title: Proximal humeral fractures in children and adolescents.
abstract: BACKGROUND
  The purpose of the study was to investigate possible reasons for the failure of closed reduction of proximal humerus fractures in children and adolescents. We assessed the rate of soft tissue entrapment, and we also investigated the long-term clinical and radiological results after an age- and deformity-focused treatment regimen according to national guidelines.
  
  
  METHODS
  Forty-three patients were included in the study. Ten (mean age, 12.4 years; range, 6-16 years) of the patients were treated conservatively. The remaining 33 patients (mean age, 14 years; range, 6-18 years) were treated surgically (n = 2 Neer grade 2, n = 16 Neer grade 3, and n = 15 Neer grade 4) with either closed (n = 16) or open reduction with internal fixation. In 17 fractures, closed anatomical reduction of the fracture under general anesthesia was not possible. Subsequent open reduction and Kirschner wire or screw fixation (n = 12) or plate fixation (n = 5) was necessary. In 9 of these 17 fractures (5 fractures were totally displaced fractures), closed reduction was impossible because of the entrapment of periost (n = 2) or the biceps tendon with parts of the periost (n = 7). At follow-up, the clinical assessment included a structured interview, a detailed physical examination, and the assessment of overall shoulder function with the Constant score.
  
  
  RESULTS
  Operative and postoperative complications did not occur. All surgically treated fractures anatomically reduced and healed without loss of reduction. At a mean follow-up of 39 months (range, 12-118 months), all patients who were evaluated had excellent results according to the Constant score and had a normal range of motion and excellent strength of the shoulder joint.
  
  
  CONCLUSIONS
  A failed closed reduction should be interpreted as a possible soft tissue entrapment most likely because of the long biceps tendon. Those cases should be addressed with open reduction and removal of the entrapped structures. If anatomical reduction is achieved and maintained until fracture healing, excellent functional and radiological results can be expected from an age- and deformity-focused treatment regimen for children and adolescents with proximal humeral fractures.
  
  
  METHODS
  Level 4 (Therapeutic study).
authors.affiliation: BG Trauma Center, Eberhard-Karls-University, Tuebingen, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Bahrs
authors.forename: Sebastian
authors.initials: S
authors.lastname: Zipplies
authors.forename: Björn Gunnar
authors.initials: BG
authors.lastname: Ochs
authors.forename: Jörg
authors.initials: J
authors.lastname: Rether
authors.forename: Justus
authors.initials: J
authors.lastname: Oehm
authors.forename: Christoph
authors.initials: C
authors.lastname: Eingartner
authors.forename: Bernd
authors.initials: B
authors.lastname: Rolauffs
authors.forename: Kuno
authors.initials: K
authors.lastname: Weise
mesh_terms: D000293:Adolescent; D000367:Age Factors; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000379:methods*; D017102:Fracture Healing; D005596:Fractures, Closed / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D011183:Postoperative Complications; D017410:Practice Guidelines as Topic; D011859:Radiography; D016059:Range of Motion, Articular; D012784:Shoulder Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D017695:Soft Tissue Injuries / Q000209:etiology / Q000503:physiopathology; D013708:Tendon Injuries / Q000209:etiology / Q000503:physiopathology; D017211:Treatment Failure