Humeral shaft fractures

Risk factors associated with delayed union after open reduction and plate fixation for humeral diaphyseal fractures

BACKGROUND

The risk factors related to delayed union in humeral diaphyseal fractures (HDFs) following surgical osteosynthesis remain unclear. Therefore, this study aimed to evaluate radiological outcomes and the risk factors associated with delayed union in a retrospective cohort of patients who underwent open reduction and plate fixation (ORPF) for acute HDFs.

MATERIALS AND METHODS

Consecutive patients with AO/OTA 12-A and AO/OTA 12-B fractures who underwent ORPF using standard compression techniques between 2017 and 2020 were enrolled in the study. Demographic data, along with serial medical records and radiographs, were collected. The included patients were divided into two groups: the timely union (union occurring within 6 months postoperatively) and the delayed union group (union occurring between 6 and 12 months postoperatively). Differences between the groups were examined, and logistic regression was subsequently applied for risk factor analysis.

RESULTS

Sixty-five cases were included in the study, consisting of 34 males and 31 females, with a median age of 38.9 years. Among these, 45 cases (69.2%) were classified in the timely union group, while 20 cases (30.8%) were classified in the delayed union group. Overall, 30 cases (46.2%) demonstrated secondary bony union. Significant differences were observed between groups in terms of fracture pattern, immediate postoperative fracture gap, union pattern, and complication rate (p < 0.05 for all comparisons). Multivariate logistic regression analysis revealed that the use of interfragmentary screw and the presence of postoperative complications were independent predictors of delayed union, with an adjusted odds ratio of 0.14 and 5.76, respectively.

CONCLUSIONS

In ORPF for acute HSFs, 30 out of 65 cases demonstrated secondary bone union despite the use of standard compression techniques. The application of interfragmentary screws significantly reduces the risk of delayed union. Conversely, the presence of postoperative complications is associated with an increased likelihood of delayed union.

LEVEL OF EVIDENCE

3 Trial Registration All procedures were approved by the institutional review board of the authors' hospital (IRB nos. A-ER-112-395 and IRB20230089).

Mechanical study of the safe distance between humerus shaft fracture and distal locking screws in antegrade nailing

BACKGROUND

Optimal positioning of distal locking screws in intramedullary humeral nailing remains uncertain, particularly the influence of the distance between the fracture plane and the proximal distal locking screw on construct stability. This study aims to evaluate the mechanical stability of humeral nailing under different fracture-to-screw distances and numbers of distal locking screws using finite element analysis and mechanical testing on bone models.

METHODS

A finite element model and mechanical testing on six sawbones models were performed under traction (500 N), compression (500 N), and torsion (3 Nm). Models were tested with two osteotomy distances from the proximal distal locking screw (2 cm and 5 cm) and with either one or two distal locking screws. Axial and torsional stiffness and fracture displacement were recorded and analyzed statistically.

RESULTS

Finite element analysis showed higher stress concentrations near the distal fracture fragment. Mechanical testing demonstrated that traction and torsional stability were significantly affected by fracture-to-screw distance (p = 0.006 and p = 0.015), while compression stability was influenced by the number of distal screws (p = 0.035).

CONCLUSION

A fracture-to-screw distance of 5 cm was associated with improved axial and torsional stability, while double distal screws enhanced compressive stiffness. These biomechanical results, although very promising, should be confirmed with clinical studies.

A radiographic analysis of humerus shaft fractures to predict non-union

BACKGROUND

Humeral shaft fracture non-union rates of up to 33% have been reported when managed non-operatively. When managed surgically, non-union rates of 10% have been seen. The initial radiographic displacement parameters may be of significance in determining whether non-operative treatment might fail.

AIMS

To determine whether the initial radiographic displacement of humeral shaft fractures can predict non-union rates and assist in decision-making for surgical intervention.

METHODS

A retrospective cohort study was performed to identify all patients with humeral shaft fractures presenting to a regional trauma centre over a three-year period. Three-observer measurements were taken on defined radiographic parameters. These were compared between groups treated successfully with surgery and with non-operative intervention. A subset group was identified who failed non-operative treatment and required delayed surgery. Statistical analysis was performed to determine whether the group that failed non-operative treatment met the proposed radiographic parameters predicting treatment failure.

RESULTS

Eighty patients were identified over the defined three-year period. Failure of non-operative management occurred in 6/43 (13.95%) patients. Failed conservative treatment was associated with increased age, female gender, and increased AP translation of lateral radiographs. Fractures successfully treated non-operatively showed a significantly lower AP translation on the lateral radiographs compared to patients who failed non-operative treatment 9.69 mm (IQR 4.90-14.05 mm) versus 22.61 mm (IQR 15.73-23.83 mm), p-value = 0.042.

CONCLUSION

Significant initial AP displacement may be associated with failure of non-operative management. This study highlights the importance of initial radiographic parameters of displacement in predicting possible failure of non-operative management for midshaft humerus fractures.

Anatomical relationship between the profunda brachii artery and the radial nerve at the entrance and within the radial groove

PURPOSE

In this study, it was aimed to examine the relationship between the profunda brachii artery and the radial nerve at the entrance to and within the radial groove considering no comparable study was found in the literature.

METHOD

Dissection was performed in 44 upper extremities (21 right and 23 left) of 24 fixed cadavers used for medical education at Istanbul University, Istanbul Medical Faculty, Department of Anatomy.

RESULTS

Profunda brachii artery was found to be a single artery in 39 extremities and a double artery in 5 extremities. In 27 cases with single PBA, the nerve was located superolateral to the PBA (Type A), and in 8 cases the nerve was located inferomedial to the PBA (Type B). In all 5 extremities with double profunda brachii artery, the proximal branch was superolateral (Type A) and the distal branch was inferomedial (Type B).

CONCLUSIONS

This research will support surgeons understanding how to better anatomically and radiologically treat humeral fractures and lateral arm flap applications.

Humeral rotation osteotomy is not associated with glenohumeral and scapulohumeral decentering at long-term follow-up

BACKGROUND

Weber rotational osteotomy that increases humeral retrotorsion in patients with anterior shoulder instability has become unpopular because of recurrence of instability and high rates of early-onset osteoarthritis (OA). However, the wear pattern in patients after rotational osteotomy remains unknown. The aim of this study was to determine the influence of surgically increased humerus retrotorsion on glenohumeral and scapulohumeral centering in a long-term follow-up.

METHODS

The data of 18 shoulders in 18 patients diagnosed with a unilateral chronic recurrent anterior shoulder instability treated with an internal rotation subcapital humerus osteotomy between 1984 and 1990 were drawn from a previously published cohort and enrolled in the study. All patients had available bilateral computed tomography (CT) scans performed after a mean follow-up of 14 (12-18) years. On these CT scans a comparison of the operated and the contralateral healthy side with regard to humerus torsion, glenoid version, glenoid offset, glenohumeral and scapulohumeral subluxation indices, rotator cuff action lines, and osteoarthritic changes was performed.

