BACKGROUND: Using a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached.
METHODS: This was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level.
RESULTS: Among patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles.
CONCLUSIONS: Persistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

BACKGROUND: Day\'s classification and treatment guidelines are considered the gold standard in crescent fractures of the pelvis. The objective of this study was to retrospectively evaluate 10 surgically treated crescent fractures of the pelvis in the context of Day\'s recommendations.
METHODS: This is a retrospective cohort study. Ten consecutive cases of crescent fractures that were treated surgically at a level 1 trauma center formed the cohort. Six were operated anteriorly, three posteriorly and one percutaneously. Classification and treatment strategy were compared to Day\'s guidelines. The minimum follow-up was 13 months. Outcomes were assessed using the modified Majeed\'s scoring system.
RESULTS: Three out of 10 cases were difficult to classify by Day\'s criteria. There were 4 type I, three type III and no type II cases. Our surgical strategy was independent of Day\'s recommendations in this series and based on ease of access, ability to restore the sacroiliac joint anatomy and other associated injuries. All the patients were mobilized early and the fractures united without any major incident. The results of these cases were quite good with outcome scores over 67/96.
CONCLUSIONS: Assigning Day\'s classification to a given case can be difficult in up to 33% patients with crescent fractures due to the obliquity of the iliac fracture line in axial sections. Sacroiliac articular alignment is the primary factor determining the surgical approach. Besides the fracture configuration, additional factors like delay in surgery, locking of the fracture fragments, comminution of the iliac or sacral fragment as well as access to the additional injuries contribute to the decision making.

OBJECTIVE: To evaluate the efficacy of open reduction and semirigid internal fixation in the management of displaced pediatric mandibular fractures.
METHODS: Ten patients with displaced mandibular fractures treated with 1.5 mm four holed titanium mini-plate and 4 mm screws which were removed within four month after surgery.
RESULTS: All cases showed satisfactory bone healing without any growth disturbance.
CONCLUSIONS: Open reduction and rigid internal fixation (ORIF) with 1.5 mm titanium mini- plates and 4 mm screws is a reliable and safe method in treatment of displaced paediatric mandibular fractures.