Functional treatment of closed humeral shaft fractures

Nonoperative Treatment of Humeral Shaft Fractures With Immediate Functional Bracing Versus Coaptation Splinting and Delayed Functional Bracing: A Retrospective Study

OBJECTIVES

To compare radiographic and clinical outcomes in nonoperative management of humeral shaft fractures treated initially with coaptation splinting (CS) followed by delayed functional bracing (FB) versus treatment with immediate FB.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Academic Level 1 Trauma Center.

PATIENT SELECTION CRITERIA

Patients with closed humeral shaft fractures managed nonoperatively with initial CS followed by delayed FB or with immediate FB from 2016 to 2022. Patients younger than 18 years and/or with less than 3 months of follow-up were excluded.

OUTCOME MEASURES AND COMPARISONS

The primary outcome was coronal and sagittal radiographic alignment assessed at the final follow-up. Secondary outcomes included rate of failure of nonoperative management (defined as surgical conversion and/or fracture nonunion), fracture union, and skin complications secondary to splint/brace wear.

RESULTS

Ninety-seven patients were managed nonoperatively with delayed FB (n = 58) or immediate FB (n = 39). Overall, the mean age was 49.9 years (range 18-94 years), and 64 (66%) patients were female. The immediate FB group had less smokers ( P = 0.003) and lower incidence of radial nerve palsy ( P = 0.025), with more proximal third humeral shaft fractures ( P = 0.001). There were no other significant differences in demographic or clinical characteristics ( P > 0.05). There were no significant differences in coronal ( P = 0.144) or sagittal ( P = 0.763) radiographic alignment between the groups. In total, 33 (34.0%) humeral shaft fractures failed nonoperative management, with 11 (28.2%) in the immediate FB group and 22 (37.9%) in the delayed FB group ( P = 0.322). There were no significant differences in fracture union ( P = 0.074) or skin complications ( P = 0.259) between the groups.

CONCLUSIONS

This study demonstrated that nonoperative treatment of humeral shaft fractures with immediate functional bracing did not result in significantly different radiographic or clinical outcomes compared to treatment with CS followed by delayed functional bracing. Future prospective studies assessing patient-reported outcomes will further guide clinical decision making.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radial Nerve Palsy in the Setting of Humeral Shaft Fracture

The upper limb has a complex anatomy comprised of many nerve and vascular structures, making humeral shaft fractures extremely important. Injury to the humeral shaft commonly occurs due to trauma and affects younger male or older female patients. The radial nerve travels along the spiral groove of the humerus, placing it at an increased risk of damage in humeral shaft fractures. If injured, there are a variety of classifications of radial nerve injury, different indications for exploration, and treatment methods that orthopedic surgeons have available in treating these injuries. This review aims to discuss the etiology of humeral shaft fracture-associated radial nerve palsy, tools for diagnosis, and treatment.

Iatrogenic open humeral shaft fractures following functional bracing

INTRODUCTION

The treatment of closed humeral shaft fractures tends to be successful with functional bracing. Treatment failure due to iatrogenic conversion to an open fracture has not been described in the literature. We present a case series of patients that experienced open humeral shaft fractures after initially being treated with functional bracing for closed humeral shaft fractures and describe what factors are associated with this complication.

MATERIALS AND METHODS

This was a retrospective case series performed at three level 1 trauma centers across North America. All nonoperatively treated humeral shaft fractures were reviewed from 2001 to 2023. Patients were included if they sustained a humeral shaft fracture, > 18 years old, were initially treated non-operatively with functional bracing which subsequently converted to an open fracture. Eight patients met inclusion criteria. All included patients were eventually treated with irrigation, debridement, and open reduction and internal fixation. Outcomes assessed included mortality rate, time until the fracture converted from closed to open, need for further surgery, and bony union. Descriptive statistics were used in analysis.

RESULTS

The eight included patients on average were 65 ± 21.4 years old and had a body mass index (BMI) of 25.6 ± 5.2. Six patients were initially injured due to a fall. Time until the fractures became open on average was 5.2 ± 3.6 weeks. Three patients (37.5%) died within 1.8 ± 0.6 years after initial injury. The average Charlson Comorbidity Index (CCI) score was 4.5 ± 3.4. Three patients (37.5%) had dementia. Common characteristics among this cohort included a history of visual disturbances (50.0%), cerebrovascular accident (50.0%), smoking (50.0%), and alcohol abuse (50.0%).

CONCLUSION

Conversion from a closed to open humeral shaft fracture after functional bracing is a potentially devastating complication. Physicians should be especially cognizant of patients with a low BMI, history of falling or visual disturbance, dementia, age ≥ 65, decreased sensorimotor protection, and significant smoking or alcohol history when choosing to use functional bracing as the final treatment modality.

LEVEL OF EVIDENCE

IV.

Anterolateral Dual Plate Fixation for Distal Metaphyseal-Diaphyseal Junction Fractures of the Humerus: Biomechanical Finite Element Analysis with Clinical Results

Background

Distal metaphyseal-diaphyseal junction fractures of the humerus are a subset of injuries between humeral shaft fractures and distal intra-articular humerus fractures. A lack of space for distal fixation and the unique anatomy of concave curvature create difficulties during operative treatment. The closely lying radial nerve is another major concern. The aim of this study was to determine whether anterolateral dual plate fixation could be effective for a distal junctional fracture of the humerus both biomechanically and clinically.

Methods

A right humerus 3-dimensional (3D) model was obtained based on plain radiographs and computed tomography data of patients. Two fractures, a spiral type and a spiral wedge type, were constructed. Three-dimensional models of locking compression plates and screws were constructed using materials provided by the manufacturer. The experiment was conducted by using COMSOL Multiphysics, a finite element analysis, solver, and simulation software package. For the clinical study, from July 2008 to March 2021, a total of 72 patients were included. Their medical records were retrospectively reviewed to obtain patient demographics, elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, Mayo Elbow Performance Scores (MEPS), and hand grip strength.

Results

No fracture fixation construct completely restored stiffness comparable to the intact model in torsion or compression. Combinations of the 7-hole and 5-hole plates and the 8-hole and 6-hole plates showed superior structural stiffness and stress than those with single lateral plates. At least 3 screws (6 cortices) should be inserted into the lateral plate to reduce the load effectively. For the anterior plate, it was sufficient to purchase only the near cortex. Regarding clinical results of the surgery, the range of motion showed satisfactory results in elbow flexion, elbow extension, and forearm rotation. The average DASH score was 4.3 and the average MEPS was 88.2.

Conclusions

Anterolateral dual plate fixation was biomechanically superior to the single-plate method in the finite element analysis of a distal junctional fracture of the humerus model. Anterolateral dual plate fixation was also clinically effective in a large cohort of patients with distal junctional fractures of the humerus.

The comparison of functional bracing of humeral shaft fractures: thermoplastic custom against preprepared commercial braces

BACKGROUND

Functional humeral bracing of midshaft humeral fractures has been widely accepted as a gold standard for nonoperative treatment. Despite reported high union rates, there is no proven superiority of any orthosis. Here we aim to compare the outcomes after the use of custom-made thermoplastic vs. commercial humeral brace with regard to time to union, nonunion rates, types of nonunion, and conversion to surgery.

METHODS

Patients with humeral fractures treated between 2018 and 2021 were identified retrospectively by electronic records. Only diaphyseal humerus fractures (AO 12) were included in the study. Proximal (AO 11) or distal (AO 13) fractures, open fractures, pathologic fractures, bilateral fractures, multiple fractures, and patients lost to follow-up were excluded. Patients attending one center received a custom-made thermoplastic splint, whereas those at the other center had an off-the-shelf humeral brace applied. Radiologic union was defined as healing of at least 3 of 4 cortices determined from follow-up radiographs. Data calculations were performed using the χ2 test.

RESULTS

A total of 53 patients treated with a thermoplastic brace and 43 with a commercial brace were identified. A total of 52 men were included, and the cohort's mean age was 60.1 years (standard deviation: 16.1 years). Both groups had similar gender and age distributions. More patients achieved union with a thermoplastic brace (79.2%) than those with a commercial brace (76.7%), which was statistically significant (χ2, P = .04). Although time to union was similar both clinically and radiologically, patients with a commercial brace converted to surgical treatment more frequently (11 vs. 14 cases).

CONCLUSION

Thermoplastic custom-made braces provide better fracture stability, allowing for statistically significantly higher rates of fracture union during a similar treatment period to commercially available splints. Patients wearing a commercial splint were significantly more likely to develop hypertrophic nonunion requiring surgery.

Operative versus non-operative treatment of extra-articular distal humeral shaft fractures: a retrospective comparative study evaluating clinical and radiological outcomes

PURPOSE

There is limited evidence for comparing operative and non-operative management of closed, extra-articular distal humeral shaft fractures. This study aims to evaluate these outcomes.