RESULTS

The analysis of follow-up CT scans revealed a significantly higher mean humeral retrotorsion in the operated side compared with the healthy side (41.6° ± 14.0° vs. 20.7° ± 8.2°, P < .001). No differences were found in terms of glenohumeral subluxation index (0.50 ± 0.08 vs. 0.51 ± 0.03, P = .259), scapulohumeral subluxation index (0.53 ± 0.09 vs. 0.54 ± 0.03, P = .283), glenoid version (-3.9° ± 4.6° vs. -4.1° ± 3.7°, P = .424), glenoid offset (4.0 ± 2.8 mm vs. 4.0 ± 1.3 mm, P = .484), infraspinatus action lines (102.5° ± 4.7° vs. 101.2° ± 2.1°, P = .116), subscapularis action lines (74.0° ± 6.0° vs. 73.1° ± 2.3°, P = .260), and resultant rotator cuff action lines (87.8° ± 4.9° vs. 87.0° ± 1.8°, P = .231) between operated and healthy shoulders. Osteoarthritic changes were observed in all operated shoulders and in 13 of 18 healthy shoulders. The OA grade was mild in 5 patients, moderate in 11, and severe in 2 cases for operated shoulders and mild in 13 healthy shoulders at the last follow-up.

CONCLUSION

The surgical increase of humeral retrotorsion by 20°-30° did not affect glenohumeral and scapulohumeral centering in patients with a Weber rotational osteotomy after a long-term follow-up compared to the healthy side. Although a high degree of early-onset OA was observed it remains unclear whether the cause is the surgical interventions performed or the joint instability itself.

Functional Outcomes in Aseptic Humeral Shaft Nonunion Treated With Plate Osteosynthesis: A Retrospective Cohort Study

Introduction

Aseptic nonunion is prevalent in orthopedic practice, causing persistent pain and functional impairment. Humeral shaft fractures, accounting for 3-5% of all fractures, have nonunion rates of 2-33% in nonoperative and 5-10% in surgical management. This study, the largest case series on operative management of aseptic humeral shaft nonunion (AHSN), treated with plate osteosynthesis.

Materials and methods

This retrospective study, conducted at a referral center in eastern India, included 132 patients with aseptic humeral shaft nonunion from May 2002 to April 2012 and May 2015 to December 2020. Patients aged 20-70 years with nonunion more than 6 months post-trauma were included. Exclusions were open fractures, infections, gap nonunions, pathologic fractures, and concomitant upper limb injuries. Surgical techniques involved excising fibrous and unhealthy tissue, compressing the nonunion site, decorticating, shingling, autologous bone grafting, and stable fixation with dynamic or locking compression plates. Outcomes were assessed using Quick DASH, VAS, Constant Shoulder score at a minimum follow-up of 24 months.

Results

The study included 132 patients, 84 males and 48 females, with a mean age of 42.3 years. Fractures were due to high-energy trauma in 78 cases and low-energy trauma in 54 cases. All patients with atrophic type of AHSN received autologous bone grafts and plating techniques. Quick DASH scores improved from 77 to 5 on average. Constant Shoulder score improved from 22 to 88 and VAS score improved from 6.7 to 1.3. Union was achieved in 21 weeks on an average, with minimal complications. Despite variations in time intervals, treatments, and follow-up durations, consistent management strategies emphasize stable fixation, bone grafts, and careful management of complications to achieve high union rates and satisfactory outcomes. Complications included seven infections, one failure needed refixation and two case of transient radial nerve palsy.

Conclusion

Absolute stability using plate with or without autologous bone grafting for aseptic humeral shaft nonunion results in high union rates and satisfactory radiologic and functional outcome.

Are patients without insurance coverage less likely to undergo surgery for humeral shaft fractures? A national database analysis

BACKGROUND

Historically, humeral shaft fractures have been managed nonoperatively in a functional brace. However, recent studies suggest an increase in rates of operative fixation. Disparities in surgical management based on insurance status have been demonstrated across many orthopedic conditions. This study aimed to identify if a correlation exists between insurance coverage and the probability of undergoing operative fixation for a humeral shaft fracture.

METHODS

A retrospective examination of the National Readmissions Database from 2016 to 2021 was conducted. Patients diagnosed with isolated closed humeral shaft fractures were identified via International Classification of Disease, 10th Revision codes, and surgical interventions were identified using International Classification of Disease, 10th Revision procedural codes. Utilizing weighted data, a total of 56,468 patients with isolated closed humeral shaft fractures were identified, 25,075 (44.4%) of whom underwent operative fixation. A univariate analysis was conducted using Pearson's chi-square test to isolate variables for inclusion in a multivariable analysis. A binary logistic regression analysis was then employed to explore demographic and other pertinent factors. Findings were reported as odds ratios.

RESULTS

After controlling for social and demographic variables, patients with Medicaid (OR, 0.54; 95% CI, 0.50-0.58; P < .001), Medicare (OR, 0.64; 95% CI, 0.60-0.68; P < .001), and self-pay patients (OR, 0.75; 95% CI, 0.67-0.84; P < .001) were less likely to undergo operative fixation of humeral shaft fracture than those with private insurance.

CONCLUSIONS

Patients without private insurance or those with no insurance coverage are less likely to undergo operative fixation for humeral shaft fractures compared to those with private insurance, even after adjusting for social and demographic variables. The observed variability underscores the necessity for more refined treatment guidelines for humeral shaft fractures. Surgeons should be aware of these potential biases affecting management decisions.

Is delayed time to surgery associated with increased postoperative complications in patients with pathologic humerus fractures?

INTRODUCTION

Delayed time to surgery, in the case of orthopedic trauma, is well known to be associated with higher morbidity and mortality, an extended duration of hospitalization, and an associated rise in overall cost. Delayed time to surgery of at least 3 days following hospital admission is associated with elevated risk of complications following surgery for a standard, non-pathologic, humeral shaft fracture. To our knowledge, it is unknown whether the same association is present for pathologic humerus fractures. The primary objective of this study was to identify risk factors, including patient characteristics, comorbidities, and postoperative complications, that are associated with delayed time to surgery following pathologic humeral fracture.

METHODS

All patients undergoing surgical management of pathologic humerus fractures across a 6-year period from 2015 to 2021 were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Postoperative complications were reported within 30 days of procedure. Delayed time to surgery was defined by ≥ 2 days from hospital admission to surgery. We identified a total of 248 patients, and 39.9% (n = 99) of patients had delayed time to surgery. Multivariate logistic regression adjusted for all significantly associated variables was employed to identify predictors of delayed time to surgery for pathologic humerus fractures.

RESULTS

The characteristics of patients significantly associated with delayed time to surgery were ASA classification ≥ 3 (p = 0.016), dependent functional status (p = 0.041), and congestive heart failure (p = 0.008). After adjusting for all significantly associated patient variables, the characteristics of patients independently associated with delayed time to surgery were non-home discharge (OR: 2.93, 95% CI 1.53-5.63; p = 0.001) and extended length of stay (OR: 2.00, 95% CI 1.06-3.77; p = 0.033).

CONCLUSION

Delayed time to surgery of at least 2 days was independently associated with non-home discharge and extended postoperative length of stay. After controlling for baseline patient characteristics and comorbidities, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic humeral fractures. This is in contrast to standard, non-pathologic humerus fractures in which delayed time to surgery is associated with an increased risk of postoperative complications.

LEVEL OF EVIDENCE III

Retrospective Cohort Comparison; Prognosis Study.

