Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents-A systematical review and meta-analysis

Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study

BACKGROUND

Proximal humerus fractures (PHFx) constitute around 2% of all pediatric fractures. Although younger children with displaced fractures often undergo nonoperative treatments, optimal treatment for adolescents is not well defined. The study aimed to assess the outcomes of operative versus nonoperative treatment of displaced proximal humerus fractures in adolescents via a prospective multicenter study.

METHODS

This prospective study assessed adolescents aged 10 to 16 years with displaced PHFx from 2018 to 2022 at 6 level 1 trauma centers. Displacement criteria for inclusion were >50% shaft diameter or angulation >30 degrees on AP/lateral shoulder X-rays. Operative versus nonoperative treatment was decided by the treating physician. Radiographic and clinical data were collected at 6 weeks, 3, and 6 months. Patient-reported outcomes (PROs) included: Patient Reported Outcome Measures (PROMIS), Shoulder Pain and Disability Index (SPADI), and QuickDASH questionnaires. Patients were further grouped into a severe displacement cohort, defined as angulation >40° or displacement >75%. Clinical and radiographic data were compared between the 2 treatment cohorts.

RESULTS

Out of 78 enrolled patients, 36 (46%) underwent operative treatment. Patients treated operatively were significantly older (13.5 vs. 12.2 y, P <0.001) and exhibited greater mean angulation on AP shoulder view at presentation (31.1° vs. 23.5°, P <0.05). All PROs improved over time. At 6 weeks, operative patients demonstrated superior PROMIS upper extremity scores based on the minimally clinically important difference (MCID) (46.4 vs. 34.3, P =0.027); however, this distinction disappeared by 3 months. In a subanalysis of 35 patients with severe displacement, 21 (60.1%) underwent surgical intervention. No metrics showed significant differences between treatment modalities, with all PROs achieving population norm values by 3 months. Range of motion showed no difference between operative and nonoperative treatments, irrespective of fracture displacement.

CONCLUSION

We found no differences in PROs and ROM between operative and nonoperative treatments of PHFx. If not contraindicated, nonoperative treatment may reduce healthcare costs and risks associated with surgery and should be considered for displaced adolescent proximal humerus fractures, irrespective of fracture displacement.

LEVEL OF EVIDENCE

II.

Open plate fixation in displaced pediatric proximal humerus fractures is safe and leads to very good functional outcomes

INTRODUCTION

In displaced pediatric proximal humerus fractures (PHF), surgical treatment ranges from closed to open procedures. Soft tissue interposition can impede closed reduction, making open techniques necessary. While K-wire fixation and elastic stable intramedullary nailing (ESIN) lead to good results, plate fixation could be an alternative in patients with limited growth potential and highly unstable or insufficiently retained fractures. Only few studies with low sample sizes have assessed plate fixation, yet. In this study, the outcome of pediatric PHFs treated with plate fixation was evaluated.

MATERIALS AND METHODS

We present a retrospective case series of 18 patients with open growth plates and unilateral, displaced PHFs, treated with plate fixation. The mean age at trauma was 12.1 years (± 2.4), the mean follow-up was 6.52 years (± 4.37). A mean fracture angulation of 32.3° (± 10.89°) was seen. Postoperative assessments included range of motion, clinical scores [Simple Shoulder Test (SST), Subjective Shoulder Value (SSV), American Shoulder and Elbow Surgeons (ASES) Shoulder Score, Pediatric/Adolescent Shoulder Score (PASS), Disabilities of Arm, Shoulder and Hand (DASH) Score], radiological parameters and subjective satisfaction.

RESULTS

All patients showed excellent results in SST (99.4% ± 0.02), SSV (98.3% ± 0.04), ASES-score (100% ± 0) and PASS (0.99 ± 0.01). In the DASH-score, 17 patients had excellent results, one patient showed a good outcome. Fracture healing occurred in all patients without complications. Eight patients complained about bothering scars. Age, gender and fracture morphology did not affect the outcome. Revision surgery after secondary fracture dislocation did not show a worsened outcome compared to primary plate fixation. Physeal growth plate bridging implants did not worsen the outcome. The timing of implant removal within the first 6 months postoperatively did not affect long-term function.

CONCLUSION

Plate fixation is a safe option in pediatric patients with limited growth potential and highly displaced PHFs. Plate fixation led to a good to excellent functional outcome, regardless of fracture morphology and implant positioning. A higher invasiveness and the need for implant removal must be considered.

Does Treatment of Adolescent Fractures Differ between Specialties? A Survey among Pediatric and Trauma Surgeons

From a traumatological point of view, adolescents (12-18 years) represent a special group of patients. This is due to their biomechanical characteristics being between pediatric and adult fracture types. In Germany, they are treated by both pediatric and trauma surgeons. For this survey, seven cases of adolescent fractures were evaluated by both pediatric and trauma surgeons and their preferred treatment options were raised. The questionnaires were completed anonymously. Additionally, information on the specialty and years of experience were asked. In total, 126 valid questionnaires were obtained (from 78 pediatric and 48 trauma surgeons). The respondents' mean clinical experience was high (71.5% stated more than 10 years of surgical experience). For every single exemplary case, a significant difference in therapy decisions between the groups could be found. For the demonstrated seven cases, a tendency toward more operative and more invasive treatments was found with trauma surgeons compared to pediatric surgeons. On the other hand, there was a risk of underestimating the severity of fracture entities similar to adult fractures in pediatric surgeons. Overall, a continuous interdisciplinary exchange between both surgical specialties is necessary to ensure optimal treatment for adolescent fractures and to develop guidelines in the future.