METHODS

A comparative retrospective study was performed for patients who underwent either operative fixation or conservative management with a humeral brace, with clinical and radiological outcomes at minimum 2-year follow-up.

RESULTS

Forty-two patients with median 4.6 years follow-up were included; 24 had surgical fixation and 18 were managed with humeral brace. Assessment of clinical and radiological outcomes demonstrated few statistically significant functional differences between the two groups. Surgical patients achieved faster union for non-comminuted fractures. All patients maintained functional range of motion, with similar complication rates.

CONCLUSION

This study suggests that similar outcomes can be achieved with both managements, though faster union times may be seen in the operative group. Further studies are recommended to evaluate the impact of fracture comminution causing delayed unions.

Outcomes of the Treatment of Humeral Shaft Fractures by Closed Reduction and Internal Fixation With Multiple Intramedullary Kirschner Wires (K-wires)

Background Humeral shaft fractures are common orthopedic injuries, and their treatment options vary based on fracture characteristics. One surgical method involves closed reduction and internal fixation (CRIF) with multiple intramedullary (IM) Kirschner wires (K-wires), which remains less explored, especially in adults. This study aims to investigate the outcomes of the treatment of humeral shaft fractures by closed reduction and internal fixation with multiple flexible intramedullary K-wires. Materials and methods We conducted a retrospective study at King Abdulaziz Medical City, Riyadh, Saudi Arabia, focusing on patients with traumatic humeral shaft fractures who underwent flexible intramedullary K-wire fixation. We analyzed nine patient records for demographic information, fracture location, type, mechanism of injury, intra-operative and post-operative factors, and complications. Results Fractures mostly affected the middle third of the humerus (55.6%) and were primarily transverse or oblique (77.8%). Motor vehicle accidents were the leading cause of injury (66.7%). Intra-operative time was 125 minutes on average, with minimal blood loss (78 mL). No participants required intra-operative blood transfusion. Complications following IM K-wire fixation were absent in all cases. Three patients had not yet undergone instrumental removal, and most reported mild or no pain during the final follow-up. All participants achieved a full range of motion for their elbows. All participants achieved complete radiological and clinical union (healing) of their fractures. Conclusion The use of multiple intramedullary K-wires for the treatment of humeral shaft fractures in this study demonstrated positive outcomes with low complication rates. This approach provides an effective option for managing these fractures, particularly in cases where surgical indications favor it.

Humerus fractures: selecting fixation for a successful outcome

Current evidence suggests at least one-third of humeral shaft fractures initially managed nonoperatively will fail closed treatment, and this review highlights surgical considerations in those circumstances. Although operative indications are well-defined, certain fracture patterns and patient cohorts are at greater risk of failure. When operative intervention is necessary, internal fixation through an anterolateral approach is a safe and sensible alternative. Determining which patients will benefit most involves shared decision-making and careful patient selection. The fracture characteristics, bone quality, and adequacy of the reduction need to be carefully evaluated for the specific operative risks for individuals with certain comorbid conditions, inevitably balancing the patient's expectations and demands against the probability of infection, nerve injury, or nonunion. As our understanding of the etiology and risk of nonunion and symptomatic malunion of the humeral diaphysis matures, adhering to the principles of diagnosis and treatment becomes increasingly important. In the event of nonunion, respect for the various contributing biological and mechanical factors enhances the likelihood that all aspects will be addressed successfully through a comprehensive solution. This review further explores specific strategies to definitively restore function of the upper extremity with the ultimate objective of an uninfected, stable union.

Comparison of Posterior and Anterolateral Surgical Approaches in Treating Adult Humeral Shaft Fractures

AIM

The purpose of this study is to compare the outcomes and complications of two different surgical approaches, the anterolateral and posterior approaches, for treating humeral shaft fractures.

MATERIALS AND METHODS

 Between January 2015 and May 2021, 51 patients with humeral shaft fractures were treated with anterolateral and posterior approaches. Twenty-nine patients were operated with the posterior approach (group 1) and 22 with the anterolateral approach (group 2). Statistical analyses were performed between the two groups regarding age, gender distribution, fractured side, body mass index (BMI), type of trauma, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) classification, and follow-up time. Complications such as operative time, amount of bleeding, incision length and implant fracture, radial nerve palsy, wound infection, and nonunion were compared between the two groups. Functional results of the elbow joint were evaluated with the Mayo Elbow Performance Score.

RESULTS

 The mean follow-up period was 49.10±21.15 months (12-75 months) in group 1 and 50.00±23.71 months (range: 15-70 months) in group 2. There was no statistical difference between the groups in terms of age, gender distribution, fractured side, BMI, trauma type, AO/OTA classification, and follow-up time (p>0.05). There was no significant difference between the two groups in terms of operation time, intraoperative bleeding, and incision length (p>0.05). The mean Mayo Elbow Performance Score was 77.24±20.03 (range: 70-100 points) in group 1 and 81.36±8.34 (range: 70-100 points) in group 2, and no significant difference was found (p>0.05). When evaluated in terms of complications, there was no significant difference between the groups (p>0.05). While there was no significant difference between the two groups regarding elbow joint range of motion, the limitation was observed in more patients in group 1.

CONCLUSION

 Similar satisfactory treatment results were obtained in patients who underwent anterolateral and posterior approaches in treating humeral shaft fractures. Furthermore, no difference was found between the two approaches regarding complication rates.

Humeral shaft fracture: systematic review of non-operative and operative treatment

INTRODUCTION

Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome.

METHODS

Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc.

RESULTS

A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group.

CONCLUSION

This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.

Use of patient reported experience measure and patient reported outcome measures to evaluate differences in surgical or non-surgical management of humeral shaft fractures

Background

The aim of this study was to evaluate the use of patient reported experience measures (PREMs) in humeral shaft fractures managed with or without surgery against patient reported outcome measures (PROMs).

Methods

Adult patients treated for a humeral shaft fracture between June 2015 and August 2017 were included in non-surgery and surgery (early and late surgery) groups. The PREM questionnaire was based on patient and clinician feedback obtained during focus groups and was posted to patients. PROMs included the short form-12 (SF-12) and visual analogue scale (VAS) for pain, stiffness, function and satisfaction.

Results

Eighty-one patients responded, 54 patients were treated in a brace and 27 with surgery (13 early, 14 late). There was moderate positive correlation between PREM and VAS satisfaction and function and moderate negative correlation with VAS pain and stiffness. There was also moderate positive correlation between PREM and SF-12 mental and weak positive correlation with SF-12 physical. The late surgery group had poorer PREMs (expectations, p = 0.002 and friends & family test, p = 0.0001) and PROMs (VAS satisfaction, p = 0.005) compared to the early surgery group.

Conclusions

PREMs can be used in conjunction with PROMs to improve the patient's quality of care and as a means of identifying, at an early stage, those patients not doing well and to offer surgery.

Fixation of Proximal Third Humeral Shaft Fractures in Older Patients

Background

Humeral shaft fractures occur frequently in older patients. The more proximal end of the shaft is prone to non-union when compared with more distal fractures. We provide an overview of several key features of this significant patient group.

Method

Our institutional fracture database was searched for all cases of proximal third humeral shaft fractures in patients over 60 years of age. Retrospective evaluation of patient demographics, management, length of stay and incidence of non-union was performed.

Results

75 patients (61 female) were analysed. 33 patients were 'frail' (Clinical Frailty Scores of >4). Non-union occurred in 19 of 45 non-surgically treated fractures and in 1 of 37 cases treated surgically. Mean length of stay was 5.9 days (non-operative) and 6.6 days (operative). Proximal extension into the humeral head is common.

Conclusion

Non-surgical management of proximal third humeral shaft fractures is associated with an increased risk of non-union. We detail an operative technique and case example supporting early fixation of displaced proximal third humeral shaft fractures in older patients that can be utilized for both primary and delayed fixation. In view of the significant association of non-union a well-constructed prospective cohort study with outcome assessment would be of value to further characterize this emerging injury population.Level of Evidence: Level IV, retrospective case series.

Rethinking Conservative Treatment of Humeral Diaphyseal Fractures in Elderly Patients With Dementia

OBJECTIVES

To assess outcomes and complications of conservatively managed humeral diaphyseal fractures in elderly patients, with an emphasis on the subgroup diagnosed with dementia.

DESIGN

Retrospective.

SETTING

Upper extremity surgery unit at an academic Level I trauma center.

PATIENTS/PARTICIPANTS

Consecutive patients 65 years of age and older who were managed conservatively for humeral diaphyseal fractures between 2007 and 2015.

INTERVENTION

Conservatively managed humeral diaphyseal fractures.

MAIN OUTCOME MEASUREMENTS

Complications and radiographic outcomes.

