Surgical management for displaced pediatric proximal humeral fractures: a cost analysis

Single versus double retrograde intramedullary nail technique for treatment of displaced proximal humeral fractures in children: A retrospective cohort study

Background

Highly displaced proximal humeral fractures in children with low remodeling potential need to be reduced and fixed. The use of two flexible retrograde nails became the most popular fixation technique due to the excellent functional outcome, the low complication rates, and the possibility of early mobilization. A modified single retrograde technique has been suggested by the authors to address the main disadvantage of this technique, the long operative duration. The aim of this study was to compare these techniques in terms of efficacy, and clinical and radiological outcomes.

Methods

We performed a retrospective, monocentric study. Two groups of patients were defined: One was treated with the standard flexible retrograde double nail technique and the other with the modified single nail technique. The demographic and fracture characteristics were similar in both groups and the postoperative immobilization with a simple sling for 2 weeks. We compared the surgical duration for the initial fixation and hardware removal procedures. The Quick Disabilities of the Arm, Shoulder, and Hand score, the secondary displacement at 1-week follow-up, the radiological union at 6-week follow-up, and the perioperative and short-term complications were also assessed for both groups.

Results

The surgical duration of the initial fixation procedure was significantly shorter in single nail technique group (p = 0.005). The percentage of excellent Quick Disabilities of the Arm, Shoulder, and Hand score (0) was similar in the two groups (p = 0.98). No secondary displacement was reported for the double nail technique group. In only one patient from the single nail technique group, we detected a secondary displacement at the first week control which did not need reoperation. In both groups, fractures were healed on the 6-week radiologic control. No cases of infection, superficial skin irritation, neurological damage, or complications related to implant removal were reported in both groups.

Conclusions

The single nail technique of fixation proximal humeral fractures in children addresses the disadvantage of long surgical times, described until today, with the double nail technique without compromising the excellent functional and radiological short-term outcomes.

Level of evidence

level III.

Operative Versus Nonoperative Management of Pediatric Proximal Humerus Fractures: A Meta-Analysis and Systematic Review

Background

Proximal humerus fractures account for 2% of all pediatric fractures. A nonoperative approach is the treatment of choice for most of these fractures; however, debates continue regarding the treatment of displaced fractures, especially in adolescents. In this study, we aimed to examine demographic data and treatment strategies for proximal humerus fractures in the pediatric population by conducting a meta-analysis. Additionally, we investigated the preferred surgical technique for operative treatment.

Methods

A systematic online search of databases, including Embase, Medline, PubMed, and Cochrane Library, was conducted to identify studies that matched our search criteria. Data collection was completed on May 1, 2022. Age, sex, degree of angulation, Neer-Horwitz classification, Salter-Harris classification, treatment method (operative vs. nonoperative), and instrument used for internal fixation were classified and documented. Effect size analysis was performed using odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), based on data types.

Results

Eight studies met our inclusion criteria. Overall, 33% of the patients (n = 195) underwent operative treatment, whereas 67% of them (n = 392) received nonoperative treatment. Among the demographic risk factors, severely displaced fracture type (OR, 10.00; 95% CI, 1.56-64.22; p = 0.020) and older age (WMD, 3.26; 95% CI, 2.29-4.23; p < 0.001) were significantly associated with operative treatment. There was no significant difference in the preference for percutaneous pinning or intramedullary nailing, the most frequently employed surgical techniques (OR, 5.09; 95% CI, 0.65-39.58; p = 0.120).

Conclusions

The operative treatment rate in pediatric proximal humerus fractures was 33%, which increased to 60% in severely displaced fractures (Neer-Horwitz grade III/IV). Severely displaced fractures and older age significantly contributed to the establishment of a treatment strategy for operative treatment. The choice of surgical technique may seem to be based on the anatomical location of the fracture rather than the surgeon's preference.

Bone cemented K-wire fixation versus elastic stable intramedullary nailing fixation of paediatric proximal humerus fractures: A prospective cohort study

BACKGROUND

The objective of this study is to compare the treatments of pediatric displaced proximal humerus fractures with external-fixation technique using the combination of K-wires and bone-cement versus close reduction and internal fixation technique using elastic stable intramedullary nail.

