Humeral Shaft Fractures Research Articles

Outcomes of Intramedullary Nailing Versus Plate Fixation in the Management of Humeral Shaft Fractures: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aimed to compare the outcomes of intramedullary nailing (IMN) and open reduction with internal fixation (ORIF) in treating traumatic humeral shaft fractures in adults (18 years and above). A comprehensive literature search was conducted in databases including PubMed, Google Scholar, Embase, and CochraneCentral Register of Controlled Trials (CENTRAL). The primary outcome was time to union, while secondary outcomes included non-union rates, incidences of iatrogenic radial nerve palsy, surgical site infections, and intra-operative comminution. Twenty-six studies, encompassing 1,674 patients (867 IMN, 807 ORIF), were included. IMN demonstrated a shorter time to union compared to ORIF (mean difference -1.06 (95% CI, -1.88 to -0.23)), with significant statistical heterogeneity (I² = 70%), and a mean difference of -2.14 (95% CI, -3.16 to -1.12) in the randomized controlled trial (RCT) subgroup analysis, which had no significant statistical heterogeneity. Both techniques had comparable non-union rates (risk ratio 0.34 (95% CI, 0.94 to 1.93)). IMN was associated with lower incidences of iatrogenic radial nerve palsy (risk ratio 0.48 (95% CI, 0.27 to 0.87)) and surgical site infections (risk ratio 0.44 (95% CI, 0.25 to 0.76)), but had a higher risk of intra-operative comminution (risk ratio 3.04 (95% CI, 1.24 to 7.44)). The studies exhibited significant heterogeneity and varying outcome measures, highlighting the need for cautious interpretation. IMN offers rapid fracture stabilization and minimal additional physiological insult, while ORIF remains preferable for achieving precise anatomical reduction. These findings highlight the importance of considering patient-specific factors and surgical expertise in selecting the appropriate fixation technique.

Modified medial approach for the treatment of fractures of the lower third of the humeral shaft: An anatomical study

BackgroundThe anatomical study of the modified medial approach for addressing fractures of the distal third of the humeral shaft aimed to elucidate the benefits of this method in providing optimal exposure for surgical intervention. MethodsSixteen upper limb specimens from eight cadavers, obtained from the Anatomy Teaching Department of Fujian Medical University, were dissected. Three-dimensional anatomical structures were mapped onto a two-dimensional coordinate system. Key anatomical structures relevant to the modified medial approach, including the medial cutaneous nerve, musculocutaneous nerve, ulnar nerve, basilic vein, brachial artery, superior ulnar collateral artery, and inferior ulnar collateral artery, were documented in detail. ResultsThe average humeral shaft length measured (29.22 ± 2.78) cm, with its medial surface being flat and well-suited for plate fixation. The basilic vein, located superficially in the upper arm's first quadrant, measured (1.35 ± 0.35) cm from the most prominent point of the medial epicondyle of the humerus, with the deep fascia being penetrated at (12.41 ± 1.71) cm. The basilic vein serves as a key landmark for the modified medial approach. The nervi cutanei antebrachii medialis, running along the medial biceps humerus, closely accompanies the basilic vein, perforating the deep fascia above the medial epicondyle and extending anterior external and posterior medial branches. These branches are positioned (0.80 ± 0.17) cm and (0.45 ± 0.29) cm, respectively, from the basilic vein. Additionally, all nervi cutanei antebrachii medialis pass anteriorly to the basilic vein before continuing distally to the forearm. The ulnar nerve initially accompanies the basilic vein in the upper arm but diverges posteriorly without branching at (14.75 ± 1.74) cm, with the maximum separation from the basilic vein measuring (2.28 ± 0.59) cm. The brachial artery bifurcates into the superior and inferior ulnar collateral arteries along the humeral shaft. The superior collateral ulnar artery primarily supplies the ulnar nerve, positioned (14.14 ± 1.27) cm from the medial epicondyle, which ensures a sufficient blood supply for operative procedures. The musculocutaneous nerve and radial nerve branch are located in the lateral region of the brachial muscle, with minimal postoperative impact on muscle strength when splitting the brachial muscle by one-third. ConclusionsThe modified medial approach, as revealed by anatomical studies, focuses on the fracture site with a straight skin incision aligned between the most prominent point of the medial epicondyle and the midpoint of the axilla, positioned one transverse finger from the radial side. Using the basilic vein as a reference, major vessels and nerves remain undisturbed, ensuring a safe operative zone. This technique allows for significant exposure of both the anterior and external humeral shaft fracture site and the ulnar side butterfly fragment while minimizing tissue damage and facilitating rapid recovery. The approach offers notable clinical value due to its reduced invasiveness and accelerated postoperative rehabilitation.