RESULTS

One-hundred twenty-four patients who were conservatively managed for humeral diaphyseal fractures were identified. Their mean age was 77 (65-92) years, 36 (30%) of them were male and 88 (70%) were female. Fifty-seven (46%) patients experienced complications associated with their treatment, and 33 (27%) patients were eventually treated surgically. Seventeen (14%) patients were diagnosed with dementia. This subgroup had 64% fracture-related complications, and all of them were operated (P-value <0.01 compared with age-matched patients among the other 107 participants in the study).

CONCLUSION

Conservative management of humeral diaphyseal fractures seems to be associated with greater morbidity in elderly patients, especially in those diagnosed with dementia. Therefore, early surgical treatment should be considered.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The devastating effects of humeral nonunion on health-related quality of life

BACKGROUND

Humeral nonunion is estimated to occur at a rate of 1.1%-25% depending on the fracture location and pattern, mechanism of injury, patient compliance with the immobilization protocol and patient's nutritional status and medical comorbidities. Fracture nonunion can cause chronic pain and limited range of motion and may hinder normal function. There is very little data from the patients' perspective regarding their experience with a humeral nonunion. The aim of this study was to establish health-related quality of life (HRQoL) norms for patients diagnosed with a humeral nonunion.

MATERIALS AND METHODS

We reviewed a prospectively collected database of 185 humeral nonunions seen and treated at our quaternary referral center. We recorded patient characteristics including sex, age, history of infection, previous surgery, associated nerve palsy, handedness, and the anatomic location of the nonunion. At initial clinical evaluation, all patients were asked to complete the 12-Item Short Form Health Survey (SF-12), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Brief Pain Inventory (BPI), and a time trade-off questionnaire. These scores were compared to other well-known chronic medical conditions' HRQoL scores.

RESULTS

The cohort reported an average utility score of 0.55 ± 0.35, average SF-12 Physical Component Summary score of 30.2 ± 7.6, average SF-12 Mental Component Summary score of 42.5 ± 6.1, and average raw DASH score of 69 ± 21, which was worse than the general US population, patients with asthma, hypertension, stroke, type 2 diabetes, and AIDS. Patients with humeral nonunion are willing to trade 45% of their remaining life to obtain perfect health, and when stratified by handedness, we found that patients with a humeral nonunion of their dominant arm were willing to trade 49.7% compared with 39.7% in patients with a humeral nonunion of their nondominant arm (P = .04).

DISCUSSION

The results of our study show that humeral nonunion is a chronic medical condition that has a debilitating effect on patients, both physically and mentally. It is important for orthopedic surgeons to acknowledge these conditions as physically and mentally debilitating to their patients. Our study highlights these physical and mental burdens and helps to quantify humeral nonunion in relation to more well-known chronic conditions, such as asthma, diabetes, AIDS, and stroke.

CONCLUSIONS

Humeral nonunions have a devastating effect on a patient's physical and mental health with HRQoL measures lower than patients with other chronic conditions, such as asthma, diabetes, AIDS, and stroke. We found that our patients, on average, would trade approximately 45% of their remaining life span for perfect health.

Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management

BACKGROUND

Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated.

METHODS

A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated.

RESULTS

Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses.

CONCLUSIONS

Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

Radiographic Scoring of Humeral Shaft Fractures Helps Identify Patients at Risk of Surgery for Delayed Union

OBJECTIVES

Assessing external validity and clinical relevance of modified radiographic union score (mRUS) to predict delayed union in closed humeral shaft fractures initially treated with conservative management.

DESIGN

Retrospective cohort.

SETTING

Single urban academic level 1 trauma center.

PATIENTS

Patients undergoing initial nonoperative treatment of a humeral shaft fracture with a minimum of 3 months follow-up and at least one set of follow-up orthogonal x-rays within 12-weeks of injury.

MAIN OUTCOME MEASUREMENTS

Interobserver and intraobserver reliability of the (mRUS) system for humeral shaft fractures, and establishing an mRUS threshold at 6 and 12 weeks postinjury to predict surgery for delayed union.

RESULTS

mRUS demonstrated substantial interobserver agreement on all assessments. Intraobserver agreement was nearly perfect for all reviewers on repeat assessment. mRUS of ≤7 at 6 ± 1 weeks follow-up was associated with surgery for delayed union with an odds ratio of 4.88 (95% CI, 2.52-9.44, P < 0.01), sensitivity of 0.286, and specificity of 0.924. At 12 ± 1 weeks follow-up, the same threshold demonstrated a stronger association with an odds ratio of 14.7 (95% CI, 4.9-44.1, P < 0.01), sensitivity of 0.225, and specificity of 0.981.

CONCLUSIONS

The mRUS for humeral shaft fractures is reliable and reproducible providing an objective way to track subtle changes in radiographs over time. An mRUS of ≤7 at 6 or 12 weeks postinjury is highly specific for delayed union. This can be helpful when counseling patients about the risk of nonunion and potential early surgical intervention.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Minimal invasive percutaneous plate osteosynthesis (MIPPO) in humeral shaft fractures

Purpose: We aimed to evaluate the radiological and functional results of humeral shaft fractures treated with minimally invasive percutaneous plate osteosynthesis (MIPPO) in our clinic. Materials and Methods: Data of 21 humeral shaft fractures of 20 patients treated with MIPPO were evaluated retrospectively. Demographic data, type of injury, fracture classification according to AO classification and fracture location, smoking, radial nerve injury were recorded. Radiographically, the union at 6th month and alignment were evaluated. Objective results were evaluated in terms of shoulder and elbow range of motion. Subjective results were assessed by the American Shoulder and Elbow Society Score (ASES), University of California, Los Angles (UCLA) score, Mayo Elbow Performance Index (MEPI), the Disability of The Arm, Shoulder and Hand (DASH) Score and Constant Shoulder Score. Results: The average elbow motion was 131.4° ± 19.8°. The mean ASES and UCLA scores were 88.5 ± 16.4 and 32.1 ± 5.2, respectively. The mean MEPI and DASH scores were 93.1 ± 11.3 and 11.8 ± 20.0, respectively, and the Constant score was mean 9.1 ± 15.3. Nonunion was observed in two patient at 6th month. Conclusion: We believe that MIPPO is a successful technique for the treatment of humeral shaft fractures with minimal soft tissue damage, intact shoulder and elbow motion function.

Surgical versus non-surgical treatment of humeral SHAFT fractures compared by a patient-reported outcome: the Scandinavian Humeral diAphyseal Fracture Trial (SHAFT)-a study protocol for a pragmatic randomized controlled trial

BACKGROUND

The outcome of non-surgical treatment is generally good, but the treatment course can be long and painful with approximately a quarter of the patients acquiring a nonunion. Both surgical and non-surgical treatment can have disabling consequences such as nerve injury, infection, and nonunion. The purpose of the study is to compare patient-reported outcomes after surgical and non-surgical treatment for humeral shaft fractures.

METHODS

A pragmatic randomized controlled trial (RCT) is planned with two study groups (SHAFT-Young and SHAFT-Elderly). A total of 287 eligible acute humeral shaft fractures are scheduled to be recruited and randomly allocated to surgical or non-surgical treatment with the option of early crossover due to delayed union. The surgical method within the allocation is decided by the surgeon. The primary outcome is the Disability of Arm, Shoulder, and Hand (DASH) score at 52 weeks, and is assessor blinded. The secondary outcomes are DASH score, EQ-5D-5L, pain assessed by visual analog score, Constant-Murley score including elbow range of motion, and anchor questions collected at all timepoints throughout the trial. All complications will be reported including; infection, nerve or vascular injury, surgical revisions (implant malpositioning, hardware failure, aseptic loosening, and peri-implant fracture), major adverse cardiovascular events, and mortality.

DISCUSSION

The SHAFT trial is a pragmatic multicenter RCT, that will compare the effectiveness of the main strategies in humeral shaft fracture treatment. This will include a variety of fracture morphologies, while taking the dilemmas within the population into account by splitting the population by age and providing the orthopedic society with an interval for early crossover surgery.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04574336 . Registered on 5 October 2020.

Factors Associated with Patient-Reported Outcomes Following a Humeral Shaft Fracture: Nonunion Results in a Poorer Outcome Despite Union after Surgical Fixation

OBJECTIVES

The primary aim was to assess patient-reported outcomes ≥1 year following a humeral diaphyseal fracture. The secondary aim was to compare outcomes of patients who united after initial management (operative/nonoperative) with those who united after nonunion fixation (NU-ORIF).

DESIGN

Retrospective.

SETTING

University teaching hospital.

