Reducing resource utilization during non-operative treatment of pediatric proximal humerus fractures.

INTRODUCTION: The majority of proximal humeral fractures in the skeletally immature are treated non-operatively. Operative indications vary but are largely based on degree of displacement. Non-union is rare. Non-operatively treated fractures are typically monitored radiographically to assess healing. HYPOTHESIS: We hypothesize that the decision to treat fractures operatively is made at the time of first imaging and that follow-up X-rays do not lead to a change in management. MATERIAL AND METHODS: We retrospectively reviewed the records of 239 patients treated for proximal humerus fractures over a 5-year period. There were 225 who were treated non-operatively. Records were reviewed for the number of clinic visits and radiographs, as well as any change to operative management based on follow-up X-rays. RESULTS: The primary outcome of the study was the proportion of proximal humerus fractures, initially treated non-operatively, for which displacement or angulation on follow-up radiographs led to a change to operative treatment. Secondary outcomes were the number of follow-up radiographs obtained after the initial diagnosis and initiation of non-operative treatment. Of the 225 patients that were initially managed non-operatively, only 1 patient required subsequent surgical management. This patient underwent a proximal humerus epiphysiodesis 365 days from injury after development of a partial growth arrest. The mean number of fracture clinic visits for patients managed non-operatively was 2.67 (±1.24). The mean number of radiology department visits and radiographs obtained was 3.57 (±1.44) and 8.36 (±3.89) respectively. No clinical or radiographic non-unions were identified in these patients. No patients suffered a refracture during the review period. DISCUSSION: This study shows that of the 239 uncomplicated pediatric proximal humerus fractures treated at our hospital over a 5-year period, only 1 had a change in treatment plan, from non-operative to operative, based on follow-up radiographs. These data suggest that non-operative treatment of proximal humerus fractures seldom results in displacement that warrants operative intervention. Moreover, they suggest that there is little utility to the routine use of postoperative radiographs in follow-up of these patients. STUDY DESIGN: Retrospective case series. LEVEL OF EVIDENCE: IV.

Sham radiation in clinical trials assessing radiotherapy for exudative age-related macular degeneration.

BACKGROUND: To evaluate the effectiveness of sham radiation treatments in masking patients to their randomization group in the Radiation of Age-Related Macular Degeneration (ROARMD) Study. METHODS: Patients with choroidal neovascularization complicating age-related macular degeneration were randomized to a treatment (RAD) group that received external beam irradiation (seven treatment sessions) or to a control (SHAM) group that received sham radiation (one sham treatment session). During a telephone survey, 62 of 73 randomized patients responded to the following questions: Do you think you received radiation? Why do you feel that way? Did the vision in your study eye worsen after enrollment? RESULTS: Eighty-one percent of the RAD group and 59% of the SHAM group thought that they had received radiation. In patients who thought that their vision had stabilized or improved, 82% thought that they had received radiation. In patients who thought that their vision was worse, only 39% thought that they had received radiation. In 54% of patients, subjective perception of vision influenced their guess as to whether they received radiation. CONCLUSIONS: Subjective patient perception of visual outcome was the most influential variable for masking. Variation between radiation treatment and sham session techniques, such as equipment used and duration of treatments, played a lesser role in the masking of patients. Seven treatment days correlated with a higher number of patients who thought that they had received radiation. Although our procedures do not strictly mask the two groups, one sham radiation session was effective in keeping patients guessing their randomization group.