Background: There is no consensus on the operative treatment of adolescent proximal humerus fractures. The purpose of this study was to investigate the trends in treatment of proximal humerus fractures in adolescents and identify predictors of operative management. Methods: The Pediatric Health Information System database was used to identify patients ages 10 to 18 diagnosed with proximal humerus fractures between 2004 to 2019. Open fractures were excluded from the analysis. Descriptive, univariate, and multivariate analyses were used to determine trends and predictors of operative management. Results: A total of 17,515 proximal humerus fracture admissions were identified and 2081 (11.9%) were treated operatively. The mean age was 12.5 years and 37.5% of patients were female. The rate of operative management decreased from 15.1% to 8.9 during the study period (p<0.01). There was a higher rate of operative management in boys (13.4% vs. 9.4%, p< 0.01). The operative cohort was older (13.4 years vs. 12.4 years, p<0.01), and patients who lived in rural areas had twice the rate of operative management (20.7% vs. 10.8%, p<0.01). Operative patients had higher billed charges and longer hospital stay (p < 0.05), but there was no significant difference in mean estimated household income between operative and nonoperative groups (p > 0.05). A multivariate analysis showed increased odds of operative management with older age (OR 1.32, 1.29-1.36), and residence in the South (OR 1.19, 1.05-1.34). The odds of operative management were lower in more recent years (OR 0.94, 0.93-0.95) and in urban settings (OR 0.41, 0.35-0.47). Conclusion: From 2004 to 2019, there has been a significant decrease in the rate of operative management of adolescent proximal humerus fractures at children’s hospitals. Patients who are older, male, or reside in rural areas or the South are more likely to be treated operatively.

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.