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Proximal humerus fractures with severe medial displacement of the humeral head are rare in adults and especially so in children. Concomitant vascular/neurovascular injury is even more uncommon but must be considered as the associated complications can carry significant morbidity. We present a case of a 12-year-old transported to the ED after a mountain bike accident in which she lost control and hit a cement wall, injuring her left upper extremity (LUE). Despite a normal vascular/sensory exam, imaging demonstrated a left comminuted proximal humerus fracture with the humerus displaced medially into the thoracic inlet as well as concern for left subclavian vessel injury. Given the possibility of vascular injury and the severe humeral head displacement, she was taken to surgery with orthopedic and vascular surgical teams. Although surgical exploration did not reveal vascular injury, this case underlines the importance of maintaining a high index of suspicion for neurovascular injury with such fractures as prompt intervention may reduce the likelihood of complications. This case also underscores the need for further research into the management of pediatric proximal humerus fractures in early adolescence.

Carbamazepine is a common anticonvulsant medication used to treat seizure disorders and is generally considered a safe medication. We describe the case of a 9-year-old female who presented with acute altered mental status and respiratory failure requiring mechanical ventilation. She was found to be intoxicated with carbamazepine through a urine drug test which was confirmed by bloodwork. After her medical condition improved, the patient admitted to self-injury through ingestion to cope with the death of a family member. She received a complete psychiatric assessment and was eventually discharged without permanent neurologic sequelae. To our knowledge, this is the first case of intentional self-injury with carbamazepine intoxication in an elementary school-aged child. When intoxication is suspected in children presenting with altered mental status, all medications available at home should be investigated. Preadolescent children may engage in nonfatal self-injury behavior, and diagnosis requires a high index of suspicion.