Operative management of children's fractures of the shoulder region.

Fractures about the shoulder in children rarely require operative treatment. Exceptions include open fractures and those associated with neurovascular compromise. Fractures of the proximal humerus in older children that cannot be adequately reduced and maintained should be treated with open reduction and internal fixation. Interposition of periosteum and biceps tendon can lead to difficulty in fracture reduction. Irreducible displaced fractures of the clavicular shaft, fractures that develop nonunion, and congenital pseudarthrosis of the clavicle can be treated by an intramedullary pin technique with bone grafting. Posterior displacement of fractures of the medical clavicle sometimes become an orthopedic emergency. Reduction by closed or open means should be accomplished to relieve compression of mediastinal structures. This injury does not require internal fixation. Types IV, V, and VI distal clavicle injuries require open reduction and reefing of the periosteal tube with occasional need for temporary lag-screw fixation. There is some debate about the type III injury. Large glenoid fractures involving the anterior rim that are associated with instability of the glenohumeral joint are best treated by open reduction and internal fixation.