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

Abbot, Samuel; Proudman, Susanna; Ravichandran, Bhuvanesh; Williams, Nicole

doi:10.1177/18632521221117445

Cited by 2 publications

(7 citation statements)

References 43 publications

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“…It is well known that proximal humeral fractures heal well in young children; however, less is known in adolescents. A recent systematic review found that, since the 1946 inception date in the National Library of Medicine’s computer-based retrospective search service, there have only been 4 prospective cohort studies and 8 retrospective cohort studies examining proximal humeral fractures in children 1 . None has explicitly focused on fractures occurring during adolescence.…”

Section: Commentarymentioning

confidence: 99%

Sometimes Less Is More!

Castañeda

2023

Journal of Bone and Joint Surgery

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The thought-provoking and well-performed study by Laḧdeoja et al. represents a retrospective review of 209 patients who sustained a proximal humeral fracture as adolescents and had an impressive follow-up ranging from 7 to 19 years and a thorough and rigorous methodology to assess outcomes. The authors did an outstanding job matching cohorts to make valid comparisons with a similar group without a fracture. The study found that patients who sustained a proximal humeral fracture as adolescents healed well and had good outcomes in long-term follow-up. The study also found no significant differences between patients treated operatively and those treated nonoperatively.It is well known that proximal humeral fractures heal well in young children; however, less is known in adolescents. A recent systematic review found that, since the 1946 inception date in the National Library of Medicine's computer-based retrospective search service, there have only been 4 prospective cohort studies and 8 retrospective cohort studies examining proximal humeral fractures in children 1 . None has explicitly focused on fractures occurring during adolescence. The current study by Laḧdeoja et al. will add to the growing mountain of evidence that shows that even adolescents do well after this kind of injury.Laḧdeoja et al. believe that their findings will influence the practice of orthopaedics as they can help to guide the treatment of proximal humeral fractures in adolescence by using the idea that less is more and noting that most patients can be treated nonoperatively with minimally burdensome methods for the patients and that parents can be assured that the outcomes are good.However, one should note that the idea of less is more can have different interpretations. Dolly Parton once famously said, "People say that less is more, but I think more is more." She was, of course, referring to the absurdity of noting that a qualifier (less) is opposite to its meaning. The architect Frank Lloyd Wright is correct in stating that "Less is more only when more is too much."Based on the results of this study, a surgical procedure for proximal humeral fractures in adolescence seems "too much." However, the incentive to operate in many health-care environments may create a substantial surgeon preference toward treating fractures operatively. There have been a decrease in some reimbursement schedules for orthopaedic procedures 2 and a concern for surgeons being incentivized to perform more cases to maintain productivity goals 3 ; decreased reimbursement is a known stressor contributing to surgeon burnout.From a purely orthopaedic viewpoint, this article confirms that nonoperative treatment yields similar or superior results to those of operative treatment of proximal humeral fractures in adolescents.This study comes from an economically highly developed Scandinavian country, Finland, where more than three-quarters of the population received health care through the public system, in 2019 4 , higher than the mean of 71.7% for Organization for Economic Coo...

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Section: Commentarymentioning

confidence: 99%

Sometimes Less Is More!

Castañeda

2023

Journal of Bone and Joint Surgery

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“… 7 , 8 Nevertheless, the treatment of NH grade 3 and 4 in adolescents approaching skeletal maturity is debatable in current literature. 9 , 10 Several treatment guidelines have been formulated from expert groups for the treatment of PHF based on the patients’ age, the extent of fracture displacement, and comorbidities. 10 – 14 Neurovascular injury and open fractures are the only absolute reasons for surgical treatment in skeletally immature patients with PHFs.…”

Section: Introductionmentioning

confidence: 99%

“… 10 Currently, no consensus and no evidence-based guideline have been published concerning treatment options in dependence of patient age, fracture severity, and grade of displacement. 9 , 15 , 16 In recent years, many authors have expanded the relative indications for surgical treatment especially in adolescents approaching skeletal maturity with highly displaced PHF. 9 , 10 , 14 , 16 In our opinion, this broadening of the indications of surgical treatment is possibly related to observed poor clinical outcomes in older children with highly displaced fractures.…”

Section: Introductionmentioning

confidence: 99%

“… 9 , 15 , 16 In recent years, many authors have expanded the relative indications for surgical treatment especially in adolescents approaching skeletal maturity with highly displaced PHF. 9 , 10 , 14 , 16 In our opinion, this broadening of the indications of surgical treatment is possibly related to observed poor clinical outcomes in older children with highly displaced fractures. Similarly, debatable is the fixation technique used in case of operative treatment.…”

Section: Introductionmentioning

confidence: 99%

“…Similarly, debatable is the fixation technique used in case of operative treatment. 9 , 10 Numerous fixation methods may be used for PHFs: external fixators, free screws, screws, and plate constructs to percutaneous pinning and elastic stable intramedullary nailing (ESIN). The latter two fixation methods tend to be the most popular in adolescent closed PHFs and are both efficient.…”

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

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

Samara,

Locatelli,

Tschopp

et al. 2024

Journal of Children's Orthopaedics

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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

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

Cited by 2 publications

References 43 publications

Sometimes Less Is More!

Sometimes Less Is More!

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

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