Sometimes Less is More!

Commentary The thought-provoking and well-performed study by Lähdeoja et al. represents a retrospective review of 209 patients who sustained a proximal humeral fracture as adolescents and had an impressive follow-up ranging from 7 to 19 years and a thorough and rigorous methodology to assess outcomes. The authors did an outstanding job matching cohorts to make valid comparisons with a similar group without a fracture. The study found that patients who sustained a proximal humeral fracture as adolescents healed well and had good outcomes in long-term follow-up. The study also found no significant differences between patients treated operatively and those treated nonoperatively. It is well known that proximal humeral fractures heal well in young children; however, less is known in adolescents. A recent systematic review found that, since the 1946 inception date in the National Library of Medicine’s computer-based retrospective search service, there have only been 4 prospective cohort studies and 8 retrospective cohort studies examining proximal humeral fractures in children1. None has explicitly focused on fractures occurring during adolescence. The current study by Lähdeoja et al. will add to the growing mountain of evidence that shows that even adolescents do well after this kind of injury. Lähdeoja et al. believe that their findings will influence the practice of orthopaedics as they can help to guide the treatment of proximal humeral fractures in adolescence by using the idea that less is more and noting that most patients can be treated nonoperatively with minimally burdensome methods for the patients and that parents can be assured that the outcomes are good. However, one should note that the idea of less is more can have different interpretations. Dolly Parton once famously said, “People say that less is more, but I think more is more.” She was, of course, referring to the absurdity of noting that a qualifier (less) is opposite to its meaning. The architect Frank Lloyd Wright is correct in stating that “Less is more only when more is too much.” Based on the results of this study, a surgical procedure for proximal humeral fractures in adolescence seems “too much.” However, the incentive to operate in many health-care environments may create a substantial surgeon preference toward treating fractures operatively. There have been a decrease in some reimbursement schedules for orthopaedic procedures2 and a concern for surgeons being incentivized to perform more cases to maintain productivity goals3; decreased reimbursement is a known stressor contributing to surgeon burnout. From a purely orthopaedic viewpoint, this article confirms that nonoperative treatment yields similar or superior results to those of operative treatment of proximal humeral fractures in adolescents. This study comes from an economically highly developed Scandinavian country, Finland, where more than three-quarters of the population received health care through the public system, in 20194, higher than the mean of 71.7% for Organization for Economic Cooperation and Development (OECD) countries5. Finland is one of the most efficient public-sector health service producers, and its model should be applauded and analyzed for generalizability. To quote one final author, Yvon Chouinard, the founder of the apparel and equipment company Patagonia, in his book6, Let My People Go Surfing: The Education of a Reluctant Businessman, “The more you know, the less you need.” In the case of proximal humeral fractures in adolescence, the more we know and understand the long-term consequences of these injuries, the less we need to worry about treating them operatively.