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Li Y, Luo Y, Peng J, Fan J, Long XT. Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials. World J Orthop 2024; 15:783-795. [PMID: 39165869 PMCID: PMC11331324 DOI: 10.5312/wjo.v15.i8.783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 06/05/2024] [Accepted: 07/11/2024] [Indexed: 08/13/2024] Open
Abstract
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.
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Affiliation(s)
- Yang Li
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Yi Luo
- Department of Orthopedics, Bishan Hospital of Chongqing, Chongqing 402760, China
| | - Jing Peng
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Jun Fan
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
| | - Xiao-Tao Long
- Department of Traumatic Orthopedics, Chongqing General Hospital, Chongqing University, Chongqing 401147, China
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Nshimiyimana A, Ingabire JDLCA, Byiringiro JC, Habumugisha B, Mwizerwa JL. The outcome of nonoperative treatment for adult humeral shaft fractures using a U-shaped slab in resource-limited settings: a prospective cohort study. J Orthop Surg Res 2024; 19:316. [PMID: 38807217 PMCID: PMC11131327 DOI: 10.1186/s13018-024-04794-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 05/12/2024] [Indexed: 05/30/2024] Open
Abstract
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.
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Affiliation(s)
- Alexis Nshimiyimana
- College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda
| | - Jean de la Croix Allen Ingabire
- College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda
- Orthopedic Department, University Teaching Hospital of Kigali, Kigali, Rwanda
| | - Jean Claude Byiringiro
- College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda
- Orthopedic Department, University Teaching Hospital of Kigali, Kigali, Rwanda
| | | | - Jean Luc Mwizerwa
- College of Medicine and Health Science, University of Rwanda, Kigali, Rwanda.
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Unal M, Katı YA, Acar B, Turan A, Ozturk S, Yuksel HY. Single versus double plate fixation of humeral shaft nonunion. Arch Orthop Trauma Surg 2024; 144:693-699. [PMID: 37930359 DOI: 10.1007/s00402-023-05111-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023]
Abstract
INTRODUCTION Humeral shaft fractures are common fractures of the diaphysis of the humerus. The aim of this study was to evaluate factors affecting the clinical outcomes of humeral nonunions surgically treated with open reduction and single- versus double-plate fixation with grafting. MATERIALS AND METHODS A total of 31 patients with nonunion treated with single- or double-plate screw fixation with bone grafting were retrospectively analysed. The patients were divided into two groups according to the treatment method as Group 1 (single-plate, n = 14) and Group 2 (double-plate, n = 17). Data including demographic and clinical characteristics of the patients, initial and final treatment, type of nonunion and localisation, graft use, shortening, follow-up, time to union, Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) scores, and patient-reported cosmetic outcomes were recorded. RESULTS Of the patients, eight were males, and 23 were females, with a mean age of 47.6 ± 15.8 (range, 20-86) years. Initial treatment was conservative treatment (Sarmiento brace) in seven patients, plate fixation in 22 patients, and intramedullary nailing in two patients. The mean follow-up was 31.0 ± 16.9 months in Group 1 and 25.4 ± 15.6 months in Group 2. There was one nonunion in Group 1 and three in Group 2. There were no significant differences in the union rate and time to union (p = 0.378 and p = 0.262, respectively). The mean Quick-DASH scores and cosmetic results were similar between the groups (p = 0.423 and p = 0.165, respectively). Radial nerve palsy developed in three patients in Group 2, and all these patients recovered completely during follow-up. CONCLUSIONS Although the double-plate fixation technique has similar clinical, radiological, and functional results to single-plate fixation, it is a more invasive and expensive technique with a longer operation time. Therefore, it should not be used as the first-line treatment option for all humeral shaft nonunion. Nevertheless, the double-plate technique may be preferred to achieve in cases requiring high stability, such as hypertrophic nonunion, osteopenia and comminuted fractures.
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Affiliation(s)
- Melih Unal
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Yusuf Alper Katı
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey.
| | - Baver Acar
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Adil Turan
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
| | - Serra Ozturk
- Department of Anatomy, Medical Faculty, Akdeniz University, Antalya, Turkey
| | - Halil Yalçın Yuksel
- Department of Orthopedics and Traumatology, Medical Faculty, University of Health Sciences, Antalya Training and Research Hospital, Antalya, Turkey
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Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study. Eur J Trauma Emerg Surg 2022; 48:3265-3277. [PMID: 35138426 PMCID: PMC9360107 DOI: 10.1007/s00068-022-01890-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/21/2022] [Indexed: 11/25/2022]
Abstract
Purpose The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery. Methods From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type. Results Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001). Conclusion Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group. Trial registration NTR3617 (registration date 18-SEP-2012). Supplementary Information The online version contains supplementary material available at 10.1007/s00068-022-01890-6.
