title: Intramedullary nailing versus percutaneous pin fixation of pediatric proximal humerus fractures: a comparison of complications and early radiographic results.
abstract: BACKGROUND
  Surgical treatment is often advocated for unstable or severely displaced proximal humerus fractures in older children. The purpose of this study is to compare the early radiographic results and complications of 2 common methods of internal fixation, percutaneous pinning (PP), and flexible intramedullary nailing (IMN), used to treat these fractures.
  
  
  METHODS
  Fifty skeletally immature patients who underwent surgical reduction and PP or IMN of proximal humerus fractures between 2000 and 2009 were reviewed. Radiographs were assessed for maximum angular deformity and Neer-Horowitz classification on preoperative, immediate postoperative, and final follow-up radiographs. t test, χ, Wilcoxon, and Cochran-Armitage trend test analyses were used to determine statistical significance. Average age at injury was 13.7 years with average follow-up of 9 months.
  
  
  RESULTS
  There were no statistically significant differences in age, sex, side of injury, reduction method, preoperative Neer-Horowitz classification or preoperative maximum angulation between the PP and IMN groups. Patients treated with both PP and IMN achieved significant improvements in both radiographic angulation and Neer-Horowitz classification. Patients treated with IMN had a slightly lower average angulation on final radiographs. Patients treated with IMN had higher average estimated blood losses (EBLs) and longer surgical times than patients treated with PP. The complication rate was higher in the PP group than in the IMN group. There were no differences in rates of loss of reduction. More patients in the IMN group underwent a second surgical procedure for implant removal.
  
  
  CONCLUSIONS
  Both IMN and PP techniques are effective at stabilizing severely displaced proximal humerus fractures in the older pediatric population. IMN has the advantage of fewer complications but involves longer surgeries, increased EBL, and a second surgery for implant removal. PP has shorter surgeries, decreased EBL, and lesser need for operative implant removal, though complication rates are higher. Ultimately both patient and surgeon factors should be used to determine which treatment is best in a given situation.
  
  
  METHODS
  III: retrospective comparative study.
authors.affiliation: Department of Orthopaedic Surgery, Children's Hospital Boston, Boston, MA 02115, USA.
authors.forename: Peter H
authors.initials: PH
authors.lastname: Hutchinson
authors.forename: Donald S
authors.initials: DS
authors.lastname: Bae
authors.forename: Peter M
authors.initials: PM
authors.lastname: Waters
mesh_terms: D000293:Adolescent; D016063:Blood Loss, Surgical; D001858:Bone Nails; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods*; D005594:Fracture Fixation, Intramedullary / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D006810:Humeral Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D008297:Male; D011183:Postoperative Complications / Q000453:epidemiology; D011859:Radiography; D012189:Retrospective Studies; D018709:Statistics, Nonparametric; D013997:Time Factors; D016896:Treatment Outcome