Most proximal humerus fractures can be treated nonoperatively and result in good radiographic healing and functional results (Table 1). Nondisplaced or minimally displaced fractures (Neer grade I or II) are treated with immobilization with a sling and swathe or sling for 2–3 weeks. In displaced fractures (Neer grade III or IV), closed reduction should be attempted in most cases (Fig. 6). In some very young children, even severely displaced fractures may be treated with only immobilization. In these cases, an above-the-elbow cast with a neck collar and cuff around the wrist to suspend the cast and allow it to apply traction to the fracture while the patient is upright may be used. This has been called “hanging arm cast ” treatment and can be effective for younger patients (less than 11 years) with displaced fractures (Fig. 7). Patients are instructed to sleep in a semi-erect position for 1–2 weeks after the fracture.

Defining the amount of residual deformity after closed reduction that is “acceptable” is dependent on the age of the child; expert opinion by Beaty has provided some general guidelines – any amount of displacement and up to 70° angulation in children less than 5 years old, displacement up to 50 % width of shaft and angulation up to 40–45° in ages 5–12 years, and displacement of <30 % width of the shaft and up to 15–20° angulation in children greater than 12 years old (Beaty 1992). There are few specific contraindications to closed reduction – open fractures or fractures with vascular injury should be treated with open reduction .

Closed reduction with immobilization: Closed reduction is achieved using traction, 90° of flexion, then 90° of abduction and external rotation. Occasionally manual pressure applied to the proximal aspect of the distal fragment (proximal metaphysis) from anterior to posterior is helpful to push the fragment back inside the soft tissue envelope as traction is applied. Once the closed reduction maneuver is performed, fluoroscopy can be used to assess the reduction with the arm held in abduction. Once reduced, the traction is then released, and some axial load applied from distal to proximal to attempt to engage the fragments and hold the reduction as the arm is brought back to the patient’s side. As in the management of all displaced fractures, the goal is to obtain an acceptable reduction and then maintain the reduction through fracture union. Often the difficulty in proximal humerus fractures is maintenance of the reduction as the arm is brought back to the side. Historically this resulted in treatment of these fractures with overhead traction or “salute” casts with the arm held in abduction, flexion, and external rotation (Mooney and Webb 2009). These techniques do not have a role in modern fracture management. After closed reduction, patients are placed in a sling and swathe, and post-reduction radiographs should be analyzed carefully. The position should be judged as acceptable or unacceptable. If mild residual varus is present, the use of a small abduction pillow between the elbow and the trunk can help maintain improved alignment. If acceptable, immobilization for approximately 3 weeks is all that is necessary. The patient can then begin progressive range-of-motion exercises. Formal physical therapy is rarely necessary in pediatric orthopedic practice after fracture. If the position is unacceptable, then closed reduction and fixation in the operating room is scheduled electively.

Fractures at this site tend to have very good outcomes as a result of increased growth (proximal humeral physis contributes 80 % of humeral growth) and remodeling that occurs here (Blount 1954; Salter 1970; Hohl 1976; Kohler and Trillaud 1983; Mooney and Webb 2009). Nonoperative management is the treatment of choice for the majority of proximal humeral fractures, even in severely displaced fractures (Bahrs et al. 2009). Large-scale studies of nonoperative management of proximal humerus fractures in the pediatric population, with 5 and 8 years of follow-up, have shown excellent functional and radiographic outcomes (Kohler and Trillaud 1983; Baxter and Wiley 1986). A recent review and meta-analysis, which studied 12 publications with follow-up ranging from 0.6 to 9 years, revealed no nonunions reported and few malunions (Pahlavan et al. 2011). Some of the long-term complications reported were stiffness, loss of motion, weakness, and functional limitations.

Surgical intervention is indicated in the rare open fracture in this location; however, most operatively treated fractures will be severely displaced fractures in adolescents near skeletal maturity (Neer grades III–IV) (Table 2). In nearly all of these patients, the surgeon will be able to achieve closed reduction under fluoroscopy once adequate anesthesia is obtained. Intra-articular fractures in skeletally immature patients are very rare, but if encountered, the principles are the same as for displaced joint fractures in other locations. Anatomic restoration of the articular surface is desired provided that can be maintained until fracture union with the use of fixation. In young patients, stiffness is not as much of a concern as in adults, and so often, less rigid fixation that is easily removed is coupled with immobilization until fracture union.