PATIENTS AND INTERVENTION

From 2008 to 2017, 291 patients [mean age, 55 years (17-86 years), 58% (n = 168/291) female] were available to complete an outcomes survey. Sixty-four (22%) were initially managed operatively and 227 (78%) nonoperatively. After initial management, 227 (78%) united (n = 62 operative, n = 165 nonoperative), 2 had a delayed union (both nonoperative), and 62 (21%) had a nonunion (n = 2 operative, n = 60 nonoperative). Fifty-two patients (93%, n = 52/56) united after NU-ORIF.

MAIN OUTCOME MEASURES

QuickDASH, EuroQol-5 Dimension (EQ-5D)/EuroQol-Visual Analogue Scale (EQ-VAS), 12-item Short Form Physical (PCS) and Mental Component Summary (MCS).

RESULTS

At a mean of 5.5 years (range, 1.2-11.0 years) postinjury, the mean QuickDASH was 20.8, EQ-5D was 0.730, EQ-VAS was 74, PCS was 44.8 and MCS was 50.2. Patients who united after NU-ORIF reported worse function (QuickDASH, 27.9 vs. 17.6; P = 0.003) and health-related quality of life (HRQoL; EQ-5D, 0.639 vs. 0.766; P = 0.008; EQ-VAS, 66 vs. 76; P = 0.036; PCS, 41.8 vs. 46.1; P = 0.036) than those who united primarily. Adjusting for confounders, union after NU-ORIF was independently associated with a poorer QuickDASH (difference, 8.1; P = 0.019) and EQ-5D (difference, -0.102; P = 0.028).

CONCLUSIONS

Humeral diaphyseal union after NU-ORIF resulted in poorer patient-reported outcomes compared with union after initial management. Targeting early operative intervention to at-risk patients may mitigate the potential impact of nonunion on longer-term outcome.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Non operative management of fractures of the humerus Evaluation of a new extension casting method

Fractures of the humeral shaft represent 2-4% of all fractures and functional bracing is the gold standard in conservative management. Complications like restricted shoulder range of motion and malunion of the proximal shaft fractures have however been reported. We conducted a retrospective chart re- view of patients treated with the extension casting method over a period of 16 years. Topographically, Garnavos P, M, D, PM and MD fractures and morphologically Simple, Complex and Intermediate fractures were included. Between 2003 and 2019, 74 patients were treated with extension casting. The fractures united at a mean of 10 weeks and there was no case of non-union. Humerus is one of the bones where conservative methodology is still very pertinent. Extension casting gives reproducible and good results. It also addresses patient comfort issues to a considerable extent by allowing shoulder motion and easier maintenance of personal hygiene.

Humeral Shaft Fractures: A Literature Review on Current Treatment Methods

In this review, we aim to provide a concise yet comprehensive summation of the assessment and management of humeral shaft fractures. These are uncommon but prevalent enough that they are part of any trauma surgeon's scope of practice. They have historically been treated using non-operative methods, including braces and casts, supported by published excellent results in the rate of the bone union. However, recently published studies challenge these results and suggest the outcomes might be better with surgery, but the complications of an operation such as infection and nerve injury can not be overlooked. In summary, non-surgical treatment is still the gold standard in the treatment of these fractures, but the indications for surgical management are now clearer and include early signs of delayed union and patients who are unable to have a brace fitted or are uncompliant. It is likely that these new developments will start to change practice, and therefore the treatment of humeral shaft fractures should be a topic of interest of any clinician who deals with them.

Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study

Purpose

The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery.

Methods

From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type.

Results

Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001).

Conclusion

Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group.

Trial registration

NTR3617 (registration date 18-SEP-2012).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01890-6.

Approach to Humeral Shaft Nonunion: Evaluation and Surgical Techniques

Humeral shaft fractures account for 1% to 3% of all fractures. Traditional nonsurgical treatment with a functional brace is still the standard treatment of these fractures; however, modern studies have reported that nonunion rates may be as high as 33%. Recent information suggests that the development of nonunion after nonsurgical treatment may be identified as early as 6 to 8 weeks postinjury. Even with surgical treatment, nonunion rates as high as 10% have been reported. Regardless of the original treatment method, nonunion results in poor quality of life for the patient and therefore should be addressed. A thorough preoperative evaluation is important to identify any metabolic or infectious factors that may contribute to the nonunion. In most cases, surgical intervention should consist of compression plating with or without bone graft. Although most patients will achieve union with standard surgical intervention, some patients may require specialized techniques such as cortical struts or vascularized fibular grafts. Successful treatment of humeral shaft nonunion improves function, reduces disability, and improves the quality of life for patients. In this article, we outline our approach to the treatment of humeral shaft nonunion in a variety of clinical settings.

Atrophic pseudarthrosis of humeral diaphyseal fractures: medico-legal implications and methodological analysis of the evaluation

Humeral shaft fractures account for 1- 3% of all fractures and about 20-27% of those involving the humerus. In the past they were often conservatively treated, with an acceptable consolidation rate. Open reduction and internal fixation (ORIF) is the best choice in polytrauma patients, in complex or pathological fractures and in those associated with vascular injuries. Regardless the type of fixation used, these fractures can evolve into delayed union or pseudarthrosis (PSA). It should be noted that the humeral shaft itself has a high intrinsic healing potential, due to the blood supply provided by the surrounding muscles. The aim of this work is to evaluate whether the causes that led to the development of atrophic pseudarthrosis in a humeral diaphyseal fracture are attributable to inadequate management of this fearful complication and to highlight the possible medico-legal repercussions. We will try to verify whether the currently used forensic evaluation parameters of permanent disability are appropriate and adequate in relation to the complexity of such injuries. This complexity also includes the repercussions on the ergonomic efficiency of the entire limb, the relative possible postural alterations, the inevitable extension of the period of traumatic illness and the relative repercussions on the overall compromised structure of the subject.

Predicting the Behavior of Humeral Shaft Fractures: An Independent Validation Study of the Radiographic Union Score for HUmeral Fractures and Value of Assessing Fracture Mobility

OBJECTIVES

To externally validate the Radiographic Union Score for HUmeral fractures (RUSHU) and to quantify the predictive relationship of fracture motion on physical examination to nonunion.

DESIGN

Retrospective cohort study.

SETTING

Single institutional center (University teaching hospital).

PATIENTS

Ninety-two consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified over a 4-year period. The average age of the population was 62 years and 42% of the cohort was men.

INTERVENTION

Clinical examination for fracture stability was routinely performed on patients by the treating physicians. Radiographic assessment of fracture callus (RUSHU score) at 6 weeks was retrospectively determined. Patients were followed up until union.

MAIN OUTCOME MEASUREMENTS

Stability was graded as motion at the fracture site or the humerus moving as a single functional unit.

RESULTS

Fractures with a RUSHU score ≤7 were 14 times more likely to proceed to nonunion at 6 months (78% sensitivity, 80% specificity). The time to union was 49 weeks for a RUSHU score of ≤7 versus 16 weeks for a RUSHU score of ≥8. The number of operations needed to avoid one nonunion was 1.7. Fractures mobile at 6 weeks were 6.5 times more likely to proceed to nonunion at 6 months (77% specificity, 67% sensitivity). Mobile fractures had a longer time to union (41 weeks) than nonmobile fractures (17 weeks).

CONCLUSION

The RUSHU score and clinical assessment of fracture mobility are effective and valid tools in identifying patients at risk of developing nonunion of humeral shaft fractures and can enhance early decision making in fracture management.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Factors associated with humeral shaft nonunion

BACKGROUND

The primary aim was to identify patient and injury factors independently associated with humeral diaphyseal fracture nonunion after nonoperative management. The secondary aim was to determine the effect of management (operative/nonoperative) on nonunion.

METHODS

From 2008-2017, a total of 734 humeral shaft fractures (732 consecutive skeletally mature patients) were retrospectively identified from a trauma database. Follow-up was available for 663 fractures (662 patients, 90%) that formed the study cohort. Patient and injury characteristics were recorded. There were 523 patients (79%) managed nonoperatively and 139 (21%) managed operatively. Outcome (union/nonunion) was determined from medical records and radiographs.

RESULTS

The median age at injury was 57 (range 16-96) years and 54% (n = 359/662) were female. Median follow-up was 5 (1.2-74) months. Nonunion occurred in 22.7% (n = 119/524) of nonoperatively managed injuries. Multivariate analysis demonstrated preinjury nonsteroidal anti-inflammatory drugs (NSAIDs; odds ratio [OR] 20.58, 95% confidence interval [CI] 2.12-199.48; P = .009) and glenohumeral arthritis (OR 2.44, 95% CI 1.03-5.77; P = .043) were independently associated with an increased risk of nonunion. Operative fixation was independently associated with a lower risk of nonunion (2.9%, n = 4/139) compared with nonoperative management (OR for nonoperative/operative management 9.91, 95% CI 3.25-30.23; P < .001). Based on these findings, 5 patients would need to undergo primary operative fixation in order to avoid 1 nonunion.

