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Gan JH, Bearne L, Walters S, Room J, Booth G, Trompeter A, Nikoletou D. The feasibility, acceptability, safety, and effects of early weight bearing in humeral fractures - a scoping review. Disabil Rehabil 2025; 47:519-530. [PMID: 38753460 PMCID: PMC11789713 DOI: 10.1080/09638288.2024.2351594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 04/29/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
PURPOSE Non-weight bearing is often recommended after humeral fractures. This review aims to summarise the extent and nature of the evidence for the feasibility, acceptability, safety, and effects of early weight bearing (EWB) in people with humeral fractures, treated operatively or non-operatively. . METHODS Data sources identified published (PUBMED, EMBASE, CINAHL) and unpublished (ClinicalTrials.gov, CENTRAL, NIHR Open Research, OpenGrey) literature. Independent data extraction was conducted by two reviewers. RESULTS 13 901 records were retrieved. Ten studies, involving 515 post-operative patients and 351 healthcare professionals, were included. EWB was found to be feasible in nine studies. There was limited evidence regarding adherence to EWB. Trauma and orthopaedic surgeons reported that EWB was acceptable. This depended on surgery type and whether it was a post-operative polytrauma case. No acceptability data was reported from patients' perspectives. Only one study reported two patients who developed unsatisfactory outcomes from excessive post-operative EWB. Positive effects of EWB were reported on disability level, pain, shoulder and elbow motion, and union. CONCLUSION There is some evidence for the feasibility, safety, and effectiveness of post-operative EWB after humeral fractures. There was limited data on the acceptability of EWB. Heterogeneous study designs, and variations in EWB protocols limit conclusions.
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Affiliation(s)
- Jia Hui Gan
- Haslemere Community Hospital, Royal Surrey NHS Foundation Trust, Surrey, UK
- Population Health Research Institute, St George’s University of London, London, UK
- Institute of Medical and Biomedical Education, St George’s University of London, London, UK
| | - Lindsay Bearne
- Population Health Research Institute, St George’s University of London, London, UK
| | - Samuel Walters
- Department of Trauma and Orthopaedic Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Jon Room
- Faculty of Health and Life Sciences, Oxford Brookes University, Oxford, UK
- Physiotherapy Research Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Greg Booth
- Population Health Research Institute, St George’s University of London, London, UK
- Therapies Department, Royal National Orthopaedic Hospital Trust, London, UK
| | - Alex Trompeter
- Institute of Medical and Biomedical Education, St George’s University of London, London, UK
- Department of Trauma and Orthopaedic Surgery, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Dimitra Nikoletou
- Institute of Medical and Biomedical Education, St George’s University of London, London, UK
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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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Liguori S, Moretti A, Toro G, Arienti C, Patrini M, Kiekens C, Negrini S, Iolascon G, Gimigliano F. Overview of Cochrane Systematic Reviews for Rehabilitation Interventions in Individuals with Upper Limb Fractures: A Mapping Synthesis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:469. [PMID: 38541195 PMCID: PMC10971878 DOI: 10.3390/medicina60030469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/01/2024] [Accepted: 03/08/2024] [Indexed: 01/06/2025]
Abstract
Background and Objectives. This overview of Cochrane systematic reviews (CSRs) reports on current evidence on the effectiveness of rehabilitation interventions for persons with upper limb fractures (ULFs), and the quality of the evidence. Materials and Methods. Following the inclusion criteria defined by the World Health Organization, all CSRs tagged in the Cochrane Rehabilitation database that were relevant for persons with ULFs were included. A mapping synthesis was used to group outcomes and comparisons of included CSRs, indicating the effect of rehabilitation interventions and the certainty of evidence. Results. A total of three CSRs were included in the evidence map. The certainty of evidence was judged as low to very low. Early occupational and hand therapy, cyclic pneumatic soft tissue compression, and cross-education, when started during immobilization, may improve grip strength and wrist range of motion, with results maintained up to 12 weeks from the cast removal, compared to no intervention. Approaches such as occupational therapy and passive mobilisation, started post-immobilization, are probably safe in terms of secondary complications. However, the overall evidence of rehabilitative interventions related to proximal humeral fractures has been judged insufficient for all the outcomes considered. A paucity of primary studies and CSRs for elbow fractures was noted. Conclusions. This overview provided the effect and the certainty of evidence of rehabilitation interventions available after ULFs using a mapping synthesis. To date, there is a need to further the effectiveness and safety of these interventions for persons with ULFs, improving methodological quality of the research in the field.
