A severely high-grade proximal humeral fracture in a polytrauma child: A Case Report

Authors

Abstract

IntroductionFractures of the proximal humerus in children are relatively rare, and the management of Neer-Horwitz grade IV injuries remains controversial.
Case PresentationWe report a case of a 9-year-old pediatric patient with a high Injury Severity Score (ISS) who sustained a severely displaced proximal humerus fracture following a motor vehicle collision. The case highlights that conservative management is a proper option for polytrauma patients with high-grade displacement and high ISS, emphasizing the importance of careful clinical judgment and individualized treatment decisions.
ConclusionWhen an explicit risk–benefit assessment favors deferring or even withdrawing surgery in the context of associated injuries, it underscores the importance of individualized, context-driven clinical decision-making.

Keywords

Introduction

The incidence of proximal humerus fractures is relatively low in the pediatric age group, accounting for less than 5% of all pediatric fractures.¹ The most common mechanism of pediatric proximal humerus fracture (PPHF) is a fall on an outstretched hand, or a direct trauma to the shoulder, and about one-third of all these fractures in children result from motor vehicle accidents.2 Most of it is usually handled conservatively due to the excellent remodeling potential in the pediatric group.²
It was estimated that approximately 33-60% of PPHF with severely persistent displacement need operative treatment.³ Operative management is unvaryingly indicated for patients with open fractures, associated neurovascular injury, poly-trauma with a high injury score, severely displaced fracture, or ipsilateral elbow or forearm injury.²
This case report shows that, in a severely displaced fracture pattern with a high Injury Severity Score (ISS), a clear risk–benefit assessment favors voiding surgery in the context of associated injuries, underscoring the importance of individualized, context-driven clinical decision-making in selected cases.

Case Presentation

A 9-year-old boy was brought to the emergency department (ED) after being hit by a car while riding a scooter (Table 1). At the scene, he had no loss of consciousness but experienced vomiting. He was initially evaluated at a nearby medical facility 12 hours before presenting to our institution, where initial resuscitation was performed, and then the patient was transferred. At the ED, the primary survey indicated no life-threatening injuries, and he was clinically stable on room air with a cervical collar applied. His blood pressure was 100/72 mmHg, heart rate 144/min, afebrile, respiratory rate 34 breaths/min, and peripheral O2 saturation 96% on room air. The Glasgow coma score was 14/15. Secondary survey demonstrated raccoon eyes, a left upper-limb deformity, and multiple abrasions over the face and both upper arms. He had a severe trauma on the ISS scale with an ISS score of 22 due to multi-system trauma involving the head, chest, and long bones.

A large-bore intravenous cannula was inserted in both hands, and he received a unit of type O-negative packed RBCs. The patient’s airway was intact, with no abdominal swelling or tenderness encountered. Laboratory workup showed hemoglobin 9.4 g/dL, white blood cell count 9.9 × 10⁹/L, platelets 333 × 10⁹/L, INR 1.0. A Foley catheter was in place with a urine output of 2.2 mL/kg/hr. Radiographs and computed tomography displayed calvarial, facial, and skull-base fractures; pulmonary contusions; right first-rib fracture; and left proximal humeral fracture, and a small pneumothorax. No acute traumatic injury was noted in the brain parenchyma, abdomen, pelvis, or spine. The patient was admitted to the ward for close observation.
Radiographs demonstrated a Neer–Horwitz grade IV closed proximal humerus fracture with >200% translation and 58° angulation, without fracture-dislocation; neurovascular examination was intact. Following an unsuccessful attempt of reduction under conscious ketamine sedation, an initial attempt at closed reduction was performed utilizing a standard traction–countertraction technique. However, the procedure failed to achieve adequate realignment, resulting in persistent displacement exceeding 200%. Consequently, conservative management was selected, with a hanging arm cast applied and the elbow maintained in flexion (Figure 1). This immobilization was continued for 3 weeks and subsequently removed upon radiographic confirmation of callus formation. Follow-up X-rays at 2, 4, and 6 weeks confirmed that the fracture was uniting. Physiotherapy was initiated six weeks after discharge.
At the two-month follow-up, (Figure 2) the patient showed modest improvement, with gradual gains in range of motion. No complications were noted during outpatient follow-up. By four months, he continued to exhibit a restricted range of motion. However, no deformity or localized tenderness was noted, and imaging confirmed ongoing bone healing. Over the subsequent months, the patient experienced progressive functional recovery. At final follow-up, (Figure 3) he had regained full, pain-free shoulder function with no neurological deficit and had returned to near normal daily activities but only had shortening deformity of 1.5 cm. His range of motion was forward flexion 170°, Abduction 160°, External Rotation 60°, Internal rotation to T7 in both shoulders.
Ethical ApprovalWritten informed consent was obtained from the patient’s parent/guardian for publication of this case report and the accompanying images. The author certifies that he has obtained all appropriate patient consent forms. The patient’s guardian understands that the child's name and initials will not be published and that due efforts will be made to conceal the child's identity, but anonymity cannot be guaranteed. This study did not require ethical approval according to the relevant guidelines.
Reporting GuidelinesThis case report is presented in accordance with the CARE guidelines.

