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Proximal Humerus Fractures in the Pediatric and Adolescent Population: Epidemiology, Outcomes, and Complications
Ana R Scherf, MPH
1, Ave A Keefer, BS
2, Dennis Morozov, BS
2, Catherine C May, BS
3, Jackson T Elkins, BS
1; Joshua M Abzug, MD
1(1)University of Maryland School of Medicine, Baltimore, MD, (2)University of Maryland School of Medicine, Hunt Valley, MD, (3)University of Maryland School of Medicine, Timonium, MD
IntroductionProximal humerus fractures account for 2% of all pediatric fractures. While most are managed conservatively with minimal complications, there is a growing trend for surgical management based on fracture severity and lack of remodeling potential in older children and adolescents. This study aimed to investigate the epidemiology, treatments, and complications associated with pediatric and adolescent proximal humerus fractures.
MethodsA retrospective chart review identified all pediatric patients treated for proximal humerus fractures from 2012 to 2025. Descriptive statistical analysis summarized patient demographics, fracture characteristics, treatment modality including surgical technique if applicable, return-to-activity time, and complications. Comparisons between non-operative and operative groups utilized independent t-tests or Wilcoxon rank-sum tests for continuous variables and chi-square or Fisher's exact tests for categorical variables.
Results217 proximal humerus fractures in 212 patients were identified. The median age at fracture was 10 years [IQR:7-12] with 55.3% of fractures occurring in males. Falls (61.3%) and sports participation (20.7%) were the most common mechanisms of injury. 65.4% of fractures were extraphyseal and 34.6% were physeal. Pathologic fractures were present in 2.3% (N=5) of patients, with 2 managed operatively using curettage and bone grafting. Concomitant injuries occurred in 18.4% of fractures, most commonly involving the shoulder girdle and forearm. 193 fractures (88.9%) were treated non-operatively with a median immobilization period of 28 days [IQR:21-34]. 24 fractures (11.1%) were treated operatively, most commonly with ORIF (N=16).
The median age was 9 years [IQR:7-12] in non-operative patients and 13.5 years [IQR:11-14.5] in operative patients (p<0.0001). Extraphyseal fractures were more common in the non-operative group (68.4%) compared to the operative group (41.7%) (p=0.009). The overall median follow-up was 46 days [IQR:28-73]. For cases with available return-to-activity data (N=181), the median return-to-activity time was 48 days [IQR:28-68]. Return-to-activity time was significantly higher in operative cases (median 84 [IQR:73-115] days) compared to non-operative cases (median 42 [IQR:21-61] days) (p<0.0001).
Complications occurred in 11.6% of fractures, with some patients experiencing multiple complications. The most common complications were continued pain, wound drainage, and worsening alignment/displacement. The operative group experienced higher complication rates (56.5%) than the non-operative group (6.3%) (p<0.0001).
DiscussionMost pediatric proximal humerus fractures can be treated non-operatively with low complication rates. Operative intervention of pediatric proximal humerus fractures leads to longer immobilization and return-to-activity periods and significantly higher complication rates. Further investigation is warranted to determine the true indications for surgical management to improve outcomes and reduce complications.
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