Proximal humeral fractures in children - controversies in decision making

BACKGROUND

Proximal humeral fractures in children are rare and usually treated non-operatively, especially in children younger than ten. The decision between operative and non-operative treatment is mostly based on age and fracture angulation. In the current literature, diverging recommendations regarding fracture angulation that is still tolerable for non-operative treatment can be found. Besides, there is no consensus on how fracture angulation should be determined. This study aimed to determine whether leading experts in pediatric trauma surgery in Germany showed agreement concerning the measurement of fracture angulation, deciding between operative and non-operative treatment, and choosing a treatment modality.

METHODS

Twenty radiographs showing a proximal humeral fracture and the patient's age were assessed twice by twenty-two senior members of the "Section of Pediatric Traumatology of the German Association for Trauma Surgery". Experts determined the fracture angulation and chose between several operative and non-operative treatment modalities. The mean of individual standard deviations was calculated to estimate the accuracy of single measurements for fracture angulation. Besides Intra-Class Correlation and Fleiss' Kappa coefficients were determined.

RESULTS

For fracture angulation, experts showed moderate (ICC = 0.60) interobserver and excellent (ICC = 0.90) intraobserver agreement. For the treatment decision, there was fair (Kappa = 0.38) interobserver and substantial (Kappa = 0.77) intraobserver agreement. Finally, experts preferred ESIN over K-wires for operative and a Gilchrist over a Cuff/Collar for non-operative treatment.

CONCLUSIONS

Firstly, there is a need for consensus among experts on how fracture angulation in PHFs in children should be reliably determined. Our data indicate that choosing one method everybody agrees to use could be more helpful than using the most sophisticated. However, the overall importance of fracture angulation should also be critically discussed. Finally, experts should agree on treatment algorithms that could translate into guidelines to standardize the care and perform reliable outcome studies.

LEVEL OF EVIDENCE

III.

[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]

BACKGROUND

Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature.

METHODOLOGY

As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this.

RESULTS

The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X‑ray images in 2 planes (true AP and Y‑images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X‑ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks).

CONCLUSION

Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Pediatric femoral shaft fractures: the American Academy of Orthopaedic Surgeons clinical practice guidelines versus actual management in a teaching hospital

Background

In 2009, the clinical practice guidelines (CPG) were released by the American Academy of Orthopaedic Surgeons (AAOS), which outline an age-based approach for treating pediatric femoral shaft fractures (PFSF), both nonoperatively and operatively. The aim of the current study was to investigate potential disparities between the recommended treatments for PFSF based on the AAOS-CPG and the actual treatments administered in The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University.

Methods

A retrospective review was conducted on the medical charts and radiographs of all PFSF treated at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2014 to January 2022. We identified 445 children who met our inclusion criteria and evaluated their treatments according to the AAOS-CPG. Actual treatments were then compared with the treatments recommended by the AAOS-CPG. Binomial and multivariate logistic regression was used to examine whether different factors could predict the choice between operative and nonoperative management.

Results

Operative treatments were undertaken in 102 of 215 (47.4%) fractures in children younger than 6 years, in 102 of 122 (83.6%) fractures in those between 6 and 12 years of age, and in 107 of 108 (99.1%) fractures in those older than 12 years. Nonoperative management was conducted in 113 of 215 (52.6%) fractures in children younger than 6 years, in 20 of 122 (16.4%) fractures in those between 6 and 12 years of age, and in 1 of 108 (0.9%) fractures in those older than 12 years of age. Surgeon decisions for non-surgery were in agreement with the CPG 52.6% of the time, whereas agreement reached 90.9% for surgical choices. Predictors of actual operative management were age (P=0.01), patient weight (P<0.001), fracture pattern (P<0.001), presence of other orthopedic injuries requiring surgery (P=0.002), and polytrauma (P=0.02).

Conclusions

There was limited concordance between actual treatments and CPG recommendations, particularly for the nonoperative management of fractures in children under 6 years old. Age, patient weight, fracture pattern, presence of other orthopedic injuries requiring surgery, and polytrauma were the main predictors of our operative decision-making process.

Single versus double retrograde intramedullary nail technique for treatment of displaced proximal humeral fractures in children: A retrospective cohort study

Background

Highly displaced proximal humeral fractures in children with low remodeling potential need to be reduced and fixed. The use of two flexible retrograde nails became the most popular fixation technique due to the excellent functional outcome, the low complication rates, and the possibility of early mobilization. A modified single retrograde technique has been suggested by the authors to address the main disadvantage of this technique, the long operative duration. The aim of this study was to compare these techniques in terms of efficacy, and clinical and radiological outcomes.

Methods

We performed a retrospective, monocentric study. Two groups of patients were defined: One was treated with the standard flexible retrograde double nail technique and the other with the modified single nail technique. The demographic and fracture characteristics were similar in both groups and the postoperative immobilization with a simple sling for 2 weeks. We compared the surgical duration for the initial fixation and hardware removal procedures. The Quick Disabilities of the Arm, Shoulder, and Hand score, the secondary displacement at 1-week follow-up, the radiological union at 6-week follow-up, and the perioperative and short-term complications were also assessed for both groups.