Operative Management of Aseptic Humeral Shaft Nonunion: A Retrospective Study from Eastern India

Aseptic nonunion is prevalent in orthopedic practice, causing persistent pain and functional impairment. Humeral shaft fractures, accounting for 3-5% of all fractures, have nonunion rates of 2-33% in nonoperative and 5-10% in surgical management. This study, the largest case series on operative management of humeral shaft nonunion, examines surgical techniques and outcomes. This retrospective study, conducted at a referral center in eastern India, included 132 patients with aseptic humeral shaft nonunion from 2002 to 2020. Cases were from May 2002 to April 2012 and May 2015 to December 2020. Patients aged 20-70 years with nonunion more than 6 months post-trauma were included. Exclusions were open fractures, infections, gap nonunions, pathological fractures, and concomitant upper limb injuries. Surgical techniques involved excising fibrous and unhealthy tissue, compressing the nonunion site, decorticating, shingling, autologous bone grafting, and stable fixation with dynamic or locking compression plates. Outcomes were assessed using DASH, VAS, and constant shoulder score scores at a minimum follow-up of 24 months. The study included 132 patients, 84 males and 48 females, with a mean age of 42.3 years. Fractures were due to high-energy trauma in 78 cases and low-energy trauma in 54 cases. All patients received autologous bone grafts and plating techniques. Quick DASH scores improved from 77 to 5 on average. Union was achieved in 21 weeks on average, with minimal complications. Despite variations in time intervals, treatments, and follow-up durations, consistent management strategies emphasize stable fixation, bone grafts, and careful complication management to achieve high union rates and satisfactory outcomes. Complications included seven infections, one failure needed refixation and one case of transient radial nerve palsy. Absolute stability using a plate with or without autologous bone grafting for aseptic humeral shaft nonunion results in high union rates and satisfactory radiological and functional outcome.

Open Reduction and Internal Fixation with Bone Morphogenetic Protein-2 for Correction of Nonunion Humeral Shaft Fracture with Pseudoarthrosis in the Geriatric Population: A Case Report

Introduction

Bone morphogenic protein-2 (BMP-2) is a potent growth factor cytokine, with indications for interbody spinal fusion surgery and open tibial shaft repairs due to its osteoinductive properties. Off-label usage of BMP-2 has been documented; however, there are limited studies regarding the efficacy of using BMP-2 in non-union humeral shaft fractures.

Case Report

We present a case of a comminuted left humeral shaft fracture with pseudoarthrosis in a 64-year-old woman. Due to the patient's significant comorbidities, initial fracture management focused on non-surgical intervention with the use of a humeral cuff to correct the fracture. However, the patient's report of persistent and significant pain and serial radiographs indicating poor healing with a non-union fracture prompted surgical intervention. The patient underwent an open reduction and internal fixation (ORIF) with the application of one pledget of BMP-2 at the fracture site to promote osteogenesis. To the best of our knowledge, there is limited information about the efficacy of using BMP-2 for humeral fractures.

Conclusion

Six months following the surgery, radiographs have shown appropriate fracture healing of the left humerus without loosening of hardware and other significant complications. The usage of BMP-2 in this patient has shown to be effective in promoting the healing of her nonunion humeral shaft fracture. Although BMP-2 has typically been FDA indicated for use in lumbar interbody spinal fusion surgery and open tibial shaft repairs, this case demonstrates that BMP-2 can also promote healing of non-union humeral shaft fractures in a safe and effective manner.

Chest wall soft tissue thickness is associated with humeral shaft non-union: A radiographic study

Background

Anecdotally, upper truncal obesity and large breasts have often been associated with inferior outcomes from non-operative management of diaphyseal humerus fractures. However, this assertion is without basis in the literature.

Aims

To produce radiographic measurements of chest wall soft tissue thickness (STT) and determine association with non-union in diaphyseal humerus fractures.

Methods

Two hundred and seventeen consecutive non-operative humeral shaft fractures were included. Radiographic STT measurements were taken at three standardised points (upper, middle and lower) using a simple reproducible method, with ratios derived (dividing these figures by the mid-humerus diameter). Bivariate and multivariable analyses were used to assess association with non-union.

Results

There were 58 (26.7%) cases of non-union. On multivariable analysis, the middle (odds ratio (OR) 1.39, p <  0.001) and lower (OR 1.23, p = 0.009) STT measurements were independently associated with non-union. Additionally, the middle (OR 1.85, p < 0.001) and lower (OR 1.47, p < 0.001) STT ratios were independently associated with non-union. A receiver operating characteristic curve determined a threshold value of a middle STT ratio of ≥ 3 (OR 3.73, p < 0.001, sensitivity 69.0%, specificity 62.3%), which was independently associated with non-union.

Conclusion

Chest wall STT is independently associated with humeral shaft non-union. Threshold values can assist in decision making for these fractures.

Intramedullary nailing of humeral shaft fractures: percutaneous nailing in the lateral position through the Neviaser approach is a reliable technique

BACKGROUND

Displaced humeral shaft fractures are frequently treated by osteosynthesis in the active patient. We aimed to evaluate the results of intramedullary nailing (IMN) in the lateral position with the Neviaser approach and to compare them with those from IMN nailing in the standard position and conventional approach.

METHODS

In the retrospectively evaluated, single-center study, we compared 20 cases of long IMN for fractures of the proximal or middle third of the humerus shaft (Multilock; Synthes Laboratory) in the lateral position with the percutaneous Neviaser approach with 52 cases of IMN in the standard position. The mean age of patients was 62 ± 21 years. Clinical outcomes were analyzed: Constant score, subjective shoulder evaluation score and range of motion. Radiographically, entry point at the proximal part of the humerus, the healing rate and the possible association between the critical shoulder angle (CSA) and the correct positioning of the nail were assessed.

RESULTS

With a mean follow-up of 26 ± 2 months, the healing rate was 89% (64/72) in the overall series, (eight patients in non-union), with no difference between the two groups. The overall mean active anterior elevation (AAE) was 125 ± 22°, mean external rotation (ER1) was 35 ± 17°, and mean internal rotation (IR) was at L3. The mean Constant score was 58 ± 23 and subjective shoulder evaluation score 73 ± 12%. ranges of motion were better in the lateral than standard position group (AAE 133 ± 17 vs. 122 ± 23, P = .03; ER1 47 ± 13 vs. 30 ± 16, P < .001; IR T12 vs. L5, P = .02). The nail was less often protruding in the lateral than standard position group (1/20 [5%] vs. 20/52 [38.5%], P = .002). The nail was better positioned from the anteroposterior view (nail centered: 16/20 [75%] vs. 26/52 [50%], P = .047) and lateral view (nail centered: 18/20 [90%] vs. 34/52 [65.4%], P = .02) in the lateral than standard position group. We found no association between nail position, type of approach and CSA.

CONCLUSIONS

In the short-term follow-up, osteosynthesis of humeral shaft fractures by using long IMN in the lateral position with the Neviaser approach is a reliable technique. The positioning of the nail, in particular its entry point, and the clinical results were better with the lateral position and Neviaser approach than with the standard position and conventional approach. Further studies with a larger number of patients, assessment of the learning curve, and analysis of the impact of this technique on comorbidities (unchanged cerebral perfusion) are needed to fully validate this technique.

