Rate of Complications and Subsequent Shoulder Complaints for Non-operatively Managed Pediatric Proximal Humerus Fractures

Abstract

The purpose of the study was to describe the early complications and delayed shoulder complaints of non-displaced or minimally displaced pediatric proximal humerus fractures treated non-operatively. Methods: Retrospective review of all pediatric proximal humerus fractures at a single institution from 2001 to 2016. Inclusion criteria were: AP and axillary radiographs upon presentation and final follow up, one follow up appointment, either a non-displaced or minimally displaced fracture, and open physis. Exclusion criteria were: pathologic fractures, re-fractures, bone metabolic disorders. Patient demographics, injury characteristics, radiographic measurements and clinical exam findings were reviewed. Delayed shoulder complaints were defined as a visit to any provider for an ipsilateral shoulder or arm complaint after final scheduled fracture appointment. Results: Sixty-nine of 177 total pediatric proximal humerus fractures met inclusion criteria. Mean age was 10 years (SD = 3.4). Sixty-five had angulation <20 degrees. Median time to last scheduled follow up was 1.4 months (Interquartile range 0.8-1.4). At last scheduled follow up, 9 (13.0%) fractures had an altered exam. One (1.4%) fracture had a complication of a fall and re-fracture. Extraphyseal fractures were more likely to increase in angulation at short term follow up, but had no association with short or long term complications. No patient initially treated with non-operative management subsequently underwent operative treatment. There were three presentations (4.3%) to health professionals for subsequent shoulder complaints; one was treated with short courses of physical therapy and the other two were simply observed. Conclusions: Non-displaced or minimally displaced proximal humerus fractures treated non-operatively sustain rare short or long term complications with no cross over to operative management. Once non-operative management is pursued, these fractures may be amenable to surveillance with primary care or allied orthopedic staff after initial evaluation by pediatric orthopedic providers.

Predictors of outcomes of proximal humerus fractures in children and adolescents: A systematic review

“… 8 – 14 The glenohumeral joint has the widest range of motion of any joint in the body and can accommodate a large degree of deformity without causing significant functional impairment. 8 , 15 , 16 Because of these unique attributes, pediatric PHFs have historically been treated non-operatively. 3 , 17 This practice continues to be accepted for NH Grade I and Grade II fractures; however, there is considerable debate regarding the management of NH Grade III and Grade IV fractures, particularly in teenagers with relatively limited remodeling potential.…”

Management of Pediatric Proximal Humerus Fractures

“…24,49 Baker et al reviewed 69 pediatric patients with nondisplaced or minimally displaced proximal humerus fractures. 28 Early complications were seen in 13% of patients, of which were reduced range of motion (7.2%), pain (4.3%), and decreased strength (1.4%). There were no cases of premature physeal closure, and all patients were managed with physical therapy or observation with none requiring operative intervention.…”

“…Physeal fractures are seen in adolescents due to the rapid growth at this age leading to a weakened physis. 27,28 With physeal fractures, growth arrest may occur leading to functional and cosmetic issues.…”

“…50 It is exceedingly rare for a proximal humerus fracture managed nonoperatively to be converted to operative intervention, and there are arguments made to minimize routine monitoring radiographs or to follow up with allied health providers. 28,51 Operative management can also lead to complications of pain, weakness, and loss of motion and include infection and neurovascular injury. Pin site infection can be a common complication of percutaneous pinning but rarely leads to osteomyelitis of the humeral head.…”

Outcomes of proximal humerus fractures in children: a study protocol for a retrospective cohort study

“…Second, the periosteum in the immature humerus is metabolically active, which enhances its ability to rapidly consolidate fractures and heal 1 16. Third, the glenohumeral joint has the widest range of motion of any joint in the body, meaning it can accommodate a large degree of displacement and angulation without causing any significant functional impairment 6 17 18. Because of these unique attributes, paediatric PHFs have historically been treated non-operatively, regardless of their severity 2 19…”