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Colombi R, Chauvet T, Labattut L, Viard B, Baulot E, Martz P. Is distal locking screw necessary for intramedullary nailing in the treatment of humeral shaft fractures? A comparative cohort study. INTERNATIONAL ORTHOPAEDICS 2018; 43:2151-2160. [PMID: 30171274 DOI: 10.1007/s00264-018-4091-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 08/02/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE The gold standard for intramedullary nailing (IMN) in humeral shaft fracture treatment is bipolar interlocking. The aim of this study was to compare clinical and radiographic outcomes in two cohorts of patients treated with IMN with or without distal interlocking. We hypothesized that there was no significant difference between isolated proximal interlocking and bipolar interlocking in terms of consolidation and clinical results. METHODS One hundred twenty-one acute humeral shaft fractures were retrospectively included in group WDI (without distal interlocking screw, n = 74) or in group DI (with distal interlocking screw, n = 47). One hundred six patients (87.60%) could be verified by an X-ray, and 63 (52.07%) could be examined clinically. Fracture union at 6 months was the primary outcome, and the second was the final clinical outcome for shoulder and elbow after at least 6 months of follow-up. Pain, operating time, and radiation time were also analyzed. RESULTS The two groups were not significantly different for population, fractures, or immobilization duration. No significant difference was found for bone union (WDI 89.06% vs DI 83.33%, p = 0.51), shoulder or elbow functional outcomes, or pain. However, there were significant differences in advantage to the WDI group for operating time (WDI 63.09 ± 21.30 min vs DI 87.96 ± 30.11 min, p < 0.01) and fluoroscopy time (WDI 59.06 ± 30.30 s vs DI 100.36 ± 48.98 s, p < 0.01). CONCLUSIONS Thus, it seems that there were no significant differences between proximal unipolar and bipolar interlocking for humeral shaft fractures in terms of consolidation and clinical outcomes. WDI avoided the additional operating time and fluoroscopy time and risks linked to DI.
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Affiliation(s)
- Romain Colombi
- Orthopedic and Traumatology Department, Dijon University Hospital, F-21000, Dijon, France
| | - Thomas Chauvet
- Orthopedic and Traumatology Department, Dijon University Hospital, F-21000, Dijon, France
| | - Ludovic Labattut
- Orthopedic and Traumatology Department, Dijon University Hospital, F-21000, Dijon, France
| | - Brice Viard
- Orthopedic and Traumatology Department, Dijon University Hospital, F-21000, Dijon, France
| | - Emmanuel Baulot
- Orthopedic and Traumatology Department, Dijon University Hospital, F-21000, Dijon, France.,INSERM UMR1093-CAPS, Burgundy Franche-Comté university, F-21000, Dijon, France
| | - Pierre Martz
- Orthopedic and Traumatology Department, Dijon University Hospital, F-21000, Dijon, France. .,INSERM UMR1093-CAPS, Burgundy Franche-Comté university, F-21000, Dijon, France. .,Orthopedic and Traumatology Department, CHU Dijon, 14 rue Paul Gaffarel, 21079, Dijon CEDEX, France.
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Cunningham BP, Brazina S, Morshed S, Miclau T. Fracture healing: A review of clinical, imaging and laboratory diagnostic options. Injury 2017; 48 Suppl 1:S69-S75. [PMID: 28483359 DOI: 10.1016/j.injury.2017.04.020] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A fundamental issue in clinical orthopaedics is the determination of when a fracture is united. However, there are no established "gold standards," nor standardized methods for assessing union, which has resulted in significant disagreement among orthopaedic surgeons in both clinical practice and research. A great deal of investigative work has been directed to addressing this problem, with a number of exciting new techniques described. This review provides a brief summary of the burden of nonunion fractures and addresses some of the challenges related to the assessment of fracture healing. The tools currently available to determine union are discussed, including various imaging modalities, biomechanical testing methods, and laboratory and clinical assessments. The evaluation of fracture healing in the setting of both patient care and clinical research is integral to the orthopaedic practice. Weighted integration of several available metrics must be considered to create a composite outcome measure of patient prognosis.
