Non-Operative vs. Operative Treatment of Pediatric Proximal Humerus Fractures: Surgery Offers No Clinical or Economic Benefit, a Retrospective Study of 152 Children

TL;DR

Surgery for certain pediatric shoulder fractures does not improve recovery or reduce costs compared to non-operative treatment.

Contribution

Demonstrates that non-operative treatment is as effective and less costly than surgery for most pediatric proximal humerus fractures.

Findings

Non-operative treatment achieves excellent long-term outcomes even for severe pediatric shoulder fractures.

Surgical treatment does not improve recovery, shoulder function, or return-to-sport rates compared to conservative care.

Conservative management costs significantly less than surgery and avoids postoperative complications.

Abstract

What are the main findings?
Non-operative treatment of pediatric proximal humerus fractures provides excellent long-term functional outcomes, even in Neer–Horowitz grade III–IV injuries.Surgical management does not improve recovery, shoulder function, or return-to-sport rates compared with conservative care.

Non-operative treatment of pediatric proximal humerus fractures provides excellent long-term functional outcomes, even in Neer–Horowitz grade III–IV injuries.

Surgical management does not improve recovery, shoulder function, or return-to-sport rates compared with conservative care.

What are the implications of the main findings?
Conservative treatment should remain the standard of care, with surgery reserved only for exceptional indications such as open fractures or neurovascular compromise.Avoiding unnecessary surgery reduces healthcare costs, minimizes postoperative issues, and limits the psychosocial burden for children and families.

Conservative treatment should remain the standard of care, with surgery reserved only for exceptional indications such as open fractures or neurovascular compromise.

Avoiding unnecessary surgery reduces healthcare costs, minimizes postoperative issues, and limits the psychosocial burden for children and families.

Background: Pediatric proximal humerus fractures (PHFs) typically heal well due to their strong remodeling potential, supporting non-operative management even in displaced injuries. However, surgery for Neer–Horowitz grade III–IV fractures has become more frequent despite limited evidence of superior outcomes. Methods: A retrospective analysis of 152 children (<14 years) treated for isolated PHFs at a tertiary pediatric orthopedic center (2004–2023) was performed. Clinical records and telephone follow-up provided demographic data, fracture classification, management, complications, and functional outcomes (QuickDASH, Tegner, return to sport). A direct cost analysis compared conservative and surgical pathways. Results: Of 152 patients, 133 were treated non-operatively and 19 surgically. Conservative management achieved excellent results across all fracture types: nearly all patients reported normal QuickDASH scores and full shoulder function. Among Neer III–IV fractures (n = 37), functional outcomes, activity levels, and sport resumption were similar between treatment strategies. Minor transient issues (pin migration, temporary stiffness, delayed return to sport) occurred only after surgery. No meaningful complications were observed in the conservative cohort. Mean costs differed substantially: €1452.09 for non-operative management versus €7832.12 for surgical treatment. Conclusions: Long-term outcomes of pediatric PHFs were uniformly excellent, regardless of fracture severity or treatment modality. Surgery did not improve recovery, function, or return to sport and was associated with higher costs and minor postoperative issues. Conservative management should remain the standard of care for nearly all pediatric PHFs, with surgery reserved for exceptional circumstances such as open fractures, neurovascular compromise, or failed closed reduction.

Figures