Surgical result of plate osteosynthesis using a locking plate system through an anterior humeral approach for distal shaft fracture of the humerus that occurred during a throwing motion

Return to work and sport after a humeral shaft fracture

Aims

The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Methods

From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS.

Results

The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS.

Conclusion

Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity.

Cite this article: Bone Jt Open 2022;3(3):236–244.

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.

Clinical outcomes of dual 3.5-mm locking compression plate fixation for humeral shaft fractures: Comparison with single 4.5-mm locking compression plate fixation

BACKGROUND

Recently, several in vitro biomechanical studies that used dual small locking plate fixation for humeral shaft fractures have investigated. However, in vivo studies about dual plate fixation for humeral shaft fractures are limited. The purpose of our study was to report the outcomes of dual small plating for humeral shaft fractures in comparison with those of single large fragment plating.

METHODS

Sixty consecutive patients who underwent an open reduction internal fixation for humeral shaft fractures at our institution from September 2014 to December 2017 were included. Single 4.5-mm locking compression plate (LCP) fixation was used in the first 40 cases, and dual 3.5-mm LCP fixation was used in the final 20 consecutive cases. Data were collected to define patient characteristics, injury mechanism, clinical outcomes, time to surgery, operative time, estimated blood loss, and complications. Using simple radiography during the follow-up period (6, 12, 24, and 52 weeks after surgery), the shoulder and elbow joint ranges of motion (ROM) were also evaluated.

RESULTS

Demographic data, time to surgery, surgical time, and estimated blood loss had no significant differences between the two groups. No significant differences were observed in nonunion rate and union rate 3 months after surgery. However, two patients (5%) in the single 4.5-mm LCP fixation group showed metal failure and breakage. No significant differences were found in postoperative shoulder and elbow ROM. Three patients (7.5%) in the single plating group and one patient (5%) in the dual plating group developed radial nerve palsy after surgery. No vascular injury and deep infection were observed in either group.

CONCLUSION

For diaphyseal humeral fractures, dual 3.5-mm LCP fixation to the humerus is a possible treatment choice. This method showed satisfactory union rate, ROM, and complication rate, without increasing surgical time, in comparison with the conventional single 4.5-mm LCP fixation. Level of evidence: III.

The socioeconomic impact of orthopaedic trauma: A systematic review and meta-analysis

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.

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.

Anterior humeral approach with nerve stimulator

INTRODUCTION

The prevalence of radial nerve injury during surgery is as high as the prevalence of radial nerve injury due to trauma. The aim of this study is to minimize the risk of iatrogenic injury of radial nerve.

MATERIALS AND METHODS

Fifty patients with middle or distal diaphysis fractures of humerus and 18 patients with pseudoarthrosis at the same localizations were treated with surgery. Plate-screw fixation was performed with anterior approach in 43 patients. Eleven patients had minimally invasive plate osteosynthesis, and 14 patients had intramedullary nailing. The localization of the radial nerve was determined with nerve stimulator at the area of dissection.

RESULTS

Iatrogenic radial nerve injury did not occur in patients treated with open reduction or minimally invasive approach.

DISCUSSION

Nerve stimulator may be a method that decreases radial nerve injury, an iatrogenic complication. This method may be used in anterior approach and minimally invasive procedures.

Modified use of a proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures

BACKGROUND

Surgical treatment of extra-articular distal-third diaphyseal humeral fractures is controversial in terms of surgical approach and position of implant. The aim of this study is to evaluate the clinical and radiological outcomes of a modified application of the proximal humeral internal locking system (PHILOS) plate in extra-articular distal-third diaphyseal humeral fractures.

MATERIALS AND METHODS

A total of 23 patients with extra-articular distal humerus fractures were treated using either open plating or the minimally invasive plate osteosynthesis (MIPO) technique with upside down application of the PHILOS plate. Fracture configuration, number of screws in the distal fragment, and time to union were analysed. Elbow range of motion, Mayo Elbow Performance Score (MEPS), and complications were evaluated at the final follow-up.

RESULTS

Fracture union was obtained in all patients at a mean postoperative time of 20.8 ± 2.9 weeks. The mean shortest and longest cortical lengths were 50.7 ± 14.0 mm and 85.2 ± 12.4 mm, respectively. The average number of screws in the distal humeral fragment was 5.6 ± 0.7. No statistically significant correlation was observed between the shortest cortical length and number of screws in the distal fragment (p = 0.224) or between the longest cortical length and the number of screws in the distal humeral fragment (p = 0.956). The average MEPS was 97.6 (range, 75-100). No postoperative complications that required reoperation were occured.

CONCLUSION

A modified anterior application of the PHILOS plate in extra-articular distal-third diaphyseal humeral fracture showed satisfactory outcomes, so it is an alternative when considering the ability to increase plate-screw density with locking screw fixation in a distal humeral fragment.