Complications and morbidity of the extended delto-pectoral approach in treating complex humeral shaft fractures with proximal metaphyseal extension using a long locking plate for internal fixation

Background Humeral shaft fractures account for up to 3% of all fractures, but complex forms of those fractures (type AO/OTA B or higher) are rare. Plate and screw fixation of the fracture are rated as consolidated from 80 to 97%. Reported complications include non-union, secondary radial nerve palsy and infection. Minimally invasive plate osteosynthesis (MIPO) should provide the same union rate as open reduction and internal fixation (ORIF) but potentially with fewer complications. The aim of our study was to review patients treated for complex humeral fractures with ORIF through an extended delto-pectoral approach using a long pre-contoured locking plate. The morbidity of the open approach, complication rates, union rate and clinical outcomes were assessed.Methods We performed a retrospective analysis of 26 consecutive complex humeral shaft fractures (7 males, mean age 59 years; 19 females, mean age 67 years) treated in our institution with a long pre-contoured locking plate between June/2011 and December/2017. Fracture healing was evaluated with standard radiographs. Eventual complications and the morbidity of the approach were assessed through chart review. The final clinical outcome and quality of life were assessed via telephone interview with DASH score and EQ-5D-3 L in 25 of the 26 patients included.Results There were no complications related to the open approach with uneventful wound healing in all cases without any infections. Mechanical complications occurred in 3 cases (11%): one tuberosity dislocation (revised) and two plate failures (one revised). Postoperative radial nerve palsy was observed in two patients (7%), of which one was transient, the other was persistent. The plate was removed in 4 cases (15%). The average radiological and clinical follow-up was 21 months (range: 12–56). At 12 months follow-up complete fracture healing was confirmed in 22 out of 26 cases and in three more patients after 18 months. After an average of 44 months, the mean DASH score was 35 (SD ± 15.83) points; the EQ-5D-3 L score 0.7 (SD ± 0.31).Conclusion ORIF with a long locking plate though an extended delto-pectoral approach is certainly still a viable option to treat complex humeral shaft fractures with good soft tissue and bone healing as well as good functional recovery. No increased morbidity was attributed to the open surgical approach. In our series, radial nerve palsy could not be completely avoided, accentuating the potential risk of this specific fracture in close proximity to the radial nerve.Trial registrationEthics Committee: Ethikkommission Ostschweiz (EKOS), Project ID: 2019-00323.

Use of Intramedullary Fibular Graft: A Novel Adjunct in Treatment of Osteoporotic Humeral Shaft Fracture Non - Union

Use of Intramedullary Fibular Graft: A Novel Adjunct in Treatment of Osteoporotic Humeral Shaft Fracture Non - Union

A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures

BackgroundThe purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it’s efficacy with that of traditional surgical intramedullary nail treatment.Materials and methodsThis was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant–Murley score) between the two groups of patients.ResultsThere was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001).ConclusionRobot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes.

