71.13 Fractures of the neck of the humerus in children

Some children with a fracture of the neck of the humerus are in great pain and are quite unable to move their arms; others have little pain and a surprising range of shoulder movement. If a child is in pain, don’t try to examine his shoulder—X–ray it. Take two views to determine the position of the fragments.

In young children the fracture is transverse and is about 2 cm below the epiphyseal line. When the fracture is complete, the shaft rides up in front of the upper fragment, and overlaps it. In an older child the fracture line passes through the epiphyseal line, so that the epiphysis separates. Sometimes, the fragments bow outwards, but do not separate, or they may separate so that the end of the shaft lies under the skin.

FRACTURES OF THE NECK OF THE HUMERUS IN CHILDREN

Check the child’s radial pulse and his axillary nerve (55.8). Treat incomplete and complete fractures in the same way.

If the fragments are not widely separated, put his arm in a sling and encourage him to move it.

If the fragments are widely separated, try to get them to hitch, as described above for widely separated unimpacted fractures in adults (71.12).

If you fail to get the fragments to hitch, put him in traction for 2 weeks, as in Fig. 72-11.

DIFFICULTIES WITH FRACTURES OF THE NECK OF THE HUMERUS IN CHILDREN

If the SHARP END OF THE DISTAL FRAGMENT HAS POKED THROUGH THE CHILD’S SHOULDER MUSCLES, and you can feel it under his skin, anaesthetize him and manipulate the broken end of his humerus back through his muscles. Use a combination of pulling and twisting movements, and get it to hitch with the proximal fragment. Sometimes the distal fragment goes right through the skin.

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Figure 71.13: REDUCING A FRACTURE DISLOCATION OF THE NECK OF THE HUMERUS. A, before reduction. B, during reduction. The arrows show where to push with your thumbs to return the head of the patient’s humerus back into his glenoid.

If you CANNOT MAINTAIN REDUCTION with his arm in a sling, apply skin traction, using overhead suspension (Fig. 72-11), a pulley, and enough weight to keep his arm raised—2 kg will probably be about right. Don’t tie his arm to a pole, because if he sits up, reduction is lost. Continue traction for 2 weeks until the fragments are sticky. Then put his arm in a sling and start pendulum exercises (Fig. 7-7).