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Affiliation(s)
- Sara Liguori
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (A.M.); (G.I.)
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Antimo Moretti
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (A.M.); (G.I.)
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (A.M.); (G.I.)
| | | | - Michele Patrini
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (M.P.); (C.K.); (S.N.)
| | - Carlotte Kiekens
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (M.P.); (C.K.); (S.N.)
| | - Stefano Negrini
- IRCCS Istituto Ortopedico Galeazzi, 20161 Milan, Italy; (M.P.); (C.K.); (S.N.)
- Department of Biomedical, Surgical and Dental Sciences, Università “La Statale”, 20122 Milan, Italy
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (S.L.); (A.M.); (G.I.)
| | - Francesca Gimigliano
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
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Farid AR, Friend TH, Atarere J, Gustin M, Suneja N, Weaver MJ, Von Keudell AG. Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis. J Bone Joint Surg Am 2023; 105:1420-1429. [PMID: 37478297 DOI: 10.2106/jbjs.22.01386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. METHODS We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. RESULTS The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. CONCLUSIONS Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. LEVEL OF EVIDENCE Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander R Farid
- Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Tynan H Friend
- Department of Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Joseph Atarere
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Gustin
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Nishant Suneja
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Michael J Weaver
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
| | - Arvind G Von Keudell
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Orthopaedic Trauma Initiative, Harvard Medical School, Boston, Massachusetts
- Department of Orthopaedic Surgery, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
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Beyer J, Rao B, Liu J, Skie M. Evaluation of Humeral Shaft Fracture Outcomes by Treatment Method: A Systematic Review and Meta-analysis Based on Comparison Studies. JBJS Rev 2023; 11:01874474-202307000-00004. [PMID: 37459427 DOI: 10.2106/jbjs.rvw.23.00037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND The purpose of this systematic review and meta-analysis was to evaluate various outcomes of humeral shaft fractures treated with different treatment methods, which included functional bracing, open reduction and internal fixation, intramedullary nailing, and locked compression plate. METHODS A systematic review was performed using research databases including PubMed, EMBASE, and Google Scholar. Keywords relating to treatment of humeral shaft fractures were used, and comparison studies that reported patient characteristics and outcomes, including nonunion, malunion, function scores, and complications, were included. One hundred fourteen records were screened, with 18 studies ultimately included in the meta-analysis. Treatment groups were consolidated into brace or surgery and then further categorized into subgroups based on surgical technique used. Postoperative events, complications, and functional scores were compared among the treatment groups. Statistical analysis for this study was conducted using Review Manager 5.3, with a standard p-value of ≤0.05 for statistical significance. RESULTS Eighteen studies were included in this review with a total of 706 patients. Z-tests showed that risks of revision, nonunion, and malunion were higher in the brace treatment group compared with the surgical treatment group (p < 0.0001, <0.0001, 0.004, respectively). Risk of infection was expectedly higher in the surgical group compared with the brace group (p = 0.04). Radial nerve injury rates were also higher in the unspecified surgical group compared with the brace group (p = 0.01). In the surgical group, the mean Constant shoulder score was also significantly higher than that in the brace group (p = 0.004). When comparing the nail and plate groups, Z-tests revealed higher risks of delayed unions and other complications in the nail group (p = 0.04 and 0.001, respectively) but higher risk of infection in the plate group (p = 0.05). CONCLUSION The conservative treatment of humeral shaft fractures with functional braces may be associated with a lower incidence of infection and nerve injury when compared with operative treatment methods. However, nonoperative treatment may also come with higher risks of revision, nonunion, and malunion than the many available surgical modalities. Operative management with either intramedullary nail or plate has shown to be a reliable method of management with reasonable outcomes for humeral shaft fractures. While the nail group had higher risk of delayed unions and other complications, the plate group had higher risk of infections. Both nail and plate surgical treatments have shown to result in high union rates and should be considered by the surgeon on a case-by-case basis when treating humeral shaft fractures. LEVEL OF EVIDENCE Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Julia Beyer
