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Solunke S, Chowdhary S. Successful Management of a Rare Pediatric Proximal Humerus Fracture-Dislocation Using K-Wire Fixation: A Case Report. J Orthop Case Rep 2025; 15:33-36. [PMID: 40351642 PMCID: PMC12064267 DOI: 10.13107/jocr.2025.v15.i05.5546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2025] [Revised: 03/22/2025] [Indexed: 05/14/2025] Open
Abstract
Introduction Proximal humerus fractures are uncommon in children, accounting for <5% of pediatric fractures, with glenohumeral dislocation being an even rarer occurrence. These injuries are challenging due to the complex shoulder anatomy and the risk of growth disturbances, as the proximal humeral physis contributes ~80% of humeral growth. While many fractures can be managed conservatively, severe displacement or associated dislocations, such as Neer-Horwitz Type IV fractures, may require surgical intervention. Treatment options include K-wires, elastic stable intramedullary nailing, and plate fixation, with K-wires offering a less invasive alternative. We present a case of a 12-year-old boy with a Neer-Horwitz Type IV fracture-dislocation, successfully treated with closed reduction and K-wire fixation, demonstrating the effectiveness of this technique in preserving growth potential while achieving stability. Case Report We present the case of a 5-year-old right-hand dominant girl who sustained a severely displaced proximal humerus fracture with anterior glenohumeral dislocation after falling from a train berth. She landed on her outstretched left hand, resulting in severe pain, deformity, and loss of arm function. Radiographs and CT imaging confirmed a Neer-Horwitz Type IV fracture with significant displacement and varus angulation. Closed reduction and percutaneous K-wire fixation were performed under general anesthesia using the Kapandji and Jyoctiky maneuver, achieving satisfactory fracture alignment and joint reduction. Postoperatively, the arm was immobilized with a Dynaplast bandage, allowing for early pendulum exercises. The patient was discharged on post-operative day two with maintained reduction and proper K-wire positioning. This case highlights the efficacy of minimally invasive techniques for complex pediatric fractures, preserving growth potential while restoring joint stability. Conclusion This case highlights the effectiveness of closed reduction and K-wire fixation in managing complex pediatric proximal humerus fracture dislocations. The technique provides adequate stability while minimizing iatrogenic physeal damage, leading to excellent functional outcomes. However, each case should be approached individually, considering factors such as age, fracture pattern, and surgeon experience.
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Affiliation(s)
- Swaroop Solunke
- Department of Orthopaedics, Dr. D.Y. Patil Medical College Hospital and Research Institute, Pimpri-Chinchwad, Maharashtra, India
| | - Sahil Chowdhary
- Department of Orthopaedics, Dr. D.Y. Patil Medical College Hospital and Research Institute, Pimpri-Chinchwad, Maharashtra, India
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Hosseinzadeh P, Torres-Izquierdo B, Tippabhatla A, Denning J, Vidyadhar U, Sanders J, Goldstein R, Baldwin K. Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study. J Pediatr Orthop 2024; 44:e823-e829. [PMID: 38912592 DOI: 10.1097/bpo.0000000000002755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
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.
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Affiliation(s)
- Pooya Hosseinzadeh
- Department of Orthopedic Surgery, Washington University in St. Louis, Saint Louis, MO
| | | | - Abhishek Tippabhatla
- Department of Orthopedic Surgery, Washington University in St. Louis, Saint Louis, MO
| | - Jaime Denning
- Department of Orthopedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Upasani Vidyadhar
- Department of Orthopedic Surgery, Rady Children's Hospital-San Diego, San Diego, CA
| | - Julia Sanders
- Department of Orthopedic Surgery, Children's Hospital Colorado, Aurora, CO
| | - Rachel Goldstein
- Department of Orthopedic Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Keith Baldwin
- Department of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
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Turazza F, Zimmermann Faggion H, Masquijo JJ. Kapandji-assisted Closed Reduction and Percutaneous K-wire Fixation for Proximal Humerus Fractures in Adolescents: A Technical Note. Rev Bras Ortop 2024; 59:e789-e792. [PMID: 39649048 PMCID: PMC11624935 DOI: 10.1055/s-0044-1787549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/06/2023] [Indexed: 12/10/2024] Open
Abstract
Proximal humerus fractures account for approximately 3 to 5% of all pediatric-adolescent fractures, with a higher incidence observed in older children, particularly between the ages of 10 and 15 years. Non-displaced or minimally displaced fractures can often be treated conservatively. However, the management of displaced or unstable proximal humerus fractures in adolescents may involve surgical intervention, with closed reduction and percutaneous pinning (CRPP) being commonly employed techniques. Closed reduction and percutaneous pinning is not without its challenges and potential difficulties. This article aims to describe a technique that can facilitate CRPP and minimize complications associated with this surgical approach.
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Affiliation(s)
- Florencia Turazza
- Departamento de Ortopedia Infantil, Sanatorio Allende, Córdoba, Argentina
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Oenning S, Michel PA, Vehring I, Heilmann L, Katthagen JC, Raschke MJ. Open plate fixation in displaced pediatric proximal humerus fractures is safe and leads to very good functional outcomes. Arch Orthop Trauma Surg 2024; 144:4283-4292. [PMID: 39277831 PMCID: PMC11564246 DOI: 10.1007/s00402-024-05526-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Accepted: 08/30/2024] [Indexed: 09/17/2024]
Abstract
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.
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Affiliation(s)
- Sebastian Oenning
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Waldeyer Straße 1, 48149, Muenster, Germany.
| | - Philipp A Michel
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Waldeyer Straße 1, 48149, Muenster, Germany
| | - Imke Vehring
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Waldeyer Straße 1, 48149, Muenster, Germany
| | - Lukas Heilmann
- Department of Trauma Surgery and Orthopedics, University Medical Center Hamburg-Eppendorf, Neues Klinikum O10, Martinistraße 52, 20246, Hamburg, Germany
| | - J Christoph Katthagen
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Waldeyer Straße 1, 48149, Muenster, Germany
| | - Michael J Raschke
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Muenster, Waldeyer Straße 1, 48149, Muenster, Germany
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Schippers P, Gercek E, Schneidmüller D, Strohm PC, Ruckes C, Wegner E, Baranowski A, Dietz SO. Proximal humeral fractures in children - controversies in decision making. Eur J Trauma Emerg Surg 2024; 50:1831-1837. [PMID: 38689019 PMCID: PMC11458729 DOI: 10.1007/s00068-024-02534-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
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.
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Affiliation(s)
- Philipp Schippers
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Erol Gercek
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Peter C Strohm
- Clinic of Orthopedics and Trauma Surgery, Sozialstiftung Bamberg, Bamberg, Germany
| | - Christian Ruckes
- Interdisciplinary Center for Clinical Trials Mainz, University Medical Center, Johannes Gutenberg University Mainz, 55131, Mainz, Germany
| | - Erik Wegner
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Andreas Baranowski
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Sven-Oliver Dietz
- Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany
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Cassidy BP, Yeramosu T, Mbomuwa FJ, Chidothi P, Wu HH, Martin C, Harrison WJ, Chokotho L, Agarwal-Harding KJ. Epidemiology and Management of Pediatric Fractures in Malawi. J Am Acad Orthop Surg Glob Res Rev 2024; 8:01979360-202407000-00013. [PMID: 39042502 PMCID: PMC11254115 DOI: 10.5435/jaaosglobal-d-24-00026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 05/29/2024] [Accepted: 06/07/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND Pediatric fractures are common in Malawi, and surgical care, when needed, remains inaccessible to many. Understanding which children in Malawi receive surgery or nonsurgical treatment would help set priorities for trauma system development. METHODS We used multivariate logistic regression to evaluate associations between surgical treatment and age, sex, school enrollment, injury mechanism, fracture type, open fracture, referral status, hospital of presentation, delayed presentation (≥2 days), healthcare provider, and inpatient vs outpatient treatment. RESULTS From 2016 to 2020, 10,400 pediatric fractures were recorded in the Malawi Fracture Registry. Fractures were most commonly of the wrist (26%), forearm (17%), and elbow (14%). Surgical fixation was performed on 4.0% of patients, and 24 (13.0%) open fractures were treated nonsurgically, without débridement or fixation. Fractures of the proximal and diaphyseal humerus (odds ratio [OR], 3.72; 95% confidence interval [CI], 2.36 to 5.87), knee (OR, 3.16; 95% CI, 1.68 to 5.95), and ankle (OR, 2.63; 95% CI, 1.49 to 4.63) had highest odds of surgery. Odds of surgical treatment were lower for children referred from another facility (OR, 0.62; 95% CI, 0.49 to 0.77). CONCLUSIONS Most Malawian children with fractures are treated nonsurgically, including many who may benefit from surgery. There is a need to increase surgical capacity, optimize referral patterns, and standardize fracture management in Malawi.
