![]() Proximal humerus fractures are characterized according to their anatomic location and displacement. Unlike adults, pediatric proximal humerus fractures rarely require computed tomography (CT) scans to identify fracture pattern and guide treatment. ![]() The tuberosities coalesce between 5 and 7 years and fuse with the humeral epiphysis at 7 to 13 years of age. The greater and lesser tuberosities appear by 3 and 5 years of age, respectively. The proximal humeral epiphysis becomes radiographically apparent at 6 months of age for this reason, infantile proximal humerus fractures require other imaging modalities (e.g., ultrasound, magnetic resonance imaging (MRI)) for adequate visualization. Understanding of the normal appearance of the secondary centers of ossification in the proximal humerus is imperative for accurate diagnosis. Radiographs should be carefully evaluated for underlying bony abnormalities, and further diagnostic workup should be considered prior to any surgical intervention in cases of diagnostic unknowns. Pathologic fractures in the setting of unicameral bone cysts, aneurysmal bone cysts, or other benign and malignant conditions commonly occur in the proximal humerus. In situations where an axillary view cannot be obtained, an apical oblique view of the shoulder (AP radiograph with 45 degrees of caudal tilt) may be useful. While axillary views are sometimes difficult to obtain, they are necessary to quantify displacement and angulation, which is often apex anterior (Figure 26-1C). Recommended for evaluation are anteroposterior (AP) lateral (scapular Y view), and axillary views of the proximal humerus. Plain radiographs will confirm the diagnosis. Careful assessment of radial nerve function (first dorsal web sensation, wrist extensor, and thumb and digital extensor motor function) is imperative in cases of humeral shaft fractures to assess for radial nerve palsy. Deltoid function and sensibility along the lateral aspect of the shoulder should be checked in cases of proximal humerus fractures to rule out concomitant axillary nerve injury. A comprehensive physical examination should rule out concomitant neurovascular injury. The affected extremity is usually held in adduction and internal rotation, with fullness or deformity about the injury site. Patients typically present with pain, swelling, ecchymosis, and limited shoulder and elbow motion. You have to see opportunity before you can seize it.
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