Results

The surgical duration of the initial fixation procedure was significantly shorter in single nail technique group (p = 0.005). The percentage of excellent Quick Disabilities of the Arm, Shoulder, and Hand score (0) was similar in the two groups (p = 0.98). No secondary displacement was reported for the double nail technique group. In only one patient from the single nail technique group, we detected a secondary displacement at the first week control which did not need reoperation. In both groups, fractures were healed on the 6-week radiologic control. No cases of infection, superficial skin irritation, neurological damage, or complications related to implant removal were reported in both groups.

Conclusions

The single nail technique of fixation proximal humeral fractures in children addresses the disadvantage of long surgical times, described until today, with the double nail technique without compromising the excellent functional and radiological short-term outcomes.

Level of evidence

level III.

Outcomes of proximal humerus fractures in children: a retrospective cohort study

OBJECTIVE

Paediatric proximal humerus fractures (PHFs) have historically been treated non-operatively. However, the management of severely displaced PHFs in older children has been debated over the years, with contemporary studies advocating for surgery. The purpose of this study was to review the outcomes of a cohort of paediatric patients treated for a PHF to guide management of future paediatric PHFs.

METHODS

The records of the Women's and Children's Hospital in South Australia were reviewed to identify paediatric PHFs occurring between 1 January 2010 and 1 June 2020. Participants completed the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH), the Shoulder Pain and Disability Index, and the Paediatric Outcomes Data Collection Instrument via phone interview. Participants' shoulder range-of-motion was assessed via telehealth using Zoom. Multivariable logistic regression was used to identify patient and clinical variables that were associated with a poorer outcome.

RESULTS

Of 307 patients contacted, 125 participated. Forty-six patients met the definition of a poorer clinical outcome, defined as a QuickDASH score of ≥2. Fractures of greater severity were predictive of a poorer outcome, and patients aged ≥12 years old at the time of injury had higher total QuickDASH scores. The findings did not suggest that these subgroups of patients have superior outcomes if treated surgically.

CONCLUSION

The majority of paediatric PHFs have an acceptable clinical outcome, irrespective of treatment methodology. Multicentre prospective studies are required to establish the indications for surgery for adolescent patients with severely displaced PHFs.

Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents?

OBJECTIVE

Pediatric proximal humerus fractures (PHFx) are uncommon and makeup ~2% of all pediatric fractures. Traditionally, most cases are treated nonoperatively with closed reduction (CR) or immobilization with no reduction (INR) with excellent outcomes. Indications for CR without fixation remain unclear as immobilization in the position of reduction (shoulder abduction and external rotation) is not practical. We aim to determine the need for CR among adolescents with displaced PHFx treated nonoperatively.

METHODS

We conducted an IRB-approved prospective multicenter study involving 42 adolescents aged 10 to 16 years, treated for displaced PHFx across 6 institutions between 2018 and 2022. CR was performed under conscious sedation in the emergency department, with data collected during follow-up visits at 6 weeks and 3 months. Radiographic measurements, range of motion, and patient-reported outcomes, including the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function, Shoulder Pain and Disability Index, and QuickDash scores, were compared between the INR and CR groups.

RESULTS

Among 42 fractures, 23 (55%) were treated with INR and 19 (45%) with CR, followed by placement in a hanging arm cast or sling. Of the cases, 62% were high-energy injuries. Radiographic alignment and range of motion were similar between groups at preoperative, 6 weeks, and 3 months with no significant differences noted.Patient-Reported Outcomes Measurement Information System Upper Extremity, Physical Function, QuickDash, and Shoulder Pain and Disability Index scores at 6 weeks and 3 months showed no significant differences between cohorts. Significant improvement was observed between 6 weeks and 3 months for every patient-reported outcome in both cohorts.

CONCLUSIONS

For displaced PHFx treated nonoperatively, our data suggests INR has a similar radiographic and clinical outcome when compared with CR. Our results question the necessity of performing CR in this group of patients.

LEVEL OF EVIDENCE

Level II-therapeutic studies: prospective cohort study.

Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study

OBJECTIVE

The purpose of this study was to compare the therapeutic effects of Kirschner wire fixation and external fixation in the treatment of proximal humeral fractures in older children and adolescents.

METHODS

A retrospective analysis was performed on the clinical data of older children and adolescents who underwent surgery at our institution for proximal humeral fractures between April 2014 and May 2022. One group (n = 28) underwent fracture reduction and Kirschner wire fixation, and the other group (n = 23) underwent external fixation. During the follow-up, the differences in shoulder joint function between the two groups were compared by analysing Quick Disabilities of the Arm, Shoulder, and Hand (Quick DASH) and Constant-Murley scores. Postoperative complications were also recorded.

RESULTS

The operation time of the Kirschner wire group was shorter than that of the external fixation group (69.07 ± 11.34 min vs. 77.39 ± 15.74 min, P = 0.33). The time to remove the fixator in the external fixation group was shorter than that in the Kirschner wire group (6.74 ± 1.57 vs. 7.61 ± 1.22, P = 0.032). The Quick DASH score and Constant-Murley score of the patients in the external fixation group were significantly better than those in the Kirschner wire group at 3 months after surgery (5.63 ± 4.33 vs. 8.93 ± 6.40, P = 0.040; 93.78 ± 2.43 vs. 91.75 ± 2.15, P = 0.003). There was no significant difference in the Quick DASH score or Constant-Murley score between the patients in the external fixator group and those in the Kirschner wire group at 9 months after the operation (2.77 ± 3.14 vs. 3.17 ± 3.68, P = 0.683; 97.39 ± 1.80 vs. 96.57 ± 2.15, P = 0.152). The most common complication of the two groups was pin tract infection. The incidence rate of infection was higher in the external fixation group than that in the Kirschner wire group (9 vs. 4, P = 0.043).