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Affiliation(s)
- Benjamin P. Cassidy
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Teja Yeramosu
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Foster J. Mbomuwa
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Paul Chidothi
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Hao-Hua Wu
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Claude Martin
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - William James Harrison
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Linda Chokotho
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
| | - Kiran J. Agarwal-Harding
- From the Virginia Commonwealth University, Richmond, VA (Mr. Cassidy and Mr. Yeramosu); the Harvard Global Orthopaedics Collaborative, Boston, MA (Mr. Cassidy, Mr. Yeramosu, Dr. Wu, and Dr. Agarwal-Harding); the Department of Surgery, Queen Elizabeth Central Hospital, Blantyre, Malawi (Mr. Mbomuwa and Mr. Chidothi); the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA (Dr. Wu); the AO Alliance Foundation, Davos, Switzerland (Dr. Martin and Dr. Harrison); the Countess of Chester Hospital NHS Trust, Chester, United Kingdom (Dr. Harrison); the Malawi University of Science and Technology, Limbe, Malawi (Dr. Chokotho); and the Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (Dr. Agarwal-Harding)
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Samara E, Locatelli I, Tschopp B, Lutz N, Zambelli PY. Single versus double retrograde intramedullary nail technique for treatment of displaced proximal humeral fractures in children: A retrospective cohort study. J Child Orthop 2024; 18:287-294. [PMID: 38831859 PMCID: PMC11144374 DOI: 10.1177/18632521241238149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 02/21/2024] [Indexed: 06/05/2024] Open
Abstract
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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Affiliation(s)
- Eleftheria Samara
- Pediatric Orthopedic Department, Lausanne Children’s Hospital, Lausanne, Switzerland
| | - Isabella Locatelli
- Unisanté, Centre universitaire de médecine générale et santé publique, Lausanne, Switzerland
| | - Benjamin Tschopp
- Pediatric Orthopedic Department, Lausanne Children’s Hospital, Lausanne, Switzerland
| | - Nicolas Lutz
- Pediatric Orthopedic Department, Lausanne Children’s Hospital, Lausanne, Switzerland
| | - Pierre-Yves Zambelli
- Pediatric Orthopedic Department, Lausanne Children’s Hospital, Lausanne, Switzerland
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Torres-Izquierdo B, Tippabhatla A, Baldwin K, Upasani V, Sanders J, Goldstein R, Denning JR, Hosseinzadeh P. Is There a Role for Isolated Closed Reduction in the Emergency Department Without Fixation for Displaced Proximal Humerus Fractures in Adolescents? J Pediatr Orthop 2024; 44:e310-e315. [PMID: 38151963 DOI: 10.1097/bpo.0000000000002609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
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.
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Affiliation(s)
| | - Abhishek Tippabhatla
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO
| | - Keith Baldwin
- Department of Orthopaedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Vidyadhar Upasani
- Department of Orthopaedic Surgery, Rady Children's Hospital-San Diego, San Diego
| | - Julia Sanders
- Department of Orthopaedic Surgery, Children's Hospital Colorado, Aurora, CO
| | - Rachel Goldstein
- Department of Orthopaedic Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Jaime Rice Denning
- Department of Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Pooya Hosseinzadeh
- Department of Orthopaedic Surgery, Washington University in St. Louis, Saint Louis, MO
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9
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Zomar BO, Chen M, Schaeffer EK, Mulpuri K, Joeris A. Management of long bone fractures and traumatic hip dislocations in paediatric patients: study protocol for a prospective global multicentre observational cohort registry. BMJ Open 2024; 14:e079836. [PMID: 38458811 PMCID: PMC10928797 DOI: 10.1136/bmjopen-2023-079836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 02/09/2024] [Indexed: 03/10/2024] Open
Abstract
INTRODUCTION Management controversy and clinical equipoise exist in treatments of long bone fractures and traumatic hip dislocation in paediatric patients due to the lack of high-quality clinical evidence. This protocol describes the effort of a large prospective global multicentre cohort study (registry) aiming at providing quality data to assist evidence-based treatment decision-making. METHODS AND ANALYSIS Eligible paediatric patients (N=750-1000) with open physes suffering from proximal humerus fractures, distal humerus fractures, proximal radius fractures, forearm shaft fractures, traumatic hip dislocations, femoral neck fractures or tibial shaft fractures will be recruited over a period of 24-36 months. Hospitalisation and treatment details (including materials and implants) will be captured in a cloud-based, searchable database. Outcome measures include radiographic assessments, clinical outcomes (such as range of motion, limb length discrepancies and implant removal), patient-reported outcomes (Patient Reported Outcomes Of Fracture, Patient-Reported Outcomes Measurement Information System (PROMIS) and EuroQol-5D (EQ-5D-Y)) and adverse events.Aside from descriptive statistics on patient demographics, baseline characteristics, types of fractures and adverse event rates, research questions will be formulated based on data availability and quality. A statistical analysis plan will be prepared before the statistical analysis. ETHICS AND DISSEMINATION Ethics approval will be obtained before patients are enrolled at each participating site. Patient enrolment will follow an informed consent process approved by the responsible ethics committee. Peer-reviewed publication is planned to disseminate the study results. TRIAL REGISTRATION NUMBER NCT04207892.
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Affiliation(s)
- Bryn O Zomar
- Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
- Department of Orthopaedics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Maio Chen
- AO Innovation Translation Center, AO Foundation, Davos, Switzerland
| | - Emily K Schaeffer
- Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
- Department of Orthopaedics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kishore Mulpuri
- Department of Orthopaedic Surgery, BC Children's Hospital, Vancouver, British Columbia, Canada
- Department of Orthopaedics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexander Joeris
- AO Innovation Translation Center, AO Foundation, Davos, Switzerland
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10
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Song HR, Song MH. Operative Versus Nonoperative Management of Pediatric Proximal Humerus Fractures: A Meta-Analysis and Systematic Review. Clin Orthop Surg 2023; 15:1022-1028. [PMID: 38045578 PMCID: PMC10689228 DOI: 10.4055/cios23077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 07/24/2023] [Accepted: 07/24/2023] [Indexed: 12/05/2023] Open
Abstract
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.
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Affiliation(s)
- Hae-Ryong Song
- Department of Orthopaedic Surgery, Korea University Guro Hospital, Seoul, Korea
| | - Mi Hyun Song
- Division of Pediatric Orthopaedics, Seoul National University Children’s Hospital and Department of Orthopedic Surgery, Seoul National University College of Medicine, Seoul, Korea
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11
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Wang Y, Wang Q, Yao W, Zhao J, Zhao X, He M. Kirschner wire versus external fixation in the treatment of proximal humeral fractures in older children and adolescents: a comparative study. BMC Musculoskelet Disord 2023; 24:899. [PMID: 37980527 PMCID: PMC10656960 DOI: 10.1186/s12891-023-07037-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 11/12/2023] [Indexed: 11/20/2023] Open
Abstract
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.
