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3. Proximal humerus fractures • Relatively uncommon ( <3% ) ,most commonly in adolescents • Almost exclusively salter-harris type I or II • In general heal & remodel because : thick periosteom ,universal motion,great growth of region ( 80% )

4. Mechanism of injury • Birth fracture • Direct trauma ( outstretched hand ) • Direct blow to the lateral aspect of the shoulder • Child abuse • Less common: malignant or benign tumor,pituitarygigantism,joint neuropathy

5. Sign & symptom • Infant : irritable,pseudoparalysis • Older children: pain, swelling,deformity • Displaced fx => epiphysis abd & ext. rot distal fragment ant.medial rot • Undisplacedfx=> arm ininternal rotation

6. Radiographic study • Not useful < 6month sonography & CT • Comprisionxray & vanishing sign • In older children: AP axillary lateral view (difficult) transthorasicaxillary view or Y view apical oblique view(AP Xray with 45” caudal tilt) • CT scan (R/O dislocation) • MRI (R/O occult fx) • Bone scan( R/O occult fx but difficult to interpret )

7. Classification • Salter- harris: type I : infants & small children type II: adolescent type III & IV : rare because universal motion or combind with dislocation • Neer-Horwitz: grade I: < 5 mm displacement grade II: 5mm to 1/3 diameter of shaft grade III: 1/3 to 2/3 diameter grade IV: more • Stress fxof metaphysis or slipped epiphysis due to chronic or repetitive trauma such as throwing ,gymnastic, localised radiation therapy

8. treatment • Nearly all proximal humeral fx can be traetednonoperatively regardless age & grade • Grade I & II: treated symptomaticlly without attempt at reduction • Grade III & IV: controversial - all agree <6month treated symptomatically -closed reduction (traction abductionforwardflextionexternal rotation (under fluoroscopic guidance )imobilization 2 to 3 weeks occasionally reduction is lost or we cannot obtain adequate closed reduction existing deformity is accepted & managed symptomatically ( family reassurance )

9. Operative treatment: • -intraarticularfx -open fx -neurovascular injury -polytraumatisedpatient

10. Complication of proximal humerusfx • Rare 1- shortening (not important): more after surgury or pathologic fx UBC 2-varus –valgus deformity 3-AVN 4-brachial & axillary nerve injury(typically transient & return in< 6month ,if >3month EMG ) 5-brachial artery disruption 6- hypertrophic scarring ( after deltopectoralaproach axillary or ant.axillary incision better )

11. Little league shoulder • Also called proximal humeral epiphysiolysis, osteochondrosis or traction apophysitis • Is overuse injury most commonly in pitchers & occasionally other overhead athletes. • Nonspecific shoulderpain,often at beginningof the season or after a significant change in training protocol • Tendernes along P.H physis ,painful or limited ROM • Due to rotary torque • Xray : normal or widening Of PHP /stress fx my be present with methaphyseallucency & periosteal new bon formation • Almost always respond to rest

12. Clavicle • The first bone to ossify & the last physis to closed (medial )often not untile the 3rd decade • Clavicle fx is 8% to 15% of all pediatric fx • Most fx in middle third (76% to 85%)

13. Mechanisem of fx • Newbornduring delivery • Children & adolescents 1-fall on outstretched hand or side of shoulder 2-direct blow ( most the lateral end fx )

14. Sign & symptom • Newborn infants: -pseudoparalysis (mistakan for brachial plexsus inj.) -head turn toward fx ( to reduce pull of SCM) -asymetricmoro reflex -edema • Older children: -pain,tenderness,ecchymosis,edema,deformity,decreasmotion,turninig head (attention to atlantoaxialsubluxation)

15. Radiographic evaluation • Xray : -AP -serendipity view (40 degree cephalic tilt) for medial clavicle injuy -stress view : for lateral end • CT scan :evaluation of medial clavicl inj. Or lateral • Sonography : dislocation of medial end in new born