CONCLUSION

Both Kirschner wire fixation and external fixation of N-H III and IV proximal humeral fractures in older children and adolescents produce good outcomes. External fixation is a preferred surgical treatment option for paediatric proximal humerus fractures because early mobilization of the affected limb can be realized.

Fractures around the shoulder in the skeletally immature: A scoping review

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.

Outcomes at a Mean of 13 Years After Proximal Humeral Fracture During Adolescence

BACKGROUND

The long-term outcomes of a proximal humeral fracture during adolescence are not well known. We investigated the course of primary treatment for these injuries and the long-term outcomes in adulthood, comparing the outcomes with those from age-matched controls. We also compared outcomes after operative and nonoperative treatment via propensity score matching.

METHODS

We included children who sustained a proximal humeral fracture between the ages of 10.0 and 16.0 years and underwent treatment between 1995 and 2005. Data from primary treatment episodes were extracted from patient files. The patients were invited to a follow-up visit with outcome assessment and radiographs or to a telephone interview if unable to attend. The primary outcome was the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. The secondary outcomes were the Simple Shoulder Test (SST), pain at rest and with strenuous use, shoulder range of motion, strength measurements, health-related quality of life (15D), and harms. Participant results were compared with the normal values of an age-matched population. The effect of operative treatment was assessed using propensity score matching and the average treatment effect was calculated.

RESULTS

This study included 209 patients (210 fractures). The mean follow-up (and standard deviation) was 13.1 ± 3.2 years. Outcome data were obtained from 152 participants (153 fractures); 78 participants attended the follow-up visit. The primary treatment episodes were uneventful. The mean scores were 2.5 (95% confidence interval [CI], 1.8 to 3.3 [range, 0 to 13]) for the DASH and 11.7 (95% CI, 11.5 to 11.8 [range, 8 to 12]) for the SST. Other outcomes were similarly good. There were no differences in function compared with the normal population values. Propensity matching showed no treatment effect for operative treatment compared with nonoperative treatment.

CONCLUSIONS

Proximal humeral fractures of adolescents heal well and rarely result in impairments whether treated operatively or nonoperatively.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

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.

Proximal humerus fractures in adolescents: Experience from East of Scotland

BACKGROUND

The management of proximal humerus fractures (PHF) in adolescent has not been agreed upon. We aim to investigate the outcomes of PHF managed conservatively in adolescents.

METHODS

All shoulder radiographs performed in patients aged from 10 to 18 years and from 2008 to 2015 were reviewed. The radiological parameters, including anatomical side, Neer and Horwitz displacement grade, angulation and any residual deformities were recorded. Mail questionnaires based on the modified 15-Upper Extremities Functional Index (15-UEFI), with a maximum of 59 points, were sent out. The return of the completed anonymized questionnaire was considered as implied consent.

RESULTS

118 patients with a median age of 12 at the time of fracture were identified. The majority of the fractures were Neer and Horwitz grade I displacement and 3 children had Neer and Horwitz grade III and IV displacement. The median angulation was 25°. The median follow-up length was 26 days. 55 patients had residual angulation and 25 patients had worsened angulation. No non-union was identified. No patients underwent subsequent corrective surgeries. 35 patients responded to the questionnaire. The median 15-UEFI was 59 points. None of the patients have contacted the research or clinical team regarding any concerns.

CONCLUSION

The vast majority of non-displaced and minimally displaced PHF in adolescent were managed conservatively in our unit. The functional outcomes for this cohort remain excellent even for those with residual deformities in the follow-up radiographs. Further large prospective multicenter studies on adolescent cohort with significantly displaced PHF are warranted.

Three-dimensional printing designed customized plate in the treatment of coronal fracture of distal humerus in teenager: A case report

RATIONALE

Because of the complicated anatomy and considerable change in size and morphology with age in teenagers, the appropriate internal fixator of coronal shear fracture of distal humerus is difficult to choose, and therefore, the fixation of this kind of fracture is difficult and controversial. Furthermore, distal humeral fractures in teenagers often involve the epiphysis, the rigid fixation of fracture and the simultaneous minimally invasive and protection of the epiphysis are contradictory. Coronal shear fractures of the distal humerus in teenagers are great challenge for orthopedic surgeons. Three-dimensional (3D) printing designed customized plate in the treatment of coronal fracture of distal humerus in teenager is a potential satisfactory choice in the treatment of the complex fractures.

PATIENT CONCERNS

A teenager suffered from an elbow joint injury due to a fall while running, resulting in pain, swelling and limited movement of the elbow joint. The epiphyseal has not closed in this patient, conventional surgical procedures have great traumatic and invasive, and to some extent affect bone growth in children.

DIAGNOSES

Coronal shear fracture of right distal humerus according to computed tomography scan.

INTERVENTIONS

We used 3D printing technology to design an internal fixation device for this patient, which was to treat the distal humeral coronal shear fracture in a teenager via an anterior approach to the elbow joint, and finally the child was instructed to perform immediate postoperative functional exercises and rehabilitation.