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Affiliation(s)
- Yu Wang
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Qian Wang
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Wuyi Yao
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Jingxin Zhao
- Department of Orthopedics, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China
| | - Xiaobin Zhao
- Department of Radiology, Affiliated Hospital of Chengde Medical University, 36 Nanyingzi Street, Chengde, Shuangqiao District, Hebei, 067000, PR China
| | - Man He
- Department of Rehabilitation, Affiliated Hospital of Chengde Medical University, Chengde, Hebei, 067000, PR China.
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12
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Kraal T, Struijs PAA, Langenberg LC, van Bergen CJA. Fractures around the shoulder in the skeletally immature: A scoping review. World J Orthop 2023; 14:604-611. [PMID: 37662664 PMCID: PMC10473910 DOI: 10.5312/wjo.v14.i8.604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/23/2023] [Accepted: 07/10/2023] [Indexed: 08/17/2023] Open
Abstract
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.
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Affiliation(s)
- Tim Kraal
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Peter AA Struijs
- Department of Orthopedic Surgery and Sports Medicine, Amsterdam University Medical Centers, Amsterdam 1105 AZ, Netherlands
| | - Lisette C Langenberg
- Department of Orthopedic Surgery, NoordWest Ziekenhuisgroep, Alkmaar 1815 JD, Netherlands
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
| | - Christiaan JA van Bergen
- Department of Orthopedic Surgery and Sports Medicine, Erasmus University Medical Center – Sophia Children’s Hospital, Rotterdam 3015 GD, Netherlands
- Department of Orthopedic Surgery, Amphia, Breda 4818 CK, Netherlands
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13
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Lähdeoja T, Pakkasjärvi N, Aronen P, Willamo P, Aronniemi J, Sintonen H, Nietosvaara Y, Paavola M. Outcomes at a Mean of 13 Years After Proximal Humeral Fracture During Adolescence. J Bone Joint Surg Am 2023; 105:839-848. [PMID: 37083587 DOI: 10.2106/jbjs.22.01131] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
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.
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Affiliation(s)
- Tuomas Lähdeoja
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Niklas Pakkasjärvi
- Department of Pediatric Surgery, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Pasi Aronen
- Biostatistics Unit, Faculty of Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Patrick Willamo
- Department of Pediatric Orthopedics and Traumatology, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Aronniemi
- Department of Radiology, New Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Harri Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Yrjänä Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
- Department of Pediatric Surgery, Kuopio University Hospital and University of Eastern Finland, Kuopio, Finland
| | - Mika Paavola
- Finnish Centre for Evidence-Based Orthopaedics (FICEBO), Department of Orthopaedics and Traumatology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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14
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Liu S, Zhang Y, Cao J, Fu S, Peng A. Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study. Medicine (Baltimore) 2023; 102:e32959. [PMID: 36820597 PMCID: PMC9907912 DOI: 10.1097/md.0000000000032959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
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.
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Affiliation(s)
- Shibo Liu
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- Department of Hand and Foot Surgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Yanlong Zhang
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jinchao Cao
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shijie Fu
- Department of Hand and Foot Surgery, Affiliated Hospital of Chengde Medical University, Chengde, China
| | - Aqin Peng
- Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
- * Correspondence: Aqin Peng, Department of Orthopedics Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei 050051, China (e-mail: )
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15
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Lim JW, Campbell DM, Clift BA. Proximal humerus fractures in adolescents: Experience from East of Scotland. Surgeon 2023; 21:31-39. [PMID: 35292214 DOI: 10.1016/j.surge.2022.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/09/2022] [Accepted: 02/17/2022] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Jun Wei Lim
- Department of Orthopaedics and Trauma, Aberdeen Royal Infirmary, Foresterhill Health Campus, Aberdeen, AB25 2ZN, UK.
| | - Donald M Campbell
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Benedict A Clift
- Department of Orthopaedics and Trauma, Ninewells Hospital, Dundee, DD1 9SY, UK
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16
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Abbot S, Proudman S, Ravichandran B, Williams N. Predictors of outcomes of proximal humerus fractures in children and adolescents: A systematic review. J Child Orthop 2022; 16:347-354. [PMID: 36238150 PMCID: PMC9550992 DOI: 10.1177/18632521221117445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/17/2022] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Samuel Abbot
- Women’s and Children’s Hospital, North
Adelaide, SA, Australia,Royal Adelaide Hospital Orthopaedic and
Trauma Service, Adelaide, SA, Australia,The Queen Elizabeth Hospital, Woodville
South, SA, Australia,Centre for Orthopaedic and Trauma
Research, University of Adelaide, Adelaide, SA, Australia,Samuel Abbot, Women’s and Children’s
Hospital, North Adelaide, SA 5006, Australia.
| | - Susanna Proudman
- Discipline of Medicine, University of
Adelaide, Adelaide, SA, Australia,Rheumatology Unit, Royal Adelaide
Hospital, Adelaide, SA, Australia
| | - Bhuvanesh Ravichandran
- Women’s and Children’s Hospital, North
Adelaide, SA, Australia,Royal Adelaide Hospital Orthopaedic and
Trauma Service, Adelaide, SA, Australia
| | - Nicole Williams
- Women’s and Children’s Hospital, North
Adelaide, SA, Australia,Centre for Orthopaedic and Trauma
Research, University of Adelaide, Adelaide, SA, Australia
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17
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Abbot SR, Proudman S, Hall K, Williams N. Outcomes of proximal humerus fractures in children: a study protocol for a retrospective cohort study. BMJ Open 2022; 12:e062586. [PMID: 36104126 PMCID: PMC9476141 DOI: 10.1136/bmjopen-2022-062586] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
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).
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Affiliation(s)
- Samuel Richard Abbot
- Orthopaedics and Trauma, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia, Australia
| | - Susanna Proudman
- Rheumatology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Kelly Hall
- Department of Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Nicole Williams
- Centre for Orthopaedic and Trauma Research, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Orthopaedic Surgery, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia
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18
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Qi L, Jiang Y, Wang Y, Peng C, Wu D. The use of the pediatric physeal slide-traction plate in the treatment of neer–horwitz grade IV proximal humeral fractures in children: A case report and literature review. Front Surg 2022; 9:960541. [PMID: 36189382 PMCID: PMC9515401 DOI: 10.3389/fsurg.2022.960541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Proximal humeral fractures (PHFs) are rare in children. Currently, the recommended surgical methods for severely displaced PHFs are closed reduction and percutaneous fixation using K-wires or intramedullary nailing, which can't provide firm internal fixation, especially for older and high-weight children. This study aimed to introduce a novel surgical approach, pediatric physeal slide-traction plate fixation (PPSP), for Neer–Horwitz grade IV PHFs in children. Case summary A 9-year-old boy presented with left shoulder pain and swelling due to a car accident. Physical examination revealed a positive shoulder deformity and local tenderness. On physical examination, we palpated bone friction without vascular and nerve damage. Based on imaging findings, we diagnosed Neer-Horwitz grade IV PHF. In view of the patient's condition, we performed PPSP after careful communication with the patient's parents. After 22 months of follow-up, the patient's left shoulder function was satisfactory, and there was no restriction of activities. Conclusion According to previous studies, PPSP is only used for femur fractures. To the best of our knowledge, this is the first in the treatment for PHFs. Given the satisfactory outcomes, it is a safe and effective method and may provide a reference to cure analogous patients in the future.
