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

Comparative Analysis of Anterolateral and Posterior Approaches for Distal Humerus Shaft Fractures: A Multicenter Retrospective Study

Background: Distal humeral shaft fractures (DHSFs) pose surgical challenges due to the proximity to the elbow joint, limited bone stock, and the risk of radial nerve injury. This study compared clinical and radiographic outcomes of anterolateral and posterior triceps-sparing approaches to determine the most effective surgical strategy. Methods: This multicenter retrospective study included 75 patients who underwent surgery for a DHSF between 2015 and 2021, with a minimum one-year follow-up, a distal fragment ≥3 cm, and no preoperative radial nerve injury. Fifty patients underwent anterior plating via anterolateral approach, and twenty-five underwent posterior plating. Clinical and radiographic outcomes were evaluated. Results: Bone union was achieved in 74 patients (98.7%), with no significant difference between the groups (p = 0.21). The anterolateral approach resulted in a shorter operative time (116 ± 29.4 vs. 143 ± 31.4 min, p = 0.03). However, intraoperative blood loss (p = 0.36), Mayo Elbow Performance Score (p = 0.71), range of motion (p = 0.36), and complication rates (p = 0.21) were not significantly different. Two cases of transient radial nerve palsy occurred in the posterior group (p = 0.17), and four cases required implant removal due to discomfort (p = 0.18) in the anterolateral group. Conclusions: Both approaches effectively treat DHSFs with high union rates and comparable functional outcomes. However, the anterolateral approach significantly reduces operative time due to supine positioning, direct access, and avoiding radial nerve dissection. Posterior plating remains viable when stable anterior fixation is unachievable. Further studies should assess the long-term outcomes and factors influencing approach selection.

Comparative Outcomes of Anterior and Posterior Plating for Distal-Third Humerus Shaft Fractures

PURPOSE

When treating distal-third humerus shaft fractures (HSFs) surgically, the optimal approach for plating is controversial. We conducted a retrospective multicenter study to investigate and compare the clinical outcomes of anterior and posterior plating in distal-third HSFs and the incidence of complications including iatrogenic radial nerve palsy.

METHODS

We identified 116 patients from our multicenter trauma database who were diagnosed as having distal-third HSFs and who underwent surgical treatment, including intramedullary nailing between 2011 and 2020. We analyzed 50 cases treated in one of two ways: open reduction internal fixation with anterior plating (group A: 20 cases) and open reduction internal fixation with posterior plating (group P: 30 cases).

RESULTS

The findings were similar in terms of operation time, estimated bleeding, and clinical and radiographic outcomes between the groups. Postoperative radial nerve palsy occurred only in group P (4 cases) and never in group A.

CONCLUSIONS

The results of this study suggest that the anterior approach is a safe and effective method for treating distal-third HSFs with satisfactory outcomes.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The greater tuberosity version angle: a novel method of acquiring humeral alignment during intramedullary nailing

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

Methods

This study analyzed 506 cadaveric humeri of adult patients. All humeri were CT scanned using 0.625 × 0.625 × 0.625 mm cubic voxels. The images acquired were used to generate 3D surface models of the humerus. Next, 3D landmarks were automatically calculated on each 3D bone using custom-written C++ software. The anatomical landmarks analyzed were the transepicondylar axis, the humerus anatomical axis, and the peak of the perpendicular axis of the greater tuberosity. Lastly, the angle between the transepicondylar axis and the greater tuberosity axis was calculated and defined as the GTVA.

Results

The value of GTVA was 20.9° (SD 4.7°) (95% CI 20.47° to 21.3°). Results of analysis of variance revealed that females had a statistically significant larger angle of 21.95° (SD 4.49°) compared to males, which were found to be 20.49° (SD 4.8°) (p = 0.001).

