Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures

Operative Versus Nonoperative Management of Pediatric Proximal Humerus Fractures: A Meta-Analysis and Systematic Review

Background

Proximal humerus fractures account for 2% of all pediatric fractures. A nonoperative approach is the treatment of choice for most of these fractures; however, debates continue regarding the treatment of displaced fractures, especially in adolescents. In this study, we aimed to examine demographic data and treatment strategies for proximal humerus fractures in the pediatric population by conducting a meta-analysis. Additionally, we investigated the preferred surgical technique for operative treatment.

Methods

A systematic online search of databases, including Embase, Medline, PubMed, and Cochrane Library, was conducted to identify studies that matched our search criteria. Data collection was completed on May 1, 2022. Age, sex, degree of angulation, Neer-Horwitz classification, Salter-Harris classification, treatment method (operative vs. nonoperative), and instrument used for internal fixation were classified and documented. Effect size analysis was performed using odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), based on data types.

Results

Eight studies met our inclusion criteria. Overall, 33% of the patients (n = 195) underwent operative treatment, whereas 67% of them (n = 392) received nonoperative treatment. Among the demographic risk factors, severely displaced fracture type (OR, 10.00; 95% CI, 1.56-64.22; p = 0.020) and older age (WMD, 3.26; 95% CI, 2.29-4.23; p < 0.001) were significantly associated with operative treatment. There was no significant difference in the preference for percutaneous pinning or intramedullary nailing, the most frequently employed surgical techniques (OR, 5.09; 95% CI, 0.65-39.58; p = 0.120).

Conclusions

The operative treatment rate in pediatric proximal humerus fractures was 33%, which increased to 60% in severely displaced fractures (Neer-Horwitz grade III/IV). Severely displaced fractures and older age significantly contributed to the establishment of a treatment strategy for operative treatment. The choice of surgical technique may seem to be based on the anatomical location of the fracture rather than the surgeon's preference.

The Utility of Routine Follow-up Radiographs in the Nonoperative Management of Proximal Humerus Fractures in Patients 65 Years and Older

Whereas prior studies have aimed to define the utility of routine radiographs for the closed treatment of upper extremity fractures, it remains uncertain whether routine radiographs influence management decisions for nonoperative treatment of proximal humerus fractures (PHFs). The purpose of this investigation was to assess the utility of routine radiographic monitoring of closed PHFs in elderly patients initially indicated for nonoperative treatment. We identified all patients 65 years and older who had a PHF from 2016 to 2019. We excluded cases of pathologic fractures or peri-prosthetic fractures, nonunion, malunion, cases with insufficient follow-up, and cases for which surgery was indicated either in the emergency department or at the first orthopedic visit. After applying these exclusion criteria, 402 cases remained. We recorded baseline demographics and fracture descriptions and noted any conversion to operative treatment after the initial office visit. Two-part fractures were most common (56%). Of the 402 fractures indicated for nonoperative treatment, 21 (5%) were converted to operative management during the follow-up period. Nine fractures (2%) were converted to operative management within 30 days of the first office visit. Eight cases (2%) were converted to operative treatment more than 120 days after the initial office visit: 6 due to nonunion and 2 due to posttraumatic arthritis. For patients 65 years and older who undergo initial nonoperative treatment of a PHF, routine follow-up radiographs do not appear to alter management decisions. Given the risk and cost associated with routine radiographs, surgeons should consider forgoing these images in the absence of clinical concern. [Orthopedics. 2023;46(4):e244-e248.].

Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study

BACKGROUND

The objective of this study is to compare the treatments of pediatric displaced proximal humerus fractures with external-fixation technique using the combination of K-wires and bone-cement versus close reduction and internal fixation technique using elastic stable intramedullary nail.

METHODS

From April 2016 to March 2020, 72 children with proximal humeral fractures were allocated to group A and 44 children with proximal humeral fractures were allocated to group B. Patients in group A were treated with bone-cemented K-wire fixation, and patients in group B were treated with elastic stable intramedullary nailing. The function of the upper limb was assessed using the Shortened Version of the Disabilities of the Arm, Shoulder and Hand questionnaire and Neer score. Patient satisfaction was assessed using the 10-cm visual analogue scale.

