Working Diagnosis:
Final diagnosis was a slipped proximal humeral epiphysis fracture.

Treatment:
Pediatric orthopedics was consulted immediately and the patient was seen the next day and scheduled for open reduction internal fixation two days later. Initially they attempted closed mobilization of the fracture, but secondary to the abundant healing callus, they converted to open mobilization of the physis with open debridement of the callus. Three internal pins were placed for fracture stabilization Case Photo #3 Case Photo #4 .


He was seen post-operatively at 3.5 weeks and was doing well. Pins were in place and the fracture appeared stable.


This patient did well and was seen 8 weeks post-operatively.

Outcome:
At 12 weeks post-operatively Case Photo #5 Case Photo #6 , he had full strength and range of motion. He was planning to return to wrestling in the fall.

Author's Comments:
Author comments: In summary, any skeletally immature athlete is at risk for physeal shoulder fractures and sports medicine physicians should be aware of this injury pattern.

Editor comments: Proximal humeral fractures account for only 0.45% of pediatric fractures and the proximal humeral epiphysis accounts for 3% of physeal injuries. This is classified as a Salter Harris type I fracture with displacement. It is an uncommon complication of shoulder dislocation. This case underscores the standard of treatment for acute shoulder dislocations which involves assessment of neurovascular status and reduction if deemed safe. Following reduction the arm should be immobilized in a sling and a period of rest should be observed until the patient can be formally evaluated. It is not recommended that patients return immediately to sport following a sideline reduction given the risk of repeat dislocation and further injury as clearly seen in this case.

Editor's Comments:
Proximal humeral fractures account for only 0.45% of pediatric fractures and the proximal humeral epiphysis accounts for 3% of physeal injuries. This is classified as a Salter Harris type I fracture with displacement. It is an uncommon complication of shoulder dislocation. This case underscores the standard of treatment for acute shoulder dislocations which involves assessment of neurovascular status and reduction if deemed safe. Following reduction the arm should be immobilized in a sling and a period of rest should be observed until the patient can be formally evaluated. It is not recommended that patients return immediately to sport following a sideline reduction given the risk of repeat dislocation and further injury as clearly seen in this case.

References:
Oldrini I, Coventry L, Novak A, et al Clinical predictors of fracture in patients with shoulder dislocation: systematic review of diagnostic test accuracy studies. Emergency Medicine Journal 2023;40:379-384.


Singh V, Garg V, Parikh S. Management of Physeal Fractures: A Review Article. Indian Journal of Orthopaedics. Indian J Orthop. 2021 Jun; 55(3): 525–538. Published online 2021 Jan 13. doi: 10.1007/s43465-020-00338-6


Watson S, Allen B, Grant JA. A Clinical Review of Return-to-Play Considerations After Anterior Shoulder Dislocation. Sports Health. 2016 Jul; 8(4):336-41. PMCID: PMC4922522.


Khoriati AA, Antonios T, Bakti N, Mohanlal P, Singh B. Outcomes following non operative management for proximal humerus fractures. J Clin Orthop Trauma. 2019 May-Jun;10(3):462-467. PMCID: PMC6491913.


Harald B, Mark S, Silke A, Christian F, Vilmos V. Physeal injuries of the proximal humerus: long-term results in seventy two patients. International Orthopaedics. 2011 May (35):1497–1502. PMCID: PMC3174291.

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