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Affiliation(s)
| | | | | | | | - Dankai Wu
- Correspondence: Dankai Wu Chuangang Peng
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19
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Stavinoha TJ, Randhawa SD, Trivedi S, Dingel A, Shea KG, Frick SL. The Axillary Nerve Danger Zone in Percutaneous Fixation in the Pediatric Shoulder: The "1-Mountain-3-Valleys" Principle. J Bone Joint Surg Am 2022; 104:1263-1268. [PMID: 35344511 DOI: 10.2106/jbjs.21.01202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Adult literature cites an axillary nerve danger zone of 5 to 7 cm distal to the acromion tip for open or percutaneous shoulder surgery, but that may not be valid for younger patients. This study sought to quantify the course of the axillary nerve in adolescent patients with reference to easily identifiable intraoperative anatomic and radiographic parameters. METHODS A single-institution hospital database was reviewed for shoulder magnetic resonance images (MRIs) in patients 10 to 17 years old. One hundred and one MRIs from patients with a mean age of 15.6 ± 1.2 years (range, 10 to 17 years) were included. Axillary nerve branches were identified in the coronal plane as they passed lateral to the proximal humerus and were measured in relation to identifiable intraoperative surface and radiographic landmarks, including the acromion tip, apex of the humeral head, lateral physis, and central apex of the physis. The physeal apex height (i.e., 1 "mountain") was defined as the vertical distance between the most lateral point of the humeral physis (LPHP) and the central intraosseous apex of the physis. RESULTS Axillary nerve branches were found in all specimens, adjacent to the lateral cortex of the proximal humerus. A mean of 3.7 branches (range, 2 to 6) were found. The mean distance from the most proximal branch (BR1) to the most distal branch (BR2) was 11.7 mm. The pediatric danger zone for the axillary nerve branches ranged from 6.6 mm proximal to 33.1 mm distal to the LPHP. The danger zone in relation to percent of physeal apex height included from 62% proximal to 242% distal to the LPHP. CONCLUSIONS All branches were found distal to the apex of the physis (1 "mountain" height proximal to the LPHP). Distal to the LPHP, no branches were found beyond a distance of 3 times the physeal apex height (3 "valleys"). In children and adolescents, percutaneous fixation of the proximal humerus should be performed with cortical penetration outside of this range. These parameters serve as readily identifiable intraoperative radiographic landmarks to minimize iatrogenic nerve injury. CLINICAL RELEVANCE This study provides valuable landmarks for percutaneous approaches to the proximal humerus. The surgical approach for the placement of percutaneous implants should be adjusted accordingly (i.e., performed at least 1 mountain proximal or 3 valleys distal to the LPHP) in order to prevent iatrogenic injury to the axillary nerve.
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Affiliation(s)
- Tyler J Stavinoha
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Sahej D Randhawa
- University of California San Diego School of Medicine, La Jolla, California
| | - Sunny Trivedi
- University of Florida College of Medicine, Gainesville, Florida
| | - Aleksei Dingel
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Kevin G Shea
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Steven L Frick
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Palo Alto, California
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20
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Torrez TW, Seidenstein A, Debell HA, Conklin M, McGwin G, Gilbert SR. Radiographic pseudosubluxation of the shoulder in pediatric proximal humeral fractures. J Pediatr Orthop B 2022; 31:270-273. [PMID: 34380986 DOI: 10.1097/bpb.0000000000000902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study was undertaken to determine the incidence, need for intervention, and time to resolution of pseudosubluxation of the shoulder in pediatric proximal humerus fractures. One hundred and ninety-nine radiographs (199 x-rays) were analyzed for pseudosubluxation of the shoulder following pediatric proximal humeral fractures. Pseudosubluxation occurs when the center of the humeral head aligns with the inferior one-fourth of the glenoid. Fourteen patients met the inclusion criteria for pseudosubluxation. The nonoperative cohort consisted of 100 females and 93 males and the operative cohort consisted of 3 males and 3 females. Total 14 children out of 199 had pseudosubluxation. Ten pseudosubluxations were seen 7 days postinjury and four were noted immediately after injury. Pseudosubluxation was seen in nine boys (64%) and five girls (36%) in the nonoperative group. Increased relative risk (RR) was associated with: fall >3 m (RR = 25.7; 95% CI, 2.7-244.0), motorized transport (RR = 11.7; 95% CI, 1.41-96.03) and sports injuries (RR = 11.0, 95% CI, 1.2-100). No statistical analysis was conducted on the operative group given the small sample. This study establishes incidence, risk factors and expected clinical course for pseudosubluxation following proximal humerus fractures. The overall incidence in the nonoperative cohort was 7.3%, radiographic evidence of pseudosubluxation resolution was available for (n = 10) patients with 100% resolution by 6 weeks. There were no readmissions or complications in the 14 patients. Pseudosubluxation occurrence was significantly increased in four mechanisms: falls >3 m, sports trauma and motor transportation. This study provides the natural history and risk factors for pseudosubluxation following proximal humerus fractures. Pseudosubluxation is more likely to occur in higher energy fracture mechanisms and will resolve without treatment. Level of Evidence: Level III, retrospective cohort.
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Affiliation(s)
- Timothy William Torrez
- University of California Los Angeles, David Geffen School of Medicine, California
- Department of Orthopedic Surgery
| | | | | | | | - Gerald McGwin
- Department of Orthopedic Surgery
- Department of Epidemiology, University of Alabama at Birmingham, Alabama, USA
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21
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Severe Infraclavicular Displacement of a Proximal Humerus Fracture with Concomitant Olecranon Fracture in a Pediatric Patient. Case Rep Orthop 2022; 2022:8673859. [PMID: 35154841 PMCID: PMC8837420 DOI: 10.1155/2022/8673859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 01/01/2022] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Proximal humerus fractures with severe medial displacement of the humeral head are rare in adults and especially so in children. Concomitant vascular/neurovascular injury is even more uncommon but must be considered as the associated complications can carry significant morbidity. We present a case of a 12-year-old transported to the ED after a mountain bike accident in which she lost control and hit a cement wall, injuring her left upper extremity (LUE). Despite a normal vascular/sensory exam, imaging demonstrated a left comminuted proximal humerus fracture with the humerus displaced medially into the thoracic inlet as well as concern for left subclavian vessel injury. Given the possibility of vascular injury and the severe humeral head displacement, she was taken to surgery with orthopedic and vascular surgical teams. Although surgical exploration did not reveal vascular injury, this case underlines the importance of maintaining a high index of suspicion for neurovascular injury with such fractures as prompt intervention may reduce the likelihood of complications. This case also underscores the need for further research into the management of pediatric proximal humerus fractures in early adolescence.
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22
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Kim AE, Chi H, Swarup I. Proximal Humerus Fractures in the Pediatric Population. Curr Rev Musculoskelet Med 2021; 14:413-420. [PMID: 34709578 DOI: 10.1007/s12178-021-09725-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Arin E Kim
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Hannah Chi
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Ishaan Swarup
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA. .,University of California, San Francisco, 747 52nd Street, OPC First Floor, Oakland, CA, 94609, USA.
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23
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Li J, Rai S, Qian H, Tang X, Liu R, Hong P. Operative choice for displaced proximal humeral fractures in adolescents with open visible physis: A comparative study of external fixator vs. Kirschner wire. Injury 2021; 52:2279-2284. [PMID: 33731292 DOI: 10.1016/j.injury.2021.03.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 02/22/2021] [Accepted: 03/04/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Jin Li
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Saroj Rai
- Department of Orthopaedics and Trauma Surgery, National Trauma Center, National Academy of Medical Sciences, Mahankal, Kathmandu, Nepal
| | - Huabing Qian
- Department of Orthopaedics, The Second People's Hospital of Lincang City, Lincang, China
| | - Xin Tang
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruikang Liu
- First School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Pan Hong
- Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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Freislederer F, Bensler S, Specht T, Magerkurth O, Eid K. Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients. CHILDREN-BASEL 2021; 8:children8080635. [PMID: 34438526 PMCID: PMC8393487 DOI: 10.3390/children8080635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/19/2021] [Accepted: 07/23/2021] [Indexed: 11/16/2022]
Abstract
Background: Recommended treatment for severely displaced proximal humeral fractures in children is the closed reduction and percutaneous fixation by K-wires or intramedullary nailing. Methods: From January 2016 to January 2017 6, 21 children/adolescents (range 8 to 16 years) with proximal humeral fractures were treated surgically for severe displacement. In these six patients, several attempts of closed reduction were unsuccessful, and an open reduction was performed. The humeral head was fixed with a 3.5 mm T-plate without affecting the growth plate. Plate removal was performed at a mean interval of 132 days after initial surgery. Two years after initial surgery, the clinical outcome was assessed by the Constant–Murley score and QuickDASH score (including sport/music and work) and the shoulder joint was evaluated with a standardized sonographic examination for the rotator cuff and the conjoint tendon. Results: In all six patients, dorsal displacement of the fracture was irreducible due to the interposition of tendinous or osseous structures. Intraoperatively, the interposed structures were the long biceps tendon in two, periosteal tissue in two, a bony fragment in one, and the long biceps tendon together with the conjoint tendon in one case. At mean follow-up of 26 months (range 22 months to 29 months), patients showed very good clinical results with an excellent mean Constant–Murley score of 97.5 (range 91 to 100) and mean QuickDASH score (including sport/music and work) of 5.5 (range 0–20.8). An X-ray follow-up 6 weeks after surgery demonstrated early consolidation and correct alignment in all patients. A sonographic evaluation at 2 years post injury showed that the biceps and the conjoined tendon were intact in all patients. Conclusions: If a proximal humeral fracture is not reducible by closed means, a tissue entrapment (most likely biceps tendon) should be considered. Treatment with an open reduction and plate fixation yields very good clinical and radiological results and preserves interposed structures as the biceps and conjoint tendon.