METHODS

From April 2016 to March 2020, 72 children with proximal humeral fractures were allocated to group A and 44 children with proximal humeral fractures were allocated to group B. Patients in group A were treated with bone-cemented K-wire fixation, and patients in group B were treated with elastic stable intramedullary nailing. The function of the upper limb was assessed using the Shortened Version of the Disabilities of the Arm, Shoulder and Hand questionnaire and Neer score. Patient satisfaction was assessed using the 10-cm visual analogue scale.

RESULTS

Bone healing was achieved in group A and B after a mean time of 6.1 ± 1.2 and 6.4 ± 1.1 weeks, respectively. The mean surgical time of groups was 33 ± 9 and 54 ± 12 minutes, respectively. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score of groups were 0.5 ± 1.4 and 0.7 ± 1.5, respectively. Based on Neer score, we obtained 69 excellent and 3 good results in group A, and 41 excellent and 3 good results in group B. There were significant differences regarding duration of operation, cost of treatment, and postoperative angle at bone healing (P < .05).

CONCLUSIONS

The external cemented K-wire fixation is a useful and reliable alternative technique for the treatment of severely displaced proximal humerus fractures in children. The technique is a minimally invasive procedure with minimal complications.

Proximal humerus fractures in adolescents: Experience from East of Scotland

BACKGROUND

The management of proximal humerus fractures (PHF) in adolescent has not been agreed upon. We aim to investigate the outcomes of PHF managed conservatively in adolescents.

METHODS

All shoulder radiographs performed in patients aged from 10 to 18 years and from 2008 to 2015 were reviewed. The radiological parameters, including anatomical side, Neer and Horwitz displacement grade, angulation and any residual deformities were recorded. Mail questionnaires based on the modified 15-Upper Extremities Functional Index (15-UEFI), with a maximum of 59 points, were sent out. The return of the completed anonymized questionnaire was considered as implied consent.

RESULTS

118 patients with a median age of 12 at the time of fracture were identified. The majority of the fractures were Neer and Horwitz grade I displacement and 3 children had Neer and Horwitz grade III and IV displacement. The median angulation was 25°. The median follow-up length was 26 days. 55 patients had residual angulation and 25 patients had worsened angulation. No non-union was identified. No patients underwent subsequent corrective surgeries. 35 patients responded to the questionnaire. The median 15-UEFI was 59 points. None of the patients have contacted the research or clinical team regarding any concerns.

CONCLUSION

The vast majority of non-displaced and minimally displaced PHF in adolescent were managed conservatively in our unit. The functional outcomes for this cohort remain excellent even for those with residual deformities in the follow-up radiographs. Further large prospective multicenter studies on adolescent cohort with significantly displaced PHF are warranted.

The use of the pediatric physeal slide-traction plate in the treatment of neer–horwitz grade IV proximal humeral fractures in children: A case report and literature review

Background

Proximal humeral fractures (PHFs) are rare in children. Currently, the recommended surgical methods for severely displaced PHFs are closed reduction and percutaneous fixation using K-wires or intramedullary nailing, which can't provide firm internal fixation, especially for older and high-weight children. This study aimed to introduce a novel surgical approach, pediatric physeal slide-traction plate fixation (PPSP), for Neer–Horwitz grade IV PHFs in children.

Case summary

A 9-year-old boy presented with left shoulder pain and swelling due to a car accident. Physical examination revealed a positive shoulder deformity and local tenderness. On physical examination, we palpated bone friction without vascular and nerve damage. Based on imaging findings, we diagnosed Neer-Horwitz grade IV PHF. In view of the patient's condition, we performed PPSP after careful communication with the patient's parents. After 22 months of follow-up, the patient's left shoulder function was satisfactory, and there was no restriction of activities.

Conclusion

According to previous studies, PPSP is only used for femur fractures. To the best of our knowledge, this is the first in the treatment for PHFs. Given the satisfactory outcomes, it is a safe and effective method and may provide a reference to cure analogous patients in the future.

The effect of different pin configurations on cyclic stability in pediatric proximal humerus fracture fixation: A Sawbones model study

BACKGROUND

In sawbones with proximal humerus fracture model, three different fixation configurations, Parallel-Straight K-wires, Cross-Straight K-wires and Palm-Tree Method, were biomechanically compared.

METHODS

A total of 36 anatomical pediatric humerus sawbones models were used. They were divided into three equal groups; parallel fixation with straight K-wires (Group PS), cross fixation with straight K-wires (Group CS), and Palm-Tree Method (Group PT). Models were tested in abduction and torsional at a speed of 0.5 mm/s and a 0-5 mm displacement range. Loading (N) and Stiffness (N/mm) data were calculated and compared statistically.