16. Classification of clavicle fx • Type I : middele part (lateral to SCM ,medial to coracoclavicularlig.) • Type II : distal end ( lateral to CC lig.) • Type III : medial end (medial to SCM)

17. Type II

18. Type III • Epiphysis of medial supported with SC lig. & capsulphysisunprotectedtrauma in children typically result in fx trough physis rather than dx of SCj in adult (salterfx type I or II) • This type classified : 1- ant (more frequent) 2- post (more serious)

19. Treatment • Neonate: asymptomatic: benign neglected symptomatic: sling & swatch 1-2weeks • Children & adolescents: midshaftfx :- rarely need to reduction -bump of callus remodel within 6- 9month - comfortable 8 bandag or sling 1 to 4 (bandag not immobilize fx , comfort patient by holding shoulder back) -reduction only skin in jeopardy - open reduction: neurovasculrjnj. or open inj. that is unstable following irrigation & debridment

20. treatment of Medial physeal separation • Because a significant remodeling  conservative treatment is the rule • If significant cosmatic deformity ,may attempt a closed reduction & often this inj. Are quiet stable after reduction , if lost we accept it • If posterior displacement is with airway, esophgeal or neurovascular impingment closed reduction or open reduction

21. Treatment of lateral end • All type I ,II,III can manag be managed symptomticlly ( sling & harness) • Type IV,V,VI usually requier open reduction,often by repairing the periosteal sleeve ,( avoiding percutanous pins)

22. Scapula fracture • Scapular body fx are often comminuted with multi direction line • Infra spinatus portion is more morefrequntlyfx • Abundant muscleprevent displacement • Scapular neck fx:ifC.Clig & clavicle intactdisplacement is minimal /// If this lig. Torn or if fx is lateral to coracoid process articular fragment displaced downward & inward bythe weight of limb

23. Mechanism of scapular fx • Most commonly direct trauma • High energy trauma result in significant injury to adjacent structres DIAGNOSIS: • often delayed or missed • Shuold be considered in upper thorasic or arm trauma • True AP xray is necessary • CTscan is helpfull

24. Treatment • Vast majority of scapular fx managed conservatively, directed toward patient comfort ( sling ,sling&swath,shoulder immobilizer) • Open reduction : 1- significantly displaced intra-articularfx 2-glenoid rim fx associated with subluxation of humeral head 3-unstabl fx through scapular neck including ipsilateralfx of neck & clavicle////displaced fx involving both the scapular spine & neck

25. Fracture of proximal metaphysis & shaft of humerus • More common inchildren than adolescents • Less common in children than adult ,but as in adults ,are frequently associated with radial nerve injury • Are the second most common birth fracture • 61% of all new fx in child abuse

26. Mechanism of fx • Proximal metaphysis: -usually high-energy direct trauma - minimal trauma suspicion of pathologic fx (UBC & other benign tumor) • Shaft: -most direct force : like fall on the side of arm (usually transvers or comminuted) -indirect force : fall on outstretched hand (oblique or spiral fx)

27. diagnosis • Obvious deformity ,localized swelling,pain clinical diagnosis straightforward classification Location: proximal ,middle,distal Patteren:spiral ,short oblique ,transverse Anatomically:proximal to the pectoralis major ,between it & deltoid ,below deltoid insertion Ao –ASIF:interobserver variability

28. Treatment • Infants with obstetric fx : imoblization 1-3 weeks /// effort to control aligment are not necessary (remodelling potential is great)/// follow-up only for brachial plexus • Proximal humralfx :remodeling potential is great these fx rarely require more than symptomatic treatment (sling) - occasionally percutaneous fixation (polytraumatized patient or open fx)

29. Treatment • Humeral shaft: -generally managed with closed technique -initially placed in a coaption splint 2-3weeks then managed in sling or hanging arm cast -end to end aligment not necessary (overriding 1 to 1.5 cm can be easily accepted) -angulation more than 15-20 degree in either plan is not desirable -rotational aligment should be maintain -clinical appearance is more important than radiographic alligment -open reduction: polytraumatised patient or open fx