Single-Plate versus Dual-Plate Utilization for Treatment of Humeral Shaft Fractures: A Retrospective Clinical Series

Objectives Dual plating is the current standard of care for displaced distal humerus fractures and even some metadiaphyseal humeral fractures. Single plate fixation is the current standard of care for humeral shaft fractures when performing open reduction and internal fixation (ORIF). A role may exist for dual plating of humeral shaft fractures. This study aims to compare clinical outcomes of single versus dual-plating when performing ORIF procedures on humeral shaft fractures. Methods A retrospective study of 143 patients (81 females, 62 males; mean age 47.3) who sustained humeral shaft fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (OTA/AO) type 12A, B, and C) and received either dual or single plating via ORIF between March 2010 and May 2022. Of the 143 patients, 79 (55%) received single plating, while 64 (45%) received dual plating. To account for possible confounders, we collected data on patient characteristics, mechanism of injury, and intra-surgical variables. Primary outcome measurements compared radiographical x-ray imaging (3-months, 6-months, and 12-months), complications, and visual analog scale (VAS) score. Results There was no statistically significant difference between VAS scores, union rates, post operative radial nerve injury, infections, or hardware failure for primary surgical outcomes. Patients were allowed to bear weight as tolerated more quickly in the dual-plating group. An association was observed between the usage of dual plates and osteoporosis. Conclusion In conclusion, we found dual-plate fixation for ORIF of humerus fractures to be not statistically significantly different compared to single plate fixation. Dual-plating has satisfactory radiograph and clinical outcomes compared to conventional single-plate fixation. While we are not advocating for the routine use of dual-plating, the results of our study suggest that the use of dual-plating produces similar outcomes when compared to single-plating for ORIF of a humerus shaft fracture.

The epidemiology of geriatric fractures: A nationwide analysis of 1 million fractures

ObjectiveFractures among the geriatric population impose a substantial burden on healthcare systems. This study aims to investigate the incidence and distribution of fractures among geriatric individuals over seven years, analyzing changes by age and sex. The findings will inform national healthcare strategies for addressing the growing impact of geriatric fractures. Materials and methodsElectronic health records from a nationwide personal health records system were analyzed, focusing on ICD-10 codes for fractures. Recurrent codes for the same patients within three months were excluded. Patients were categorized into three age groups (65–74, 75–84, and 85+ years), and fractures were grouped anatomically. Incidence rates for specific fracture locations were calculated based on the actual population at risk annually. Incidence rates were further stratified by sex and age groups using Turkey's age- and sex-specific populations. ResultsA total of 1,004,663 geriatric fractures (66.9 % female, 33.1 % male) were identified over seven years. The overall fracture incidence among the geriatric population was 1.9 % (1910/100,000). Hip fractures were the most common (25.2 %), followed by wrist (15 %) and lumbar-pelvic fractures (11.9 %). Femur fractures were predominant in the 75–84 and 85+ age groups, while wrist fractures were more common in the 65–74 age group. Fracture incidences generally increased with age, except for ankle, foot, and toe fractures, which decreased with age for both sexes (p < 0.05). The male/female ratio was lowest for wrist, elbow, and humeral shaft fractures (1:3.2, 1:2.7, and 1:2.7, respectively). The lowest overall fracture incidence was observed in 2020 (1568/100,000), while the highest was in 2017 (2523/100,000). ConclusionWith Turkey's aging population, the socioeconomic impact of geriatric fractures is anticipated to rise. Fracture patterns and incidence vary by age and sex among geriatric individuals. These findings provide valuable insights for healthcare planning and the development of community-based preventive measures tailored to specific fracture locations and demographics.