RESULTS

Bone healing was achieved in group A and B after a mean time of 6.1 ± 1.2 and 6.4 ± 1.1 weeks, respectively. The mean surgical time of groups was 33 ± 9 and 54 ± 12 minutes, respectively. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score of groups were 0.5 ± 1.4 and 0.7 ± 1.5, respectively. Based on Neer score, we obtained 69 excellent and 3 good results in group A, and 41 excellent and 3 good results in group B. There were significant differences regarding duration of operation, cost of treatment, and postoperative angle at bone healing (P < .05).

CONCLUSIONS

The external cemented K-wire fixation is a useful and reliable alternative technique for the treatment of severely displaced proximal humerus fractures in children. The technique is a minimally invasive procedure with minimal complications.

Management of Pediatric Proximal Humerus Fractures

Proximal humerus fractures have an outstanding potential to remodel due to their proximity to the proximal humeral physis. Fractures in young children can be treated nonoperatively with excellent outcomes. The incidence peaks in adolescent patients and these injuries most commonly occur after a fall or direct trauma. The muscle attachments of the proximal humerus act as deforming forces and anatomic structures such as the periosteum and biceps tendon may act as blocks to reduction. Operative management is uniformly indicated for patients with open fractures, ipsilateral elbow or forearm injury, associated neurovascular injury, or poly-trauma patients. Operative treatment may be further considered in older children with minimal growth remaining and with fractures that are considered significantly displaced by available classification systems. Unfortunately, there are significant challenges in recommending treatment based on displacement and age alone. The purpose of this paper is to review what is known about these injuries and how they can be treated in light of current deficiencies in the literature; this may stimulate further work to refine indications for treatment based upon age and displacement. Key Concepts•The proximal humerus physis is responsible for 80% of the growth of the entire bone, and proximal humerus fractures have tremendous potential to remodel.•Proximal humerus fractures occur most commonly due to a fall or direct trauma but other causes include overuse injury and pathologic lesions.•Treatment indications for pediatric proximal fractures are guided by age of the patient, fracture displacement, and associated injuries; the majority of these injuries may be treated nonoperatively.•Outcomes after operative and nonoperative management of proximal humerus fractures are generally good.

Proximal Humerus Fractures in the Pediatric Population

PURPOSE OF REVIEW

The purpose of this review is to review recent literature focusing on proximal humerus anatomy, epidemiology of these fractures, diagnosis and treatment options, and clinical outcomes.

RECENT FINDINGS

Non- or minimally displaced proximal humerus fractures treated nonoperatively do not lead to short- or long-term complication and do not cross over to operative treatment. There is a higher rate of operative management with older age, increased injury severity score, treatment at an adult hospital, and private insurance. Operative management is preferred with closed or open reduction and percutaneous pinning, but elastic nailing and plate fixation are other options with good postoperative outcomes. Pediatric proximal humerus fractures occur after fall onto the affected shoulder or arm. Diagnosis is usually made with radiographs. Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential. There is considerable debate around the management of proximal humerus fractures in the pediatric population. Treatment is based on patient age, fracture displacement, and remodeling capacity. Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures.

Operative choice for displaced proximal humeral fractures in adolescents with open visible physis: A comparative study of external fixator vs. Kirschner wire

BACKGROUND

For adolescents with severely displaced proximal humeral fracture (PHF), surgery is a good choice yielding excellent outcomes, and Kirchner wire (KW) is a cost-effective choice for fixation. Purpose of this study is to compare the clinical outcomes of external fixator (EF) and KW for the treatment of PHF in adolescents.

METHODS

Patients of PHF operated at our institute, from January 2008 to January 2016, were reviewed retrospectively. Demographic data, including sex, age at the time of surgery, operated side, and hardware choice, were collected from the hospital database. Preoperative radiographs were reviewed and classified according to Neer-Horwitz classification. Shoulder function was evaluated at the last follow-up using the American Shoulder and Elbow Surgeons (ASES) score. Complications, including infection, malunion, nonunion, stiffness of the shoulder joint, and failure of fixation were also recorded.

