Purpose

Proximal humerus fractures and epiphyseal separations in skeletally immature children and adolescents are traditionally treated non-operatively. Recently, authors have described the operative fixation of these injuries, particularly in older children and adolescents with displaced fractures. We performed a systematic review of the literature to identify operative indications for proximal humerus fractures in children and to compare the results by age, displacement, and treatment modality.

Methods

A systematic review of the literature from January 1960 to April 2010 was performed. All studies with patients under the age of 18 years who were treated for a proximal humerus fracture either operatively or non-operatively were included.

Results

The available literature is largely composed of uncontrolled case series (Level IV). According to findings, the literature shows that asymptomatic union is the rule in proximal humerus fractures in children and adolescents. Poorer outcomes were noted in operatively treated patients, patients with more displaced fractures, and older patients.

Conclusions

The currently available literature supports a non-operative treatment approach, particularly in younger children with more growth remaining. Older patients (>13 years) with more widely displaced fractures may benefit from anatomic reduction with stabilization, though the data in the literature at this point is too weak to strongly recommend this approach. Further analysis with a more rigorous scientific method is necessary to evaluate the optimum treatment modality in this subgroup.

OBJECTIVE:Adequate resources are required to rapidly diagnose and treat pediatric musculoskeletal infection (MSKI). The workload MSKI consults contribute to pediatric orthopaedic services is unknown as prior epidemiologic studies are variable and negative work-ups are not included in national discharge databases. The hypothesis was tested that MSKI consults constitute a substantial volume of total consultations for pediatric orthopaedic services across the United States. STUDY DESIGN:Eighteen institutions from the Children's ORthopaedic Trauma and Infection Consortium for Evidence-based Study (CORTICES) group retrospectively reviewed a minimum of 1 year of hospital data, reporting the total number of surgeons, total consultations, and MSKI-related consultations. Consultations were classified by the location of consultation (emergency department or inpatient). Culture positivity rate and pathogens were also reported. RESULTS:87,449 total orthopaedic consultations and 7,814 MSKI-related consultations performed by 229 pediatric orthopaedic surgeons were reviewed. There was an average of 13 orthopaedic surgeons per site each performing an average of 154 consultations per year. On average, 9% of consultations were MSKI related and 37% of these consults yielded positive cultures. Finally, a weak inverse monotonic relationship was noted between percent culture positivity and percent of total orthopedic consults for MSKI. CONCLUSION:At large, academic pediatric tertiary care centers, pediatric orthopaedic services consult on an average of ~3,000 'rule-out' MSKI cases annually. These patients account for nearly 1 in 10 orthopaedic consultations, of which 1 in 3 are culture positive. Considering that 2 in 3 consultations were culture negative, estimating resources required for pediatric orthopaedic consult services to work up and treat children based on culture positive administrative discharge data underestimates clinical need. Finally, ascertainment bias must be considered when comparing differences in culture rates from different institution's pediatric orthopaedics services, given the variability in when orthopaedic physicians become involved in a MSKI workup.