OUTCOMES

Radiographic reexamination performed 1 day and 2 month after the operation showed that the internal fixation was in good position, no fracture displacement. the patient was instructed to perform active flexion and extension internal and external rotation of the right elbow 6 weeks postoperatively. The Mayo elbow function score was excellent 5 months postoperatively. The range of motion of the elbow was (15°-130°).

LESSONS

The treatment of coronal shear fractures of the distal humerus in teenager is controversial at present. This report 3D printing technology designed customized plate in treatment of such fractures showed satisfactory results, which provides a feasible method for the treatment of fractures without suitable internal fixation devices in the future.

Efficacy analysis of a double-Schanz screw external fixator combined with anti-rotating Kirschner wire in the treatment of proximal humerus fractures in skeletally immature patients

OBJECTIVES

The objective of this study is to evaluate the efficacy of a double-Schanz screw external fixator combined with anti-rotating Kirschner wire in the treatment of displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients.

METHODS

A retrospective analysis was performed on 22 cases of displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients who were treated with a double-Schanz screw external fixator combined with anti-rotating Kirschner wire. Patients included were the Neer-Horowitz (N-H) type 2, 3, and 4 of fracture. The basic information of the patients was recorded, fracture healing and shoulder range of motion were assessed at the last follow-up visit. The disabilities of the arm, hand (DASH) score and Constant-Murley score of the shoulder were performed to observe the occurrence of complications.

RESULTS

The mean age at the time of surgery was 12.41 years, and all patients completed a median follow-up of 18.18 months. There were two cases of N-H type 2, 12 cases of N-H type 3, and eight cases of N-H type 4 among the patients. At the last follow-up, all patients were able to achieve pain-free shoulder movement. There was no significant difference in shoulder function between the injured side and the uninjured side. The DASH score mean was 2.43 (95% CI 1.44-3.52). The constant score mean was 98.55 (95% CI 97.73-99.27). All patients returned to their pre-injury daily life and physical activities, and there was no significant difference in bilateral limb length at the last follow-up (p < 0.05). The most common complication of double-Schanz screw external fixator combined with anti-rotating Kirschner wire surgery was pin tract infection, which occurred in 5 cases (22.7%). There were no complications such as deep infections, vascular and nerve damage, failure of fixation, secondary fracture displacement, non-union of fracture, osteonecrosis of the humerus, joint stiffness, rotator cuff weakness and limb deformity.

CONCLUSION

The double-Schanz screw external fixator combined with anti-rotating Kirschner wire is a safe and effective treatment for displaced Salter-Harris type II proximal humerus fractures in skeletally immature patients over the age of 10 years.

Predictors of outcomes of proximal humerus fractures in children and adolescents: A systematic review

PURPOSE

Minimally displaced pediatric proximal humerus fractures can be reliably managed non-operatively; however, there is considerable debate regarding the appropriate management of severely displaced proximal humerus fractures, particularly in older children and adolescents with limited remodeling potential. The purpose of this study was to perform a systematic review to answer the questions: "What are the functional and quality-of-life outcomes of pediatric proximal humerus fractures?" and "What factors have been associated with a poorer outcome?"

METHODS

A review of Medline and Embase was performed on 4 July 2021 using search terms relevant to proximal humerus fractures, surgery, non-operative management, pediatrics, and outcomes. Studies including ≥10 pediatric patients with proximal humerus fractures, which assessed clinical outcomes by use of an established outcome measure, were selected. The following clinical information was collected: participant characteristics, treatment, complications, and outcomes.

RESULTS

Twelve articles were selected, including four prospective cohort studies and eight retrospective cohort studies. Favorable outcome scores were found for patients with minimally displaced fractures, and for children aged less than 10 years, irrespective of treatment methodology or grade of fracture displacement. Older age at injury and higher grade of fracture displacement were reported as risk factors for a poorer patient-reported outcome score.

CONCLUSION

An excellent functional outcome can be expected following non-operative management for minimally displaced pediatric proximal humerus fractures. Prospective trials are required to establish a guideline for the management of severely displaced proximal humerus fractures in children and adolescents according to fracture displacement and the degree of skeletal maturity.

LEVEL OF EVIDENCE

level V.

Outcomes of proximal humerus fractures in children: a study protocol for a retrospective cohort study

INTRODUCTION

Proximal humerus fractures (PHFs) comprise <3% of all fractures in children and adolescents. While it is accepted that minimally displaced PHFs can be treated conservatively, the management of severely displaced PHFs remains controversial, especially in older children. This study will aim to analyse the functional and quality-of-life outcomes of children with PHFs, in order to inform their optimal management.

METHODS AND ANALYSIS

We will conduct a retrospective cohort study to evaluate the outcomes of patients who were diagnosed with a paediatric PHF at the Women's and Children's Hospital (WCH) in South Australia. The primary outcome will be each participant's pain and quality-of-life outcome, determined by use of the Quick Disabilities of the Arm, Shoulder and Hand, Shoulder Pain and Disability Index and Paediatric Outcomes Data Collection Instrument. Secondary outcomes will include rates of non-union, persistent deformity and complications. The information for these variables will be acquired during a brief clinic appointment, and from the medical records and WCH radiology database. Multivariable logistic regression will be performed to determine the clinical variables associated with a worse clinical outcome.