Conclusion

This study identified a consistent relationship between palpable anatomical landmarks, enhancing IMN accuracy by utilizing 3D CT scans and replicating a 20.9° angle from the greater tuberosity to the transepicondylar axis. Using this angle as a secondary reference may help mitigate the complications associated with malrotation of the humerus following IMN. However, future trials are needed for clinical validation.

Biomechanical performance evaluation of a modified proximal humerus locking plate for distal humerus shaft fracture using finite element analysis

The extra-articular distal humerus plate (EADHP) has been widely used for surgical treatment of distal humerus shaft fracture (DHSF). However, the surgical approach, fixation methods, and implant positions of the EADHP remain controversial owing to iatrogenic radial nerve injury and complaints such as skin irritation related to the plate. Anterior plating with a modified (upside-down application) proximal humerus locking plate (PHILOS) has been proposed as an alternative, However, research on its biomechanical performance remain insufficient and were mostly based on retrospective studies. This study quantitatively compared and evaluated the biomechanical performance between posterior plating with the EADHP and anterior plating with a modified PHILOS using finite element analysis (FEA). The FEA simulation results that both the EADHP and PHILOS had adequate biomechanical performance and stability under axial, bending, and varus force load conditions. The PHILOS has a fixed stability comparable to that of the EADHP, and fixation was achieved using only four locking screws within a fixed range of 30 mm just above the olecranon fossa. The results show that the PHILOS could be an option for the fixation of a DHSF when considering the dissection range and complaints (e.g. skin irritation) associated with the EADHP.

Extra-Articular Distal Humerus Plate 3D Model Creation by Using the Method of Anatomical Features

Proper fixation techniques are crucial in orthopedic surgery for the treatment of various medical conditions. Fractures of the distal humerus can occur due to either high-energy trauma with skin rupture or low-energy trauma in osteoporotic bone. The recommended surgical approach for treating these extra-articular distal humerus fractures involves performing an open reduction and internal fixation procedure using plate implants. This surgical intervention plays a crucial role in enhancing patient recovery and minimizing soft tissue complications. Dynamic Compression Plates (DCPs) and Locking Compression Plates (LCPs) are commonly used for bone fixation, with LCP extra-articular distal humerus plates being the preferred choice for extra-articular fractures. These fixation systems have anatomically shaped designs that provide angular stability to the bone. However, depending on the shape and position of the bone fracture, additional plate bending may be required during surgery. This can pose challenges such as increased surgery time and the risk of incorrect plate shaping. To enhance the accuracy of plate placement, the study introduces the Method of Anatomical Features (MAF) in conjunction with the Characteristic Product Features methodology (CPF). The utilization of the MAF enables the development of a parametric model for the contact surface between the plate and the humerus. This model is created using specialized Referential Geometrical Entities (RGEs), Constitutive Geometrical Entities (CGEs), and Regions of Interest (ROI) that are specific to the human humerus bone. By utilizing this anatomically tailored contact surface model, the standard plate model can be customized (bent) to precisely conform to the distinct shape of the patient's humerus bone during the pre-operative planning phase. Alternatively, the newly designed model can be fabricated using a specific manufacturing technology. This approach aims to improve geometrical accuracy of plate fixation, thus optimizing surgical outcomes and patient recovery.

Clinical Characteristics, Mechanism, and Outcome of Humeral Shaft Fractures Sustained during Arm Wrestling in Young Men: A Retrospective Study

OBJECTIVE

Humeral fractures are common in arm wrestling and other sports and military activities requiring similar movements; however, the precise mechanism is poorly understood. Here, we present an overview of the characteristics, possible mechanisms, and treatment of humeral shaft fractures sustained during arm wrestling.

METHODS

We reviewed 8 years (January 2013 to January 2021) of medical records and retrospectively analyzed data from 27 patients with humeral shaft fractures sustained during arm wrestling. The clinical data included sex, age, affected arm, alcohol consumption, muscle warm-up, history of competitive participation, opponents' characteristics, wrist position, and post-fracture radial nerve injuries. The fracture configurations were radiographically assessed and analyzed. Surgical management included single or dual plating. Scores on the Disability of the Arm, Shoulder, and Hand questionnaire (DASH) were evaluated preoperatively and postoperatively at the last follow-up visit.

