Keywords
adolescents - closed reduction - humeral fractures - Kirschner wire
Introduction
Proximal humerus fractures account for approximately 3 to 5% of all pediatric fractures,
with a higher incidence observed in older children, particularly between the ages
of 10 and 15 years.[1] Male children tend to be more affected than females. These fractures commonly result
from falls, sports-related injuries, or direct trauma to the shoulder region.
The management of proximal humerus fractures in adolescents depends on various factors,
including fracture characteristics, age, and skeletal maturity. Non-displaced or minimally
displaced fractures can often be treated conservatively with immobilization using
slings or braces. However, displaced or unstable fractures in patients with a limited
remodeling potential may require surgical intervention. Closed reduction and percutaneous
pinning (CRPP) are commonly employed surgical techniques for the management of displaced
or unstable proximal humerus fractures in adolescents.[2]
[3]
[4] While these procedures can be effective in achieving anatomical alignment and promoting
fracture healing, they are not without challenges and potential difficulties. This
article aims to describe a technique that can facilitate CRPP and minimize complications
associated with this surgical approach.
Technical Description
The indications for surgical management of proximal humerus fractures are described
in [Table 1]. Reduction is considered for fractures that are displaced by more than 33% (Neer
III or IV) or fractures exhibiting an angulation of over 40 degrees in patients who
are within 2 years of reaching skeletal maturity (boys aged ≥ 14 years and girls aged
≥ 12 years).[5] The patient is positioned in the supine or modified beach chair position to allow
orthogonal imaging ([Figs. 1] and [2]). Subsequently, the entire upper extremity is draped. With the arm in adduction,
2 2.0-mm Kirschner wires are percutaneously inserted and advanced to the fracture
site. In this position, it is easier to introduce pins than with the arm in abduction
and rotation. It is crucial to avoid the axillary nerve during percutaneous placement
of the pins. The nerve is located within 6 cm of the anterolateral aspect of the acromion,
and the pins are placed distal to this site. Once the position of the pins has been
confirmed radiographically, a closed reduction of the fracture is performed with traction,
abduction, and rotation. If the reduction is deemed inadequate, a 2.5-mm Steinmann
pin is used to facilitate the reduction (Kapandji technique). Occasionally, the periosteum
or the long head of the biceps may interfere at the fracture site, requiring an open
reduction through a deltopectoral approach. Once reduction is achieved, the pins are
advanced, and the Steinmann pin is removed. It is important to avoid penetrating the
articular surface with the Kirschner wires. Subsequently, tests are performed with
continuous fluoroscopy for maximum internal and external rotation to assess stability
and the final position of the pins. If signs of fracture instability are observed,
a third 2.0-mm crossed pin is inserted. The wires are then cut, bent, and kept outside
the skin, thus allowing for their removal in the office.
Fig. 1 A) Clinical image and radiographs at initial presentation. B) Fluoroscopic images
during closed reduction and percutaneous pinning. C) Anteroposterior and lateral radiographs
at 3 months follow-up.
Fig. 2 Diagram showing the Kapandji-assisted closed reduction and percutaneous K-wire fixation
for proximal humerus fractures.
Table 1
|
Indications
|
|
Open fractures
|
|
Fractures associated with neurovascular compromise
|
|
Skin tenting or risk of impending open fracture
|
|
Older children approaching skeletal maturity with displaced and angulated fractures
|
|
Polytrauma requiring early weight-bearing of the affected upper extremity
|
|
Ipsilateral extremity fractures (floating elbow)
|
Postoperatively, the affected limb is placed in a sling with a cushion to maintain
a certain degree of abduction. The fracture is followed biweekly to assess healing,
and the sling and pins are removed at 4 weeks in the office. Passive and progressive
active shoulder range-of-motion exercises, including forward elevation and external
rotation with the arm at the side, as well as pendulum exercises, are initiated following
pin removal.
Discussion
The proximal humeral physis exhibits remarkable potential for remodeling, enabling
significant tolerance for deformities in skeletally immature children. However, surgical
intervention may be necessary in certain situations. This article presents a straightforward
and effective technique that facilitates CRPP, minimizing the operative time and complications
associated with this surgical approach ([Table 2]).
Table 2
|
Pitfalls
|
How to avoid them
|
|
Axillary nerve injury
|
The nerve is located within 6 cm of the anterolateral aspect of the acromion, and
the pins should be placed distal to this site
|
|
Articular surface penetration
|
Perform continuous fluoroscopy to assess the final position of the pins in all views
|
|
Loss of fixation
|
Perform continuous fluoroscopy for maximum internal and external rotation to assess
stability
|
|
Skin necrosis
|
Evaluate the need of relaxing skin incisions at the site of pin insertion
|
|
Pin-site infection
|
Prophylactic antibiotics, pin care, and close observation
|
The utilization of CRPP encounters two main challenges: 1) reduction, as controlling
the proximal fragment becomes quite challenging due to muscle forces, and 2) fixation,
since achieving the required oblique entry angle for pins to traverse the fracture
may pose difficulties.
The closed reduction maneuver involves the application of axial traction, abduction,
and external rotation to the arm. However, inserting K-wires in this position presents
significant challenges due to the oblique entry angle required to traverse the fracture
in hard cortical bone. To overcome this difficulty, the use of a drill guide has been
proposed to ensure a more secure wire anchoring. Nonetheless, it is common for the
pins to skive when attempting a distal-to-proximal trajectory.[6] Based on our experience, we have found that percutaneously placing 2 2.0-mm Kirschner
wires until reaching the fracture with the arm in adduction is easier than introducing
the pins in the reduction position. Once the appropriate position of the pins is confirmed
using fluoroscopy, a closed reduction of the fracture is performed, and the pins are
advanced into the epiphysis. Traditionally, if this maneuver does not achieve satisfactory
reduction, one would perform an open reduction with a deltopectoral approach, which
is not without risks. In our proposed technique, in situations in which the reduction
is inadequate with closed maneuvers, a 2.5-mm Steinmann pin is employed to assist
with the reduction using a Kapanji-type maneuver. This technique can aid in achieving
proper alignment of the fracture avoiding an open reduction. Recently, Goldstein et
al.[6] proposed the use of a blunt hemostat for similar purposes. This tool provides safe
access to the fracture site, leverages the cortex of the distal fragment, and translates
it to align with the proximal humerus.
Final Considerations
In summary, the majority of proximal humerus fractures in the pediatric-adolescent
population can be managed without surgery owing to its remarkable remodeling potential.
However, in cases in which angulation and displacement exceed the acceptable limits,
our CRPP technique can provide a reliable approach for achieving satisfactory reduction
and stable fixation. This method offers a reproducible means to address fractures
that require surgical intervention.
