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Proximal humeral fractures in children - controversies in decision making
Philipp Schippers1, Erol Gercek2, Dorien Schneidmüller3
1Department of Orthopedics and Traumatology, University Medical Center of the Johannes Gutenberg University, Langenbeckstr. 1, 55131, Mainz, Germany. philipp.schippers@gmail.com.
Insights
Pediatric proximal humeral fractures (PHFs) show moderate agreement in angulation measurement and fair agreement in treatment decisions among experts. Standardized measurement methods and treatment algorithms are needed for proximal humeral fractures in children.
Area of Science:
- Orthopedic Surgery
- Pediatric Trauma
- Radiographic Assessment
Background:
- Proximal humeral fractures (PHFs) in children are rare and typically managed non-operatively.
- Treatment decisions for pediatric PHFs often rely on age and fracture angulation, but consensus on measurement and acceptable thresholds is lacking.
Purpose of the Study:
- To assess interobserver and intraobserver agreement among German pediatric trauma surgery experts.
- To evaluate expert consensus on measuring fracture angulation and selecting treatment for pediatric PHFs.
Main Methods:
- Twenty pediatric PHF radiographs were reviewed twice by 22 experts.
- Experts measured fracture angulation and chose operative or non-operative treatments.
- Intra-Class Correlation (ICC) and Fleiss' Kappa coefficients were calculated.
Main Results:
- Moderate interobserver (ICC=0.60) and excellent intraobserver (ICC=0.90) agreement for angulation measurement.
- Fair interobserver (Kappa=0.38) and substantial intraobserver (Kappa=0.77) agreement for treatment decisions.
- Elastic Stable Intramedullary Nailing (ESIN) preferred over K-wires; Gilchrist sling preferred over Cuff/Collar.
Conclusions:
- A need exists for consensus on reliable fracture angulation measurement methods for pediatric PHFs.
- Standardized treatment algorithms and guidelines are crucial for consistent care and reliable outcome studies.
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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