RESULTS

All fractures sustained during arm wrestling were spiral fractures of the distal third of the humerus. Of these, 11 were 12-A1 type and 16 were 12-B2 type with a wedge fragment. The two subtypes differed in the total fracture line length (12-A1: 0.18 ± 0.04; 12-B2: 0.23 ± 0.04; P < 0.001). The radial nerve injury rate was 0/11 (0%) in patients with 12-A1 type fractures and 7/16 (43.8%) in patients with 12-B2 type fractures (P = 0.011). Most patients were young men (mean age, ~25 years) with a history of competitively participating in arm wrestling for >2 years. Cold seasonal temperatures and a lack of warm-ups increased the risk of injury. All patients showed improved DASH scores at the last follow-up (12-A1:77.82 ± 5.14 to 10.25 [5.38]; 12-B2:78.91 ± 7.46 to 8.95 [3.17]; P < 0.001). No significant differences were observed among the different surgical treatments.

CONCLUSIONS

Individuals who participated in arm wrestling were at risk of humeral shaft fractures (type 12-A1 or 12-B2). The 12-B2 type occurs with a wedge fragment and is frequently accompanied by radial nerve injuries. The characteristics of arm-wrestling fractures and the mechanism(s) underlying these fractures can help orthopedic surgeons understand the causes of these fractures and similar fractures sustained in traditional sports. This understanding will help surgeons choose more effective surgical treatments that will result in more desirable functional outcomes and a faster return to work.

Risk factors for hardware-related complications after extra-articular distal humerus fracture fixation using an anatomical locking plate

PURPOSE

We aimed to identify the incidence and risk factors of hardware-related complications in patients treated with anatomical locking plate fixation for extra-articular distal humerus fractures.

METHODS

From 2013 to 2020, patients with extra-articular distal humerus fractures who underwent open reduction and internal fixation with an extra-articular distal humerus locking plate (EADHP) were retrospectively reviewed and categorized according to the presence/absence of hardware-related complications. Hardware-related complications were defined as the occurrence of skin prominence on the plate and discomfort in activities of daily living. Patient demographics, the lateral condylar angle, lateral body length, shaft-condylar angle of the humerus, and plate length were analyzed.

RESULTS

Of the 29 patients, 10 (34%) did not develop hardware-related complications (group A), whereas 19 (66%) did (group B). Patient demographics did not differ between the groups. However, the number of patients who underwent hardware removal was significantly greater in group B (16/19) than in group A (4/10; p = 0.032). Radiologic assessment revealed no significant difference in the lateral condylar or shaft-condylar angle. However, the lateral body length was greater in group A than in group B (44.5 ± 4.8 vs. 39.5 ± 3.7, p = 0.007). The plate length significantly differed between the groups. Twelve of 19 (63%) patients in group B received short-hole plates (six holes), while nine of ten (90%) patients in group A received long-hole plates (eight holes). In the multivariable analysis, the lateral body length of the distal humerus (p = 0.047, odds ratio = 0.734, 95% confidence interval: 0.542-0.996) and plate length (p = 0.036, odds ratio = 0.076, 95% confidence interval: 0.542-0.996) were associated with hardware-related complications.

CONCLUSIONS

Most patients developed hardware-related complications, particularly with short plates, mainly because of the narrow lateral body length of the distal humerus. Surgeons should be careful to secure EADHP in the appropriate position, especially when short plates are used in patients with narrow lateral body length.

Risk of Radial Nerve Injury in Anterolateral Humeral Shaft Plating

PURPOSE

The purpose of this study was to evaluate and compare the risk of iatrogenic radial nerve injury between arm positionings of 45° and 60° abduction in anterolateral humeral plating using a 4.5-mm narrow dynamic compression plate.