- Department of Orthopedic Surgery, University of Toledo Medical Center, Toledo, Ohio
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Kandemir U, Naclerio EH, McKee MD, Weatherby DJ, Cole PA, Tetsworth K. Humerus fractures: selecting fixation for a successful outcome. OTA Int 2023; 6:e259. [PMID: 37533442 PMCID: PMC10392438 DOI: 10.1097/oi9.0000000000000259] [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: 09/28/2022] [Accepted: 12/28/2022] [Indexed: 08/04/2023]
Abstract
Current evidence suggests at least one-third of humeral shaft fractures initially managed nonoperatively will fail closed treatment, and this review highlights surgical considerations in those circumstances. Although operative indications are well-defined, certain fracture patterns and patient cohorts are at greater risk of failure. When operative intervention is necessary, internal fixation through an anterolateral approach is a safe and sensible alternative. Determining which patients will benefit most involves shared decision-making and careful patient selection. The fracture characteristics, bone quality, and adequacy of the reduction need to be carefully evaluated for the specific operative risks for individuals with certain comorbid conditions, inevitably balancing the patient's expectations and demands against the probability of infection, nerve injury, or nonunion. As our understanding of the etiology and risk of nonunion and symptomatic malunion of the humeral diaphysis matures, adhering to the principles of diagnosis and treatment becomes increasingly important. In the event of nonunion, respect for the various contributing biological and mechanical factors enhances the likelihood that all aspects will be addressed successfully through a comprehensive solution. This review further explores specific strategies to definitively restore function of the upper extremity with the ultimate objective of an uninfected, stable union.
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Affiliation(s)
- Utku Kandemir
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA
| | - Emily H. Naclerio
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ
| | - Michael D. McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ
| | - David J. Weatherby
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
- Department of Orthopaedic Trauma, Regions Hospital, Saint Paul, MN
| | - Peter A. Cole
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN
- Department of Orthopaedic Trauma, Regions Hospital, Saint Paul, MN
- HealthPartners, Orthopaedics and Sports Medicine, Bloomington, MN
| | - Kevin Tetsworth
- Royal Brisbane and Women's Hospital, Brisbane, Australia; and
- University of Queensland School of Medicine, Brisbane, Australia
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Van Bergen SH, Mahabier KC, Van Lieshout EMM, Van der Torre T, Notenboom CAW, Jawahier PA, Verhofstad MHJ, Den Hartog D. Humeral shaft fracture: systematic review of non-operative and operative treatment. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04836-8. [PMID: 37093269 PMCID: PMC10374687 DOI: 10.1007/s00402-023-04836-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 03/01/2023] [Indexed: 04/25/2023]
Abstract
INTRODUCTION Humeral shaft fractures can be treated non-operatively or operatively. The optimal management is subject to debate. The aim was to compare non-operative and operative treatment of a humeral shaft fracture in terms of fracture healing, complications, and functional outcome. METHODS Databases of Embase, Medline ALL, Web-of-Science Core Collection, and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched for publications reporting clinical and functional outcomes of humeral shaft fractures after non-operative treatment with a functional brace or operative treatment by intramedullary nailing (IMN; antegrade or retrograde) or plate osteosynthesis (open plating or minimally invasive). A pooled analysis of the results was performed using MedCalc. RESULTS A total of 173 studies, describing 11,868 patients, were included. The fracture healing rate for the non-operative group was 89% (95% confidence interval (CI) 84-92%), 94% (95% CI 92-95%) for the IMN group and 96% (95% CI 95-97%) for the plating group. The rate of secondary radial nerve palsies was 1% in patients treated non-operatively, 3% in the IMN, and 6% in the plating group. Intraoperative complications and implant failures occurred more frequently in the IMN group than in the plating group. The DASH score was the lowest (7/100; 95% CI 1-13) in the minimally invasive plate osteosynthesis group. The Constant-Murley and UCLA shoulder score were the highest [93/100 (95% CI 92-95) and 33/35 (95% CI 32-33), respectively] in the plating group. CONCLUSION This study suggests that even though all treatment modalities result in satisfactory outcomes, operative treatment is associated with the most favorable results. Disregarding secondary radial nerve palsy, specifically plate osteosynthesis seems to result in the highest fracture healing rates, least complications, and best functional outcomes compared with the other treatment modalities.