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Affiliation(s)
- Florian Freislederer
- Department of Orthopaedics and Traumatology, Kantonsspital Baden (KSB), Im Ergel 1, 5404 Baden, Switzerland;
- Correspondence: (F.F.); (K.E.)
| | - Susanne Bensler
- Unit for Musculoskeletal Radiology, Department of Radiology, Kantonsspital Baden (KSB), Im Ergel 1, 5404 Baden, Switzerland;
| | - Thomas Specht
- Department of Orthopaedics and Traumatology, Kantonsspital Baden (KSB), Im Ergel 1, 5404 Baden, Switzerland;
| | - Olaf Magerkurth
- Unit for Pediatric Radiology, Department of Radiology, Kantonsspital Baden (KSB), Im Ergel 1, 5404 Baden, Switzerland;
| | - Karim Eid
- Department of Orthopaedics and Traumatology, Kantonsspital Baden (KSB), Im Ergel 1, 5404 Baden, Switzerland;
- Correspondence: (F.F.); (K.E.)
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25
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Abstract
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.
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26
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Liebs TR, Rompen I, Berger SM, Ziebarth K. Health-related quality of life after conservatively and surgically-treated paediatric proximal humeral fractures. J Child Orthop 2021; 15:204-214. [PMID: 34211596 PMCID: PMC8223095 DOI: 10.1302/1863-2548.15.210054] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Thoralf R. Liebs
- Department of Pediatric Orthopaedics and Traumatology, Clinic for Pediatric Surgery, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ingmar Rompen
- Department of Pediatric Orthopaedics and Traumatology, Clinic for Pediatric Surgery, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Steffen M. Berger
- Department of Pediatric Orthopaedics and Traumatology, Clinic for Pediatric Surgery, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kai Ziebarth
- Department of Pediatric Orthopaedics and Traumatology, Clinic for Pediatric Surgery, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
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27
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CANAVESE F, ALBERGHINA F, DIMEGLIO A, ANDREACCHIO A. Proximal humerus fractures in children and adolescents. MINERVA ORTHOPEDICS 2021; 72. [DOI: 10.23736/s2784-8469.20.04036-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
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28
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Yu A, Janney CF, Panchbhavi VK, Jupiter DC. National electronic injury surveillance system sports-related arm fractures in the United States: thrower's fractures. J Sports Med Phys Fitness 2021; 61:1235-1241. [PMID: 33555665 DOI: 10.23736/s0022-4707.21.11675-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Humerus fractures are common in the United States. The purpose of this study was to utilize the National Electronic Injury Surveillance System (1) to compare overall and age stratified incidence rates of proximal and distal arm fractures presenting to United States emergency departments, (2) to compare relative humerus fracture locations by age, and (3) to compare anatomical humerus fracture locations stratified by sports between 2005-2009 and 2015-2019. METHODS The National Electronic Injury Surveillance System was used to obtain estimated proximal and distal arm fractures between 2005-2009 and 2015-2019. Fracture rates were normalized using United States census estimates and stratified by age. Case summaries were filtered for anatomical and non-specific (proximal, middle, distal third) humerus fractures. Relative humerus fractures, inclusive of anatomical and non-specific fractures, were stratified by age and compared between 2005-2009 and 2015-2019. Anatomical fractures were stratified by sports. Chi-squared tests was used to compare fracture rates between time periods. RESULTS There was a decrease (p<.0001) in proximal and distal arm fracture rates and a difference (p<.0001) in fracture rates with respect to age between 2005-2009 and 2015-2019. There was a significant difference in reported relative humeral fractures (p<.0001) between the two periods. Impact related sports trauma accounted for most fracture cases for both periods. Non-impact related sports trauma consisted entirely of thrower's fractures. CONCLUSIONS United States proximal and distal arm fracture rates decreased, and distributions differed by age between 2005-2009 and 2015-2019. Relative humerus fractures differed by time periods. One major non-impact sports related humerus fracture was extreme external rotational torque from throwing.
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Affiliation(s)
- Alexander Yu
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA -
| | - Cory F Janney
- Department of Orthopaedic Surgery, Naval Medical Center San Diego, San Diego, CA, USA
| | - Vinod K Panchbhavi
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
| | - Daniel C Jupiter
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA.,Department of Preventive Medicine and Population Health, University of Texas Medical Branch, Galveston, TX, USA
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Do pediatric shoulder fractures benefit from surgery? Curr Opin Pediatr 2021; 33:97-104. [PMID: 33315684 DOI: 10.1097/mop.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Baker C, Larson N, Shaughnessy W, Stans A, Milbrandt T. Rate of Complications and Subsequent Shoulder Complaints for Non-operatively Managed Pediatric Proximal Humerus Fractures. Front Surg 2020; 7:48. [PMID: 32850945 PMCID: PMC7418452 DOI: 10.3389/fsurg.2020.00048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
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.
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Hannonen J, Hyvönen H, Korhonen L, Serlo W, Sinikumpu JJ. The incidence and treatment trends of pediatric proximal humerus fractures. BMC Musculoskelet Disord 2019; 20:571. [PMID: 31775692 PMCID: PMC6882178 DOI: 10.1186/s12891-019-2948-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 11/14/2019] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Juuli Hannonen
- Department of Children and Adolescents, Pediatric Surgery and Orthopedics, Oulu University Hospital, Medical Research Centre Oulu and PEDEGO Research Group, Oulu University, PoB 23, 90029 OYS, Oulu, Finland.
| | - Hanna Hyvönen
- Department of Children and Adolescents, Pediatric Surgery and Orthopedics, Oulu University Hospital, Medical Research Centre Oulu and PEDEGO Research Group, Oulu University, PoB 23, 90029 OYS, Oulu, Finland
| | - Linda Korhonen
- Department of Children and Adolescents, Pediatric Surgery and Orthopedics, Oulu University Hospital, Medical Research Centre Oulu and PEDEGO Research Group, Oulu University, PoB 23, 90029 OYS, Oulu, Finland
| | - Willy Serlo
- Department of Children and Adolescents, Pediatric Surgery and Orthopedics, Oulu University Hospital, Medical Research Centre Oulu and PEDEGO Research Group, Oulu University, PoB 23, 90029 OYS, Oulu, Finland
| | - Juha-Jaakko Sinikumpu
- Department of Children and Adolescents, Pediatric Surgery and Orthopedics, Oulu University Hospital, Medical Research Centre Oulu and PEDEGO Research Group, Oulu University, PoB 23, 90029 OYS, Oulu, Finland
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Chae W, Khan A, Abbott S, Assiotis A. Proximal Humerus Fractures in Children: Experience from a Central London Paediatric Orthopaedic Service. Open Orthop J 2019. [DOI: 10.2174/1874325001913010202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023] Open
Abstract
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.
