Age, fracture severity, injury mechanisms and concomitant injuries predict surgical intervention in pediatric proximal humerus fractures

Abstract

Objective: Proximal humerus fractures (PHFs) in children often heal well with conservative treatment due to the region’s high remodeling potential. However, the decision to operate becomes more nuanced in older children or those with severe fracture displacement or high-energy trauma. This study aimed to identify factors associated with operative management of pediatric PHFs.

Materials and Methods: We retrospectively reviewed 41 pediatric patients (aged 6–16 years) with PHFs treated between 2014 and 2024. Patient demographics, Neer-Horowitz classification, injury mechanisms, and presence of concomitant injuries were analyzed. Injury mechanisms were categorized as low-energy or high-energy. Outcomes were assessed using the Pediatric/Adolescent Shoulder Survey (PASS) at final follow-up. Multivariate logistic regression was used to identify independent predictors of surgical treatment.

Results: Of the 41 patients, 19 (46.3%) underwent surgical fixation, while 22 (53.7%) were treated nonoperatively. Patients in the operative group were older (mean 13.2 vs. 10.7 years, p < 0.001) and more likely to have Neer-Horowitz Grade III or IV fractures (89.5% vs. 40.0%, p < 0.001). High-energy trauma (94.7% vs. 59.1%, p = 0.003) and concomitant injuries (52.6% vs. 27.3%, p = 0.001) were significantly more frequent in the surgical group. On multivariate analysis, independent predictors of surgery included older age (OR 1.49, p = 0.018), Grade III/IV fractures (OR 5.41, p = 0.015), high-energy trauma (OR 4.57, p = 0.040), and concomitant fractures (OR 5.13, p = 0.042). At final follow-up, there was no significant difference in PASS scores between groups (operative: 87.8, nonoperative: 88.9; p = 0.68).

Conclusion: Age, fracture severity, high-energy trauma, and concomitant injuries are significant predictors of surgical intervention in pediatric PHFs. However, both surgical and nonoperative treatments yielded excellent functional outcomes, highlighting the importance of individualized treatment strategy.