METHODS

Fifty-six humeri of cadavers in the supine position with 45° of arm abduction were exposed through the anterolateral approach. A hypothetical fracture line was marked at the middle of the humerus, and a precontoured ten-hole 4.5-mm narrow dynamic compression plate was applied and fixed to the anterolateral surface. After the fixation, the radial nerve was exposed through a triceps-splitting approach. Screws in contact with or which had penetrated the radial nerve were deemed to be injuries. Then, the screws and plate were removed, the arm changed to the 60° arm abduction position, and the steps of applying the plate and inserting the screws were followed as in the 45° arm abduction step.

RESULTS

The screws which could potentially injure the radial nerve were those of the second to sixth screw holes in both the 45° and 60° of arm abduction positions. The incidences of iatrogenic radial nerve injury of the second to sixth screw holes in the 45° position were 5.36%, 39.29%, 80.36%, 60.71%, and 10.71%, respectively, and at the 60° position were 5.36%, 53.57%, 83.93%, 60.71%, and 7.14%, respectively. There were no statistically significant differences in risk of injury between the two positions in all screw holes (all P-values > 0.05).

DISCUSSION

In anterolateral humeral shaft fixation, arm abduction position did not affect the risk of iatrogenic radial nerve injury, with the main risk from certain screw holes. The surgeon should be careful in screw insertion, especially at the fourth and fifth screw holes.

LEVEL OF EVIDENCE

IV; cadaveric study.

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.

Application of Smart Healthcare in Comparative Analysis of Effect of Early External Fixator and Plate Internal Fixation Treatment on Postoperative Complications and Lower Limb Function Recovery of Patients With Unstable Pelvic Fracture

Objective

To comparatively analyze the effect of early external fixator and plate internal fixation treatment on postoperative complications and lower limb function recovery of patients with unstable pelvic fracture based on smart healthcare.

Methods

The clinical data of 98 patients with unstable pelvic fractures treated in our hospital from August 2018 to August 2021 were collected for retrospective analysis, and the patients were split into group A (plate internal fixation, n = 49) and group B (early external fixator treatment, n = 49) according to the surgical modalities. The time of operation, intraoperative blood loss, postoperative complications, etc. were compared between the two groups.

Results

Between the two groups, group B had significantly better clinical indicators (P &lt; 0.001), a greatly higher good rate of fracture reduction and postoperative Harris score (P &lt; 0.05), and obviously lower VAS score and total incidence rate of postoperative complications (P &lt; 0.05).

Conclusion

Through the analysis based on smart healthcare, it is found that compared with plate internal fixation treatment, early external fixator treatment presents a better effect in treating patients with unstable pelvic fracture, because it is a reliable method to accelerate fracture healing, reduce postoperative complications, and improve lower limb function.

The risk of iatrogenic radial nerve and/or profunda brachii artery injury in anterolateral humeral plating using a 4.5 mm narrow DCP: A cadaveric study

INTRODUCTION

Fixation of humeral shaft fractures with a plate and screws can endanger the neurovascular structure if proper care is not taken. No studies to our knowledge have studied the risk of iatrogenic radial nerve and/or profunda brachii artery (RNPBA) injury from each screw hole of a 4.5 mm narrow dynamic compression plate (narrow DCP). The purpose of this study is to evaluate the risk of RNPBA injury in anterolateral humeral plating with a 4.5 mm narrow DCP.

MATERIAL AND METHODS

18 humeri of 9 fresh-frozen cadavers in the supine position were exposed via the anterolateral approach with 45 degrees of arm abduction. A hypothetical fracture line was marked at the midpoint of each humerus. A precontoured ten-hole 4.5mm narrow DCP was applied to the anterolateral surface of the humerus using the fracture line to position the center of the plate. All screw holes were drilled and screws inserted. The cadaver was then turned over to the prone position with 45 degrees of arm abduction, and the RNPBA exposed. The holes through in which 100% of the screw had contact with or penetrated the RNPBA were identified as dangerous screw holes, while lesser percentages of contact were defined as risky.