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Affiliation(s)
- Saskia H Van Bergen
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Kiran C Mahabier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Tim Van der Torre
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Cornelia A W Notenboom
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Priscilla A Jawahier
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Michael H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - Dennis Den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
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Ritter V, Lin FC, Miller A, Ostrum RF. Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes. Injury 2023; 54:573-577. [PMID: 36470765 DOI: 10.1016/j.injury.2022.11.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Surgical fixation of humeral shaft fractures is widely considered a relative indication for polytraumatized patients to improve mobility and expedite care. This study aimed to determine whether operative treatment of humeral shaft fractures improves short term outcomes in polytrauma (PT] patients. METHODS Using the National Trauma Data Bank, PT patients with humeral shaft fractures were identified from 2010-2015. Three PT groups were analyzed: Group 1 - PT with nonoperative humeral shaft fracture, Group 2 - PT with humeral fixation on Day 1, and Group 3 - PT with humeral fixation on Day 2+. Cox proportional hazards regression models were used to compare discharge timing and days on ventilator and in ICU between the three groups. RESULTS There were 395 patients in Group 1, 1,346 in Group 2, and 1,318 in Group 3. There were no differences between the three groups when comparing Glasgow Coma Scale (p=0.3]; however, Injury Severity Score and Abbreviated Injury Scale were statistically different (p<0.001]. No differences were found in ICU or ventilator days between the three groups (p=0.2, p=0.5]. For Length of Stay, no difference was observed in Group 1 vs. Group 2 and Group 2 vs. Group 3. However, non-surgical patients were discharged 20% faster than those with Day 1 surgery (p=0.005]. Open fractures were treated one day earlier than closed fractures but discharged one day later (p<0.001]. CONCLUSIONS This NTDB study demonstrates no differences in length of stay, days in the ICU or on the ventilator in patients with humeral shaft fractures treated non-operatively versus operative fixation. Overall, 44%-58% in all 3 groups had an ISS ≥ 14. Based on these results, we assert that fixation of the humeral shaft provides no short-term benefits in the multiply injured patient.
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Affiliation(s)
- Victor Ritter
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA.
| | - Feng-Chang Lin
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA.
| | - Anna Miller
- Department of Orthopaedic Surgery, Washington University, St Louis, MO, USA.
| | - Robert F Ostrum
- Department of Biostatistics, University of North Carolina, Chapel Hill, NC, USA; Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC, USA.
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Fox HM, Hsue LJ, Thompson AR, Ramsey DC, Hadden RW, Mirarchi AJ, Nazir OF. Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management. J Shoulder Elbow Surg 2022; 31:1969-1981. [PMID: 35398163 DOI: 10.1016/j.jse.2022.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/12/2022] [Accepted: 02/24/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated. METHODS A decision tree was constructed describing the management of humeral shaft fractures with open reduction-internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated. RESULTS Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model-accounting for both health care and societal costs-the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses. CONCLUSIONS Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.
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Affiliation(s)
- Henry M Fox
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Lauren J Hsue
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Austin R Thompson
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Duncan C Ramsey
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Ryan W Hadden
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Adam J Mirarchi
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA
| | - Omar F Nazir
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, OR, USA.