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Affiliation(s)
| | | | - Saam Morshed
- Orthopaedic Trauma Institute San Francisco, CA, USA
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Chamseddine AH, Abdallah A, Zein H, Taha A. Transfracture medial transposition of the radial nerve associated with plate fixation of the humerus. INTERNATIONAL ORTHOPAEDICS 2017; 41:1463-1470. [DOI: 10.1007/s00264-016-3397-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 12/28/2016] [Indexed: 10/20/2022]
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Abstract
Determining whether a bone fracture is healed is one of the most important and fundamental clinical determinations made in orthopaedics. However, there are currently no standardized methods of assessing fracture union, which in turn has created significant disagreement among orthopaedic surgeons in both clinical and research settings. An extensive amount of research has been dedicated to finding novel and reliable ways of determining healing with some promising results. Recent advancements in imaging techniques and introduction of new radiographic scores have helped decrease the amount of disagreement on this topic among physicians. The knowledge gained from biomechanical studies of bone healing has helped us refine our tools and create more efficient and practical research instruments. Additionally, a deeper understanding of the molecular pathways involved in the bone healing process has led to emergence of serologic markers as possible candidates in assessment of fracture union. In addition to our current physician centered methods, patient-centered approaches assessing quality of life and function are gaining popularity in assessment of fracture union. Despite these advances, assessment of union remains an imperfect practice in the clinical setting. Therefore, clinicians need to draw on multiple modalities that directly and indirectly measure or correlate with bone healing when counseling patients.
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Affiliation(s)
- Saam Morshed
- Department of Orthopaedic Surgery, University of San Francisco School of Medicine, San Francisco, CA 94143-0410, USA
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Chamseddine AH, Zein HK, Alasiry AA, Mansour NA, Bazzal AM. Trans-fracture transposition of the radial nerve during the open approach of humeral shaft fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2012; 23:725-30. [PMID: 23412197 DOI: 10.1007/s00590-012-1065-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 07/28/2012] [Indexed: 11/30/2022]
Abstract
The radial nerve constitutes a major problem in humeral shaft fractures; it may be injured immediately or during closed reduction or open reduction and internal fixation with plate and screws. After fixation, the nerve always runs directly over the plate without any interposed structure. If a revision surgery is indicated, the nerve is at high risk as it is usually difficult to dissect from surrounding fibrotic scar tissue or callus formation. To avoid these complications, some authors reported transposition of the radial nerve through the fracture line. We present herein the surgical technique of the trans-fracture transposition of the radial nerve during open reduction and internal fixation of humeral shaft fractures, along with our preliminary results in 6 cases and a review of the literature.
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Affiliation(s)
- Ali H Chamseddine
- Department of Orthopaedic and Trauma Surgery, Sahel General Hospital, University Medical Centre, PO Box 99/25, Ghoubeiry, Beirut, Lebanon.
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Lekic N, Montero NM, Takemoto RC, Davidovitch RI, Egol KA. Treatment of two-part proximal humerus fractures: intramedullary nail compared to locked plating. HSS J 2012; 8:86-91. [PMID: 23874244 PMCID: PMC3715617 DOI: 10.1007/s11420-012-9274-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2012] [Accepted: 04/09/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Two-part proximal humerus fractures are common orthopedic injuries for which surgical intervention is often indicated. Choosing a fixation device remains a topic of debate. PURPOSE The purpose of this study is to compare two methods of fixation for two-part proximal humerus fractures, locking plate (LP) with screws versus intramedullary nailing (IMN), with respect to alignment, healing, patient outcomes, and complications. To our knowledge, a direct comparison of these two devices in treating two-part proximal humerus fractures has never before been studied. We hope that our results will help surgeons assess the utility of LP versus IMN. METHODS A retrospective chart review was performed on 24 cases of displaced two-part surgical neck fractures of the humerus. Twelve shoulders were treated using IMN fixation and 12 others were fixated with LP. Data collected included sociodemographic, operative details, and postoperative care and function. RESULTS Radiographic comparison of fixation demonstrated an average neck-shaft angle of 124° and 120° in the IMN group and LP group, respectively. Adjusted postoperative 6-month follow-up range of motion was 134° of forward elevation in the IMN group and 141 in the LP group. The differences in range of motion and in complication rates were not found to be significant. CONCLUSIONS Our results suggest that either LP fixation or IMN fixation for a two-part proximal humerus fracture provides acceptable fixation and results in a similar range of shoulder motion. Although complication rates were low and insignificant between the two groups, a trend toward increased complications in the IMN group is noted.