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Abbott S, Grewal S, Mehdi H, Rafferty M. A painful shoulder after a fall. BMJ 2019; 366:l2155. [PMID: 31506271 DOI: 10.1136/bmj.l2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Li NY, Kalagara S, Hersey A, Eltorai AEM, Daniels AH, Cruz AI. Impact of obesity on operative treatment and inpatient outcomes of paediatric limb fractures. Bone Joint J 2019; 101-B:491-496. [PMID: 30929488 DOI: 10.1302/0301-620x.101b4.bjj-2018-0740.r2] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
AIMS The aim of this study was to utilize a national paediatric inpatient database to determine whether obesity influences the operative management and inpatient outcomes of paediatric limb fractures. PATIENTS AND METHODS The Kids' Inpatient Database (KID) was used to evaluate children between birth and 17 years of age, from 1997 and 2012, who had undergone open and closed treatment of humeral, radial and ulna, femoral, tibial, and ankle fractures. Demographics, hospital charges, lengths of stay (LOS), and complications were analyzed. RESULTS Obesity was significantly associated with increased rates of open reduction and internal fixation (ORIF) for: distal humeral (odds ratio (OR) = 2.139, 95% confidence interval (CI) 1.92 to 3.44; p < 0.001); distal radius and ulna fractures (OR = 1.436, 95% CI 1.14 to 2.16; p < 0.05); distal femoral (OR = 2.051, 95% CI 1.69 to 3.60; p < 0.05); tibial and fibula shaft (OR = 2.101, 95% CI 2.10 to 3.50; p < 0.001); and ankle (OR = 1.733, 95% CI 1.70 to 2.39; p < 0.001). Older age was significantly associated with ORIF for all fractures (p < 0.05). LOS, hospital charges, and complications were significantly increased in obese patients following ORIF for upper and lower limb fractures (p < 0.05). CONCLUSION Obese paediatric patients are more likely to undergo ORIF in both upper and lower limb fractures and have more inpatient complications. These findings may assist in informing obese paediatric fracture patients and their families regarding the increased risk for open operative fixation and associated outcomes. Cite this article: Bone Joint J 2019;101-B:491-496.
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Affiliation(s)
- N Y Li
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - S Kalagara
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A Hersey
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A E M Eltorai
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A H Daniels
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A I Cruz
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Crawford EJ, Pincus D, Camp MW, Coyte PC. Cost savings of implementing the SickKids Paediatric Orthopaedic Pathway for proximal humerus fractures in Ontario, Canada. Paediatr Child Health 2018; 23:e109-e116. [PMID: 30455581 DOI: 10.1093/pch/pxx208] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Eric J Crawford
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario
| | - Daniel Pincus
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario
| | - Mark W Camp
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario.,Division of Orthopaedic Surgery, The Hospital for Sick Children, Toronto, Ontario
| | - Peter C Coyte
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario
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Missed Thrower's Fracture of the Humerus in a Pediatric Athlete: A Case Report. J Emerg Med 2018; 55:547-552. [DOI: 10.1016/j.jemermed.2018.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Accepted: 07/11/2018] [Indexed: 11/19/2022]
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Akhavan-Sigari R, Mielke D, Farhadi A, Rohde V. Study of Radial Nerve Injury Caused By Gunshot Wounds and Explosive Injuries among Iraqi Soldiers. Open Access Maced J Med Sci 2018; 6:1622-1626. [PMID: 30337976 PMCID: PMC6182541 DOI: 10.3889/oamjms.2018.346] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Gunshot wounds and blast injuries to the upper limbs produce complex wounds requiring management by multiple surgical specialities. AIM We sought to determine the pattern of peripheral nerve injuries among Iraqi soldiers in the war. METHODS We performed a 3 year retrospective cohort analysis based on medical records of patients with sustaining gunshot wounds and blast injuries to the upper limbs. Ethical approval was obtained from the institutional review board. The patients included were male, serving military personnel of all age groups and ranks presenting with weakness or sensory loss of radial nerve. Three hundred eighteen patients aged 24 years or older with a high-energy, diaphyseal fracture of the humerus and complete motor and sensory radial nerve palsy were reviewed retrospectively. In these patients, the physical examination and electrodiagnostic study were carried out by experienced neurologists. Seddon's classification system was used to assess the severity of the injury. The data related to the types of fracture, the type of damage, the factors causing damage and the failure of treatment were entered into the IBM SPSS 23 software after extraction of files. Based on mid-range indicators and data distribution, traumatic injuries among Iraqi soldiers in the war against ISIL were then investigated. RESULTS A group of 318 patients with mean age of 25.41 ± 6 years were enrolled in the study, of which 127 patients were included with an open fracture and 191 patients with closed lesions. All 127 patients with a transected radial nerve had an open humerus fracture and were part of a complex upper-extremity injury. 113 of 127 subjects had primary repair of the radial nerve and recovered well. 14 of 127 subjects were not recovered. 3 of them had iatrogenic radial nerve injury due to the internal fixation device. Furthermore, all 191 patients with closed injuries recovered well. The average time to initial signs of recovery was 8 weeks (range, 1-27 weeks). Axonotmesis and Neurotmesis were found in 283 (89%) subjects. The average time to full recovery was determined to be 6 months (range, 1-22 months). The blast was found to be the main cause of nerve injury in 236 (74.2%) cases, followed by gunshot damage (21.4%, 68 subjects), falling from height and motor vehicle accidents (4.4%, 14 subjects) and multiple injuries (17%, 54 cases). CONCLUSIONS Trauma caused by factors such as explosions and gunshot worsens the condition of the injuries and presents the treatment conditions with many challenges. However, the success rate in post-surgical recovery of humerus fracture and injured radial nerve can be remarkably higher in young people as compared to other age groups.
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Affiliation(s)
- Reza Akhavan-Sigari
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
- Department of Neurosurgery, Bouali Hospital, Tehran Medical Sciences Branch, Islamic Azad University, Tehran, Iran
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Afshin Farhadi
- Department of Orthopedic Surgery, Tehran Medical Sciences Branch, Islamic Azad University, Bouali Hospital, Tehran, Iran
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
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Epidemiological investigation of traumatic upper extremity fractures in children who applied to emergency department. JOURNAL OF CONTEMPORARY MEDICINE 2018. [DOI: 10.16899/gopctd.454562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Cruz Jr AI, Kleiner JE, Gil JA, Goodman AD, Daniels AH, Eberson CP. Inpatient surgical treatment of paediatric proximal humerus fractures between 2000 and 2012. J Child Orthop 2018; 12:111-116. [PMID: 29707048 PMCID: PMC5902743 DOI: 10.1302/1863-2548.12.170220] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
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, 9th 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.