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10
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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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Capitani P, Chiodini F, Di Mento L, Cavanna M, Bove F, Capitani D, Berlusconi M. Locking compression plate fixation in humeral shaft fractures: A comparative study to literature conservative treatment. Injury 2021; 54 Suppl 1:S2-S8. [PMID: 33757663 DOI: 10.1016/j.injury.2021.03.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Humeral shaft fractures represent about 3% of all fractures. While there are several treatment options for this type of fractures, there is no evidence in literature showing which is the best one. This study aims at analysing the outcomes for patients with humeral shaft fractures treated with Locking Compression Plate (LCP) fixation in our hospital and comparing them with the outcome for patients conservatively treated (according to data from Pubmed),in order to determine the best treatment option. MATERIALS AND METHODS We treated surgically 220 humeral shaft fractures in our department from February 2005 to March 2012. Seventy-three of them met all the inclusion criteria for this study. All fractures were then classified according to the AO classification. The follow-up considered the radiographic healing of the fracture. All patients were treated with plate fixation (LCP - DePuySynthes Co). At the end of the four-year follow-up, the function was evaluated by means of the DASH score. A systematic review of the literature of the last 20 years was performed on MEDLINE (PubMed). RESULTS We had 2 infections and 8 patients had postoperative nerve palsy which recovered in average time of 6.7 months. In addition, 4 fractures (5.48%) didn't heal within 6 months and they were considered as nonunions and healed after a second surgery. One of these 4 nonunions was infected. The mean DASH score was 18.24±19.18. No malunions were found. We identified 13 studies that were eligible for our systematic review. The mean non-union rate found was 17% in 2517 fractures with a follow-up that ranging from 67% to 100% of patients and a primary radial nerve palsy ranging from 0 to 115 patients. Malalignment rate ranged from 12.7 to 42%. CONCLUSIONS After taking into account both the conservative and the surgical treatment, for humeral shaft fractures we suggest the operative treatment, because the patient's function of the upper limb recovers quickly in the immediate postoperative period and the incidence of malunions may be avoided.
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Affiliation(s)
- P Capitani
- Department of Orthopedic Surgery and Traumatology, ASST GOM Niguarda, Milan, Italy; Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.
| | - F Chiodini
- Department of Orthopedics and Traumatology, ASST Ovest Milanese - Ospedale di Legnano, Legnano, Italy
| | - L Di Mento
- Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - M Cavanna
- Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - F Bove
- Department of Orthopedic Surgery and Traumatology, ASST GOM Niguarda, Milan, Italy
| | - D Capitani
- Department of Orthopedic Surgery and Traumatology, ASST GOM Niguarda, Milan, Italy
| | - M Berlusconi
- Trauma Unit, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
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Hendrickx LAM, Hilgersom NFJ, Alkaduhimi H, Doornberg JN, van den Bekerom MPJ. Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients. Arch Orthop Trauma Surg 2021; 141:561-568. [PMID: 32285189 PMCID: PMC7966639 DOI: 10.1007/s00402-020-03446-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Humeral shaft fractures are often associated with radial nerve palsy (RNP) (8-16%). The primary aim of this systematic review was to assess the incidence of primary and secondary RNP in closed humeral shaft fractures. The secondary aim was to compare the recovery rate of primary RNP and the incidence of secondary RNP between operative and non-operative treatment. METHODS A systematic literature search was performed in 'Trip Database', 'Embase' and 'PubMed' to identify original studies reporting on RNP in closed humeral shaft fractures. The Coleman Methodology Score was used to grade the quality of the studies. The incidence and recovery of RNP, fracture characteristics and treatment characteristics were extracted. Chi-square and Fisher exact tests were used to compare operative versus non-operative treatment. RESULTS Forty studies reporting on 1758 patients with closed humeral shaft fractures were included. The incidence of primary RNP was 10%. There was no difference in the recovery rate of primary RNP when comparing operative treatment with radial nerve exploration (98%) versus non-operative treatment (91%) (p = 0.29). The incidence of secondary RNP after operative and non-operative treatment was 4% and 0.4%, respectively (p < 0.01). INTERPRETATION One-in-ten patients with a closed humeral shaft fracture has an associated primary RNP, of which > 90% recovers without the need of (re-)intervention. No beneficial effect of early exploration on the recovery of primary RNP could be demonstrated when comparing patients managed non-operatively with those explored early. Patients managed operatively for closed humeral shaft fractures have a higher risk of developing secondary RNP. LEVEL OF EVIDENCE Level IV; Systematic Review.