CONCLUSIONS

Preinjury NSAIDs and glenohumeral arthritis were independently associated with nonunion following nonoperative management of a humeral diaphyseal fracture. Operative fixation was the independent factor most strongly associated with a lower risk of nonunion. Targeting early operative fixation to at-risk patients may reduce the rate of nonunion and the morbidity associated with delayed definitive management.

Outcomes With Surgery vs Functional Bracing for Patients With Closed, Displaced Humeral Shaft Fractures and the Need for Secondary Surgery: A Prespecified Secondary Analysis of the FISH Randomized Clinical Trial

IMPORTANCE

Existing evidence indicates that surgery fails to provide superior functional outcome over nonoperative care in patients with a closed humeral shaft fracture. However, up to one-third of patients treated nonoperatively may require secondary surgery.

OBJECTIVE

To compare the 2-year outcomes of patients who required secondary surgery with the outcomes of patients with successful initial treatment.

DESIGN, SETTING, AND PARTICIPANTS

This 2-year follow-up of the Finnish Shaft of the Humerus (FISH) randomized clinical trial comparing surgery with nonoperative treatment (functional brace) was completed in January 2020. Enrollment in the original trial was between November 2012 and January 2018 at 2 university hospital trauma centers in Finland. A total of 321 adult patients with closed, displaced humeral shaft fracture were assessed for eligibility. After excluding patients with cognitive disabilities, multimorbidity, or multiple trauma and those refusing randomization, 82 patients were randomized.

INTERVENTIONS

Interventions were surgery with plate fixation (n = 38; initial surgery group) or functional bracing (n = 44); the latter group was divided into the successful fracture healing group (n = 30; bracing group) and the secondary surgery group (n = 14) with fracture healing problems.

MAIN OUTCOMES AND MEASURES

The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 2 years (range, 0 to 100 points; 0 denotes no disability, 100 extreme disability; minimal clinically important difference, 10 points).

RESULTS

Of 82 randomized patients, 38 (46%) were female. The mean (SD) age was 48.9 (17.1) years. A total of 74 patients (90%) completed the 2-year follow-up. At 2 years, the mean DASH score was 6.8 (95% CI, 2.3 to 11.4) in the initial surgery group, 6.0 (95% CI, 1.0 to 11.0) in the bracing group, and 17.5 (95% CI, 10.5 to 24.5) in the secondary surgery group. The between-group difference was -10.7 points (95% CI, -19.1 to -2.3; P = .01) between the initial and secondary surgery groups and -11.5 points (95% CI, -20.1 to -2.9; P = .009) between the bracing group and secondary surgery group.

CONCLUSIONS AND RELEVANCE

Patients contemplating treatment for closed humeral shaft fracture should be informed that two-thirds of patients treated with functional bracing may heal successfully while one-third may experience fracture healing problems that require secondary surgery and lead to inferior functional outcomes 2 years after the injury.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01719887.

Locking compression plate fixation in humeral shaft fractures: A comparative study to literature conservative treatment

INTRODUCTION

Humeral shaft fractures represent about 3% of all fractures. While there are several treatment options for this type of fractures, there is no evidence in literature showing which is the best one. This study aims at analysing the outcomes for patients with humeral shaft fractures treated with Locking Compression Plate (LCP) fixation in our hospital and comparing them with the outcome for patients conservatively treated (according to data from Pubmed),in order to determine the best treatment option.

MATERIALS AND METHODS

We treated surgically 220 humeral shaft fractures in our department from February 2005 to March 2012. Seventy-three of them met all the inclusion criteria for this study. All fractures were then classified according to the AO classification. The follow-up considered the radiographic healing of the fracture. All patients were treated with plate fixation (LCP - DePuySynthes Co). At the end of the four-year follow-up, the function was evaluated by means of the DASH score. A systematic review of the literature of the last 20 years was performed on MEDLINE (PubMed).

RESULTS

We had 2 infections and 8 patients had postoperative nerve palsy which recovered in average time of 6.7 months. In addition, 4 fractures (5.48%) didn't heal within 6 months and they were considered as nonunions and healed after a second surgery. One of these 4 nonunions was infected. The mean DASH score was 18.24±19.18. No malunions were found. We identified 13 studies that were eligible for our systematic review. The mean non-union rate found was 17% in 2517 fractures with a follow-up that ranging from 67% to 100% of patients and a primary radial nerve palsy ranging from 0 to 115 patients. Malalignment rate ranged from 12.7 to 42%.

CONCLUSIONS

After taking into account both the conservative and the surgical treatment, for humeral shaft fractures we suggest the operative treatment, because the patient's function of the upper limb recovers quickly in the immediate postoperative period and the incidence of malunions may be avoided.

The comparison of single plate and double plate fixation methods for treatment of humeral shaft nonunions

Objectives

This study aims to evaluate the early- and mid-term shoulder and elbow functions and compare the union rates after the application of single plate and double plate for the treatment of humerus shaft nonunions.

Patients and methods

This retrospective study included 56 patients (36 males, 20 females; mean age 53.8±9.5; range, 28 to 68 years) treated with double plate (n=25) and single plate (n=31) osteosynthesis between October 2012 and January 2016. Surgical treatment of the nonunion was applied in the fourth month after the fracture at the earliest. Autograft taken from the iliac bone was applied during the surgery in all patients. Evaluation was performed using The University of California at Los Angeles (UCLA) Shoulder Score, Mayo Elbow Performance Score (MEPS), Visual Analog Scale (VAS), Constant Shoulder Score, and Disabilities of the Arm Shoulder and Hand (DASH) questionnaire.

Results

The mean postoperative follow-up time was 40.7±9.6 (range, 25 to 58) months. No statistically significant difference was determined in respect of time to union, follow-up time, DASH questionnaire score, UCLA Shoulder Score, VAS, MEPS and Constant Shoulder Score after union in the comparison of the two groups (p>0.05). In the examination of postoperative early (three months) recovery phase of shoulder and elbow functions, statistically significant superior scores were obtained in the double plate group for MEPS (double plate median=85 [min 75-max 90], single plate median=75 [min 70-max 85]) and Constant Shoulder Score (double plate median=89 [min 85-max 92], single plate median=81 [min 75-max 90]) (p<0.001).

Conclusion

There was no statistically significant difference in terms of time to union and union rates between single plate and double plate fixations for surgical treatment of humeral shaft nonunions. However, superior clinical results were obtained in the early recovery phase of shoulder and elbow functions with double plate fixation.

Humeral shaft fractures

Humeral shaft fractures are relatively common, representing approximately 1% to 5% of all fractures.

Conservative management is the treatment of choice for most humeral shaft fractures and offers functional results and union rates that are not inferior to surgical management.

Age and oblique fractures of the proximal third are risk factors for nonunion. Surgical indication threshold should be lower in patients older than 55 years presenting with this type of fracture.

Functional outcomes and union rates after plating and intramedullary nailing are comparable, but the likelihood of shoulder complications is higher with intramedullary nailing.

There is no advantage to early exploration of the radial nerve even in secondary radial nerve palsy.

Cite this article: EFORT Open Rev 2021;6:24-34. DOI: 10.1302/2058-5241.6.200033

Treatment fracture of the diaphisis humerus with functional plaster

Treatment of humerus fractures is divided into operative and non-operative treatment Fractures of the diaphysis of the humerus heal well. Surgeons today have many opportunities to treat them. The decision on the type of treatment to be applied depends on the location of the fracture, the existence of associated injuries, the age and the general condition of the patient. Non-operative treatment is most often applied, although there are fractures in which surgical intervention is necessary in order to perform healing and prevent complications. Non-operative treatment of fractures of the diaphysis of the humerus gives good results, with little angulation and minimal or no shortening of the arm. Adequate repositioning, appropriate plaster immobilization and regular X-rays heal the fracture within the allotted time. Disciplined early physical therapy in terms of circular movements prevents shoulder contracture and allows later physical therapy to last significantly shorter. Non-operative treatment lasts from 7-11,5 weeks.

Reliability of Radiographic Union Scoring in Humeral Shaft Fractures

OBJECTIVES

To establish the reliability of 2 radiographic union scoring systems for nonoperative humeral shaft fractures.

DESIGN

Retrospective medical record review. Patients identified had humeral shaft fractures and radiographs at various follow-up time points, which were graded according to the both the standard (RUST) and modified radiographic union scoring systems (mRUST).

SETTING

A single North American Level-1 Trauma center in Connecticut, including emergency department and clinic follow-up visits.

PATIENTS/PARTICIPANTS

Forty-five adult patients (162 image sets) met the following inclusion criteria: diaphyseal humerus fracture, initial nonoperative management, and greater than 2 weeks of follow-up with imaging.