Development of the humeral head offset index for control of humeral torsion

BackgroundControl of humeral torsion can present a challenge, especially intraoperatively during closed reduction and fixation of humeral shaft fractures or 2-part surgical neck fractures of the proximal humerus. The objective of this study is to develop and validate an indirect method for the assessment of humeral torsion using an index that is linearly correlated with rotational arm position and can be derived from only a single plain radiographic image of the proximal humerus.MethodsThe Humeral Head Offset Index (HHOI) is calculated as the ratio of the medial and lateral offset of the humeral head measured from the outer cortices of the shaft on a plain radiographic or fluoroscopic image. The relationship of HHOI with humeral torsion was first verified on a sawbone model with radiopaque characteristics under fluoroscopic control. Different degrees of retroversion were simulated through manual rotation of the humerus with a digital protractor in 5° increments until 40° internally rotated and then in 5° increments until 40° externally rotated from the neutral position. The same procedure was subsequently performed digitally on Digitally Reconstructed Radiographs (DRRs) from computed tomography (CT) dataset of the sawbone. Next, the HHOI index was applied to eight randomly selected patients with total humerus CT using the same method. Spearman’s rho was calculated for the bivariate analysis of correlation between the simulated degree of retroversion and the HHOI. Strength of correlation was classified according to Koo and Li. Interrater and intrarater reliability of three blinded observers with repetition of measurement after three months were analyzed by assessing the intraclass correlation coefficient (ICC).ResultsBoth in the sawbone model and in DRRs, we demonstrated a high to very high significant linear correlation between simulated retroversion and the HHOI. ICC values demonstrated excellent interrater reliability and excellent intrarater reliability for measurement of the HHOI.ConclusionsThe HHOI is a new, simple, reliable index that has a linear relationship to the rotation of the humerus and can therefore allow an indirect control of humeral torsion in comparison to the contralateral side.

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

Historically, humeral shaft fractures have been managed nonoperatively in a functional brace. However, recent studies suggest an increase in rates of operative fixation. Disparities in surgical management based on insurance status have been demonstrated across many orthopedic conditions. This study aimed to identify if a correlation exists between insurance coverage and the probability of undergoing operative fixation for a humeral shaft fracture. A retrospective examination of the National Readmissions Database from 2016 to 2021 was conducted. Patients diagnosed with isolated closed humeral shaft fractures were identified via International Classification of Disease, 10th Revision codes, and surgical interventions were identified using International Classification of Disease, 10th Revision procedural codes. Utilizing weighted data, a total of 56,468 patients with isolated closed humeral shaft fractures were identified, 25,075 (44.4%) of whom underwent operative fixation. A univariate analysis was conducted using Pearson's chi-square test to isolate variables for inclusion in a multivariable analysis. A binary logistic regression analysis was then employed to explore demographic and other pertinent factors. Findings were reported as odds ratios. After controlling for social and demographic variables, patients with Medicaid (OR, 0.54; 95% CI, 0.50-0.58; P<.001), Medicare (OR, 0.64; 95% CI, 0.60-0.68; P<.001), and self-pay patients (OR, 0.75; 95% CI, 0.67-0.84; P<.001) were less likely to undergo operative fixation of humeral shaft fracture than those with private insurance. Patients without private insurance or those with no insurance coverage are less likely to undergo operative fixation for humeral shaft fractures compared to those with private insurance, even after adjusting for social and demographic variables. The observed variability underscores the necessity for more refined treatment guidelines for humeral shaft fractures. Surgeons should be aware of these potential biases affecting management decisions.

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

Delayed time to surgery, in the case of orthopedic trauma, is well known to be associated with higher morbidity and mortality, an extended duration of hospitalization, and an associated rise in overall cost. Delayed time to surgery of at least 3days following hospital admission is associated with elevated risk of complications following surgery for a standard, non-pathologic, humeral shaft fracture. To our knowledge, it is unknown whether the same association is present for pathologic humerus fractures. The primary objective of this study was to identify risk factors, including patient characteristics, comorbidities, and postoperative complications, that are associated with delayed time to surgery following pathologic humeral fracture. All patients undergoing surgical management of pathologic humerus fractures across a 6-year period from 2015 to 2021 were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Postoperative complications were reported within 30days of procedure. Delayed time to surgery was defined by ≥ 2days from hospital admission to surgery. We identified a total of 248 patients, and 39.9% (n = 99) of patients had delayed time to surgery. Multivariate logistic regression adjusted for all significantly associated variables was employed to identify predictors of delayed time to surgery for pathologic humerus fractures. The characteristics of patients significantly associated with delayed time to surgery were ASA classification ≥ 3 (p = 0.016), dependent functional status (p = 0.041), and congestive heart failure (p = 0.008). After adjusting for all significantly associated patient variables, the characteristics of patients independently associated with delayed time to surgery were non-home discharge (OR: 2.93, 95% CI 1.53-5.63; p = 0.001) and extended length of stay (OR: 2.00, 95% CI 1.06-3.77; p = 0.033). Delayed time to surgery of at least 2days was independently associated with non-home discharge and extended postoperative length of stay. After controlling for baseline patient characteristics and comorbidities, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic humeral fractures. This is in contrast to standard, non-pathologic humerus fractures in which delayed time to surgery is associated with an increased risk of postoperative complications. Retrospective Cohort Comparison; Prognosis Study.

