Operative Versus Nonoperative Treatment of Displaced Proximal Humeral Physeal Fractures

Chaus, George W.; Carry, Patrick M.; Pishkenari, Azin K.; Hadley-Miller, Nancy

doi:10.1097/bpo.0000000000000265

Cited by 39 publications

(55 citation statements)

References 10 publications

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“…Among several studies that have examined functional outcomes after percutaneous pinning of pediatric proximal humeral fractures 3 . There were no differences in functional outcomes, complications, or rate of return to preinjury activity; however, less than desirable outcomes were noted in patients at least 12 years old who were managed nonoperatively.…”

Section: Resultsmentioning

confidence: 99%

Percutaneous Pinning of Pediatric Proximal Humeral Fractures

Swarup

Hughes

Bram

et al. 2019

JBJS Essential Surgical Techniques

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Background: Proximal humeral fractures are relatively common in pediatric patients. These injuries are usually treated nonoperatively in younger children or children with minimally displaced fractures. However, closed reduction or open reduction followed by percutaneous pinning is recommended for older children with displaced fractures. Percutaneous pinning has several advantages, but there are limited reports of a safe and reliable surgical technique in the literature. Description: Patients are positioned in a modified beach-chair position to allow orthogonal imaging. The injured extremity is draped free from the remainder of the body. Closed reduction, which comprises a combination of traction, abduction, and rotation, is attempted. Internal or external rotation may be required, depending on the fracture line and deforming forces. If an anatomic closed reduction cannot be obtained, a block to reduction should be suspected and open reduction should be performed via a deltopectoral approach. Once the fracture is reduced, two 2.5-mm threaded Kirschner wires from the small external fixator set are used to percutaneously fix the fracture. Any small external fixator set can be used, and if not available, individual threaded wires of similar size can be used. Alternatively, Kirschner wires can be advanced to the fracture site prior to reduction and then advanced into the humeral epiphysis once the fracture is reduced. Care is taken to avoid the axillary nerve, which is reliably within 6 cm of the anterolateral aspect of the acromion, and wires are placed distal to this site. Once pin position has been confirmed radiographically, the construct is secured with pin-to-pin clamps to improve rigidity and further decrease the risk of pin migration. A soft dressing and shoulder immobilizer are placed postoperatively. Patients are followed with biweekly radiographs, and pins are removed in the outpatient office or under conscious sedation at 4 weeks. Leaving pins for a longer period may increase the risk of skin irritation and potentially infection. Alternatives: Alternatives to closed reduction or open reduction and percutaneous pinning include nonoperative management and elastic intramedullary nailing. Nonoperative treatment is a reliable option for most patients. However, it is not suitable for older children with severely displaced fractures because of diminished remodeling potential. Elastic intramedullary nailing is a good option for distal fractures. However, it is not suitable for proximal fractures, and it has been associated with longer operative times and more blood loss than percutaneous pinning. It also requires a second procedure.

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Section: Resultsmentioning

confidence: 99%

Percutaneous Pinning of Pediatric Proximal Humeral Fractures

Swarup

Hughes

Bram

et al. 2019

JBJS Essential Surgical Techniques

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“…19 studies were analysed for the above-named parameters. [ 6 – 9 , 12 – 17 , 26 – 29 ] Quality assessment led to a calculation of a mean Coleman Methodology Score of 70.95 ± 7.41 points (range 57–86 points, confer Table 1 ). One study was of Level III evidence according to the Oxford Centre for Evidence-based Medicine, 18 studies were of Level IV evidence.…”

Section: Resultsmentioning

confidence: 99%

“…All of the conservatively treated patients with a less than desirable outcome were at least 13 years of age. [ 26 ] Dameron et al reported patients who had limitations in their final range-of-motion; all of them were 14 years and older. [ 5 ]…”

Section: Resultsmentioning

confidence: 99%

“…Conservative treatment had low complication rates and the complications observed frequently showed loss of reduction. [ 6 , 9 , 26 ] Nilsson et al[ 31 ] reported one case of occasional numbness and muscular atrophy after immobilization in a supporting bandage. A closer look at the case revealed that displacement was so severe that an open reduction had to be performed before immobilisation.…”

Section: Discussionmentioning

confidence: 99%

“…This is backed up by the fact that the studies which have been published since 2010 have only treated this subject. [ 12 – 15 , 26 , 27 ] Since 2000 only two studies meeting the inclusion criteria comprising more than 3 patients have been published which evaluated conservative treatment options for significantly displaced fractures. [ 26 , 30 ]…”

Section: Discussionmentioning

confidence: 99%

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Age- and severity-adjusted treatment of proximal humerus fractures in children and adolescents—A systematical review and meta-analysis

et al. 2017

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BackgroundFractures 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 findingsThe 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.ConclusionsBy performing this meta-analysis an evidence-based treatment algorithm could be introduced to treat the fractures according to the severity of displacement and according...

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