INTERVENTION

All 162 image sets of anterior-posterior and lateral radiographs were scored and divided into 4 tiers based on increasing score. Anterior-posterior and lateral image sets were randomly selected from each tier for a total of 50 that were then scored by 7 different reviewers using both the RUST and mRUST systems.

MAIN OUTCOME MEASURES

The intraclass correlation coefficients for the cortical and system scores for the RUST and mRUST systems.

RESULTS

Interobserver reliability was 0.795 for the RUST system and 0.801 for mRUST. Intraobserver reliability was 0.909 for RUST and 0.949 for mRUST. For mRUST, 92% of values were within ± 1 point from each other.

CONCLUSIONS

The RUST and mRUST systems can be applied to humeral shaft fractures with excellent reliability. They have the potential to assist in the diagnosis of humeral shaft union by providing an objective and standardized method to assess healing of bone over time.

Fractures of the proximal- and middle-thirds of the humeral shaft should be considered as fragility fractures

Aims

The aim of this study was to determine the current incidence and epidemiology of humeral diaphyseal fractures. The secondary aim was to explore variation in patient and injury characteristics by fracture location within the humeral diaphysis.

Methods

Over ten years (2008 to 2017), all adult patients (aged ≥ 16 years) sustaining an acute fracture of the humeral diaphysis managed at the study centre were retrospectively identified from a trauma database. Patient age, sex, medical/social background, injury mechanism, fracture classification, and associated injuries were recorded and analyzed.

Results

A total of 900 fractures (typical 88.9%, n = 800/900; pathological 8.3%, n = 75/900; periprosthetic 2.8%, n = 25/900) were identified in 898 patients (mean age 57 years (16 to 97), 55.5% (n = 498/898) female). Overall fracture incidence was 12.6/100,000/year. For patients with a typical fracture (n = 798, mean age 56 years (16 to 96), 55.1% (n = 440/798) female), there was a bimodal distribution in men and unimodal distribution in older women (Type G). A fall from standing was the most common injury mechanism (72.6%, n = 581/800). The majority of fractures involved the middle-third of the diaphysis (47.6%, n = 381/800) followed by the proximal- (30.5%, n = 244/800) and distal-thirds (n = 175/800, 21.9%). In all, 18 injuries (2.3%) were open and a radial nerve palsy occurred in 6.7% (n = 53/795). Fractures involving the proximal- and middle-thirds were more likely to occur in older (p < 0.001), female patients (p < 0.001) with comorbidities (p < 0.001) after a fall from standing (p < 0.001). Proximal-third fractures were also more likely to occur in patients with alcohol excess (p = 0.003) and to be classified as AO-Orthopaedic Trauma Association type B or C injuries (p < 0.001).

Conclusion

This study updates the incidence and epidemiology of humeral diaphyseal fractures. Important differences in patient and injury characteristics were observed based upon fracture location. Injuries involving the proximal- and middle-thirds of the humeral diaphysis should be considered as fragility fractures. Cite this article: Bone Joint J 2020;102-B(11):1475–1483.

Risk factors for nonunion after traumatic humeral shaft fractures in adults

Introduction

Humeral shaft fractures account for 3% of adult fractures. Optimal management remains a topic of debate given variable union rates reported in the literature after surgery or functional bracing. The primary aim was to compare these 2 cohorts of patients and their primary fracture union rates. A secondary aim was to identify predictors of nonunion.

Methods

A retrospective cohort study of 164 adult patients with traumatic humeral shaft fractures was performed. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification. Primary outcomes included rate nonunion, including symptomatic fractures requiring conversion to open reduction and internal fixation (ORIF). Secondary outcomes included rates of complications and secondary procedures.

Results

Ninety-four (57%) patients were treated initially with ORIF. Nonoperative patients were older (47.1 vs. 41.5 years, P = .028) and had more medical comorbidity (62% vs. 43%, P = .017), low-energy trauma (62% vs. 34%, P < .0001), and isolated injuries (74% vs. 32%, P < .0001). All patients with open fractures (23%) were treated with débridement and ORIF, and surgical patients had more nerve injuries on presentation (36% vs. 9%, P < .0001). The overall rate of primary fracture union was 88%, similar after ORIF and nonoperative management (92% vs. 83%, P = .095). Multivariate analysis found alcohol abuse (odds ratio [OR]: 3.4, 95% confidence interval [CI]: 1.0-11.0, P = .046) and deep infection (OR: 19.9, 95% CI: 2.6-150.5, P = .004) to be significant predictors of nonunion. Chronic liver disease demonstrated a trend toward increased risk of nonunion (OR: 4.1, 95% CI: 0.8-20.9, P = .088). Seventeen operative patients (18%) developed 17 postoperative complications: iatrogenic nerve palsy (5%), deep infection (5%), and implant failure (3%), the most common. Reoperation rate was 10%, primarily for revision ORIF (4%).

Conclusion

Patients managed nonoperatively were more often older patients with isolated fractures and more medical comorbidity. Surgical candidates were younger, more often with higher energy injuries, and were frequently with concomitant injury. Primary union occurred in 88%, with a trend toward a higher rate after ORIF. Patients with chronic liver disease and/or alcohol abuse are at greater risk for nonunion, irrespective of treatment.

Locking compression plate fixation versus intramedullary nailing of humeral shaft fractures: which one is better? A single-centre prospective randomized study

PURPOSE

To compare the radiological and clinical outcomes of interlocking nail (ILN) and locking plate fixation (LCP) for humeral shaft fractures.

METHODS

A total of 63 patients with displaced humeral shaft fractures between October 2014 and January 2017 were evaluated prospectively. They were divided randomly into two as LCP fixation (group 1) and interlocking nail (ILN) (group 2). Functional outcomes were evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH), American Shoulder and Elbow Surgeons (ASES), the University of California at Los Angeles (UCLA) shoulder scores, and Short Form-36 (SF-36) questionnaires, and pain was assessed with visual analogue scale (VAS).

RESULTS

After fracture callus was radiologically observed, DASH, ASES, and UCLA scores as well as SF-36 questionnaires and VAS results were noted to have no significant difference between the two groups (p = 0.109, p = 0.082, p = 0.146, p = 0.322, and p = 0.175, respectively). At the last follow-up (post-operative 24 months), the UCLA score was significantly better in group 1 (p = 0.034), whereas VAS result was significantly worse in group 2 (p = 0.017). DASH, ASES scores, and SF-36 questionnaires had no difference (p = 0.193, p = 0.088, p = 0.289). Other parameters revealed no significant differences. Fracture consolidation was observed at a mean of four months in both groups (3 to 7 months in group 1 and 3 to 8 months in group 2) (p = 0.189). Four patients in group 1 and five patients in group 2 underwent surgery for nonunion (p = 0.725). Post-operative radial nerve palsy was seen in one patient in group 2. Two patients in group 1 with superficial infection were treated with antibiotics, and they recovered.

CONCLUSIONS

Regarding our results, the LCP group had significantly better shoulder function than the ILN group, whereas the ILN group had significantly less pain, with similar complication rates. Therefore, both procedures are favourable surgical options for patients with humeral shaft fractures.

Early outcomes of magnetic intramedullary compression nailing for humeral fractures

PURPOSE

The optimal treatment protocol for humeral shaft fractures at risk for nonunions is controversial. Here, we aim to describe magnetic intramedullary compression nailing as an option for these challenging scenarios and to evaluate its clinical and radiographic outcomes.

METHODS

This retrospective case series was performed at an urban university-based level-1 trauma center. Patients aged 18-65 who underwent fixation of their at-risk humerus shaft fracture using the PRECICE nail were included in this investigation. These fractures are characterized by a persistent distraction gap, minimal callous formation, or malalignment greater than 20 degrees. The study data were collected through a retrospective chart review and review of the radiographic studies. Primary outcome measure was radiographic union. Secondary outcome measures included mechanical failure, nonunion, malunion, medical, and surgical complications. Functional outcome was determined by range of motion and restoration of rotator cuff strength.

RESULTS

A total of six patients were included who underwent treatment of their humeral shaft fracture with a NuVasive PRECICE nail after failure of conservative management. After nail placement along with our compression protocol, all patients achieved bony union and experienced favorable outcomes with return to their previous working status. Two complications included a superficial incisional infection treated with antibiotics and a backing out of proximal screw which did not cause discomfort. No other mechanical failures, surgical complications, or medical complications occurred.

CONCLUSIONS

Early results of controlled compression nailing for humeral shaft fracture demonstrated favorable clinical outcomes. This technique may be utilized for these challenging situations.

Comparison of the Posterior and Anterolateral Surgical Approaches in the Treatment of Humeral Mid-Shaft Fractures: A Retrospective Study

Background

The aim of this study was to retrospectively assess and compare the functional outcomes and complications following anterolateral versus posterior surgical approaches for the treatment of mid-shaft fractures of the humerus.