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Affiliation(s)
- Laurent A. M. Hendrickx
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands ,Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, 5042 Australia
| | - Nick F. J. Hilgersom
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands ,Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, 1091 Amsterdam, The Netherlands
| | - Hassanin Alkaduhimi
- Department of Orthopaedic Surgery, Onze Lieve Vrouwe Gasthuis, 1091 Amsterdam, The Netherlands
| | - Job N. Doornberg
- Department of Orthopaedic Surgery, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands ,Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, 5042 Australia
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Lode I, Nordviste V, Erichsen JL, Schmal H, Viberg B. Operative versus nonoperative treatment of humeral shaft fractures: a systematic review and meta-analysis. J Shoulder Elbow Surg 2020; 29:2495-2504. [PMID: 32553853 DOI: 10.1016/j.jse.2020.05.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Revised: 05/27/2020] [Accepted: 05/30/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND The humeral shaft fracture accounts for 1%-3% of all fractures and occurs in both the young and old population. However, the optimal treatment is still a matter of debate. Even though nonoperative treatment is commonly considered the gold standard, advantages have been described using operative stabilization. This systematic review aims to compare operative and nonoperative treatment in adult patients with humeral shaft fractures. METHOD We used the following databases: PubMed, Embase, Cochrane, and CINAHL on October 1, 2018, searching for randomized controlled trials (RCTs) and cohort studies. Two reviewers screened the studies using Covidence, followed by systematic data extraction. The primary outcome was defined as posttreatment complications such as nonunion, radial nerve palsy, malunion, and infections. The secondary outcomes were functional scores and patient-reported outcome measures (PROMs). To assess study quality, the risk of bias in nonrandomized studies of interventions and the Cochrane risk of bias tool were used. RESULTS Twelve studies were included: 1 RCT, 1 prospective cohort, and 10 retrospective cohorts with a total of 1406 patients, of whom 835 were treated operatively and 571 nonoperatively. Mean age ranged from 35 to 64, and 54% of the patients were male. The cohort studies had, in general, moderate bias, whereas the RCT had a low bias. There were statistically significant fewer nonunions in the operative treated group with a risk ratio of 0.49 (0.35-0.67), yielding a number needed to treat = 12. There were more deep infections in the operative group with a risk ratio of 2.76 (1.01-7.53) but otherwise no statistical differences concerning malunion or nerve damage. Only 1 study included PROM data. CONCLUSION There were fewer nonunions in the operative group but more deep infections. Because of the lack of studies reporting PROMs, the potential positive effect of operative therapy in early aftercare could not be evaluated. Therefore, PROMs should be mandatory in future comparative studies.
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Affiliation(s)
- Ingunn Lode
- Department of Orthopaedic Surgery and Traumatology, Kolding Hospital-Part of Hospital Lillebaelt, Kolding, Denmark.
| | - Vegard Nordviste
- Department of Orthopaedic Surgery and Traumatology, Kolding Hospital-Part of Hospital Lillebaelt, Kolding, Denmark
| | - Julie Ladeby Erichsen
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Hagen Schmal
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Odense, Denmark
| | - Bjarke Viberg
- Department of Orthopaedic Surgery and Traumatology, Kolding Hospital-Part of Hospital Lillebaelt, Kolding, Denmark
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Sharareh B, Perkins C. Variation in management of humeral and clavicular shaft fractures amongst fellowship trained orthopedic traumatologists. BMC Musculoskelet Disord 2020; 21:618. [PMID: 32948174 PMCID: PMC7499960 DOI: 10.1186/s12891-020-03639-x] [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: 06/17/2020] [Accepted: 09/08/2020] [Indexed: 11/12/2022] Open
Abstract
Background There exists a wide variety of opinions on the appropriate management of diaphyseal humeral and clavicular fractures amongst orthopedic surgeons. The purpose of this study is to determine if there is a preference amongst orthopedic traumatologists on treatment of diaphyseal humerus and clavicle fractures with respect to various patient populations. Methods A 6-question survey was created using Surveymonkey.com and distributed via the Orthopedic Trauma Association (OTA) website to fellowship trained orthopedic surgery traumatologists to survey the preferred management of a simple oblique middle 1/3rd diaphyseal humerus fracture and a middle 1/3rd displaced diaphyseal clavicle fracture in the following 3 clinical settings: a healthy laborer, an older patient with co-morbidities, and if the surgeon themselves sustained the injury. The ratio of operative to non-operative management was calculated for all 6 questions. A chi-square value was performed to determine if the results are clinically significant based on the clinical scenario. Results There was 56 responses to the survey that were included in the analysis. Overall, there was a statistically significant trend towards surgical management of the surgeon’s own diaphyseal humerus fractures (55%) compared to that of healthy patients (41%) and those with medical comorbidities (21%) (p = 0.02) A similar trend was noted for operative management for diaphyseal clavicle fractures by the surgeon on their own fractures (43%) compared to that of healthy patients (38%) and those with medical comorbidities (18%) (p = 0.02). Conclusion While there are an increasing number of relative indications for treatment of diaphyseal humerus shaft and clavicle fractures, the results of this survey indicate that fellow-ship-trained orthopedic trauma surgeons prefer surgical management of simple humerus and clavicular fractures in young, healthy patients as well as in themselves.