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Affiliation(s)
- Nikola Lekic
- />Georgetown University School of Medicine, Washington, DC 20057 USA
| | - Nicole M. Montero
- />New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 USA
| | - Richelle C. Takemoto
- />New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 USA
| | - Roy I. Davidovitch
- />New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 USA
| | - Kenneth A. Egol
- />New York University Hospital for Joint Diseases, 301 E 17th St, New York, NY 10003 USA
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Gosler MW, Testroote M, Morrenhof JW, Janzing HMJ. Surgical versus non-surgical interventions for treating humeral shaft fractures in adults. Cochrane Database Syst Rev 2012; 1:CD008832. [PMID: 22258990 DOI: 10.1002/14651858.cd008832.pub2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Fractures of the shaft of the humerus account for 1% to 3% of all fractures in adults. The management of these fractures, including surgical intervention, varies widely. OBJECTIVES To assess and compare the effects of surgical versus non-surgical intervention for non-pathological fractures of the humeral shaft in adults. SEARCH METHODS We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, trial registers, and bibliographies of trial reports. The full search was conducted in October 2011. SELECTION CRITERIA Considered for inclusion were all randomised and quasi-randomised (method of allocating participants to a treatment which is not strictly random; e.g. by date of birth, hospital record number or alternation) controlled trials that compared surgical with non-surgical intervention for humeral shaft fractures in adults. DATA COLLECTION AND ANALYSIS Two authors independently selected and assessed potential eligible studies for inclusion. MAIN RESULTS We found six completed studies that appeared to meet our inclusion criteria. After scrutiny, we excluded all six studies: five were retrospective studies and one was a prospective study without randomisation. We identified three potentially eligible ongoing studies, two of which involve randomisation of treatment allocation and one, which we excluded, that does not. AUTHORS' CONCLUSIONS There is no evidence available from randomised controlled trials to ascertain whether surgical intervention of humeral shaft fractures gives a better or worse outcome than no surgery. Sufficiently powered good quality multi-centre randomised controlled trials comparing surgical versus non-surgical interventions for treating humeral shaft fractures in adults are needed. It is likely that the results from the two ongoing randomised trials on this topic will help inform practice in due course.
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Affiliation(s)
- Maurits W Gosler
- Department of Surgery and Orthopaedic Surgery, Viecuri Medical Centre of Northern Limburg, Venlo,
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12
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Heineman DJ, Poolman RW, Nork SE, Ponsen KJ, Bhandari M. Plate fixation or intramedullary fixation of humeral shaft fractures. Acta Orthop 2010; 81:216-23. [PMID: 20170424 PMCID: PMC2895341 DOI: 10.3109/17453671003635884] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The optimal approach to operative treatment of humeral shaft fractures remains debatable. Previously published trials have been limited in size and have been inconclusive regarding important patient outcome variables following treatment with either intramedullary nails or plates. We conducted a meta-analysis of available trials comparing treatment of humeral shaft fractures. METHODS We performed a literature search from 1967 to November 2007 in the main medical search engines and selected 4 randomized trials that compared nails and plates in patients with humeral shaft fractures and that reported on complications due to surgery. We statistically pooled patient data using standard meta-analytic approaches. Our primary outcome was the total complication rate, comprised of all complications listed in the articles included. Secondary outcomes included non-union, infection, nerve palsy, and reoperation rate. Methodology was assessed using the CLEAR NPT. RESULTS When pooling the data of the 4 trials (n = 203 patients), we did not find a statistically significant difference between implants in the rate of total complications, non-union, infection, nerve-palsy, or the need for reoperation. The studies included were small and had methodological limitations. CONCLUSIONS Our meta-analysis suggests stastistically insignificant differences between plates and nails in the treatment of humeral shaft fractures. Small sample sizes, study heterogeneity, and methodological limitations argue strongly for a definitive, large trial. We recommend that this trial should be a randomized controlled trial with appropriate allocation of patients and blinding of patients and care providers and outcome assessors, and that it should include patient-important outcomes.
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Affiliation(s)
- David J Heineman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdamthe Netherlands
| | - Rudolf W Poolman
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdamthe Netherlands
| | - Sean E Nork
- Department of Orthopaedic Surgery, Harborview Medical Center, University of Washington, Seattle, WAthe Netherlands
| | - Kees-Jan Ponsen
- Trauma Unit, Department of Surgery, AMC, Amsterdamthe Netherlands
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ONCanada
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Abstract
Despite the enormous progress made during recent decades in the treatment of long-bone fractures, fracture healing is still haunted by complications and above all non-unions. Non-unions represent a particular challenge, and the difficulties surrounding their management are frequently underestimated. Knowledge of the epidemiology of long-bone non-union can assist the treating surgeon in the application of the optimum fracture treatment.