Material/Methods

This study included 107 patients treated for mid-shaft fractures between May 2015 and July 2018. Demographic and surgical data were collected for each patient. During follow-up visits, radiographs were acquired and evaluated. The clinical outcomes of the involved joints were assessed by the Constant scoring system, range of motion (ROM), and the Mayo Elbow Performance Scoring system at the 12-month follow-up.

Results

The posterior approach was performed in 57 patients with type A fractures (group I, n=28) and type B or C fractures (group III, n=29). The anterolateral approach was performed in 50 patients with type A fractures (group II, n=32) and type B or C fractures (group IV, n=18). There were no significant differences between group I and group II nor between group III and group IV with respect to patient demographic data, surgical data, Constant score, ROM, or Mayo Elbow Performance score. A significant difference in the total complication rate was observed between group I and II.

Conclusions

The anterolateral approach showed an advantage over the posterior approach for treating simple humeral mid-shaft fractures. However, this advantage was not observed in treating comminuted fractures.

Effect of Surgery vs Functional Bracing on Functional Outcome Among Patients With Closed Displaced Humeral Shaft Fractures: The FISH Randomized Clinical Trial

IMPORTANCE

Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend.

OBJECTIVE

To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures.

DESIGN, SETTING, AND PARTICIPANTS

Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma.

INTERVENTIONS

Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44).

MAIN OUTCOME AND MEASURE

The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points).

RESULTS

Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy.

CONCLUSIONS AND RELEVANCE

Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01719887.

Evaluation of Clinical and Radiological Results of Humeral Diaphyseal Fractures with Treated Sarmiento Brace

Aim

In our study, we aimed to evaluate the duration and rate of the union of adult humerus diaphysis fractures treated with a functional brace.

Methods

Forty-six adult patients admitted to our hospital with humeral diaphyseal fracture between January 2010 and April 2014 and treated with a functional brace were evaluated retrospectively. The demographic data, fracture type, level of fracture, and presence of bone union of the patients were evaluated from clinic records. The Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire score of the patients was registered for patients and analyzed, and its correlation with parameters such as patient age and fracture bone union time was evaluated.

Results

It was observed that of the patients with the mean age of 45.5 years, six (13.6%) had non-union and five had delayed bone union (10.86%). Three (6.5%) patients had radial nerve injury, and all recovered without sequelae. Out of the patients with the bone union, 12 (30%) had an angulation above give degrees, and 3 (7.5%) had radiological shortness. The mean Quick-DASH score was 6.7, and there was no statistically significant correlation with parameters such as fracture type, level, angulation, radiological shortness and radial nerve involvement (p>0.05).

Conclusions

A functional brace is a good treatment choice with low complication rates and has satisfactory bone union rates in humerus diaphyseal fractures. 

A Case Report of Humeral Nail Breakage after 11 Years Secondary to Shaft Nonunion: Treatment with Autogenous Iliac Crest Bone Graft and Compression Plate

INTRODUCTION

The rate of nonunion of operatively treated fractures of humeral shaft is low. Increased incidence of nonunion is associated with different conditions such as open fractures, bone loss, or fracture gapping. Nonunions after prior intramedullary nailing can be difficult to address, even more with hardware failure. We present the case of a humeral nail breakage 11 years after implantation, secondary to nonunion.

CASE REPORT

A 33-year-old man referred to our hospital with oligotrophic nonunion of the middle humeral diaphysis and nail breakage after 11 years from the first fracture. We decided then to schedule a one-stage surgical procedure of nail removal and new osteosynthesis with autogenous iliac crest bone graft.

CONCLUSIONS

The patient presented good clinical evolution, without functional limitation or pain. Bone graft union was radiologically confirmed at final follow-up. To the best of our knowledge, this is the first case of non-traumatic nail breakage in a humeral shaft nonunion after such a long period of time. In this case, we found that a one-stage surgical procedure with nail removal and locking compression plate fixation associated with tricortical autogenous iliac crest bone grafting after long-standing humeral shaft nonunion is favorable.

Open reduction and internal fixation of humeral midshaft fractures: anterior versus posterior plate fixation

Background

Fractures of the humeral shaft represent 2–4% of all fractures. Fractures of the humerus have traditionally been approached posteriorly for open reduction and internal fixation. Reports of treating midshaft fractures with an open anterolateral approach and anterior plating are limited. The purpose of this study was to evaluate a series of humeral shaft fractures treated with plate osteosynthesis regarding the effect of the approach and plate location on the healing rate and occurrence of complications.

Methods

We conducted a retrospective chart review of patients aged over 18 years with humeral midshaft fractures treated with anterior or posterior plate fixation. Selection of the approach to the humerus was based on the particular pattern of injury and soft tissue involvement. The minimum follow-up duration was set at six months. The outcomes included the rate of union, primary nerve palsy recovery, secondary nerve damage, infection and revision surgery.

Results

Between 2006 and 2014, 58 patients (mean age, 59.9; range, 19–97 years) with humeral midshaft fractures were treated with anterior (n = 33) or posterior (n = 25) plate fixation. After a mean follow-up duration of 34 months, 57 of 58 fractures achieved union after index procedure. Twelve fractures were associated with primary radial nerve palsy. Ten of the twelve patients with primary radial palsy recovered completely within six months after the index surgery. In total, one patient developed secondary palsy after anterior plating, and three patients developed secondary palsy after posterior plating. No significant difference in the healing rate (p = 0.4), primary nerve palsy recovery rate (p = 0.6) or prevalence of secondary nerve palsy (p = 0.4) was found between the two clinical groups. No cases of infection after plate fixation were documented.

Conclusions

Open reduction and internal fixation using an anterior approach with plate fixation provides a safe alternative to posterior plating in the treatment of humeral shaft fractures. An anterior approach allows supine positioning of the patient and yields union and complication rates comparable to those of a posterior approach with plate fixation for the treatment of humeral shaft fractures.

The Radiographic Union Score for HUmeral fractures (RUSHU) predicts humeral shaft nonunion

AIMS

The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury.

PATIENTS AND METHODS

Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers.

RESULTS

After refinement, the interobserver intraclass correlation coefficient (ICC) was 0.79 (95% confidence interval (CI) 0.67 to 0.87), indicating substantial agreement. At six weeks after injury, patients whose fractures united had a significantly higher median score than those who developed nonunion (10 vs 7; p < 0.001). A receiver operating characteristic curve determined that a RUSHU cut-off of < 8 was predictive of nonunion (area under the curve = 0.84, 95% CI 0.74 to 0.94). The sensitivity was 75% and specificity 80% with a positive predictive value (PPV) of 65% and a negative predictive value of 86%. Patients with a RUSHU < 8 (n = 23) were more likely to develop nonunion than those with a RUSHU ≥ 8 (n = 37, odds ratio 12.0, 95% CI 3.4 to 42.9). Based on a PPV of 65%, if all patients with a RUSHU < 8 underwent fixation, the number of procedures needed to avoid one nonunion would be 1.5.

CONCLUSION

The RUSHU is reliable and effective in identifying patients at risk of nonunion of a humeral shaft fracture at six weeks after injury. This tool requires external validation but could potentially reduce the morbidity associated with delayed treatment of an established nonunion. Cite this article: Bone Joint J 2019;101-B:1300-1306.

Humeral shaft fracture: a randomized controlled trial of nonoperative versus operative management (plate fixation)

Purpose

This randomized controlled trial was conducted to investigate the outcomes of humeral shaft–fracture management with the functional Sarmiento brace (nonoperative) versus open reduction internal fixation (ORIF).

Methods

Sixty humeral shaft–fracture patients with a minimum age of 18 years were randomly assigned into two groups: operative treatment with open reduction–internal fixation (ORIF) or functional brace (Sarmiento). A similar postoperative rehabilitation program was applied for all subjects for the next 12 months. The outcomes of each method were measured in terms of nonunion rate, union time, “quick” Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire scores, and rate of complications, such as malunion, infection, and radial nerve injury.

Results

The two groups had similar baseline characteristics, including age, sex, smoking status, and type and mechanism of fracture. The mean union time was about 4.8 weeks shorter in the ORIF group (13.9 weeks in operative group versus 18.7 weeks in nonoperative group), indicating a definite significant superiority (p=0.001) of ORIF management to functional Sarmiento bracing. However, a comparison of quick DASH scores revealed a borderline-significant difference between the groups (p=0.065). Additionally, we found that treatment of humeral shaft fractures using functional bracing was associated with slightly higher risk of nonunion; however this was not significant (p=0.492).

Conclusion

According to the present findings, there is remarkable superiority of ORIF over functional Sarmiento bracing in the management of patients with humeral shaft fracture.

