Decreasing Rate of Operative Management of Proximal Humerus Fractures in Adolescents: A National Database Study

Abstract

Background: There is no consensus on the operative treatment of adolescent proximal humerus fractures. The purpose of this study was to investigate the trends in treatment of proximal humerus fractures in adolescents and identify predictors of operative management. Methods: The Pediatric Health Information System database was used to identify patients ages 10 to 18 diagnosed with proximal humerus fractures between 2004 to 2019. Open fractures were excluded from the analysis. Descriptive, univariate, and multivariate analyses were used to determine trends and predictors of operative management. Results: A total of 17,515 proximal humerus fracture admissions were identified and 2081 (11.9%) were treated operatively. The mean age was 12.5 years and 37.5% of patients were female. The rate of operative management decreased from 15.1% to 8.9 during the study period (p<0.01). There was a higher rate of operative management in boys (13.4% vs. 9.4%, p< 0.01). The operative cohort was older (13.4 years vs. 12.4 years, p<0.01), and patients who lived in rural areas had twice the rate of operative management (20.7% vs. 10.8%, p<0.01). Operative patients had higher billed charges and longer hospital stay (p < 0.05), but there was no significant difference in mean estimated household income between operative and nonoperative groups (p > 0.05). A multivariate analysis showed increased odds of operative management with older age (OR 1.32, 1.29-1.36), and residence in the South (OR 1.19, 1.05-1.34). The odds of operative management were lower in more recent years (OR 0.94, 0.93-0.95) and in urban settings (OR 0.41, 0.35-0.47). Conclusion: From 2004 to 2019, there has been a significant decrease in the rate of operative management of adolescent proximal humerus fractures at children’s hospitals. Patients who are older, male, or reside in rural areas or the South are more likely to be treated operatively.

Management of Pediatric Proximal Humerus Fractures

“…3 Studies have shown proximal humerus fractures to be up 3-4 times more common in males compared with females, though these numbers vary across studies. 2,[4][5][6] Proximal humerus fractures in children below the age of 2 years may occur during the birthing process or as a result of child abuse. [7][8][9][10] Proximal humerus fractures most commonly result from a backwards fall onto an outstretched hand with an extended, abducted, and externally rotated arm.…”

“…Overall, there has been a decreasing rate of operative management of adolescent proximal humerus fractures in recent years with considerable geographic variation. 6 There is also difference in management depending on the treating hospital with higher rate of operative management in general hospitals compared to children's hospitals which demonstrates this lack of consensus. 5,6 Management of Fractures with Acceptable Alignment Nonoperative management consists of simple immobilization with a sling or a hanging arm cast.…”

“…6 There is also difference in management depending on the treating hospital with higher rate of operative management in general hospitals compared to children's hospitals which demonstrates this lack of consensus. 5,6 Management of Fractures with Acceptable Alignment Nonoperative management consists of simple immobilization with a sling or a hanging arm cast. A shoulder spica cast is poorly tolerated in older children and rarely needed in younger children, so it is not commonly used by the authors.…”

Proximal Humerus Fractures in the Pediatric Population

“…Factors increasing likelihood of operative management are older age, male sex, non-Medicaid payer status, increased injury severity score, and admission to an adult hospital [11•, 15•]. The rate of operative management for pediatric proximal humerus fractures is 43.2% across children's and adult hospitals compared to 11.9% at children's hospitals [15,43]. Neuromuscular disorders or nerve palsies which may unpredictably impact muscular forces may also be indications for operative fixation [10].…”

Die Behandlung der proximalen Humerusfraktur im Kindes- und im Jugendalter

“…In den letzten Jahren ist trotz zahlreicher Studien, die die große Erfolgsrate der konservativen Therapie zeigten, ein Anstieg der operativen Versorgung zu verzeichnen [ 8 ]. Interessant hierbei ist, dass an Krankenhäusern, die sowohl Erwachsene als auch Kinder- und Jugendliche versorgen, die Rate an operativ versorgten Fällen bei 48,2 % lag, während sie an Kinderkrankenhäusern 11,8 % betrug [ 11 , 13 ]. Akzeptable Toleranzgrenzen unterscheiden sich in der Literatur erheblich.…”