Anterograde Intramedullary Nailing without Bone Grafting for Humeral Shaft Nonunion Associated with Early Exploration of Secondary Radial Nerve Palsy: A Case Report

BACKGROUND

Humeral shaft fractures are relatively common. Complications associated with this type of fracture and its treatment include nonunion and radial nerve palsy. Plate osteosynthesis with autologous bone grafting is considered the gold standard for treating nonunion. However, bone grafts might not always be necessary in cases of hypertrophic nonunion, and treatment should be tailored to the specific type and characteristics of the nonunion. The treatment of radial nerve palsy is debated, with some favoring expectant management based on the nerve's ability to regenerate, and others preferring early surgical exploration to prevent possible lasting nerve damage.

METHODS

We present the case of a 46-year-old male patient with a six-year-old humeral shaft fracture resulting in hypertrophic nonunion. We treated the nonunion with anterograde intramedullary nailing without bone grafting. Postoperatively, the patient developed severe radial nerve palsy. After repeated electrophysiological studies, a decision was made to surgically explore the nerve 10 days after the nonunion surgery. The nerve was subsequently found to be intact and treated with neurolysis.

RESULTS

Bony union was shown at six months after nonunion surgery. Four months after the nonunion surgery, the patient started to show clinical signs of nerve recovery, and at 12 months he achieved nearly full clinical recovery of radial nerve function.

CONCLUSIONS

Anterograde intramedullary nailing without autologous bone grafting may be considered an option for treating hypertrophic nonunion. The management of radial nerve palsy requires effective cooperation and communication between patient and physician. Further research is necessary to be able to better predict nerve recovery.

Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials

BACKGROUND

Whether operation is superior to non-operation for humeral shaft fracture remains debatable. We hypothesized that operation could decrease the nonunion and reintervention rates and increase the functional outcomes.

AIM

To compare the clinical efficacy between operative and nonoperative approaches for humeral shaft fractures.

METHODS

We searched the PubMed, Web of Science, ScienceDirect, and Cochrane databases from 1990 to December 2023 for clinical trials and cohort studies comparing the effects of operative and conservative methods on humeral shaft fractures. Two investigators independently extracted data from the eligible studies, and the other two assessed the methodological quality of each study. The quality of the included studies was assessed using the Cochrane risk bias or Newcastle-Ottawa Scale. The nonunion, reintervention and the overall complications and functional scores were pooled and analyzed using Review Manager software (version 5.3).

RESULTS

A total of four randomized control trials and 13 cohort studies were included, with 1285 and 1346 patients in the operative and nonoperative groups, respectively. Patients in the operative group were treated with a plate or nail, whereas those in the conservative group were managed with splint or functional bracing. Four studies were assessed as having a high risk of bias, and the other 13 were of a low risk of bias according to the Newcastle-Ottawa Scale or Cochrane risk bias tool. The operative group had a significantly decreased rate of nonunion [odds ratio (OR) 0.30; 95%CI: 0.23 to 0.40), reintervention (OR: 0.33; 95%CI: 0.24 to 0.47), and overall complications (OR: 0.62; 95%CI: 0.49 to 0.78)]. The pooled effect of the Disabilities of Arm, Shoulder, and Hand score showed a significant difference at 3 [mean difference (MD) -8.26; 95%CI: -13.60 to -2.92], 6 (MD: -6.72; 95%CI: -11.34 to -2.10), and 12 months (MD: -2.55; 95%CI: -4.36 to -0.74). The pooled effect of Visual Analog Scale scores and the Constant-Murley score did not significantly differ between the two groups.

CONCLUSION

This systematic review and meta-analysis revealed a trend of rapid functional recovery and decreased rates of nonunion and reintervention after operation for humeral shaft fracture compared to conservative treatment.

Anterior medial minimally invasive plate osteosynthesis for humeral shaft fractures shows superior early shoulder and elbow function compared to locking compression plate: A retrospective study

INTRODUCTION

Humeral shaft fractures are a common injury of the upper limb, with the primary surgical treatment modality being the locking compression plate (LCP) technique. The advent of Anterior medial minimally invasive plate osteosynthesis (MIPO) technology has led to its gradual implementation in clinical practice. However, the efficacy and long-term outcomes of MIPO require further investigation. The objective of this study is to compare the therapeutic effects of LCP and MIPO in the management of humeral shaft fractures.

METHODS

The present study conducted a retrospective review of patients diagnosed with humeral shaft fractures between June 2016 and December 2019. The patients were divided into MIPO and LCP groups based on the different surgical methods. The study analyzed the length of hospital stay, radiation exposure, operative time, and postoperative Disabilities of the Arm, Shoulder and Hand (DASH) scores using statistical methods.

RESULTS

A total of 53 patients who met the inclusion criteria were included in the study. The MIPO group demonstrated a statistically significant reduction in length of hospital stay compared to the LCP group (length of hospital stay: 5.39 ± 2.23 days vs 12.00 ± 7.19 days, P < 0.001). All patients achieved callus formation after surgery. However, the MIPO group had significantly more radiation exposures than the LCP group (45.96 ± 19.49 vs 5.33 ± 2.20, P < 0.001). Additionally, there was no statistically significant difference observed in the time from admission to surgery, operative time,and healing time between the two groups (the time from admission to surgery: P = 0.593; operative time: P = 0.407; Healing time: P = 0.664). During the postoperative follow-up, the MIPO group exhibited significantly lower 6-week and 3-month DASH scores compared to the LCP group (6-week: 34.17 ± 12.16 vs 45.65 ± 22.94, P = 0.028; 3-month: 17.43 ± 11.70 vs 30.12 ± 9.80, P < 0.001). However, there was no statistically significant difference in the 6-month and 12-month DASH scores between the two groups (6-month: P = 0.787; 12-month: P = 0.058).

CONCLUSION

The MIPO technique provides better short-term functional recovery of the shoulder and elbow compared to the LCP technique in the treatment of humeral shaft fractures, while ensuring equivalent surgical healing.

Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022

Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

Risk factors of poor mid-term shoulder functional outcomes of osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures: a retrospective study with a minimum 5-year follow-up

BACKGROUND

Osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures.

METHODS

We retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups.

RESULTS

Five of the 33 patients had poor shoulder functional outcomes (adjusted Constant score < 55) at a mean follow-up of 7.5 years postoperatively. Proximal protrusion of the nail at the time of bone union (P = 0.004) and older age (P = 0.009) were significantly associated with clinical failure in the univariate analyses. Multivariate analysis showed that proximal protrusion of the nail (P = 0.031) was a risk factor for poor outcomes.

CONCLUSIONS

The findings of this study provide new information on predictive factors affecting mid-term outcomes following osteosynthesis using antegrade nails. Our results demonstrated that proximal protrusion of the nail was significantly associated with poor mid-term functional shoulder outcomes. Therefore, particularly in older adults, it is essential to place the proximal end of the intramedullary nail below the level of the articular cartilage.

Augmented Fixation in Transverse Midshaft Humerus Fractures Using a Nitinol Staple: Surgical Technique and Case Series

Maintaining the reduction of a transverse humeral shaft fracture can be particularly challenging while applying a compression plate for definitive fixation. Nitinol compression staples are being increasingly utilized in orthopedic surgery due to their unique ability to apply continuous compression between staple legs at body temperature. We have found them to be particularly useful in the maintenance of the reduction of transverse humeral shaft fractures before compression plate application. This simple technique allows for the removal of reduction clamps and precise plate placement. We describe our technique for using nitinol compression staples to augment fracture fixation in transverse humeral shaft fractures as well as our experience using this technique in a case series of 4 patients.

