Fracture Guideline IndexSee also: Proximal humeral fractures - Emergency Department
- How often should these fractures be followed up in fracture clinics?
- What should I review at each appointment?
- What are the potential complications associated with this injury?
- When should I refer for an orthopaedic consultant opinion?
- What are the indications for discharge?
1. How often should these fractures be followed up in fracture clinics?
Table 1: Recommended follow-up schedule for proximal humeral fractures.
Fracture
|
First appointment
|
Subsequent review appointments
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Discharge advice to parents
|
Metaphyseal fractures - angulation and displacement within age parameters
|
Within 7 days post- immobilisation with x-ray
|
At 4 weeks post- immobilisation. Removal of sling and x-ray to assess union
Clinical evaluation at 8 weeks
If no concerns, discharge
|
Gradual return to sports 4-6 weeks post removal of sling
Aim for full function by 8-10 weeks
|
Physeal fractures
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Within 7 days post- immobilisation with x-ray
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At 4 weeks post- immobilisation. Removal of sling and x-ray to assess union
Clinical evaluation at 8 weeks
If no concerns, discharge
|
Gradual return to sports 4-6 weeks post removal of sling
Aim for full function by 8-10 weeks
|
2. What should I review at each appointment?
Check for redisplacement and whether the sling is appropriate. Assess neurovascular status and document findings.
Assess analgesic requirements.
After four weeks assess range of motion (ROM) and encourage mobilisation as tolerated.
3. What are the complications associated with this injury?
Loss of position and malunion are the most common complications.
- Loss of position
- Uncommon in proximal humeral fractures. These are generally reasonably stable with good periosteal support. Loss of position indicates a generally unstable fracture, and consideration should be given to closed reduction and possibly minimally invasive stabilisation (wires)
- Malunion
- Can occur if the fracture is significantly displaced or position is lost. Mild malunion on x-ray is well tolerated
- Mild shortening and angulation will not cause cosmetic or functional deficit
- Rotational malunion >30 degrees will cause obvious cosmetic issues, and may affect function
Nonunion is rare
4. When should I refer for an orthopaedic consultant opinion?
Indications for an orthopaedic consultant review are:
- loss of position at follow-up visit with unacceptable alignment (Table 1)
- shift of >15 degrees on AP x-ray within one week of follow-up.
Table 1: Acceptable angulations and displacements for proximal humerus metaphyseal fractures.
Age
|
AP x-ray
|
Lateral x-ray
|
5-12 years
|
<60 degrees
<50% displacement
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<60 degrees
<50% displacement
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12-15 years*
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<30 degrees
<30% displacement
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<30 degrees
<30% displacement
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* As girls mature earlier, acceptable angulations may be less
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5. What are the indications for discharge?
The indications for discharge are a healed fracture clinically (i.e. pain free on movement and on palpation at the fracture site) and radiographically with acceptable alignment. Usually occurs at eight weeks post-fracture and immobilisation.
References (Outpatient setting)
Erikson M, Frick S. Fractures of the proximal radius and ulna . In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.405-45.
Pahlavan S, Baldwin K, Pandya N, Namdari S, Hosalkar H. Proximal humerus fractures in the pediatric population: a systematic review. J Child Ortho 2011; 5 (3) : 187-94.
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