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Affiliation(s)
- Behnam Sharareh
- Department of Orthopedic Surgery, Baylor College of Medicine, 7200 Cambridge St. Suite 10A, Houston, TX, 77030, USA.
| | - Christopher Perkins
- Department of Orthopedic Surgery, Baylor College of Medicine, 7200 Cambridge St. Suite 10A, Houston, TX, 77030, USA
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van de Wall BJM, Ochen Y, Beeres FJP, Babst R, Link BC, Heng M, van der Velde D, Knobe M, Groenwold RHH, Houwert MR. Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. J Shoulder Elbow Surg 2020; 29:1493-1504. [PMID: 32249144 DOI: 10.1016/j.jse.2020.01.072] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 12/19/2019] [Accepted: 01/01/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND This meta-analysis aimed to compare conservative vs. operative treatment for humeral shaft fractures in terms of the nonunion rate, reintervention rate, permanent radial nerve palsy rate, and functional outcomes. Secondarily, effect estimates from observational studies were compared with estimates of randomized clinical trials (RCTs). METHODS The PubMed/Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for both RCTs and observational studies comparing conservative with operative treatment for humeral shaft fractures. RESULTS A total of 2 RCTs (150 patients) and 10 observational studies (1262 patients) were included. The pooled nonunion rate of all studies was higher in patients treated conservatively (15.3%) vs. operatively (6.4%) (risk difference, 8%; odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.5; I2 = 0%). The reintervention rate was also higher for conservative treatment (14.3%) than for operative treatment (8.9%) (risk difference, 6%; OR, 1.9; 95% CI, 1.1-3.5; I2 = 30%). The higher reintervention rate was predominantly attributable to the higher nonunion rate in patients treated conservatively. The permanent radial nerve palsy rate was equal in both groups (OR, 0.6; 95% CI, 0.2-1.9; I2 = 18%). There appeared to be no difference in mean time to union and mean Disabilities of the Arm, Shoulder and Hand scores between the treatment groups. No difference was found between effect estimates form observational studies and RCTs. CONCLUSION This systematic review shows that satisfactory results can be achieved with both conservative and operative management; however, operative treatment reduces the risk of nonunion compared with conservative treatment, with comparable reintervention rates (for indications other than nonunion). Furthermore, operative treatment results in a similar permanent radial nerve palsy rate, despite its inherent additional surgery-related risks. No difference in mean time-to-union and short-term functional results was detected.
