Purpose or Case Report: Pediatric proximal humerus fractures lack comprehensive radiographic characterization, limiting understanding of injury patterns and surgical criteria. This study aimed to characterize radiographic patterns of proximal humerus fractures across skeletal maturity and identify predictors of surgery.
Methods & Materials: This IRB-approved retrospective case series included pediatric patients (≤18 years) with radiographically confirmed proximal humerus fractures over a 10-year period. Cases were identified by radiology report search using the terms “proximal humerus fracture,” “radiographs,” and “humerus.” Duplicates, patients >18 years, non-proximal fractures, and unconfirmed cases were excluded. Skeletal maturity, Salter-Harris pattern, maximum fracture displacement, angulation, and physeal involvement were collected along with demographics, injury mechanism, and treatment. Patients were categorized according to treatment as surgical or non-surgical (conservative management). Logistic regression was used to identify radiographic and clinical factors associated with surgical treatment; p<0.05 was considered statistically significant.
Results: In 418 included children (mean age 10.5±7.2 years, range, 1–17; 47% boys); 376 fractures occurred in skeletally immature, 37 in maturing, and 5 in mature shoulders. Physeal involvement occurred in 58 (15.4%) immature shoulders, predominantly Salter–Harris II (n=50, 86%). Median overall fracture displacement was 4.1mm (IQR, 2.0-11.2); relative displacement (percentage of shaft width) was 24% (IQR, 12-53%), and angulation was 17.5° (IQR, 10–28°). Among 380 patients with available follow-up radiographs, the median follow-up duration was 1.7 months (IQR, 1.0–2.5). Overall, 42 (10%) underwent surgery. Stepwise analysis found a significant association between surgery and ≥50 % displacement (33 % vs 1 %, p<0.01) and ≥30° angulation (33% vs 4%, p<0.01). On multivariable analysis, independent predictors of surgery included older age (OR, 1.53, 95% CI 1.28–1.92, p<0.01), ≥50% fracture displacement (OR 15.1, 95% CI 5.22–55.21, p<0.01), and angulation ≥30° (OR 2.91, 95% CI 1.18–7.36, p<0.02).
Conclusions: Fracture displacement ≥50% and angulation ≥30° were the strongest radiographic predictors of surgery in pediatric proximal humerus fractures, with older age also independently associated with operative management. Reporting these imaging findings can help guide clinical decision-making and surgical referral.