Short-term complication rates of open reduction and plate fixation and intramedullary nailing in the treatment of humeral shaft fractures: a propensity score matched analysis

IntroductionThis is a retrospective cohort study designed to compare short-term postoperative complication rates between closed humeral shaft fractures treated by open reduction and internal fixation (ORIF) versus intramedullary nailing (IMN), as well as secondary independent risk factors for adverse outcomes.Materials and methodsThe American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using CPT codes to identify patients that underwent an open reduction and plate fixation or intramedullary nailing procedure for a closed humeral shaft fracture from 2010 to 2021. Cohorts were matched using propensity scores to account for demographic differences and rates of complications were compared between the two groups.ResultsFrom the database, a total of 4,222 patients were identified who met inclusion criteria, with 3,326 and 896 undergoing ORIF and IMN respectively. After propensity score matching, 866 of the nearest-neighbor matches were included in each cohort for a total of 1,732 patients in the final analysis. The rate of any adverse event (AAE) was significantly higher in the ORIF cohort (16.3%) than the IMN cohort (12.1%, p = 0.01). The ORIF group had higher rates of postoperative transfusion (p = 0.002), return to OR (p = 0.005), and surgical site infection (SSI, p = 0.03). After multivariate analysis, ASA class 4, increasing age, increasing operative time, and history of bleeding disorder were found to increase the risk of AAE in both ORIF and IMN patients.ConclusionsWhile prior studies have claimed higher complication rates in IMN patients, this study found a significantly higher short-term risk of AAE in ORIF patients when compared in matched cohorts. However, individual 30-day complication rates do not differ significantly between procedures, and both have been shown to be safe and effective tools in the management of humeral shaft fractures.

Greater Socioeconomic Deprivation is Associated with Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures.

This study explored the hypothesis that social determinants of health (SDOH), including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation (ORIF) of humeral shaft fractures. Design: Retrospective. Single, academic, tertiary Level-I trauma center. Adults with midshaft humerus fractures (AO/OTA 12) treated operatively with plate fixation from 05/2011 to 05/2021 with a minimum follow-up of nine months. Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. SDOH were assessed using the Area Deprivation Index (ADI). Demographics, complications rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles. 196 patients fit the study criteria. The average age of the cohort was 47 years with 50 women (51%). Comparisons of the least deprived quartile (n=49) to the most deprived quartile (n=49) yielded similar sex distribution (59% vs 43% female, p=0.15), fewer non-white patients (8% vs 51%, p<0.01), older average age (51 years vs 43 years, p=0.05), similar BMI (30.5 vs. 31.8, p=0.45), and higher Charlson Comorbidity Index (CCI) (2.2 vs.1.1, p=0.03). While nonunion rates were similar (p=0.20) between groups, the most deprived quartile had 2.3 times greater odds of post-operative complications (p=0.04). Patients in the most deprived group exhibited higher PROMIS Pain Interference (PI) scores (p<0.01) and PROMIS Depression (D) scores (p=0.01), with lower PROMIS Physical Function (PF) scores (p<0.01) at 6-month follow-up than the least depriver cohort. The most deprived cohort had three times higher odds of missing scheduled appointments within the first post-operative year (p<0.01), resulting in a significantly higher no-show rate (p<0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments (p<0.01), no-show rates (p=0.04), and experiencing one of the following post-operative complications during recovery: Nonunion, radial nerve injury, or dysfunction (p=0.03). Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation, emphasizing that baseline socioeconomic disparities predict unfavorable post-operative outcomes even given favorable baseline health status according to the CCI score. Level III. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound evaluation of radial nerve injuries by cortex overlapping screw tips after internal fixation of humeral fractures: a cadaveric study