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Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. ACTA ACUST UNITED AC 2006; 88:1469-73. [PMID: 17075092 DOI: 10.1302/0301-620x.88b11.17634] [Citation(s) in RCA: 197] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We studied the epidemiology of 401 fractures of the shaft of the humerus in 397 patients aged 16 years or older. The incidence was 14.5 per 100 000 per year with a gradually increasing age-specific incidence from the fifth decade, reaching almost 60 per 100 000 per year in the ninth decade. Most were closed fractures in elderly patients which had been sustained as the result of a simple fall. The age distribution in women was characterised by a peak in the eighth decade while that in men was more even. Simple fractures were by far the most common and most were located in the middle or proximal shaft. The incidence of palsy of the radial nerve was 8% and fractures in the middle and distal shaft were most likely to be responsible. Only 2% of the fractures were open and 8% were pathological. These figures are representative of a population with a low incidence of high-energy and penetrating trauma, which probably reflects the situation in most European countries.
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Affiliation(s)
- R Ekholm
- Department of Orthopaedics, Stockholm Söder Hospital, Stockholm, Sweden.
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Chantelot C, Ferry S, Lahoude-Chantelot S, Prodomme G, Guinand C, Fontaine R. Étude rétrospective des résultats du traitement chirurgical de 21 pseudarthroses de l'humérus. ACTA ACUST UNITED AC 2005; 24:84-91. [PMID: 15861977 DOI: 10.1016/j.main.2005.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The morbidity of surgery for non-union of the humerus is not insignificant: the aims of this retrospective study were to study the results of these rather difficult procedures and to make some logical suggestions regarding surgical technique. PATIENTS AND METHODS Between 1996 and 2000, 21 patients had a surgical procedure for non-union of the humeral shaft. At follow-up, the mean age was 40 years. The causes of the initial trauma were: 12 road accidents, seven standing height falls, one fall from a window, one farm machine accident. The commonest fracture site was the middle third. In 17 procedures, we performed plate osteosyntesis. Three patients were treated by external fixator because of infection. In one patient we used a nail. For the follow-up evaluation, we used the score of the Western Orthopaedic Society. RESULTS According to the "WOS" score evaluation, we noted: ten very good results, five good results, three poor results and one bad result. The bad result corresponded to the patient in whom consolidation was not obtained. DISCUSSION AND CONCLUSION Management of non-union of the humerus should be by immediate surgery. The best treatment of non-union of the humerus is its prevention by correct management of the initial fracture.
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Affiliation(s)
- C Chantelot
- Service de chirurgie de la main et du membre supérieur, hôpital Roger-Salengro, CHRU de Lille, France.
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Abstract
We reviewed 49 patients following plate osteosynthesis of humeral shaft fractures. There were no complications as a result of surgery. Union occurred in 47 patients (96%) at a mean of 9 weeks. Two patients required secondary procedures to achieve union. All patients had full range of motion in the elbow and shoulder joints following union. In the light of the popularisation of intramedullary nailing techniques in the last decade, with recognised complications of iatrogenic radial nerve injury, inadequate rotational stabilisation, non-union and shoulder impingement, we advocate plating of humeral shaft fractures as the surgical treatment of choice.
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Affiliation(s)
- D M Niall
- Department of Orthopaedic Surgery, The Meath and Adelaide Hospital (incorporating the National Children's Hospital), Tallaght, Dublin 24, Ireland.
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Chantelot C, Robert G, Aihonnou T, Gueguen G, Migaud H, Fontaine C. [Role of external fixators for treatment of humeral fractures: report of 23 cases using Orthofix fixators]. CHIRURGIE DE LA MAIN 2002; 21:134-9. [PMID: 11980341 DOI: 10.1016/s1297-3203(02)00098-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
From 1991 to 1998, 23 humeral fractures has been treated using the Orthofix external fixator. Average age of the patient was 42 y and average follow-up 55.5 m. Initial trauma was: 13 traffic accidents, four falls at home, two devastating farming accidents, two sports accidents, one aggression and one gun accident. AO classification was used and location of the fracture was classified using Hackethal classification modified by de la Caffinière. Majority of fractures were located at the one-third distal humerus and the majority was also comminuted. At follow-up, elbow range of motion was 130 degrees, shoulder range of motion 161 degrees, external rotation 69.5 degrees and internal rotation 92.5 degrees. Using the classification of Stewart and Hundley, eight excellent, seven good, three fair and two bad results were obtained. There were no postoperative radial nerve palsy. Two external fixators had to be removed because of pin mobility. Failures were: non union and pin mobility in one patient which has to be reoperated on; two non unions have been grafted on and plated. There were no malunion in the postoperative X-rays. This device is our favourite for this type of injury because of its rigidity and the possibility of secondary dynamization. The external fixator was removed after union: this explains the long delay of union in our series.
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Affiliation(s)
- C Chantelot
- Service d'orthopédie B, hôpital Roger Salengro, CHRU de Lille, centre hospitalier universitaire, Lille, France
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