The outcome of nonoperative treatment for adult humeral shaft fractures using a U-shaped slab in resource-limited settings: a prospective cohort study

BACKGROUND

Humeral shaft fractures, constituting 3-5% of musculoskeletal injuries, are commonly managed conservatively using functional braces. However, this approach may not be feasible in resource-limited settings. This study aimed to evaluate the functional outcomes of nonoperative treatment for humeral shaft fractures in adults utilizing a U-shaped slab.

METHODS

This prospective study was conducted from August 2021 to August 2022 involving 16-year-old and older individuals who received nonsurgical treatment for humeral shaft fractures at public tertiary hospitals in Rwanda. The assessment focused on various functional outcomes, including alignment, union rate, range of motion, return to activities of daily living, and DASH score.

RESULTS

The study included 73 participants, predominantly males (73.9%), with a median age of 33 years. The union rate was high at 89.04%, and 10.96% experienced delayed union. Radial nerve palsy occurred in 4.11% of patients, but all the patients fully recovered within three months. Despite angular deformities during healing in the majority of participants, these deformities did not significantly impact functional outcomes. According to the international classification of disabilities, 77% of participants achieved a good functional grade.

CONCLUSION

The conservative U-shaped slab method was effective at managing humeral shaft fractures. However, optimal results necessitate careful participant selection and comprehensive rehabilitation education. Implementing these measures can improve the overall success of nonoperative management.

Correlation between Peripheric Blood Markers and Surgical Invasiveness during Humeral Shaft Fracture Osteosynthesis in Young and Middle-Aged Patients

The treatment for humeral shaft fractures (HSFs) is still controversial, consisting of a wide variety of orthopedic osteosynthesis materials that imply different grades of invasiveness. The aim of this study is to investigate the correlation between inflammatory blood-derived markers and the magnitude of the surgical procedure in young and middle-aged patients who sustained these fractures. Observational, retrospective research was conducted between January 2018 and December 2023. It followed patients diagnosed with recent HFSs (AO/OTA 12-A and B) and followed operative treatment. They were split in two groups, depending on the surgical protocol: group A, operated by closed reduction and internal fixation (CRIF) with intramedullary nails (IMNs), and group B, operated by open reduction and internal fixation (ORIF) with dynamic compression plates (DCPs). Statistically significant differences (p < 0.05) between the two groups could be observed in injury on the basis of surgery durations, surgical times, pre- and postoperative neutrophil-per-lymphocyte ratio (NLR), postoperative platelet-per-lymphocyte ratio (PLR), monocyte-per-lymphocyte ratio (MLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI) and aggregate inflammatory systemic index (AISI). The multivariate regression model proposed revealed that NLR > 7.99 (p = 0.007), AISI > 1668.58 (p = 0.008), and the surgical times (p < 0.0001) are strongly correlated to the magnitude of the surgical protocol followed. Using receiver operating characteristic (ROC) curve analysis, a balanced reliability was determined for both postoperative NLR > 7.99 (sensitivity 75.0% and specificity 75.6) and AISI > 1668.58 (sensitivity 70.6% and specificity 82.2%). Postoperative NLR and AISI as inflammatory markers are highly associated with the magnitude of surgical trauma sustained during humeral shaft fracture osteosynthesis in a younger population.

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.

Top fifty cited articles on humeral fractures

Background

Humeral fractures (HF) are common orthopedic pathologies. Reviewing the content and quality of influential literature over time is important to advance scientific research regarding a specific topic. This study aims to explore and appraise the fifty most cited HF studies that had been published in orthopedic literature.

Methods

The Web of Science database was used to conduct a systematic search for articles pertaining to HF. Articles were sorted out in descending order of citations and were included based on their relevance to HF. Data and metrics of the included studies were recorded. The methodological quality of the studies was assessed using the Modified Coleman Methodology Score (MCMS) and the Methodological Index for Non-randomized Studies criteria. Statistical analysis was conducted to explore any significant relationships between the date of publication and other relevant variables.

Results

Included articles (N = 50) were published between 1959 and 2015, with a total of 14,864 accumulated citations. Europe and North America contributed to all but one of the included studies. The Journal of Bone and Joint Surgery contributed to the highest number of included articles with 27 articles (54%). The proximal humerus was the most commonly explored HF location in our study (72%). The average MCMS and Methodological Index for Non-randomized Studies scores were reported to be 64.6 and 10.4, respectively, and the majority of articles (52%) were considered level four case series. Year of publication was found to have a positive correlation with increasing level of evidence(r = -0.301, P = .044), citation density (r = 0.734, P < .001), and MCMS score (r = 0.41, P = .01).

Conclusion

The level of evidence, MCMS scores, and citation density of influential HF literature has been increasing with time, reflecting the increasing effort and work being put in that field. While the findings seem encouraging, additional high-quality research is needed to help achieve better treatment strategies and outcomes.

Comparing the Clinical and Radiographic Outcomes of Humeral Shaft Fractures by Treatment Type

PURPOSE

Humeral shaft fractures are common orthopedic injuries, representing 1-5% of all fractures. There is conflicting literature regarding the superiority of operative versus nonoperative treatment of these fractures. The purpose of this study was to examine functional outcomes and time to radiographic union in humeral shaft fractures with the hypothesis that both would be improved in patients treated operatively relative to those treated nonoperatively.

METHODS

This retrospective cohort study examined patients with humeral shaft fractures treated at a single large healthcare system between 2010 and 2020. A chart and radiograph review were performed to collect information on demographics, fracture, treatment, and outcome information. These measures were compared between patients treated operatively and nonoperatively.

RESULTS

Five hundred seventeen adult patients meeting inclusion criteria were identified; 233 were treated nonoperatively, and 284 were treated operatively. The mean patient age was 50.2 years in those who underwent surgery relative to 59.9 years in those treated without surgery (P<0.001). Operatively-treated patients had significantly faster time to radiographic union at a median of 113 days compared to a median of 161 days in nonoperatively-treated patients (P=0.001). The operative group was made weight-bearing as tolerated significantly faster than the nonoperative group (84 days versus 98 days, respectively, P=0.002). No statistically significant difference was seen between the two treatment groups in rates of complications or range of motion at the time of radiographic union. However, patients who underwent surgery were found to be up to two times more likely to achieve full shoulder forward elevation by the time of their final follow-up than those treated without surgery (P=0.011).

CONCLUSION

Patients with humeral shaft fractures treated operatively have faster time to union, earlier weight bearing, and no change in the rate of complications compared to patients treated nonoperatively.

Integrated Physical Therapy in a Unique Case of Holstein-Lewis Fracture With Radial Palsy: A Case Report

The term "Holstein-Lewis fracture" describes a spiral fracture that occurs in the shaft of the humerus at its distal third, which has been linked to radial nerve palsy in adults, and operative treatment is the preferred method of treating the trapped nerve at the fracture site. This paper describes a clinical case involving a 20-year-old male patient demonstrating a humeral fracture syndrome accompanied by complications associated with radial nerve palsy. After the necessary investigation, he was diagnosed with a Holstein-Lewis fracture with radial nerve paralysis; he underwent open reduction internal fixation (ORIF), after which he was referred to physical therapy. Developing a successful postoperative rehabilitation program that consists mostly of functional physical therapy interventions is essential for the treatment of this condition. Outcome measures like the Numerical Pain Rating Scale (NPRS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Patient-Rated Wrist Evaluation (PRWE) score were recorded before and after rehabilitation, and pain reduction, improvement in strength, range of motion (ROM), grip strength, and activities of daily living (ADL) were found. The purpose of this case report is to present a comprehensive treatment plan that includes ROM exercises, cryotherapy, and strengthening of grip using a robotic glove for a patient who had a wrist drop and underwent ORIF surgery. This tailored intervention was effective in speeding up the return of functional abilities and improving function in ADLs.