ETHICS AND DISSEMINATION

The study has been approved by the Women's and Children's Health Network Human Research Ethics Committee (protocol number: 2021/HRE00250). The study findings will be submitted to peer-reviewed scientific journals for publication and disseminated at conference presentations.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry (ACTRN12622000176763).

Radiographic Results after Vertebral Body Tethering

Vertebral body tethering (VBT), otherwise known as fusion-less anterior scoliosis correction (ASC), is a new and increasingly interesting therapeutic option for selected scoliosis patients. The available data on this surgical technique are still limited and guidelines on patient selection or surgical timing are not available. The aim of this study was to conduct a systematic review of the available literature on VBT. The analysis was performed in accordance with the PRISMA Statement. Nine studies with data from 175 patients were available. On average, 7.3 vertebrae were instrumented. Surgical time was 230 min and the estimated blood loss 153 ml. The mean correction on the coronal plane was 52%, and there was no significant change in sagittal parameters. The revision rate was 18.9%. The methodological quality assessment with the Coleman score gave unsatisfactory results, so that available data are not sufficient to propose general indications or guidelines to perform VBT.

Hamstring, bone-patellar tendon-bone, quadriceps and peroneus longus tendon autografts for primary isolated posterior cruciate ligament reconstruction: a systematic review

INTRODUCTION

Several autografts are available to reconstruct the posterior cruciate ligament (PCL).

SOURCE OF DATA

Current scientific literature published in PubMed, Google scholar, Embase and Scopus.

AREAS OF AGREEMENT

Hamstring, bone-patellar tendon-bone (BPTB), quadriceps and peroneus longus (PLT) are the most common tendon autografts used for primary isolated PCL reconstruction.

AREAS OF CONTROVERSY

The optimal tendon source for PCL reconstruction remains nevertheless debated. Identifying the most suitable tendon autograft could assist the surgeon during primary PCL reconstruction.

GROWING POINTS

The present study compared the outcome of PCL reconstruction using hamstring, BPTB, quadriceps and PLT autografts. The focus was on patient-reported outcome measures (PROMs), joint laxity, range of motion and complications.

AREAS TIMELY FOR DEVELOPING RESEARCH

All autografts are viable options for PCL reconstruction, with BTB and hamstring autografts demonstrating superior PROMs. However, further clinical investigations are required to determine the ideal autograft construct.

Interference screws vs. suture anchors for isolated medial patellofemoral ligament femoral fixation: A systematic review

PURPOSE

The present study aimed to systematically review and compare 2 femoral autograft fixation techniques, namely, interference screws and suture anchors, for isolated medial patellofemoral ligament reconstruction in patients with recurrent patellofemoral instability at mid- to long-term follow-up.

METHODS

A literature search was performed in September 2020. All studies reporting the outcomes of primary isolated medial patellofemoral ligament reconstruction for recurrent patellofemoral instability were considered for inclusion. Only studies reporting the type of femoral autograft fixation under examination were considered. Studies reporting data from patients with elevated tibial tuberosity-tibial groove, patella alta, and/or Dejour's trochlear dysplasia types C and D, were not included. Only articles reporting data with a minimum follow-up period of 18 months were considered.

RESULTS

Data from 19 studies (615 patients) were retrieved. The overall age was 24.4 ± 6.7 years (mean ± SD). The mean follow-up was 46.5 ± 20.9 months. There were 76 patients in the anchor group and 539 in the screw group. Comparability was found with regard to age and follow-up duration between the 2 study groups. There was comparability between the Kujala, Lysholm, and Tegner scores at baseline. At the last follow-up, no worthy differences were found in terms of mean Kujala (+2.1%; p = 0.04), Lysholm (+1.7%; p = 0.05), and Tegner (+15.8%; p = 0.05) scores. Although complications occurred almost exclusively in the screw cohort, no statistically significant difference was found.

CONCLUSION

Femoral autograft fixation through interference screws or suture anchors report similar clinical scores and rate of apprehension test, persistent joint instability, re-dislocations, and revisions. These results must be interpreted within the limitations of the present study.

Epidemiology of Pediatric Upper Extremity Fractures in a Tertiary Care Center in Switzerland

OBJECTIVE

Fractures in children are common and account for 10% to 25% of injuries in children with considerable effects on activity restriction and subsequent high socioeconomically impact. Eighty percent of all fractures in children occur at the upper extremity. The article investigates the epidemiology and fracture pattern of the upper extremity within a pediatric population consulting a tertiary referral hospital in Switzerland.

METHODS

Study population included all patients younger than 18 years presenting with an upper extremity fracture. Recorded data were age, sex, side, season of the year, mechanism, type of fracture, and applied treatment.

RESULTS

Fractures of the upper extremities represented 76% with a mean age of 9 years and 7 months. Compared with girls, boys had a risk ratio of 1.35 (1.14-1.6) of having a traumatic injury. The radius, with 298 fractures (37%), was the most injured bone. Overall simple fall from his or her height and soccer represented the main injury mechanisms accounting for 26% and 9%, respectively. Eighty-six percent of fractures were treated by cast with or without closed reduction, 11% (92) by closed reduction and pinning or elastic stable intramedullary, and only 3% of fractures were treated by open reduction and internal fixation.