RESULTS

The relative distance ratios of the entire humeral length from the lateral epicondyle of the humerus to the 4th, 3rd, 2nd and 1st proximal holes were 0.64, 0.60, 0.56 and 0.52, respectively. The most dangerous screw hole was the 2nd proximal, in which all 18 screws had contacted or penetrated the nerve, followed by the risky 1st (12/18), 3rd (8/18) and 4th (2/18) holes.

CONCLUSION

In humeral shaft plating with the 4.5mm narrow DCP using the anterolateral approach, the 2nd proximal screw hole carries the highest risk of iatrogenic radial nerve and/or profunda brachii artery injury.

Treatment of humeral shaft fractures: a new minimally-invasive plate osteosynthesis versus open reduction and internal fixation: a case control study

Background

To evaluate the feasibility and safety of a new minimally-invasive surgical approach–anteromedial minimally-invasive plate osteosynthesis (MIPO)–in the treatment of middle and distal humeral shaft fractures.

Methods

Fourteen patients with humeral shaft fracture treated with anteromedial MIPO from November 2016 to March 2020 (MIPO Group) were selected as the study subjects. Open reduction and internal fixation (ORIF) were used to treat 14 patients with humeral shaft fractures as the control group (ORIF group). The two groups were fixed with a locking compression plate (LCP) or LCP + multi-directional locking screw system (MDLS). The incision length, intraoperative blood loss, intraoperative fluoroscopy time, operation time, length of hospital stay, fracture healing time, QuickDASH score and Constant score were observed and compared between the two groups.

Results

Fourteen patients were enrolled in each group. The incision length (7.79 ± 2.39 cm), intraoperative blood loss (96.07 ± 14.96 mL), operative time (110.57 ± 21.90 min), hospital stay (6.29 ± 1.49 days) and fracture healing time (14.94 ± 0.99 weeks) in the MIPO group were all lower than those in the ORIF group, and the difference was statistically significant for each parameter (P < 0.05). The intraoperative fluoroscopy time (20.07 ± 3.22) in the MIPO group was significantly higher than that in the ORIF group (P < 0.05). There were no significant differences in age (P = 0.078), QuickDASH score (P = 0.074) or Constant score (P = 0.293) between the two groups and no postoperative complications occurred in any of the patients.

Conclusion

The anteromedial approach MIPO technique has the advantages of less trauma, less bleeding, low risk of nerve injury and high rate of fracture healing. It is one of the most effective methods for the treatment of middle and middle–distal humeral shaft fractures.

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.

Surgical approach for fracture of distal humerus: Posterior vs lateral

Humeral fractures have an incidence of 3-5% and a bimodal age distribution. They may occur in young patients after highenergy traumas or in elderly osteoporotic patients after low-energy injuries. In nondisplaced fractures or in elderly patients, humeral fractures are treated by conservative methods. Open reduction and internal fixation (ORIF) should be the treatment of choice in case of multi-fragmentary fractures associated with radial nerve palsy or not. ORIF is usually regarded as the gold standard treatment, but, depending on the different types of fracture, the surgical approach can change. In this review, we compare results and complication rates between lateral and posterior surgical approaches in the management of extraarticular distal humeral shaft fractures. An internet-based literature research was performed on Pubmed, Google Scholars and Cochrane Library. 265 patients were enrolled: 148 were treated by lateral or antero-lateral approach, while 117 by posterior or postero-lateral approach. The literature shows that no differences between the posterior and lateral approach exist. Certainly, the posterior approach offers undoubted advantages in terms of exposure of the fracture and visualization of the radial nerve. In our opinion, the posterior approach may also allow better management of complex and multi-fragmentary fractures.