RESULTS

Thirty-five patients, including 23 males and 12 females, were included in the EF group, whereas 40 patients, including 25 males and 15 females, were included in the KW group (P = 0.867). The average age of patients in the EF group was 13.3 ± 1.7 years, and that of KW was 13.6 ± 1.8 years (P = 0.409). Patients in both groups were followed-up for at least 12 months. The operative time in the EF group (42.4 ± 11.2 min) was significantly shorter than those in the KW group (54 ± 13.6 min) (P < 0.001). The frequency of fluoroscopy in the EF group (12 ± 2.4 times) was significantly less than those in the KW group (17 ± 2.8 times (P < 0.001). The rate of open reduction was significantly higher in KW (35%) group than those in the EF group (0%) (P < 0.001). There was no case of nonunion and malunion in both groups.

CONCLUSION

External fixator is superior to Kirschner wire in the treatment of proximal humeral fractures in adolescents with shorter operative time and lower rate of open reduction with comparable clinical outcomes.

Are Postcast Removal X-rays and a Second Follow-up Necessary in the Treatment of Nondisplaced Supracondylar Humerus Fractures?

BACKGROUND

The utility of routine follow-up radiographs for the treatment of nondisplaced pediatric supracondylar humerus fractures has not been established. The purpose of this study is to (1) determine the frequency that postcast removal x-rays change patient management and (2) determine the role of routine follow-up for range of motion evaluation after cast removal in the treatment of nondisplaced supracondylar humerus fractures.

METHODS

We conducted a single center retrospective chart review of patients under the age of 18 years old that sustained nondisplaced supracondylar humerus fractures between January 1, 2010 and July 1, 2018. Demographic information, fracture characteristics, time to follow-up and each appointment outcome were recorded. A change in patient management after postcast removal x-ray was defined as a need for an additional period of immobilization, a delay in initiation of range of motion exercises, or need for operative intervention. In addition, the appointment for range of motion evaluation was considered to alter management if further activity restriction was required, a formal physical therapy program was recommended or an additional office visit required. Unscheduled appointments were also noted.

RESULTS

A total of 489 patients met inclusion criteria. The average age was 4.90±2.68 years and 51.8% were female. A total of 487 patients had routine follow-up x-rays after cast removal. No patient had a change of management based on postcast removal radiographs. In all, 290 patients returned for range of motion follow-up with 94.8% of patients being discharged from care. There were 14 patients whose management changed based on this evaluation (4.8%). The most common reason was an additional appointment for range of motion evaluation (12/14 patients, 86%). There were 13 patients with unscheduled evaluation after discharge from care, 77% were secondary to repeat injury.

CONCLUSION

This study suggests that postcast removal x-rays and routine follow-up after cast removal rarely change patient management and may not be necessary in the treatment of nondisplaced pediatric supracondylar humerus fractures.

LEVEL OF EVIDENCE

Level IV-case series.

Rate of Complications and Subsequent Shoulder Complaints for Non-operatively Managed Pediatric Proximal Humerus Fractures

Purpose: The purpose of the study was to describe the early complications and delayed shoulder complaints of non-displaced or minimally displaced pediatric proximal humerus fractures treated non-operatively.

Methods: Retrospective review of all pediatric proximal humerus fractures at a single institution from 2001 to 2016. Inclusion criteria were: AP and axillary radiographs upon presentation and final follow up, one follow up appointment, either a non-displaced or minimally displaced fracture, and open physis. Exclusion criteria were: pathologic fractures, re-fractures, bone metabolic disorders. Patient demographics, injury characteristics, radiographic measurements and clinical exam findings were reviewed. Delayed shoulder complaints were defined as a visit to any provider for an ipsilateral shoulder or arm complaint after final scheduled fracture appointment.

Results: Sixty-nine of 177 total pediatric proximal humerus fractures met inclusion criteria. Mean age was 10 years (SD = 3.4). Sixty-five had angulation <20 degrees. Median time to last scheduled follow up was 1.4 months (Interquartile range 0.8–1.4). At last scheduled follow up, 9 (13.0%) fractures had an altered exam. One (1.4%) fracture had a complication of a fall and re-fracture. Extraphyseal fractures were more likely to increase in angulation at short term follow up, but had no association with short or long term complications. No patient initially treated with non-operative management subsequently underwent operative treatment. There were three presentations (4.3%) to health professionals for subsequent shoulder complaints; one was treated with short courses of physical therapy and the other two were simply observed.