CONCLUSIONS

Eighty-six percent of all fractures could be treated by conservative methods. Only 17% need surgical treatments by orthopedic surgeons. This shows how important it is to train residents in pediatrics for the treatment of upper limb fractures in children.

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.

Proximal Humerus Fractures: What Alignment is Acceptable in Children 10 and Up?

BACKGROUND

Fractures of the proximal humerus in skeletally immature patients are rare, and even rarer still in individuals approaching skeletal maturity. Concepts regarding remodeling potential, amount of deformity and functional demands can guide our treatment decision making, but criteria are poorly defined. The purpose of this manuscript is to discuss the issues and the best available evidence.

METHODS

A search of the English literature was carried out using PubMed to identify papers on the topic of proximal humerus fractures in skeletally immature individuals.

RESULTS

The literature available on the topic of pediatric proximal humerus fractures is limited, especially regarding fractures in patients approaching skeletal maturity. Certainly, as the remodeling potential decreases and the amount of deformity and functional demand increase, the need for operative treatment increases. The exact tolerances and criteria have not been established. A variety of surgical techniques exist, and have been shown to be helpful.

CONCLUSIONS

Operative treatment may be necessary in individuals approaching skeletal maturity. Concepts discussed in this paper regarding remodeling, amount of deformity and functional demand may help the surgeon to make appropriate treatment decisions. Future prospective comparative studies which are pending will hopefully shed further light on this matter.

Failure and progression to total hip arthroplasty among the treatments for femoral head osteonecrosis: a Bayesian network meta-analysis

INTRODUCTION

Osteonecrosis of the femoral head (ONFH) often leads to secondary osteoarthritis and total hip arthroplasty.

SOURCE OF DATA

Recent published literatures.

AREAS OF AGREEMENT

There has been increasing focus on the early intervention in ONFH patients to preserve the native hip articulation, reduce pain and improve function.

AREAS OF CONTROVERSY

Efficacy of surgical strategies for ONFH is debated. Several clinical studies showed controversial results, and the best treatment has not yet been clarified.

GROWING POINTS

To provide an overview over current treatment options for ONFH compares their failure rates and conversion to total hip arthroplasty (THA) rates.

AREAS TIMELY FOR DEVELOPING RESEARCH

Core decompression (CD) augmented with autologous bone grafting plus the implantation of bone marrow concentrate can decrease the rate of failure and progression to THA rates compared to CD alone.

Health-related quality of life after conservatively and surgically-treated paediatric proximal humeral fractures

PURPOSE

The health-related quality of life (HRQoL) after conservatively versus surgically treated paediatric proximal humeral fractures is poorly understood. We assessed the HRQoL after this injury and asked if HRQoL was associated with age, radiological classification or treatment chosen.

METHODS

We identified 228 patients who were treated for proximal humeral fractures between 2004 and 2017. These patients completed the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) (primary outcome), the Paediatric Quality of Life Inventory (PedsQL) and questions regarding patient satisfaction. Fractures were classified radiologically following the Paediatric Comprehensive AO Classification.

RESULTS

We were able to follow-up on 190 children; 147 (mean age 8.7 years (0.8 to 15.7)) sustained a metaphyseal and 43 (mean age 11.6 years (3.7 to 15.8)) sustained a Salter Harris type I or II injury. Most fractures (90%) were simple, 10% were multifragmentary. In total, 137 children (72%) were treated nonoperatively, 51 (27%) were treated by elastic stable intramedullary nailing (ESIN). After a median follow-up of 7.6 years (0.8 to 14.3) there was an overall mean Quick-DASH of 4.3 (SD 9.3) for girls and 1.2 (SD 3.1) for boys. The mean function score of the PedsQL was 94.7 (SD 11.1) for girls and 98.0 (SD 6.0) for boys. The mean psychosocial score of the PedsQL was 92.0 (SD 11.1) for girls and 94.1 (SD 11.6) for boys. Most children (79%) were very satisfied with the cosmetic result and 74% were very satisfied with the treatment overall. Surgery and female sex were associated with lower satisfaction.

CONCLUSION

In this cohort of 190 patients, where immobilization for mildly displaced fractures, and closed reduction and ESIN was used for displaced fractures, there was equally excellent mid- and long-term HRQoL when assessed by the Quick-Dash and the PedsQL.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Do pediatric shoulder fractures benefit from surgery?

PURPOSE OF REVIEW

We aimed to review considerations, current treatment options, and complications in the management of pediatric proximal humerus fractures.

RECENT FINDINGS

Recent literature has shown an increased incidence of operative management of proximal humerus fractures. With increased age, and increased deformity, studies report excellent outcomes after operative treatment. Still, patients under the age of 12 and with Neer grade I and II fractures are consistently treated nonoperatively.

SUMMARY

Indications for operative management of proximal humerus fractures in skeletally immature patients have become increasingly widened. Current literature emphasizes the stratification of patients based on displacement, angulation, and shortening, with overall positive outcomes. Each case should be considered on individual bases, accounting for both radiographic parameters, developmental stages of patients, and potential complications. In the authors' opinion, adolescent patients with Neer Horowitz 3 and 4 fractures surgical management should be considered. In younger patients with nonoperative management, even with significant displacement, is the mainstay of treatment because of the tremendous remodeling potential of the proximal humerus in children.

VIDEO ABSTRACT

http://links.lww.com/MOP/A56.

