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Non-Operative vs. Operative Treatment of Pediatric Proximal Humerus Fractures: Surgery Offers No Clinical or Economic
Tosca Cerasoli1, Marina Magnani2, Marco Todisco2
1II Orthopaedic and Traumatologic Clinic, IRCCS Istituto Ortopedico Rizzoli, 40136 Bologna, Italy.
Insights
Non-operative management is effective for pediatric proximal humerus fractures (PHFs), yielding excellent outcomes. Surgery for PHFs is costly and offers no functional advantage over conservative care.
Area of Science:
- Orthopedic Surgery
- Pediatric Orthopedics
- Traumatology
Background:
- Pediatric proximal humerus fractures (PHFs) possess significant remodeling potential, favoring non-operative treatment.
- Surgical interventions for Neer-Horowitz grade III-IV PHFs are increasing despite limited evidence supporting their superiority.
Purpose of the Study:
- To evaluate the functional outcomes and costs associated with non-operative versus surgical management of pediatric proximal humerus fractures.
- To compare recovery, return to sport, and complication rates between treatment modalities for PHFs.
Main Methods:
- Retrospective analysis of 152 children (<14 years) with isolated PHFs treated between 2004-2023.
- Data collection included fracture classification, management, complications, and functional outcomes (QuickDASH, Tegner, return to sport).
- Direct cost analysis comparing conservative and surgical treatment pathways.
Main Results:
- Non-operative management (133 patients) yielded excellent results with normal QuickDASH scores and full shoulder function.
- Outcomes for Neer III-IV fractures (37 patients) were similar between non-operative and surgical groups.
- Surgical treatment incurred significantly higher costs (€7832.12 vs €1452.09) and was associated with minor transient complications.
Conclusions:
- Pediatric PHFs demonstrate uniformly excellent long-term outcomes irrespective of fracture severity or treatment.
- Surgery for PHFs does not enhance recovery, function, or return to sport, and increases costs.
- Conservative management should be the standard for most pediatric PHFs, reserving surgery for specific complex cases.
Background:
Pediatric proximal humerus fractures (PHFs) typically heal well due to their strong remodeling potential, supporting non-operative management even in displaced injuries. However, surgery for Neer-Horowitz grade III-IV fractures has become more frequent despite limited evidence of superior outcomes.
Methods:
A retrospective analysis of 152 children (<14 years) treated for isolated PHFs at a tertiary pediatric orthopedic center (2004-2023) was performed. Clinical records and telephone follow-up provided demographic data, fracture classification, management, complications, and functional outcomes (QuickDASH, Tegner, return to sport). A direct cost analysis compared conservative and surgical pathways.
Results:
Of 152 patients, 133 were treated non-operatively and 19 surgically. Conservative management achieved excellent results across all fracture types: nearly all patients reported normal QuickDASH scores and full shoulder function. Among Neer III-IV fractures (n = 37), functional outcomes, activity levels, and sport resumption were similar between treatment strategies. Minor transient issues (pin migration, temporary stiffness, delayed return to sport) occurred only after surgery. No meaningful complications were observed in the conservative cohort. Mean costs differed substantially: €1452.09 for non-operative management versus €7832.12 for surgical treatment.
Conclusions:
Long-term outcomes of pediatric PHFs were uniformly excellent, regardless of fracture severity or treatment modality. Surgery did not improve recovery, function, or return to sport and was associated with higher costs and minor postoperative issues. Conservative management should remain the standard of care for nearly all pediatric PHFs, with surgery reserved for exceptional circumstances such as open fractures, neurovascular compromise, or failed closed reduction.
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