Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Orthop. Aug 18, 2023; 14(8): 604-611
Published online Aug 18, 2023. doi: 10.5312/wjo.v14.i8.604
Fractures around the shoulder in the skeletally immature: A scoping review
Tim Kraal, Peter AA Struijs, Lisette C Langenberg, Christiaan JA van Bergen
Tim Kraal, Peter AA Struijs, Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
Lisette C Langenberg, Department of Orthopedic Surgery, NoordWest Ziekenhuisgroep, Alkmaar 1815 JD, Netherlands
Lisette C Langenberg, Christiaan JA van Bergen, Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
Christiaan JA van Bergen, Department of Orthopedic Surgery, Amphia, Breda 4818 CK, Netherlands
Author contributions: Kraal T was the primary author; Struijs PA and Langenberg LC reviewed the text and provided figures; van Bergen CJA initiated and coordinated the project, reviewed the text and provided figures.
Conflict-of-interest statement: The authors report no conflict of interest.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Christiaan JA van Bergen, MD, PhD, Surgeon, Department of Orthopedic Surgery, Amphia, Molengracht 21, Breda 4818 CK, Netherlands.
Received: May 10, 2023
Peer-review started: May 10, 2023
First decision: June 14, 2023
Revised: June 23, 2023
Accepted: July 10, 2023
Article in press: July 10, 2023
Published online: August 18, 2023

Fractures around the shoulder girdle in children are mainly caused by sports accidents. The clavicle and the proximal humerus are most commonly involved. Both the clavicle and the proximal humerus have a remarkable potential for remodeling, which is why most of these fractures in children can be treated conservatively. However, the key is to understand when a child benefits from surgical management. Clear indications for surgery of these fractures are lacking. This review focuses on the available evidence on the management of clavicle and proximal humerus fractures in children. The only strict indications for surgery for diaphyseal clavicle fractures in children are open fractures, tenting of the skin with necrosis, associated neurovascular injury, or a floating shoulder. There is no evidence to argue for surgery of displaced clavicle fractures to prevent malunion since most malunions are asymptomatic. In the rare case of a symptomatic malunion of the clavicle in children, corrective osteosynthesis is a viable treatment option. For proximal humerus fractures in children, treatment is dictated by the patient's age (and thus remodeling potential) and the amount of fracture displacement. Under ten years of age, even severely displaced fractures can be treated conservatively. From the age of 13 and onwards, surgery has better outcomes for severely displaced (Neer types III and IV) fractures. Between 10 and 13 years of age, the indications for surgical treatment are less clear, with varying cut-off values of angulation (30-60 degrees) or displacement (1/3 – 2/3 shaft width) in the current literature.

Keywords: Clavicle fracture, Proximal humerus fracture, Pediatric, Skeletally immature, Children, Shoulder

Core Tip: Fractures of the clavicle and proximal humerus in children can be treated conservatively in most patients because of their large remodeling potential. The difficulty is to understand when a child is better off with surgical treatment of his/her clavicle or proximal humerus fracture. This review aims to provide a better understanding of the indications for surgical management of these fractures in the skeletally immature based on the latest literature.