Discussion

This pediatric male patient typically presents with major transportation accidents that cause an acute fracture with polytrauma. He also had a significantly displaced (high-grade) proximal humerus fracture (Neer-Horowitz grade IV fractures).² Even after a trial of closed reduction, the malalignment remained the key factor in our decision to proceed with open reduction and fixation or not. The decision to avoid surgery was based on 1) still high remodeling potential at age 9 years with adequate neurovascular status; 2) the patient’s associated injuries (pneumothorax and pulmonary contusion) and the anesthesia assessment of increased perioperative respiratory risk; and 3) absence of fracture-dislocation.
Though quite a few surgeons will stabilize such a fracture to prevent a long-term limb-length discrepancy or loss of shoulder strength. The author differed from that course because he believed it would yield the same superior functional outcomes. This deviation from the average care was to prioritize patient stabilization and pulmonary recovery. It was also predicated on the hypothesis that non-operative management would yield outcomes comparable to those of operative management.
Most current research still supports the non-operative option over the operative approach in PPHF,^2,4,5 particularly before adolescence, as fair clinical and radiological outcomes were marked in both groups.⁶ Nevertheless, the operative management rate for PPHF is increasing, especially in severely displaced fractures (grade III and IV).^1,3 Reasonable management, in cases of increased injury severity score and hospital admission, is associated with a higher likelihood of operative management.⁴
Questions persist about the distinction between prevailing and optimal outcomes. There remains considerable variability in proposed surgical thresholds, with no universally accepted, evidence-based guidelines. However, a review of 300 children showed that although most were managed nonoperatively, only 3.3% subsequently required surgical intervention due to redisplacement.¹ In pediatric cases, fixation is most commonly achieved with percutaneous pinning, typically after closed reduction.⁵ While many surgeons prefer elastic stable intramedullary nailing (ESIN) for its stability and soft-tissue safety, plate and screw fixation is infrequently used in preadolescent patients.² We acknowledged the burdens of surgery, particularly its increased invasiveness, the requirement for later implant removal, and the risk of bothersome scarring.⁷
Though we had managed the patient's fracture non-operatively after a failed trial of closed realignment, the presence of a fracture dislocation would have compelled us to do an urgent open surgery for joint reduction and fracture fixation. A case report by Fannouch et al. described a posterior dislocation with fracture fixation via open reduction and internal fixation using ESIN.⁸

Limitations

Limitations include the single-patient design, which limits generalizability, and the lack of follow-up beyond skeletal maturity.

Conclusion

Clinicians should feel confident considering the non-surgical option, even in polytrauma pediatric patients and those with high-grade displaced PPHF. Our case demonstrates that an unsuccessful reduction does not inherently signify failure of conservative management. Nevertheless, a fracture reduction attempt is advisable, and the family's comfort is essential to ensure understanding of the treatment rationale, expected course, and the likelihood of favorable outcomes.

Declarations

Abbreviations

CARE: case report guidelines
ED: emergency department
ESIN: elastic stable intramedullary nailing
ISS: injury severity score
PPHF: pediatric proximal humerus fracture

References

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About This Article

Received:

February 17, 2026

Accepted:

April 17, 2026

Published Online:

April 17, 2026