RESULTS

Group PS was significantly higher than the other two groups in abduction bending cyclic load values (P<0.001). It was also significantly higher in Group CS than in Group PT (P < 0.001). No significant differences were detected between the three different fixation groups' cyclic torsional load values (p < 0.05).

CONCLUSION

The parallel configuration with straight K-wires will provide a more stable fixation than the cross configuration with straight or Palm-Tree Method in pediatric proximal humeral sawbones fracture modeling.

Proximal Humerus Fractures in the Pediatric Population

PURPOSE OF REVIEW

The purpose of this review is to review recent literature focusing on proximal humerus anatomy, epidemiology of these fractures, diagnosis and treatment options, and clinical outcomes.

RECENT FINDINGS

Non- or minimally displaced proximal humerus fractures treated nonoperatively do not lead to short- or long-term complication and do not cross over to operative treatment. There is a higher rate of operative management with older age, increased injury severity score, treatment at an adult hospital, and private insurance. Operative management is preferred with closed or open reduction and percutaneous pinning, but elastic nailing and plate fixation are other options with good postoperative outcomes. Pediatric proximal humerus fractures occur after fall onto the affected shoulder or arm. Diagnosis is usually made with radiographs. Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential. There is considerable debate around the management of proximal humerus fractures in the pediatric population. Treatment is based on patient age, fracture displacement, and remodeling capacity. Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures.

A Single Retrograde Intramedullary Nail Technique for Treatment of Displaced Proximal Humeral Fractures in Children: Case Series and Review of the Literature

Displaced proximal humeral fractures in older children with low remodeling potential need to be reduced and fixed. There are many options for stabilization, including external fixation, rigid internal fixation with screws and plates, percutaneous pinning, and flexible intramedullary nailing. The use of 2 flexible retrograde nails, originated at the University of Nancy, France, became the most popular technique in Europe. The aim of this study was to describe and assess a modified, single retrograde nail technique to treat fractures of the proximal part of the humerus.

Methods

We performed a retrospective monocentric study. From June 2016 to May 2019, a modified retrograde nail technique with 1 prebent nail was used for the management of 21 consecutive children with a closed displaced proximal humeral fracture. Demographic and surgical data were collected. The surgical technique is similar to the classic elastic stable intramedullary nailing, but only 1 nail is used. The average surgical time and perioperative complications were used as criteria for the feasibility of this technique. Radiographs were obtained preoperatively; at 1, 4, and 6 weeks postoperatively; and after implant removal at an average of 4.2 months postoperatively. The clinical outcomes were assessed on the basis of the shoulder range of motion documented in the medical records and by using the French edition of the QuickDASH (shortened version of the Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire) evaluation scale at the time of implant removal.

Results

Nineteen patients with a mean age of 12.6 years and a mean follow-up of 6 months were included in the study. The mean surgical time was 49 minutes. The single intramedullary nail technique provided a satisfactory reduction of all fractures. No perioperative complication occurred. In 1 case, partial loss of reduction was observed on the first-week control radiograph. All patients had a healed fracture, no deficits, excellent results according to the QuickDASH score, a normal range of motion, and excellent strength of the shoulder joint at the time of implant removal (at a mean of 4.2 months).

Conclusions

The current study confirms the feasibility and efficacy of the single retrograde intramedullary nail technique to treat displaced proximal humeral fractures in children.

Level of Evidence

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cost-Effectiveness of Titanium Elastic Nail (TEN) in the Treatment of Forearm Fractures in Children

Background and objectives: There are various methods in the management of forearm fractures in children. Elastic stable intramedullary nailing using Titanium Elastic Nail (TEN) is nowadays employed in diaphysis fractures of children, with clear benefits over other treatment options. However, in the case of TEN versus other treatment methods of forearm fractures in children, cost is an important issue. This report will focus on the cost assessment of using TEN versus other therapeutic means in the treatment of forearm fractures in children. Materials and Methods: We performed a retrospective longitudinal study of 173 consecutive patients with forearm fractures treated in a single institution during 2017. We calculated the cost for each patient by summing up direct costs plus indirect costs, calculated at an aggregate level. Hospital income data were extracted from the Diagnosis Related Groups database. Results: A total of 173 patients with forearm fractures were treated, 44 using TEN, 86 using K-wire, and 46 using closed reduction and cast. There were 66 radius fractures, 1 ulna fracture, and 106 that were both radius and ulna fractures. Mean treatment cost were $632.76 for TEN, $499.50 for K-wire, and $451.30 for closed reduction and cast. Costs for TEN were higher than for K-wire insertion (p = 0.00) and higher than closed reduction and cast ($182.42; p = 0.00). Reimbursement per patient was higher with TEN versus K-wire patients; $497.88 vs. $364.64 /patient (p = 0.00), and higher than for patients treated with closed reduction and cast (p = 0.00). Conclusions: The treatment of upper extremity fractures using TEN was more expensive than the other methods. In Romania, because the reimbursement for TEN is higher as well, there are no differences in the financial burden when treating forearm fractures with TEN versus K-wire. Non-surgical treatment has the lowest cost but also the lowest reimbursement.