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Affiliation(s)
- A. I. Cruz Jr
- Department of Orthopaedics, Division of Paediatric Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island, USA, Correspondence should be sent to Aristides I. Cruz Jr, Department of Orthopaedics, Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital, 2 Dudley St., Ste 200, Providence, Rhode Island 02905, USA. E-mail:
| | - J. E. Kleiner
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - J. A. Gil
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A. D. Goodman
- Department of Orthopaedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - A. H. Daniels
- Department of Orthopaedics, Division of Spine Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - C. P. Eberson
- Department of Orthopaedics, Division of Paediatric Orthopaedic Surgery, Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island, USA
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Hohloch L, Eberbach H, Wagner FC, Strohm PC, Reising K, Südkamp NP, Zwingmann J. Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents-A systematical review and meta-analysis. PLoS One 2017; 12:e0183157. [PMID: 28837601 PMCID: PMC5570290 DOI: 10.1371/journal.pone.0183157] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/31/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fractures of the proximal humerus in patients under the age of 18 years show a low incidence; existing clinical studies only comprise small patient numbers. Different treatment methods are mentioned in the literature but a comparison of the outcome of these methods is rarely made. Up to now, no evidence-based algorithm for conservative and operative treatment is available. The aim of this systematic review with meta-analysis was therefore to gather the best evidence of different treatment methods and their associated functional outcome, complication rates, rates of limb length discrepancies and radiological outcome. METHODS AND FINDINGS The OVID database was systematically searched on September 30th in 2016 in order to find all published clinical studies on the subject of proximal humerus fractures of patients ≤18 years. Exclusion criteria were previously defined. The Coleman Methodology Score was used to evaluate the quality of the single studies. 886 studies have been identified by the search strategy. 19 studies with a total of 643 children (mean age: 11.8 years) were included into the meta-analysis with a mean Coleman Methodology Score of 71 ± 7.4 points. 18 of the 19 studies eligible for inclusion were retrospective ones, of the best quality available (mean follow-up ≥ 1 year, mean follow-up rate ≥ 65%). 56% of the patients were male. Proximal humerus fractures were treated conservatively in 41% and surgically in 59% of the cases (Elastic Stable Intramedullary Nailing (ESIN): 31%; K-wires: 20%; 8% other methods, e.g. plate osteosynthesis, olecranon traction). The overall success rate (good/excellent outcome) for all treatment methods was 93%. The success rate of ESIN (98%) and of K- wire fixation (95%) was significantly higher (p = 0.01) than the success rate of conservative treatment options (91%). A subgroup analysis of severely displaced fractures (Neer grade III/IV, angulation ≥ 20°) resulted in a change of success rates, to the disadvantage of conservative treatment methods (conservative treatment 82%, ESIN 98%, K-wires 95%; p < 0.001). Complication rates did not differ to a significant extent. 9% of the complications occurred in the patients treated by K-wire fixation, 8% if a conservative treatment option was chosen and 7% in the fractures that were stabilized by ESIN. A change from a one-nail technique to a two-nail technique reduced the complication rate of ESIN significantly. Follow-up X- rays without residual deformity could be found in 96% of the patients treated by ESIN, a rate which was higher than in the patients treated conservatively (93%) or by K-wire fixation (88%). The rate of arm length discrepancies at final follow- up was lower if the fractures were stabilized by ESIN (4%) than if they were treated conservatively (9%) or by K-wires (19%). An evaluation of age-dependent treatment options was performed. CONCLUSIONS By performing this meta-analysis an evidence-based treatment algorithm could be introduced to treat the fractures according to the severity of displacement and according to the patient's age. For severely displaced fractures ESIN is the method of choice, with the best clinical and radiological outcome.
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Affiliation(s)
- Lisa Hohloch
- Department of Orthopedics and Trauma Surgery, Medical Center—Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
- * E-mail:
| | - Helge Eberbach
- Department of Orthopedics and Trauma Surgery, Medical Center—Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Ferdinand C. Wagner
- Department of Orthopedics and Trauma Surgery, Medical Center—Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Peter C. Strohm
- Clinic for Orthopedics and Trauma Surgery, Klinikum Bamberg, Bamberg, Germany
| | - Kilian Reising
- Department of Orthopedics and Trauma Surgery, Medical Center—Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Norbert P. Südkamp
- Department of Orthopedics and Trauma Surgery, Medical Center—Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
| | - Jörn Zwingmann
- Department of Orthopedics and Trauma Surgery, Medical Center—Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Albert-Ludwigs-University of Freiburg, Freiburg, Germany
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Weinberger JM, Fabricant PD, Taylor SA, Mei JY, Jones KJ. Influence of graft source and configuration on revision rate and patient-reported outcomes after MPFL reconstruction: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2017; 25:2511-2519. [PMID: 26856314 DOI: 10.1007/s00167-016-4006-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 01/18/2016] [Indexed: 12/13/2022]
Abstract
PURPOSE The purpose of this systematic review and meta-analysis was to determine the influence of graft source (allograft vs. autograft) and configuration (single-limbed vs. double-limbed) on failure rate and disease-specific patient-reported outcome (Kujala score) after medial patellofemoral ligament (MPFL) reconstruction for patellar instability. METHODS A systematic review of PubMed, Scopus, and the Cochrane Library was performed. A total of 31 studies met inclusion/exclusion criteria and were used to extract cohorts of patients who underwent ligament reconstruction with various allograft, autograft, single-limbed, and double-limbed constructs. Failure rates and postoperative improvements in Kujala scores were compared between cohorts using inverse-variance weighting in a random-effects analysis model and appropriate comparative statistical analyses (Chi-squared and independent samples t tests). RESULTS A total of 1065 MPFL reconstructions were identified in 31 studies. Autograft reconstructions were associated with greater postoperative improvements in Kujala scores when compared to allograft (32.2 vs. 22.5, p < 0.001), but there was no difference in recurrent instability (5.7 vs. 6.7 %, p = 0.74). Double-limbed reconstructions were associated with both improved postoperative Kujala scores (37.8 vs. 31.6, p < 0.001) and lower failure rate (10.6 vs. 5.5 %, p = 0.030). CONCLUSION MPFL reconstructions should be performed using double-limbed graft configurations. While autograft tendon may be associated with higher patient-reported outcomes in the absence of associated connective tissue disorders or ligamentous laxity, patient factors and allograft processing techniques should be carefully considered when selecting an MPFL graft source, as revision rates were no different between graft sources. LEVEL OF EVIDENCE IV.
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Affiliation(s)
| | | | | | - Jenny Y Mei
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Gladstein AZ, Schade AT, Howard AW, Camp MW. Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures. Orthop Traumatol Surg Res 2017; 103:115-118. [PMID: 27894835 DOI: 10.1016/j.otsr.2016.09.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 08/10/2016] [Accepted: 09/05/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The majority of proximal humeral fractures in the skeletally immature are treated non-operatively. Operative indications vary but are largely based on degree of displacement. Non-union is rare. Non-operatively treated fractures are typically monitored radiographically to assess healing. HYPOTHESIS We hypothesize that the decision to treat fractures operatively is made at the time of first imaging and that follow-up X-rays do not lead to a change in management. MATERIAL AND METHODS We retrospectively reviewed the records of 239 patients treated for proximal humerus fractures over a 5-year period. There were 225 who were treated non-operatively. Records were reviewed for the number of clinic visits and radiographs, as well as any change to operative management based on follow-up X-rays. RESULTS The primary outcome of the study was the proportion of proximal humerus fractures, initially treated non-operatively, for which displacement or angulation on follow-up radiographs led to a change to operative treatment. Secondary outcomes were the number of follow-up radiographs obtained after the initial diagnosis and initiation of non-operative treatment. Of the 225 patients that were initially managed non-operatively, only 1 patient required subsequent surgical management. This patient underwent a proximal humerus epiphysiodesis 365 days from injury after development of a partial growth arrest. The mean number of fracture clinic visits for patients managed non-operatively was 2.67 (±1.24). The mean number of radiology department visits and radiographs obtained was 3.57 (±1.44) and 8.36 (±3.89) respectively. No clinical or radiographic non-unions were identified in these patients. No patients suffered a refracture during the review period. DISCUSSION This study shows that of the 239 uncomplicated pediatric proximal humerus fractures treated at our hospital over a 5-year period, only 1 had a change in treatment plan, from non-operative to operative, based on follow-up radiographs. These data suggest that non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention. Moreover, they suggest that there is little utility to the routine use of postoperative radiographs in follow-up of these patients. STUDY DESIGN Retrospective case series. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- A Z Gladstein
- Pennsylvania Hospital, Sports Medicine, 800, Spruce street, Philadelphia, PA 19103 United States; Texas Children's Hospital Department of Orthopaedic Surgery, 6620 Fannin, St. Houston, TX 77030, United States.
