocation using radiography.

Tactics depend on displacement:

• Without reduction: if there is no displacement or it is minimal (width displacement up to 1/4 of the diameter, external rotation up to 10–20°). A posterior splint is applied from the base of the fingers to the upper third of the humerus, with the forearm in a neutral position.
• With reduction: when acceptable limits are exceeded. Urgent reduction and deep splint fixation are required. The immobilization period is 10–12 days for children under 7 and 12–16 days for those over 7. Prolonged fixation carries the risk of joint stiffness.

Surgery (osteosynthesis with wires) is indicated for vascular and nerve injuries, open fractures, or soft tissue interposition. Strict monitoring is necessary during the first 24 hours after injury: if signs of compression appear (risk of Volkmann's contracture), the splint is loosened immediately.

Fractures of the condyles and epicondylar eminences

Fractures of the epicondylar eminences are typical for adolescents aged 8–14 years and occur as an apophysiolysis. They result from a fall on an outstretched hand with elbow hyperextension and severe valgus stress. Muscle contraction and tension of the collateral ligament tear off the medial epicondyle. If the injury is accompanied by a dislocation, the fragment may become entrapped within the joint space. When displacement and rotation of the internal epicondyle exceed 15°, reduction with fixation is indicated (using a pressure pad or Bairov's wire).

Capitellum fractures (osteoepiphysiolysis) are more common in children aged 4–10 years. Clinical presentation includes a semi-flexed arm, valgus deviation of the forearm, and smoothing of the joint contours due to hemarthrosis. If fragment rotation exceeds 60° or closed reduction fails, open wire osteosynthesis is performed for 2–3 weeks.

Isolated fracture of the humeral trochlea causes a step-like deformity of the arm and disruption of Hueter's triangle. Significant displacements are generally absent, so fixation with a plaster splint for up to 2 weeks is sufficient.

Obstetric traumatic epiphysiolysis

Injury to the distal humeral epiphysis in newborns is usually an obstetric trauma. The infant holds the arm in a forced (extended) position, active movements are absent, and passive movements cause sharp pain. Edema and subcutaneous hematoma are noted, sometimes with pathological mobility (in the first two days).

X-ray diagnostics in the first days of life are extremely difficult. Epiphyses in newborns consist of cartilage tissue, so in epiphysiolysis without displacement, bone fragments are not visualized on radiographs. A reliable diagnosis in preschool children often requires mandatory comparison with an image of the healthy limb.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of percutaneous wire fixation according to G.A. Bairov
• Differential diagnosis of supracondylar fracture and forearm dislocation
• Radiological features of elbow ossification centers in children
• Mechanism of development of Volkmann's ischemic contracture

Other topics in the section "Specifics of bone and joint injuries in children"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.