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Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures
A Z Gladstein1, A T Schade2, A W Howard3
1Pennsylvania 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.
Insights
Pediatric proximal humerus fractures are usually treated non-operatively. Follow-up X-rays rarely change management, indicating routine radiographic monitoring may not be necessary for these fractures.
Area of Science:
- Orthopedic surgery
- Pediatric orthopedics
- Traumatology
Background:
- Proximal humeral fractures in skeletally immature patients are predominantly managed non-operatively.
- Indications for operative intervention are typically based on fracture displacement, with non-union being uncommon.
- Radiographic monitoring is standard for assessing healing in non-operatively treated fractures.
Purpose of the Study:
- To test the hypothesis that operative treatment decisions for pediatric proximal humerus fractures are made at initial imaging.
- To determine if follow-up radiographs alter the management of non-operatively treated fractures.
- To evaluate the utility of routine radiographic follow-up in these cases.
Main Methods:
- A retrospective review of 239 pediatric proximal humerus fractures over five years.
- Analysis of records for 225 non-operatively treated fractures.
- Assessment of clinic visits, radiographs, and changes in management based on follow-up imaging.
Main Results:
- Only one of 225 non-operatively treated fractures required a change to operative management due to displacement.
- This patient underwent epiphysiodesis for a partial growth arrest.
- No clinical or radiographic non-unions or refractures were observed.
Conclusions:
- Non-operative treatment for uncomplicated pediatric proximal humerus fractures rarely necessitates a change to operative intervention based on follow-up imaging.
- Routine postoperative radiographs may have limited utility in the follow-up of these patients.
- Current management strategies appear effective, with minimal need for intervention changes post-initial diagnosis.
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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