A prospective randomised controlled trial of operative versus non-operative management of fractures of the humeral diaphysis: the HUmeral Shaft Fracture FIXation (HU-FIX) Study protocol

BACKGROUND

Humeral shaft fractures constitute around 1% of adult fractures in the UK, with an annual incidence of approximately 13 per 100,000 population. Historically, these injuries have been primarily managed non-operatively, with operative fixation reserved for specific indications. Although some recent retrospective studies have suggested there are potential benefits of operative fixation over humeral bracing, there is a deficiency in level 1 evidence to support operative management as the primary treatment for humeral shaft fractures.

METHODS/DESIGN

This single-centre prospective randomised controlled trial aims to recruit 70 adult patients with an isolated closed fracture of the humeral diaphysis into one of two treatment arms: operative (n = 35) or non-operative (n = 35). The operative arm will undergo open reduction and internal fixation (ORIF) of the fracture using a standard fixation technique (plate and screws). The non-operative arm will be fitted with a prefabricated humeral brace until fracture union. All patients will be followed up for 1 year post-intervention. The primary outcome measure will be the Disabilities of the Arm, Shoulder and Hand (DASH) score at 3 months post-intervention. Secondary outcome measures will include pain, treatment complications, return to work or sporting activities, shoulder and elbow range of motion, radiographic assessment, EuroQol (EQ-5D) Health Outcome score and 12-item Short Form (SF-12) Health Survey score. A health economic analysis will be performed to compare the cost implications of each treatment strategy.

DISCUSSION

This randomised controlled trial will provide level 1 evidence comparing a standard ORIF technique against functional bracing for isolated closed humeral shaft fractures. The investigators hope that the study results will assist surgeons in their decision-making when managing patients with these injuries.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03689335 . Registered on 28 September 2018 (retrospectively).

A Case Report of Humeral Nail Breakage after 11 Years Secondary to Shaft Nonunion: Treatment with Autogenous Iliac Crest Bone Graft and Compression Plate

Introduction

The rate of nonunion of operatively treated fractures of humeral shaft is low. Increased incidence of nonunion is associated with different conditions such as open fractures, bone loss, or fracture gapping. Nonunions after prior intramedullary nailing can be difficult to address, even more with hardware failure. We present the case of a humeral nail breakage 11 years after implantation, secondary to nonunion.

Case Report

A 33-year-old man referred to our hospital with oligotrophic nonunion of the middle humeral diaphysis and nail breakage after 11 years from the first fracture. We decided then to schedule a one-stage surgical procedure of nail removal and new osteosynthesis with autogenous iliac crest bone graft.

Conclusions

The patient presented good clinical evolution, without functional limitation or pain. Bone graft union was radiologically confirmed at final follow-up. To the best of our knowledge, this is the first case of non-traumatic nail breakage in a humeral shaft nonunion after such a long period of time. In this case, we found that a one-stage surgical procedure with nail removal and locking compression plate fixation associated with tricortical autogenous iliac crest bone grafting after long-standing humeral shaft nonunion is favorable.

Anterior approach in humeral plating osteosynthesis

CONTEXT

Humeral plating osteosynthesis is controversial, particularly regarding the choice between anterior and lateral approach, data for which in the context of a low-income country are lacking.

HYPOTHESIS

The anterior approach is an easy surgical technique, allowing good anatomic reconstruction. We hypothesize that the anterior approach is associated with fewer neurovascular lesions and functional sequelae than the lateral approach.

MATERIALS AND METHODS

A retrospective study with assessment update was carried out over a period of 6years 4months from January 2010 to June 2016, with consecutive recruitment in the city of Yaoundé, Cameroon. It consisted in a review of medical records, with physical reassessment on pre-designed and tested data-sheet. Sixty-two osteosyntheses were documented in 60 subjects operated on for humeral fracture or non-union. The following variables were studied: sociodemographic data, fracture profile, clinical profile, and functional shoulder and elbow results. Data analysis used the Statistical Package for Social Sciences (SPSS), version 23.0. Associations between qualitative variables were assessed on Chi square test, or Fisher test when the expected sample size was less than 5, and between quantitative and qualitative variables on Student t-test for comparison of means; p values≤0.05 were considered statistically significant.

RESULTS

The anterior approach showed better results. Operative time was shorter, at 102.5min on average, for 262cm³ blood loss, versus 141.6min and 330cm³ on the lateral approach, with a significant correlation between the two variables. The incidence of postoperative radial paralysis was significantly higher with the lateral approach (22.6% versus 3.2%; p=0.02), and there were likewise higher rates of postoperative infection (9.7% versus 6.5%), secondary displacement, implant damage, and malunion. Reduction was more often anatomical with the anterior approach (28.1% versus 11%) and cortical fixation was better (83.9% versus 61.3%). Functional shoulder and elbow recovery was nearly normal with both approaches, with superimposable values and no statistically significant difference in (p=0.4).

CONCLUSION

Cameroon being a low-income country, the anterior approach is of therapeutic and prognostic interest, being easy to perform, with a low rate of postoperative complications and good functional outcome.

Humeral shaft fractures

Fractures of the humeral shaft are common injuries with multiple management strategies. Many still regard nonoperative management as the standard of care; however, as the understanding of these injuries increases, treatment recommendations are also evolving. Fracture pattern, fracture location, and identifiable patient risk factors may predict poor outcome with nonoperative management, and earlier operative intervention may be recommended. Operative management includes open reduction and internal fixation through a variety of exposures, intramedullary nail fixation, and external fixation. With increasing rates of shoulder arthroplasty, periprosthetic humeral shaft fractures also deserve special consideration.

Set it and Forget it: Diaphyseal Fractures of the Humerus Undergo Minimal Change in Angulation After Functional Brace Application

OBJECTIVES

To quantify radiographic changes observed in humeral shaft frctures throughout course of treatment with functional bracing.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Trauma Center and affiliated Tertiary Care Center.

PATIENTS

72 retrospectively identified patients with fracture of the humeral diaphysis.

INTERVENTION

Application of functional brace with radiographs obtained immediately after brace application and at 1 week, 2 weeks, 3 weeks, 6 weeks, 3 months, 6 months and 12 month follow-up.Main Outcome Measure: Fracture angulation, measured in the coronal and sagittal planes.

RESULTS

522 radiographs from 72 patients were critically reviewed. All fractures were followed to healing. Sixty-six patients (92%) successfully healed their fractures with non-operative treatment. The average angulation on immediate post-brace X-ray was 12 degrees varus ad 7 degrees procurvatum. At final follow-up, average coronal angulation was 14 degrees and 4 degrees procurvatum. Fracture angulation changed a mean 2 degrees in the AP plane and 3 degrees in the sagittal plane over the course of care. Linear regression determined fracture angulation proceeds toward both varus and recurvatum at 0.01 degrees per day.

CONCLUSION

Humeral shaft fractures treated non-operatively heal with minimal change in angulation after brace application. If angulation on the post-brace radiograph is acceptable and there is no history of repeat trauma and no cosmetic deformity, radiographs may be utilized less frequently. Patients should be evaluated via history and physical exam at follow-up prior to the 6-week point, at which time regular radiographs (6 week, 3 month, 6 month, 12 month) should commence.

Fracture Site Mobility at 6 Weeks After Humeral Shaft Fracture Predicts Nonunion Without Surgery

OBJECTIVES

To assess the presence of fracture site gross motion on physical examination to predict humeral shaft fracture progression to nonunion in patients managed nonoperatively.

DESIGN

Retrospective cohort study.

SETTING

Single trauma level 1 institutional center.

PATIENTS

Eighty-four consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture were identified. The average age of the population was 48.3 years, and 50% of the cohort was men.

INTERVENTION

Clinical examination for fracture stability was routinely performed on patients by the treating physicians and documented it in the medical record. Patients were followed until union or surgery for persistent fracture mobility.

MAIN OUTCOME MEASUREMENTS

Stability was graded if there was motion at the site (1: motion of any kind and 0: moved as a unit).

RESULTS

Seventy-three patients (87%) healed their fracture within our study cohort by 6 months postfracture. Of the remaining 11 patients, after discussion with their treating physicians about the option of surgical intervention, 8 chose to undergo open reduction internal fixation at an average of 8 months, 1 proceeded nonsurgical interventions, and 2 were lost of follow-up. If the humeral shaft fracture site was mobile at 6 weeks follow-up visit, it identified future fracture nonunion with 82% sensitivity and 99% specificity (only 1 patient with motion at 6 weeks proceeded to fracture union).

CONCLUSION

With a high negative predictive value, clinical examination of fracture motion at 6 weeks should be assessed in every patient to determine which patients should obtain closer follow-up for the risk of nonunion progression. Knowledge of gross fracture motion can be used in the shared decision-making model in counseling about early surgical options.

LEVEL OF EVIDENCE

Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.