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American Association for Hand Surgery

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Variation Amongst Orthopedic Surgeons Regarding the Treatment of Pediatric and Adolescent Proximal Humerus Fractures
Jalaluddin Baten, MD1, Casey M Codd, BA2, Blessing Enobun, MD, MPH1 and Joshua M Abzug, MD2, (1)University of Maryland School of Medicine, Timonium, MD, (2)University of Maryland School of Medicine, Baltimore, MD

Introduction
A conservative approach is typically adequate and preferred in younger patients with less displaced proximal humerus fractures, but a consensus standardized treatment recommendation is lacking when it comes to older children and adolescents that have displaced fractures. The purpose of this study was to determine if variation exists amongst orthopedic surgeons when treating pediatric and adolescent proximal humerus fractures and determine the potential factors regarding this variation.
Materials & Methods
Eleven sets of radiographic images of proximal humerus fractures including anteroposterior (AP), lateral, axial, and Y views were collected from patients 6-16 years of age. Each set of images was accompanied by the patient's sex, age, and mechanism of injury. The images, along with a brief demographic questionnaire, were evaluated by 51 orthopedic surgeons. The surgeons were asked questions regarding the management of each set of images. Predictors of surgeons' decisions in the management of proximal humerus fractures were explored using linear mixed effects models.
Results
A surgeons' inclination to utilize a hanging arm cast for non-operative management increased by 23% if the patient was female (β = 0.23; p=0.04) and by 47% if the fracture was displaced (β = 0.47; p=0.001). The use of a hanging arm cast versus a sling or shoulder immobilizer was unchanged based on the patient's age (β = -0.03; p=0.22).
The surgeon's decision for operative intervention on pediatric proximal humeral fractures increased by 18% (Estimate [β]=0.18, p<0.0001) with each additional year of patient's age. The decision to operate decreased by 21% (β = -0.21, p=0.006) if the patient was female. Operative intervention was not influenced by the amount of fracture displacement (β = -0.05; p=0.69).
An open reduction and internal fixation (ORIF) was the preferred operative management option for older children (β = 0.10, p=0.004),) but this treatment was not influenced based on displacement of the fracture (β = -0.005; p=0.99).
Conclusions
The treatment of proximal humerus fractures in the pediatric and adolescent populations is not standardized. Patient age and sex appear to be the most important factors in the determination of conservative versus operative intervention and this decision surprisingly was not influenced by the amount of fracture displacement. Both the age and sex of the patient influenced the preference toward ORIF when treating the fracture with operative intervention while sex and displacement, but not age, influenced the surgeons' choice to utilize a hanging arm cast during non-operative management.


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