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Pediatric Humeral Fracture

Welcome to Texas State University's Evidence-based Practice project space. This is a wiki
created by and for the students in the Doctor of Physical Therapy program at Texas State
University - San Marcos. Please do not edit unless you are involved in this project, but please
come back in the near future to check out new information!!

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

Lead Editors

Contents
[hide]

1 Search Strategy

2 Definition/Description
 3 Epidemiology/Etiology

4 Characteristics/Clinical Presentation

5 Differential Diagnosis

6 Outcome Measures

7 Examination

8 Medical Management

9 Physical Therapy Management

10 Key Research

11 Resources

12 Clinical Bottom Line

13 Recent Related Research (from Pubmed)

14 References

Search Strategy
Databases Searched: CINAHL, JOSPT, Pubmed, Medline with Full Text, PEDro

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), 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 nursemaids elbow: Patient presentation is similar to
supracondylar fracture. The history of traction mechanism with nursemaids 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 childs 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 patients 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:

Allens 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 childs 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

Baumanns 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

Gartlands 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 childs 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
http://lib.sh.lsuhsc.edu/portals/orthopaedic/humeralfractures.pdf

Clinical Bottom Line

Supracondylar humeral fractures are common in the pediatric population. The childs age,
ossification periods, and mechanism of injury are important to consider. Examining the patients
neurovascular status is imperative and should be monitored throughout the course of treatment.
Stiffness and limited range of motion are common impairments that should be addressed in
physical therapy. There is limited evidence for physical therapy treatment and therefore
clinicians should implement an impairment based approach.

Recent Related Research (from Pubmed)

The comparative evaluation of treatment outcomes in pediatric displaced supracondylar
humerus fractures managed with either open or closed reduction and percutaneous
pinning.

References
see adding references tutorial.

1. 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 1.24 1.25 1.26 1.27
Hart ES, Grottkau BE, Rebello GN, Albright MB. Broken Bones: Common Pediatric
Upper Extremity Fractures Part II. Orthopaedic Nursing. 2006;25(5):311-323.

2. 2.0 2.1 2.2 2.3 Tejwani N, Phillips D, Goldstein RY. Management of Lateral Humeral
Condylar Fracture in Children. Journal of the American Academy of Orthopaedic
Surgeons. 2011;19:350-358.

3. Louahem DM, Bourelle S, Buscayret F, Mazeau P, Kelly P, Dimeglio A, Cottalorda J.

Displaced medial epicondyle fractures of the humerus: surgical treatment and results. A
report of 139 cases. Archives of Orthopaedic and Trauma Surgery. 2010;130:649-655.

4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 4.12 4.13 4.14 4.15 4.16 4.17 Lord B, Sarraf KM. Paediatric
supracondylar fractures of the humerus: acute assessment and management. British
Journal of Hospital Medicine. 2011;72(1):M8-M11.
5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 5.7 5.8 Ryan LM. Evaluation and management of supracondylar fractures
in children. UpToDate. 2010:1-37.

6. 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Marquis CP, Cheung G, Dwyer JSM, Emery DFG. Supracondylar
fractures of the humerus. Current Orthopaedics. 2008;22(1):62-69.

7. 7.0 7.1 7.2 Wu J, Perron A, Miller M, Powell S, Brady W. Orthopedic pitfalls in the ED:
pediatric supracondylar humerus fractures. American Journal Of Emergency Medicine.
October 2002;20(6):544-550. Available from: CINAHL Plus with Full Text, Ipswich,
MA. Accessed November 27, 2011.

8. 8.0 8.1 Fu D, Xiao B, Yang S, et al. Open reduction and bioabsorbable pin fixation for late
presenting irreducible supracondylar humeral fracture in children. International Orthop
(SICOT). 2011;35:725-730.

9. 9.0 9.1 9.2 Kraus R, Wessel L. The Treatment of Upper Limb Fractures in Children and
Adolescents. Dtsch Arztebl. 2010; 107(51-52): 903-910.

10. 10.0 10.1 Mallo G, Stanat S, Gaffney J. Use of the Gartland classification system for
treatment of pediatric supracondylar humerus fractures. Orthopedics. 2010;33(1):19.
Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed November 27,
2011.

11. Marcheix PS, Vacquerie V, Longis B, Peyrou P, Fourcade L, Moulies D. Distal humerus
lateral condyle fracture in children: When is the conservative treatment a valid option?
Orthopaedics and Traumatology: Surgery and Research. 2011;97:304-307.

12. 12.0 12.1 12.2 12.3 Keppler P, Salem K, Schwarting B, et al. The Effectiveness of
Physiotherapy After Operative Treatment of Supracondylar Humeral Fractures in
Children. J Pediatr Orthop. 2005;25(3):314-316.

13. 13.0 13.1 Bernthal NM, Hoshino CM, Dichter D, et al. Recovery of Elbow Motion
Following Pediatric Lateral Condylar Fractures of the Humerus. J Bone Joint Surg Am.
2011;93: 871-877.