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Affiliation(s)
- Bryan J M van de Wall
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland; Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Yassine Ochen
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank J P Beeres
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Björn C Link
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Marilyn Heng
- Department of Orthopedic Surgery, Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital Boston, Boston, MA, USA
| | | | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Luzern, Switzerland
| | - Rolf H H Groenwold
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marijn R Houwert
- Department of Trauma Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Length of stay and 30-day readmissions after isolated humeral shaft fracture open reduction and internal fixation compared to intramedullary nailing. Injury 2020; 51:942-946. [PMID: 32070557 DOI: 10.1016/j.injury.2020.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/27/2020] [Accepted: 02/02/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Open reduction with internal fixation (ORIF) and intramedullary nailing (IMN) have similar union rates for treating humerus shaft fractures, but IMN leads to increased incidence of shoulder impingement and reoperation. The difference in 30-day readmission rate and length of stay (LOS) between these procedures is unknown. The objective of the study was to compare 30-day unplanned readmissions and length of stay between humeral shaft fractures fixed with either ORIF or IMN. METHODS The nationwide readmissions database (NRD) was queried for patients with humeral shaft fractures treated with ORIF or IMN between 2015-2016. IMN cases were propensity matched to ORIF cases based on demographic and co-morbid variables. Multivariable logistic regression determined if treatment modality was an independent risk factor for 30-day readmission or length of stay >3 days. RESULTS There were 406 patients treated with IMN matched to 406 patients treated with ORIF. The 30-day readmission rate was 6.4% for IMN and 4.9% for ORIF (p = 0.45), and the median LOS was 3 days for each group (p = 0.45). Congestive heart failure (CHF)(OR=2.7, p = 0.04), depression (OR=3.3, p = 0.0008), and electrolyte abnormality (OR=3.6, p = 0.0003) were independent risk factors for readmission. Older age (OR=1.02, p = 0.03), CHF (OR=2.4, p = 0.03), electrolyte abnormality (OR=2.6, p = 0.0001), obesity (OR=2.8, p<0.0001), Medicaid (OR=2.1, p = 0.04), discharge to a facility (OR = 5.2, p<0.0001), discharge with home health services (OR=2.4, p = 0.0003), and open fracture (OR=2.3, p = 0.01) were independent risk factors for LOS >3 days. Procedure (ORIF vs. IMN) was not a predictor of 30-day readmission or LOS >3 days. CONCLUSION Comorbid conditions are risk factors for 30-day readmission and increased LOS. Comorbidity, discharge disposition, and open fractures are risk factors for increased LOS. Treating humeral shaft fractures with either ORIF or IMN did not affect readmission or length of stay.
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Ferree S, van der Vliet QMJ, Nawijn F, Bhashyam AR, Houwert RM, Leenen LPH, Hietbrink F. Epidemiology of distal radius fractures in polytrauma patients and the influence of high traumatic energy transfer. Injury 2018; 49:630-635. [PMID: 29429577 DOI: 10.1016/j.injury.2018.02.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2017] [Accepted: 02/05/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION For several extremity fractures differences in morphology, incidence rate and functional outcome were found when polytrauma patients were compared to patients with an isolated injury. This is not proven for distal radius fractures (DRF). Therefore, this study aimed to analyse fracture morphology in relation to energy transfer in both poly- and mono-trauma patients with a DRF. METHODS This was a retrospective cohort study. All patients aged 16 years and older with a DRF were included. Patients with an Injury Severity Score of 16 or higher were classified as polytrauma patients. Injuries were defined as high or low energy. All DRFs were classified using the AO/OTA fracture classification system. RESULTS A total of 830 patients with a DRF were included, 12% were polytrauma. The incidence rate of DRF in polytrauma patients was 3.5%. Ipsilateral upper extremity injury was found in >30% of polytrauma and high-energy monotrauma patients, compared to 5% in low-energy monotrauma patients. More type C DRF were found in polytrauma and high-energy monotrauma patients versus low-energy monotrauma patients. Operative intervention rates for all types of DRF were similar for polytrauma and high-energy monotrauma patients. Non-union rates were higher in polytrauma patients. CONCLUSION Higher energy mechanisms of injury, in polytrauma and high-energy monotrauma patients, were associated with more severe complex articular distal radius fractures and more ipsilateral upper extremity injuries. Polytrauma and high-energy monotrauma patient have a similar fracture morphology. However, polytrauma patients have in addition to more injured body regions also more non-union related interventions than high-energy monotrauma patients.
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Affiliation(s)
- Steven Ferree
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
| | | | - Femke Nawijn
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
| | - Abhiram R Bhashyam
- Harvard Combined Orthopaedics Residency Program, Boston, MA, United States.
| | - Roderick M Houwert
- Department of surgery, University Medical Centre Utrecht, The Netherlands; Utrecht Traumacenter, Utrecht, The Netherlands.
| | - Luke P H Leenen
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
| | - Falco Hietbrink
- Department of surgery, University Medical Centre Utrecht, The Netherlands.
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