Dynamic Compression Plating Versus Antegrade Intramedullary Nailing for the Treatment of OTA/AO 12-A Fractures: A Retrospective Cohort Study

BACKGROUND

Fractures of the humerus diaphysis are common and often result from motor vehicle accidents (MVAs). Treatment methods range from nonoperative approaches to various operative techniques, including antegrade intramedullary nailing (AIMN) and dynamic compression plate (DCP) fixation. This study aimed to compare the cost effectiveness and outcomes of plating and nailing for humerus diaphyseal fractures.

METHODS

 A retrospective cohort study involving 59 cases of humerus diaphyseal OTA/AO 12-A fractures was conducted at King Saud Medical City (KSMC), a level I trauma center located in the center region in Riyadh, Saudi Arabia. Patients treated with AIMN, anterolateral plating, or posterior plating were included. Data on demographics, clinical parameters, radiographic healing, and costs were collected and analyzed.

RESULTS

The average surgical duration was shorter in the AIMN group compared to the anterolateral and posterior plating groups but with no statistical significance (P > 0.05). The average length of stay (LOS) was shorter, and the change in hemoglobin levels was lower in the AIMN group when compared to other groups but without a statistically significant difference (P > 0.05). The average cost of AIMN was significantly higher than that of anterolateral and posterior plating groups (P < 0.0001).

CONCLUSION

 While both nailing and plating procedures are options for treating OTA/AO 12-A fractures, AIMN carries a higher overall procedural cost. The practice of drain placement in our study population is likely the cause of the increased LOS in the plating groups. Relative additional analgesic requirements were associated with AIMN. Surgeons should consider meticulous hemostasis to avoid drain placement, which can decrease LOS, thus possibly decreasing unnecessary treatment costs of humerus shaft fractures.

Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials

BACKGROUND

The purpose of this study was to perform a meta-analysis of randomized controlled trials (RCTs) to compare outcomes following intramedullary nailing (IMN) vs. open reduction-internal fixation (ORIF) for humeral shaft fractures.

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. RCTs comparing IMN and ORIF for humeral shaft fractures were included. Clinical outcomes were compared using RevMan. P < .05 was considered statistically significant.

RESULTS

Ten RCTs with 512 patients were included. Overall, 8.4% of patients treated with IMN and 6.4% of patients treated with ORIF had nonunion (P = .57, I2 = 0%), with a significantly faster time to union with IMN (10 weeks vs. 11.9 weeks, P < .05). There was no significant difference in the rate of reoperation (11.6% in IMN group vs. 7.6% in ORIF group, P = .26) or radial nerve palsy (2.8% in IMN group vs. 4.2% in ORIF group, P = .58). A lower rate of infection was noted with IMN (1.2% vs. 5.3%, P < .05). Additionally, there was a lower operative time with IMN (61 minutes vs. 88 minutes, P < .05).

CONCLUSIONS

The Level I evidence in the literature does not show a significant difference in rates of union, reoperation, or radial nerve palsy between IMN and ORIF for humeral shaft fractures. Overall, treatment with IMN results in a lower infection rate, less operative time, and a modestly quicker time to union. The optimal treatment strategy for humeral shaft fractures may be best informed by fracture pattern and surgeon preference.

Medial minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures: a case series and novel technique description

INTRODUCTION

Minimally Invasive Percutaneous Plate Osteosynthesis (MIPPO) is increasingly favored for treating humeral shaft fractures (HSFs). However, conventional MIPPO techniques pose challenges in fixing fractures near fossa olecranon and carry a risk of iatrogenic radial nerve palsy. A novel technique using a medial MIPPO for treating humeral shaft fractures (HSFs) is described. Results of clinical follow-up are presented.

MATERIALS AND METHODS

This study is a retrospective case series study. Twenty-one patients (mean age 43.9 ± 17.66 [22‒81] years) with HSFs were treated with the novel MIPPO fixation method. Clinical outcomes including time for radiographic consolidation, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and complications were assessed at the last follow-up. The mean follow-up was 26 ± 17.12 (range 12-67) months.

RESULTS

All patients had a bony union at a mean of 15.76 ± 6.74 (range 8-40) weeks based on X-ray with an early and aggressive range of motion. The complication rate was 0. The mean DASH score was3.29 ± 4.09 (range 0-14.17) at the time of the last follow-up. The mean screw density was 0.49 ± 0.1 (range 0.2-0.65).

CONCLUSION

This novel surgical technique for HSFs is a viable alternative to previously described methods with the advantage of being less prone to nerve injury and easy to fix distal extra-articular HSFs. The learning curve is short.

LEVEL OF EVIDENCE

IV.

A Rare Encounter: Unravelling the Enigma of a Bilateral Humerus Shaft Fracture With a Unique Mode of Injury

Humerus bone fractures make up 4-6% of all adult fractures, of which proximal humerus shaft fracture is only six percent. Simultaneous occurrences of bilateral humerus shaft fractures are infrequently encountered in clinical practice. Precise statistics regarding these injuries are lacking, with scant documentation in the existing literature concerning the subject matter. These fractures may arise due to convulsions triggered by incidents like an electric shock, epilepsy, alcohol withdrawal, and hypoglycemia, which typically give rise to sudden and excessive muscular contractions. Such fractures usually coincide with dislocations of the shoulder joint. However, in our case, the bilateral humerus shaft fractures were caused by physical injuries despite the individual remaining conscious throughout the ordeal. We present a clinical scenario wherein a 28-year-old male sustained fractures in both humerus shafts as a consequence of a road traffic collision with a unique mode of injury, i.e., both the arms of the patient hitting the trolley of a stationary truck. Radiographic investigation revealed a mid-arm shaft fracture on the right side and a fracture of the proximal one-third of the humerus shaft on the left side. He was managed with closed reduction and internal fixation with intramedullary (CRIF) nailing on the right side, and open reduction and internal fixation (ORIF) with plate osteosynthesis for the left side were done. So this is a compelling rare case of bilateral humerus shaft fracture following high-velocity trauma with a unique mode of injury, treated operatively with satisfactory results on follow-up.

Unchanged incidence but change in treatment trends from 1996 to 2018: 23,718 humeral shaft fractures from the Danish National Patient Registry

BACKGROUND AND PURPOSE

Humeral shaft fractures (HSF) can be treated surgically or non-surgically. National trends and distributions are sparsely reported. We present the temporal trends in epidemiology of adult HSF in Denmark, with the primary aim of reporting HSF incidences, and the secondary aim of reporting on the primary treatment management.

PATIENTS AND METHODS

The diagnosis (International Classification of Diseases Version 10 [ICD-10]: S42.3) and surgical procedure codes for HSF were obtained from the Danish National Patient Registry (DNPR) covering 1996-2018. The diagnosis code for HSF is validated in the DNPR with a positive predictive value of 89%. Patients aged 18 years and above were included. Surgical treatment was defined as a diagnosis of HSF combined with a surgical procedure within 3 weeks of injury. Cases without relevant registered procedures within 3 weeks were defined as nonsurgical treatment cases.