LEVEL OF EVIDENCE

Therapeutic level IV, case series.

Modified anterolateral approach for internal fixation of Holstein-Lewis humeral shaft fractures

BACKGROUND

The authors modified the anterolateral approach for Holstein-Lewis humeral shaft fractures using a plating technique to achieve sufficient distal fixation by minimal splitting of the brachioradialis muscle to fix the most distal screws. The purpose of this retrospective study was to evaluate the efficacy of our modified anterolateral approach for Holstein-Lewis humeral fractures and document clinical and functional results.

MATERIALS AND METHODS

Between 2008 and 2014, 18 patients (mean age 35.4 years) with a Holstein-Lewis humeral shaft fracture who underwent open reduction and internal fixation with a plate and screws using the modified anterolateral approach and followed for a minimum of 12 months were included. Radiologic fracture configurations, number of distal cortical fixations, union rate, and time to union were analyzed. Clinical outcomes were evaluated using the Mayo elbow performance index system, range of elbow motion, and postoperative complications.

RESULTS

Mean fracture length was 60.2 ± 10.2 mm (range 49.2-77.2) and mean distal cortical length was 41.4 ± 7.04 mm (range 22.8-59.6). Distal fragments were fixed at a minimum of six cortical points (range 6-8) in all cases using the modified anterolateral approach. Average time to union was 10.5 weeks (range 8-12 weeks). All cases of radial nerve palsy completely recovered within 3 months. Mean elbow range of motion at final follow-up was 3.2 degrees of flexion contracture (range 0-10) and 135.4 degrees of further flexion (range 120-140), and the average Mayo elbow performance score was 96.3 points (range 90-100). There were no non-union or metal failures.

CONCLUSIONS

The results obtained indicate that the modified anterolateral approach is a safe and easy accessible method that provides sufficient distal osseous fixation for Holstein-Lewis humeral shaft fractures without serious complications. The modified anterolateral approach for plate osteosynthesis appears to be one of the most available options for the treatment of Holstein-Lewis humeral fractures.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Antero-lateral minimally invasive plate osteosynthesis (MIPO) with the radial nerve exploration for extra-articular distal-third diaphyseal fractures of the humerus

INTRODUCTION

Traditional open reduction and internal fixation (ORIF) of extra-articular distal humerus fractures has a risk of iatrogenic radial nerve injury, extensive soft tissue stripping, and long incision scar. We performed an antero-lateral minimally invasive plate osteosynthesis (MIPO) technique with the radial nerve exploration for distal-third diaphyseal fractures of the humerus and evaluated clinical and radiographic outcomes through this respective study.

METHODS

From April 2010 to June 2016, 28 cases of extra-articular distal-third diaphyseal fractures were treated with an antero-lateral MIPO procedure. Patient demographics, Disabilities of the Arm, Shoulder and Hand (DASH) Score, Mayo Elbow Performance (MEP) Score, elbow range of motion, scars and post-operative complications were recorded and analyzed.

RESULTS

All fractures were united with a mean time of 3.5 months. One patient exhibited delayed union (3.6%). The mean DASH Score was 6.6, and all patients had excellent or good MEP Score values. The average scar length was 6.8 cm, and the shortest was 4.5 cm.

CONCLUSIONS

The MIPO technique via an antero-lateral approach for extra-articular distal-third diaphyseal fractures of the humerus results in satisfactory clinical outcomes.

LEVEL OF EVIDENCE

Level IV, case series, treatment study.

Newly designed minimally invasive plating of a humerus shaft fracture; a different introduction of the plate

PURPOSE

Open reductions and internal fixations are currently being used the most in surgeries of humeral shaft fractures. However, there are some limitations such as invasive techniques and formation of many operation scars. To overcome these limitations, a minimally invasive plate osteosynthesis has been recently introduced. However, this has technical limitations such as deep dissections of the distal portion and narrowness of the fixation space. To address these problems, we designed another introductory technique of a minimally invasive osteosynthesis and we have examined the clinical usefulness of that.

METHODS

The results were retrospectively analyzed with 83 patients who visited INHA hospital due to a humeral shaft fractures and who had undergone the above said surgery from the beginning of 2010 to the end of 2012. The patients were divided into two groups: patients treated by the MIPO technique using the newly designed dual approaches (group A) and patients treated by open reduction and plating internal fixation (group B).

RESULTS

There was no significant difference in mean duration of injury, the mean fracture union time, range of motion and MEPI for group A and B. There was no statistical significance between the two groups. However, the occurrence of iatrogenic radial nerve palsy in group B, was significantly higher than in group A.

CONCLUSIONS

MIPOs using the dual approaches on the adult humerus shaft fracture show an excellent bony union without nerve injury which is clinically useful.