PurposeThe radial nerve may be painfully irritated or damaged by open reduction and internal fixation (ORIF) of humeral fractures. Secondary radial nerve lesions after ORIF of humeral shaft fractures are described in up to 16%. Not only peripheral nerves but also orthopaedic instruments and osteosynthesis material are well visible by ultrasound. The aim of this study was to evaluate the accuracy of ultrasound in assessing the relation between the bone overlapping screw tips and the radial nerve close to the humeral bone.MethodsUltrasound-guided drilling was used to place screws as close as possible to the radial nerve in 8 humeral bones of four cadavers. The relation between the radial nerve and the screw tips was assessed by high-resolution ultrasound, and the overlap of all screw tips over the bone was measured by ultrasound and fluoroscopy. Thereafter, the findings were validated by anatomical dissection.ResultsWe could correctly identify all screw tips and their relation to the radial nerve by ultrasound. In 7 of 8 cases, the screw tip had direct contact with the radial nerve. The overlaying length of the screw tip was accurately measured by using ultrasound in all cases. In contrast fluoroscopy underestimated this length in 50% of cases.ConclusionWith this study, we show that ultrasound can reliable visualize the screw tips and its relation to the radial nerve. Ultrasound is a promising diagnostic tool to evaluate patients with radial nerve irritations or lesions after ORIF of humeral fractures. Furthermore, ultrasound could be an adequate tool to guide drilling.

Long-term patient-reported outcomes of open subpectoral biceps tenodesis with cortical button fixation.

Open subpectoral biceps tenodesis (OSBT) with cortical button fixation has been shown to deliver acceptable results in the short and intermediate term for long head of the biceps (LHB) pathology with the benefit of smaller bone tunnel diameter and a reduced risk of postoperative humeral shaft fracture. The primary purpose of this study was to determine whether OSBT with cortical button fixation results in significant improvements in patient reported outcomes (PROs) from pre-operative to long-term final follow-up. A retrospective analysis of patients who underwent OSBT with cortical button fixation at a single institution between the years of 2012 and 2014 was conducted and PROs were collected in the intermediate (> 2years follow-up) and long term (> 9years follow-up). PROs were measured pre-operatively, at intermediate follow-up, and at long-term follow-up using three validated questionnaires: American Shoulder and Elbow Surgeons (ASES) score, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Oxford Shoulder Score (OSS). Patients were additionally asked at final follow-up if they would undergo the same procedure again if they needed it. Twenty-nine (29) patients with a mean age of 51.16 ± 9.06years at the time of surgery were included in the study at final follow-up. Mean final follow-up time was 10.2 ± 0.5years (range: 9.2-11.1years). All PROs (ASES, OSS, and DASH) demonstrated statistically significant improvements from pre-operative to final follow-up with p < 0.01 for each. The proportions of patients exceeding established values for minimum clinically important difference (MCID) were 96.55%, 93.10%, and 75.86% for ASES, OSS, and DASH respectively. Only one patient had required re-operation as of final follow-up. None experienced humeral fractures post-operatively. A significant majority (89.66%; p < 0.01) of patients reported that they would undergo the same procedure again if they needed it. Fifty-three (53) patients were included in the study at intermediate follow-up with a mean follow-up time of 3.5 ± 1.4years (range: 2-5.3years). There were no statistically significant differences in any of the PRO measures from intermediate to long-term follow-up. This study reported a minimum 9-year follow-up of patients undergoing OSBT with cortical button fixation for the management of LHBT pathology in the setting of concomitant shoulder procedures. All patients had significantly improved functional outcomes assessed with ASES, OSS, and DASH and no obvious differences in median group scores were found between patients assessed at intermediate (mean 3.5years) and final (mean 10.2years) follow-up. No infections, fractures, or fixation failures were reported.