Percutaneous Pinning of Pediatric Proximal Humeral Fractures

Background

Proximal humeral fractures are relatively common in pediatric patients. These injuries are usually treated nonoperatively in younger children or children with minimally displaced fractures. However, closed reduction or open reduction followed by percutaneous pinning is recommended for older children with displaced fractures. Percutaneous pinning has several advantages, but there are limited reports of a safe and reliable surgical technique in the literature.

Description

Patients are positioned in a modified beach-chair position to allow orthogonal imaging. The injured extremity is draped free from the remainder of the body. Closed reduction, which comprises a combination of traction, abduction, and rotation, is attempted. Internal or external rotation may be required, depending on the fracture line and deforming forces. If an anatomic closed reduction cannot be obtained, a block to reduction should be suspected and open reduction should be performed via a deltopectoral approach. Once the fracture is reduced, two 2.5-mm threaded Kirschner wires from the small external fixator set are used to percutaneously fix the fracture. Any small external fixator set can be used, and if not available, individual threaded wires of similar size can be used. Alternatively, Kirschner wires can be advanced to the fracture site prior to reduction and then advanced into the humeral epiphysis once the fracture is reduced. Care is taken to avoid the axillary nerve, which is reliably within 6 cm of the anterolateral aspect of the acromion, and wires are placed distal to this site. Once pin position has been confirmed radiographically, the construct is secured with pin-to-pin clamps to improve rigidity and further decrease the risk of pin migration. A soft dressing and shoulder immobilizer are placed postoperatively. Patients are followed with biweekly radiographs, and pins are removed in the outpatient office or under conscious sedation at 4 weeks. Leaving pins for a longer period may increase the risk of skin irritation and potentially infection.

Alternatives

Alternatives to closed reduction or open reduction and percutaneous pinning include nonoperative management and elastic intramedullary nailing. Nonoperative treatment is a reliable option for most patients. However, it is not suitable for older children with severely displaced fractures because of diminished remodeling potential. Elastic intramedullary nailing is a good option for distal fractures. However, it is not suitable for proximal fractures, and it has been associated with longer operative times and more blood loss than percutaneous pinning. It also requires a second procedure.

Rationale

This procedure allows for anatomic fixation of proximal humeral fractures and provides a rigid construct to maintain reduction. It is not technically challenging, requires limited postoperative immobilization, and decreases the risk of a second general anesthetic.

Proximal Humerus Fractures in Children: Experience from a Central London Paediatric Orthopaedic Service

Objective:

Proximal humeral fractures are commonly observed in children who sustain falls whilst running, or from heights. Appropriate and correct treatment is key in order to avoid limb length discrepancy and functional deficiencies. Current treatment methods include non-operative management such as collar and cuff immobilisation, and operative methods such as elastic stable intramedullary nails or Kirschner wires. This paper aims to present the demographics of this patient population and our experience in managing patients with proximal humerus fractures in an urban tertiary referral centre.

Method:

We assessed 41 cases across two sites in central London, identified via hospital electronic notes and our radiology digital system. We analysed patient demographics, mechanism of injury, time to discharge from orthopaedic services taking into account radiological and clinical union, and the treatment methods utilised.

Results:

The mean age of the cohort was 8.6 years old. 70% of the injuries were due to falls and 85% of cases were treated without an operation. The mean time to discharge from our service following radiological and clinical union was 46 days (9 – 161 days). Mean radiological and clinical union were 21.8 and 36.2 days respectively.

Conclusion:

These results support a non-operative approach, especially in cases with patients under 10 years of age. Surgery should only be undertaken in patients who have severe displacement and who have failed attempts at closed reduction. We would advocate a similar approach in institutions dealing with a comparable population of patients, as long as there are provisions for referral of more complex cases that require surgical stabilisation.

Inpatient surgical treatment of paediatric proximal humerus fractures between 2000 and 2012

PURPOSE

To estimate the rate of surgical treatment of paediatric proximal humerus fractures over time utilizing a large, publicly available national database.

METHODS

The Healthcare Cost and Utilization Project Kids' Inpatient Database was evaluated between the years 2000 and 2012. Proximal humerus fractures were identified using International Classification of Diseases, 9^th Revision, Clinical Modification (ICD-9 CM) diagnosis codes. ICD-9 CM procedure codes were used to identify patients who received surgical treatment. Univariable and multivariable logistic regression were used to determine variables associated with greater proportions of surgical treatment. All statistical analyses were performed utilizing SAS statistical software v.9.4. Statistical significance was set at p < 0.05.

RESULTS

A total of 7520 proximal humerus fracture admissions were identified; 3247 (43.2%) were treated surgically. The percentage of patients receiving surgery increased from 39.3% in 2000 to 46.4% in 2012 (p < 0.001). After adjustment for potential confounders, increased age, increased ICD-9 derived injury severity scores (ICISS) and more recent year were associated with an increased proportion of patients receiving surgical treatment (p < 0.001). Medicaid payer status (p < 0.001) and admission to a children's hospital (p = 0.045) were associated with a lower proportion of surgical treatment.

CONCLUSION

The rate of operative treatment of paediatric proximal humerus fractures increased over time between 2000 and 2012. Increased surgical rates were independently associated with older age, increased ICISS, treatment at a non-children's hospital and non-Medicaid insurance status. Further study is needed to provide evidence to support improved outcomes after operative treatment of paediatric proximal humerus fractures.