| | - A T Schade
- Royal Stoke University Hospitals, Stoke on Trent, St4-6QG, United Kingdom
| | - A W Howard
- Department of Orthopaedic Surgery, The Hospital for Sick Children, M5G 1X8 Toronto, Ontario, Canada
| | - M W Camp
- Department of Orthopaedic Surgery, The Hospital for Sick Children, M5G 1X8 Toronto, Ontario, Canada
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Fabricant PD, Flynn JM. Fractures, Dislocations, and Acquired Problems of the Shoulder in Children. ROCKWOOD AND MATSEN'S THE SHOULDER 2017:515-541.e4. [DOI: 10.1016/b978-0-323-29731-8.00012-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/06/2025]
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Brooks JT, Lee RJ. Nonoperative Treatment of a Completely Displaced Pediatric Type-I Open Fracture of the Proximal Part of the Humerus: A Case Report. JBJS Case Connect 2016; 6:e94. [PMID: 29252748 DOI: 10.2106/jbjs.cc.16.00053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Most pediatric closed fractures of the proximal part of the humerus are treated nonoperatively. However, with open fractures of the proximal part of the humerus, nonoperative treatment typically is not indicated, and no such cases previously have been reported in the literature. We describe a 10-year-old boy with a completely displaced type-I open fracture of the proximal part of the humerus who was treated definitively in the emergency department with local irrigation and debridement, antibiotics, and the application of a hanging arm cast. One year later, he had complete radiographic union, no infectious sequelae, and no functional impairment of the shoulder. CONCLUSION Nonoperative treatment of a pediatric type-I open fracture of the proximal part of the humerus can be successful.
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Affiliation(s)
- Jaysson T Brooks
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Delgado J, Jaramillo D, Chauvin NA. Imaging the Injured Pediatric Athlete: Upper Extremity. Radiographics 2016; 36:1672-1687. [DOI: 10.1148/rg.2016160036] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Pavone V, de Cristo C, Cannavò L, Testa G, Buscema A, Condorelli G, Sessa G. Midterm results of surgical treatment of displaced proximal humeral fractures in children. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2016; 26:461-467. [PMID: 27151160 DOI: 10.1007/s00590-016-1773-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Accepted: 04/24/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To analyse the clinical outcomes of 26 children treated surgically for displaced proximal humerus fracture. MATERIALS AND METHODS From January 2008 to December 2012, 26 children/adolescents (14 boys, 12 girls) were treated surgically for displaced fractures at the proximal extremity of the humerus. Ten were grade III and 16 were grade IV according to the Neer-Horowitz classification with a mean age of 12.8 ± 4.2 years. Twenty young patients were surgically treated with a closed reduction and direct percutaneous pinning; six required an open approach. To obtain a proper analysis, we compared the Costant scores with the contralateral shoulder (Δ Costant). RESULTS The mean follow-up period was 34 months (range 10-55). Two grade IV patients showed a loss in the reduction after percutaneous treatment. This required open surgery with a plate and screws. On average, the treated fractures healed at 40 days. The mean Δ Costant score was 8.43 (range 2-22). There was a statistically significant improvement in the mean Δ Costant score in grade III patients. In grade IV patients, there was a significant improvement in the mean Δ Costant score in those treated with open surgery versus mini-invasive surgery. CONCLUSIONS Our study shows excellent results with percutaneous k-wires. This closed surgery had success in these patients, and the excellent outcomes noted here lead us to prefer the mini-invasive surgical approach in NH grade III fractures. In grade IV, the best results were noted in patients treated with open surgery. We suggest an open approach for these patients. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Vito Pavone
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy.
| | - Claudia de Cristo
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy
| | - Luca Cannavò
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy
| | - Gianluca Testa
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy
| | - Antonio Buscema
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy
| | - Giuseppe Condorelli
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy
| | - Giuseppe Sessa
- Orthopaedic Clinic, AOU Policlinico- Vittorio Emanuele, University of Catania, Catania, Italy
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Abstract
Most proximal humerus fractures in skeletally immature individuals are treated nonoperatively with excellent functional results. Extensive remodeling of the proximal humerus and the wide arc of motion of the glenohumeral joint accommodate a large degree of fracture displacement and angulation. The treatment of severely displaced fractures and/or severely angulated fractures continues to be debated. Older patients and those with significantly displaced fractures may benefit from surgery because of their inability to remodel displacement and angulation during their limited remaining growth. The decision to treat a proximal humerus fracture in a skeletally immature patient operatively versus nonoperatively is dependent on the following 3 factors: displacement, bone age, and capacity to remodel. There is an increasing trend toward treating severely displaced and severely angulated fractures surgically, especially in older patients and adolescents. Smooth wires, percutaneous threaded wires, cannulated screws, and retrograde elastic stable intramedullary nailing are acceptable options for fixation.
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Taylor SA, Ramkumar PN, Fabricant PD, Dines JS, Gausden E, White A, Conway JE, O'Brien SJ. The Clinical Impact of Bicipital Tunnel Decompression During Long Head of the Biceps Tendon Surgery: A Systematic Review and Meta-analysis. Arthroscopy 2016; 32:1155-64. [PMID: 27132781 DOI: 10.1016/j.arthro.2016.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 02/18/2016] [Accepted: 02/22/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE (1) To identify existing outcomes studies and (2) to use meta-analysis techniques to summarize pooled clinical outcomes for surgical techniques that decompress the bicipital tunnel and those that do not, to identify important areas for future clinical investigation. METHODS A systematic review of the PubMed database was performed in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Patients were categorized into 2 groups for analysis. Group 1, the "tunnel decompressed" group, included open subpectoral tenodesis, long head of the biceps tendon transfer procedures, and proximal tenodesis techniques that explicitly released the bicipital sheath. Group 2, the "tunnel not decompressed" group, included proximal tenodesis techniques and tenotomy. Validated clinical outcome measures (Constant; University of California, Los Angeles; Simple Shoulder Test; visual analog scale for pain; and American Shoulder and Elbow Surgeons) and revision rates were summarized using inverse-variance weighting in a random-effects model. Because the constituent studies were largely single-cohort observational studies, direct between-group statistical comparisons could not be made. RESULTS Thirty studies (comprising 1,881 patients) met the inclusion and exclusion criteria. The Constant score was the most commonly reported outcome measure (16 cohorts, 961 patients) and was seemingly higher in group 1 (88.3 v 81.7). Revision rates; University of California, Los Angeles scores; Simple Shoulder Test scores; visual analog scale scores for pain; and American Shoulder and Elbow Surgeons scores appeared to be similar between groups. The mean patient age was 50.7 ± 5.7 years for group 1 and 58.9 ± 6.3 years for group 2. The Egger intercept method showed an intercept of -13.29 (P < .001) for the Constant score, indicating a high likelihood of publication bias in the included studies. CONCLUSIONS Bicipital tunnel-decompressing techniques showed apparently higher Constant scores compared with non-decompressing techniques but may have been affected by differences in mean patient age between groups. Existing literature consists of largely single-cohort retrospective observational Level IV studies, which are likely influenced by significant publication bias. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.
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Affiliation(s)
- Samuel A Taylor
- Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A..
| | - Prem N Ramkumar
- Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Peter D Fabricant
- Pediatric Orthopaedic Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Joshua S Dines
- Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Elizabeth Gausden
- Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - Alexander White
- Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
| | - John E Conway
- Orthopedic Specialty Associates, Texas Health Physicians Group, Dallas, Texas, U.S.A
| | - Stephen J O'Brien
- Sports Medicine and Shoulder Surgery Service, Hospital for Special Surgery, New York, New York, U.S.A
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Bryson D, Shivji F, Price K, Lawniczak D, Chell J, Hunter J. The lost art of conservative management of paediatric fractures. ACTA ACUST UNITED AC 2016. [DOI: 10.1302/2048-0105.51.360403] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Koper MC, Jakma TSC. Case report of a proximal humeral fracture with an avulsion fracture of the lesser tuberosity in an adolescent girl. J Shoulder Elbow Surg 2015; 24:e260-3. [PMID: 26187137 DOI: 10.1016/j.jse.2015.05.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 02/01/2023]
Affiliation(s)
- Maarten C Koper
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
| | - Tijs S C Jakma
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands
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