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

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Abstract
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 (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.

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