Conclusions: Non-displaced or minimally displaced proximal humerus fractures treated non-operatively sustain rare short or long term complications with no cross over to operative management. Once non-operative management is pursued, these fractures may be amenable to surveillance with primary care or allied orthopedic staff after initial evaluation by pediatric orthopedic providers.

Level of Evidence: Level III retrospective cohort study.

The incidence and treatment trends of pediatric proximal humerus fractures

BACKGROUND

Proximal humerus fractures comprise approximately 2% of all pediatric fractures. In general, upper extremity fractures have increased in children. However, recent trends of proximal humerus fractures are not analyzed yet. The aim was to study the incidence and treatment trends of proximal humerus fractures in children.

METHODS

All 300 children, aged < 16 years, who suffered from a proximal humerus fracture in the catchment area of Oulu University Hospital, Finland, between 2005 and 2015, were included. Radiographs were reviewed, and patients, injuries, treatments, and outcomes were comprehensively studied. Annual incidence was based on the child population at risk, which changed between 84.500 and 88.100 in the study time.

RESULTS

The annual incidence of childhood proximal humerus fractures was mean 31.4/100,000 and no variation trend was found. The majority (92%) was treated nonoperatively, however, there was an increase of operative fixation from 0 to 16% during the study time (Difference 16, 95% CI 0.3 to 34.9%, P = 0.045). Bayonet displacement increased the risk of surgical fixation up to 16-fold (95% CI 4.8-51.4, P < 0.001) in a multivariate analysis when adjusted with other potential risk factors. Higher age was also associated with operative treatment (P = 0.002). The most usual recreational activities were horse riding, downhill skiing, snowboarding, and trampolining.

CONCLUSION

Contrary to most upper extremity fractures in children, proximal humerus fractures did not increase during the long study period. However, their operative treatment increased compared to nonoperative treatment, but the evidence supporting that trend remains unclear.

The Emergency Evaluation and Management of Pediatric Extremity Fractures

Approximately one-third of children sustain a fracture before the age of 16 years; however, their unique anatomy and healing properties often result in a good outcome. This article focuses on the diagnosis and management of pediatric extremity injuries. The article describes the anatomic features and healing principles unique to children and discusses pediatric upper and lower extremity fractures and presents evidence-based and standard practice for their management. Finally, the article describes the conditions under which emergency physicians are likely to miss pediatric fractures by highlighting specific examples and discussing the general factors that lead to these errors.

Cost savings of implementing the SickKids Paediatric Orthopaedic Pathway for proximal humerus fractures in Ontario, Canada

Background

The SickKids Paediatric Orthopaedic Pathway (SKPOP) for proximal humerus fractures may safely reduce the number of radiographs and follow-up assessments for children with these injuries. The study objective was to examine potential cost-savings of the SKPOP from the perspective of the Ministry of Health and Long-term Care (MOHLTC).

Methods

Two sets of resource profiles, based on direct health care costs were created for a cohort of patients treated at our institution: the first based on actual follow-up assessment values, and the other based on follow-up assessments according to the SKPOP. Differences between the two profiles represent potential cost-savings. A decision-analysis and associated probabilistic sensitivity analysis (PSA) were performed.

Results

In a cohort of 239 patients treated between 2009 and 2014, 92.9% (222) would have met SKPOP eligibility. Management according to this pathway would have reduced orthopaedic assessments and shoulder radiograph series by 83.6% (470/562) and 70.8% (367/589), respectively. For the cohort examined, a potential cost-savings of $30,040.56 ($135.32/patient) was observed. A PSA, accounting for variable SKPOP adherence and health care utilization, yielded cost-savings in 96.5% of the iterations run through the decision-analysis model and an average cost-savings of $57.82/patient. Based on these results and the annual provincial incidence rate of eligible patients (n=575), the MOHLTC could potentially save $33,249.45 annually with province-wide implementation.

Conclusions

Implementation of the SKPOP for a cohort of patients managed at our institution could have resulted in cost-savings due to substantial reductions in health care utilization. Cost-savings are likely to occur with provincial implementation of the SKPOP for proximal humerus fractures.