RESULTS

23,718 HSF (62% female) were identified in the DNPR. The overall mean incidence was 25/100,000/year and was stable over 23 years. The population above 50 years accounted for 78% of all HSF. Non-surgical treatment accounted for 87% of treatments and was stable during the study period. Temporal changes were observed regarding surgical procedures; intramedullary nailing decreased from 57% to 26% and plate osteosynthesis increased from 12% to 69%.

CONCLUSION

The overall incidence for HSF remained stable from 1996 to 2018. Most cases were females aged 50 years and above. The preferred primary treatment for HSF was non-surgical for all ages. Plate osteosynthesis became more popular than intramedullary nailing over the study period.

Proximal fracture line extension in humeral shaft fractures

Introduction

Humeral shaft fractures are common injuries treated by orthopaedic surgeons. The purpose of this study is to evaluate displaced diaphyseal humerus fractures and describe the incidence and characteristics associated with non or minimally displaced fracture line extension into the proximal metadiaphyseal region of the humerus.

Methods and materials

All adult patients with diaphyseal humeral shaft fractures located within the distal two-thirds of the humeral shaft, treated at a single level I trauma institution between 2007 and 2020, were retrospectively identified. 202 patients with 203 fractures of the humeral shaft were included. Fracture patterns were classified according to AO/OTA classification and fracture line extension into the proximal metadiaphyseal region was evaluated on radiographs. Patient demographics, management details, and radiographic outcomes were obtained from review of the electronic medical record.

Results

Of 203 diaphyseal humerus fractures, 11.8 % (n = 24) had non or minimally displaced proximal extension of their main fracture line. This included 43.7 % (n = 7) of all proximal third junction diaphyseal fractures, 10.7 % (n = 16) of all middle third diaphyseal fractures, and 2.6 % (n = 1) of all distal third diaphyseal fractures. Patients with proximal fracture extension were, on average, older (61.7 versus 44.4 years, p < 0.001), and a higher percentage were female (75 % versus 45.5 %, p < 0.01) compared to patients without fracture proximal extension. Fractures with proximal extension were all closed fractures (n = 24), were more often sustained from low-energy fall (87.5 % versus 35.2 %, p < 0.001), and were more often spiral type fractures (62.5 % versus 17.2 %). Fractures with proximal extension were more often treated non-operatively (58.3 % versus 42.1 %, p < 0.01), but were found to have a higher rate of nonunion after non-operative treatment (17.6 % versus 8.1 %) compared to fractures without proximal extension. All operatively treated fractures that had proximal metaphyseal extension were secured with a fixation construct to achieve fixation proximal to the extent of the fracture line, most often into the humeral head and neck. Operative management with proximal fixation into the humeral head was also pursued for a patient with nonunion, including persistent lucency of the proximal extension line, after failed non-operative treatment. Mean follow-up was 35.5 weeks (range: 0-607 weeks).

Conclusions

Proximal fracture line extension in the setting of diaphyseal humerus fractures is not uncommon. Detection and consideration of this sometimes subtle finding is important when planning to treat these injuries operatively.

Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials

PURPOSE

Humeral shaft fractures (HSFs) can be treated non-operatively (Non-OP), with open reduction and plate osteosynthesis (ORPO), minimally invasive plate osteosynthesis (MIPO), or with intramedullary nails (IMN). However, the best treatment for HSFs still remains controversial.We performed a network meta-analysis to explore which should be the best method for HSFs.

METHODS

The computerized search had been conducted on electronic databases PubMed, EMBASE, Cochrane Library, and Medline from the establishment of the database to the end of December 2022. The quality evaluation of the included literature had been completed by Review Manager (version 5.4.1). Stata 17.0 software (Stata Corporation, College Station, Texas, USA)was used for network meta-analysis.We included randomized controlled trials (RCTs) comparing different treatments to treating HSFs.

RESULTS

The pairwise comparison results demonstrated that there was no statistical difference between IMN, MIPO, Non-OP, and ORPO in terms of radial nerve injury and infection, and Non-OP presented significantly more nonunion than ORPO, IMN, and MIPO. However, no statistically significant difference between ORPO, IMN, and MIPO was discovered. The results of the network meta-analysis displayed that surface under the cumulative ranking curve (SUCRA) probabilities of IMN, MIPO, Non-OP, and ORPO in radial nerve injury were 46.5%, 66.9%, 77.3%, and 9.3%, respectively, in contrast, that in infection were 68.6%, 53.3%, 62.4%, and 15.4%, respectively, and that in nonunion were 51.7%, 93.1%, 0.7%, and 54.5%, respectively.

CONCLUSION

We came to the conclusion that MIPO is currently the most effective way to treat HSFs.

TRIAL REGISTRATION

Name of the registry: Prospero, 2. Unique Identifying number or registration ID: CRD42023411293.

Successful treatment of a multifocal comminuted open fracture of humerus with severe soft tissue defect: a case report

BACKGROUND

Choosing the appropriate treatment approach for a multifocal comminuted open fracture of humerus with severe soft tissue defect is a challenging issue, which could be interesting for every orthopedic surgeon especially for those working in the trauma centers.

CASE PRESENTATION

This study described an innovative approach using titanium elastic nailing to treat a multifocal comminuted open fracture of humerus with severe soft tissue defect. In this study, we report a 40-year-old Persian female patient in whom the treatment achieved complete fracture union and skin graft healing by elastic medullary nailing, vacuum dressing, and skin grafting.

CONCLUSIONS

Elastic medullary nailing is a viable option for reconstruction of simultaneous comminuted fracture and soft tissue defect.

Humeral torsional side differences after nonoperative treatment of proximal humerus fractures and humeral shaft fractures: clinical and ultrasonographic assessment

BACKGROUND

The purposes of this study were to investigate (1) sonographic humeral torsion (SHT) and side differences (∆SHT), and (2) to determine the relationship between SHT and range of rotational motion (RORM) as well as functional outcome scores of nonoperatively treated proximal humerus fractures (PHF) and humeral shaft fractures (HSF).

METHODS

Between October 2020 and July 2021, consecutive patients with radiographically healed nonoperatively treated PHF and HSF were included in this analysis. Subjective perception of torsional side difference, correlation between SHT and RORM, Subjective Shoulder Value as well as absolute and adjusted Constant Score were determined. Degree of humeral torsional side differences were classified as follows: 0°-15°: minor; > 15°-30°: moderate; > 30°: major. Factors including gender, hand dominance, fracture type, and displacement were also assessed in order to investigate any association between these variables and ∆SHT.

RESULTS

Sixty-five patients with nonoperatively treated PHF (n = 47) and HSF (n = 18) were analyzed. Mean follow-up was 13.2 months (range, 2.1-72.6). The majority (80% (52)) resulted in only minor, 15.4% (10) in moderate, and 4.6% (3) in major torsional side differences. Patients with minor or moderate torsional differences did not perceive any subjective side difference. While RORM correlated fairly to highly with functional outcomes, only very low to low correlation was observed between these measures and SHT and ∆SHT. Gender, fracture displacement, and type of fracture were not related to SHT and ∆SHT. However, significantly greater torsional side differences were observed, when the dominant side was involved (p = 0.026).