The incidence and treatment trends of pediatric proximal humerus fractures

BACKGROUND

Proximal humerus fractures comprise approximately 2% of all pediatric fractures. In general, upper extremity fractures have increased in children. However, recent trends of proximal humerus fractures are not analyzed yet. The aim was to study the incidence and treatment trends of proximal humerus fractures in children.

METHODS

All 300 children, aged < 16 years, who suffered from a proximal humerus fracture in the catchment area of Oulu University Hospital, Finland, between 2005 and 2015, were included. Radiographs were reviewed, and patients, injuries, treatments, and outcomes were comprehensively studied. Annual incidence was based on the child population at risk, which changed between 84.500 and 88.100 in the study time.

RESULTS

The annual incidence of childhood proximal humerus fractures was mean 31.4/100,000 and no variation trend was found. The majority (92%) was treated nonoperatively, however, there was an increase of operative fixation from 0 to 16% during the study time (Difference 16, 95% CI 0.3 to 34.9%, P = 0.045). Bayonet displacement increased the risk of surgical fixation up to 16-fold (95% CI 4.8-51.4, P < 0.001) in a multivariate analysis when adjusted with other potential risk factors. Higher age was also associated with operative treatment (P = 0.002). The most usual recreational activities were horse riding, downhill skiing, snowboarding, and trampolining.

CONCLUSION

Contrary to most upper extremity fractures in children, proximal humerus fractures did not increase during the long study period. However, their operative treatment increased compared to nonoperative treatment, but the evidence supporting that trend remains unclear.

Three point fixation of pediatric proximal humerus fractures by prebent wave-shaped wires: technical notes

Pediatric proximal humerus fractures are uncommon and mostly treated conservatively. However, surgical treatment should be considered in displaced fractures classified as Neer-Horowitz grade III-IV in children older than 11 years. We describe a three-point fixation method of applying two Kirschner wires, prebent into a wave shape, and inserted into the proximal humerus through a single cortical hole. In this minimally invasive approach, we treated four boys, obtaining accurate reduction and stable fixation, with all patients starting pendulous exercises the day after surgery. At follow-up, all patients had regained full shoulder range of motion, with no residual pain and no complications recorded.

Shoulder Injuries in Pediatric Athletes

Shoulder injuries in pediatric athletes are typically caused by acute or overuse injuries. The developing structures of the shoulder lead to injury patterns that are distinct from those of adult athletes. Overuse injuries often affect the physeal structures of the proximal humerus and can lead to pain and loss of sports participation. Shoulder instability is common in pediatric athletes, and recurrence is also a concern in this population. Fractures of the proximal humerus and clavicle are typically treated with conservative management, but there is a trend toward surgical intervention.

Which Proximal Humerus Fractures Should Be Pinned? Treatment in Skeletally Immature Patients

Most proximal humerus fractures in skeletally immature individuals are treated nonoperatively with excellent functional results. Extensive remodeling of the proximal humerus and the wide arc of motion of the glenohumeral joint accommodate a large degree of fracture displacement and angulation. The treatment of severely displaced fractures and/or severely angulated fractures continues to be debated. Older patients and those with significantly displaced fractures may benefit from surgery because of their inability to remodel displacement and angulation during their limited remaining growth. The decision to treat a proximal humerus fracture in a skeletally immature patient operatively versus nonoperatively is dependent on the following 3 factors: displacement, bone age, and capacity to remodel. There is an increasing trend toward treating severely displaced and severely angulated fractures surgically, especially in older patients and adolescents. Smooth wires, percutaneous threaded wires, cannulated screws, and retrograde elastic stable intramedullary nailing are acceptable options for fixation.