CONCLUSION

Nonoperative early functional treatment of proximal humerus and humeral shaft fractures results mainly in only minor humeral torsional side differences. Minor and moderate amounts of torsional side differences might not be perceived by patients.

[Effectiveness comparison of two minimally invasive plate osteosynthesis techniques for proximal humeral shaft fractures]

Objective

To compare the effectiveness of lateral approach minimally invasive plate osteosynthesis (MIPO) and helical plate MIPO in the treatment of proximal humeral shaft fractures.

Methods

The clinical data of patients with proximal humeral shaft fractures who underwent MIPO via lateral approach (group A, 25 cases) and MIPO with helical plate (group B, 30 cases) between December 2009 and April 2021 were retrospectively analyzed. There was no significant difference in gender, age, injured side, cause of injury, American Orthopaedic Trauma Association (OTA) fracture classification, and time from fracture to operation between the two groups ( P>0.05). The operation time, intraoperative blood loss, fluoroscopy times, and complications were compared between two groups. The angular deformity and the fracture healing were evaluated according to anteroposterior and lateral X-ray films postoperatively. The modified University of California Los Angeles (UCLA) score for shoulder and the Mayo Elbow Performance (MEP) score for elbow were analyzed at last follow-up.

Results

The operation time in group A was significantly shorter than that in group B ( P<0.05). However, the intraoperative blood loss and fluoroscopy times presented no significant difference between the two groups ( P>0.05). All patients were followed up 12-90 months, with an average of 19.4 months. There was no significant difference in follow-up time between the two groups ( P>0.05). In terms of the quality of postoperative fracture reduction, there were 4 (16.0%) and 11 (36.7%) patients with angulation deformity in group A and group B, respectively, and there was no significant difference in the incidence of angulation deformity ( χ 2=2.936， P=0.087). All fractures achieved bony union, there was no significant difference in fracture healing time between group A and group B ( P>0.05); delayed union occurred in 2 cases and 1 case in group A and group B, respectively (healing time was 30, 42, and 36 weeks after operation, respectively). In group A and group B, 1 patient had superficial infection of incision, respectively; 2 patients and 1 patient had subacromial impact after operation, respectively; and 3 patients in group A had symptoms of radial nerve paralysis of different degrees; all of them were cured after symptomatic treatment. The overall complication incidence of group A (32%) was significantly higher than that of group B (10%) ( χ 2=4.125, P=0.042). At last follow-up, there was no significant difference in the modified UCLA score and MEPs score between the two groups ( P>0.05).

Conclusion

Both lateral approach MIPO and helical plate MIPO can achieve satisfied effectiveness in the treatment of proximal humeral shaft fractures. Lateral approach MIPO may be beneficial to shorten the operation time, while the overall complication incidence of helical plate MIPO is lower.

Derotational osteotomy and internal fixation of a 180° malrotated humerus: A case report

BACKGROUND

Humeral shaft fractures are relatively common in adults. Rotational malalignment is reported as one complication but severe rotational deformity of the humerus is extremely rare. To our knowledge, only three cases of symptomatic humeral malrotation have been reported. There are sparse literature reports of humeral reconstruction correction.

CASE SUMMARY

We present a case of extreme rotational deformity of the humerus (180°) after humeral shaft fracture. The patient complained of pain and difficulties with activities of daily living. In addition, she found the deformity cosmetically unacceptable. Therefore, she was searching for surgical correction. Neurolysis of the radial nerve followed by derotational osteotomy of the humerus and internal fixation were performed. Postoperatively, the patient demonstrated transient iatrogenic radial nerve palsy which recovered completely during postoperative follow-up. The Disabilities of the Arm, Shoulder, and Hand score improved from 55 preoperatively to 16 at the final 2-year follow-up.

CONCLUSION

Single-stage radial neurolysis, derotational osteotomy and stable fixation is a feasible option to improve anatomic and functional problems of severely malrotated humeral shaft fractures.

Helical plating for a re-nonunion and a peri-implant fracture after humeral intramedullary nailing: A report of two cases

Introduction and importance

A re-nonunion after failed intramedullary nailing for a nonunion of the humeral shaft and a peri-implant distal humeral fracture with an ununited humeral shaft are rare cases. Therefore, no consensus has been established regarding the treatment strategies.

Case presentation

Case 1: An 84-year-old woman presented with humeral shaft re-nonunion after intramedullary nailing. The images revealed callus formation and loosening of the implant, suggesting a lack of mechanical stability. Nail removal and helical plating were performed. One year postoperatively, bony union was achieved. Case 2: A 59-year-old woman presented with a peri-implant distal humeral fracture with an ununited humeral shaft after nailing. Nail removal and helical plating were performed using a minimally invasive plate osteosynthesis (MIPO) technique. The distal humeral fracture was fixed with plates. One year postoperatively, bony union was achieved.

Clinical discussion

Imaging findings in Case 1 indicated that nonunion was caused by a lack of mechanical stability. In Case 2, stabilization of the ununited humeral shaft was also needed. Helical plating provides a mechanically strong fixation and prevents damage to the radial nerve and soft tissues.

Conclusion

Evaluating the causative factors of nonunions is important. Helical plating provides mechanical stability and is associated with bony union without autologous bone grafting for a re-nonunion of humeral shaft lacking mechanical instability. For a peri-implant distal humeral fracture with an ununited humeral shaft, helical plating with the MIPO technique provides diaphyseal fracture union and enables the minimal length of distal humeral plate fixation.

•

We report on two cases using helical plating.

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A re-nonunion after failed intramedullary nailing for a humeral shaft nonunion.

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A peri-implant distal humeral fracture with an ununited humeral shaft post-nailing.

•

Considering the causative factors of nonunions is important.

•

Helical plating provides mechanical stability with less soft tissue damage.

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.

DOES CEMENT CURING CAUSE CONCERNING INCREASE OF THE TEMPERATURE WHEN DELIVERED IN THE HUMAN HUMERUS?

For the treatment of humeral fractures, numerous strategies exist to improve the clinical outcome of the reconstruction and to reduce the incidence of fixation failure. Injection of acrylic-based cements to reinforce the bone and/or augment the screws is one option. The heat generated during cement polymerization raises some concerns, as it could cause tissue damage. The first aim of this study was to measure the temperature over time during polymerization when acrylic cements are delivered inside the bone to treat fracture. The second aim was to assess if the ISO-5833:2002 standard can predict what happens in a real bone. Different tests were performed using two acrylic-based cements (Mendec and Cal-Cemex): (i) the ISO-5833:2002 standard (Annex C); (ii) tests on human bones (humeral diaphysis and humeral head) injected with cement to simulate fracture treatment. In the humeri, the highest temperature was measured in the diaphysis (68.6∘C for Mendec, 62.7∘C for Cal-Cemex). These values are comparable with the temperature reached in other consolidated applications (vertebroplasty). Exposure to high temperature was shorter for the diaphysis than for the head. For both cements, in both the diaphysis and the head, temperatures exceeded 48∘C for less than 10[Formula: see text]min. This is within the threshold for tissue necrosis. The ISO-5833:2002 yielded significantly different results in terms of maximum temperature (difference exceeding 15∘C) and exposure to temperature above 48∘C and 45∘C. This discrepancy is probably due to a combination of factors affecting the amount of heat produced and dissipated (e.g., amount and shape of the cement, thermal conductivity).