ASSESSMENT OF NEAR-REDUCTION UNION RATES WITH CONSERVATIVE HUMERUS FRACTURE TREATMENT

This study attempts to determine near-reduction union rates with non-operative treatment of humeral shaft fractures, assess alignment and functional outcomes, and compare these with historic and surgical management approaches. Methods: This was a cross-sectional study at the Department of Orthopedics, Jinnah Postgraduate Medical Centre, Karachi, from January 2024 to June 2024. Twenty patients aged between 17–72 years who suffered from humeral shaft fractures were inducted through consecutive sampling. The conservative treatment mode was applied with a "U"-shaped coaptation splint, where alignment was assessed on radiographs, and functional outcome was achieved with a grading system. Data was analyzed using SPSS-20 regarding union rates, functional recovery, and factors influencing treatment success. Results: In this study of 20 fractures, the initial angulation was 30%, while deviations in sagittal plane alignment in the anterior or posterior direction were seen in 45%. Nineteen of these fractures united within an average time of 42 days in men and 44 days in women; one case showed a delayed union of 13 weeks. Functional results were also excellent, with 60% of patients achieving Grade V function, signifying the absence of pain or limitations, and 35% reporting Grade IV, meaning minimal limitations. Comparisons with historical studies showed that conservative management was similarly successful, with a high union rate and acceptable functional outcome in most cases noted. Conclusion: The conservative approach to treating humeral shaft fractures, characterized by limited immobilization with early mobilization, had a high union rate with excellent functional outcomes equal to surgical interventions. Success with treatment was considerably influenced by patient age, type of fracture, and degree of initial displacement, thus indicating that treatment has to be individualized. This study supports a conservative approach as a modality of choice in managing humeral shaft fractures, emphasizing individuated care for optimum recovery and satisfaction of patients.

Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury

ObjectivesTo compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery.MethodsThe online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches.ResultsFifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p > 0.05).ConclusionIntramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation.Level of evidenceLevel IV.

Investigating the Determinants of Nonaccidental Trauma Evaluation in Pediatric Femur Fractures.

Femoral fractures in children have the highest probability for abuse after skull fractures and humeral shaft fractures. However, the reported proportion of pediatric femur fractures that result from nonaccidental trauma (NAT) varies in the literature from 2% to 60%. The purpose of this study was to determine the patient characteristics associated with a physician's decision to conduct a NAT workup and challenge universal clinical practice guidelines stating that all children younger than 3 years with a diaphyseal femur fracture be evaluated for NAT. A retrospective review was conducted on patients aged 0 to 36 months diagnosed with a femur fracture between January 1, 2004, and April 9, 2019, at our institution. NAT was defined as a diagnosis of trauma that was nonaccidental in the medical chart after a positive workup by skeletal survey, ophthalmological examination, or other appropriate referral made by the institution's child abuse and neglect team. Patients with incomplete medical records were excluded. A total of 299 patients were identified, and 22 were excluded. 71% (197/277) were screened for NAT. Patients younger than 1 year were significantly more likely to undergo a NAT workup (P = 0.009; Odds Ratio [OR], 2.3; 95% CI, 1.2 to 4.4) and receive a positive result from the NAT workup (P < 0.0005; OR, 11.3; 95% CI, 4.6 to 27.4). Additional injuries were also a significant predictor of a positive NAT workup (P < 0.001; OR, 5.3; 95% CI, 2.4 to 11.9). Patient race/ethnicity, sex, and fracture type were not markedly associated with the physician's decision to conduct a NAT workup. Infants younger than 1 year with a femur fracture and children younger than 3 years presenting with a femur fracture and another injury are at increased risk of possible NAT. While clinical practice guidelines may minimize racial bias in NAT evaluation, this study demonstrates that universal NAT workups for walking-age children in the absence of other evidence of abuse may be unnecessary. This is a Level III retrospective cohort study.

Trends in reported outcomes and patient reported outcome measures (PROMs) in humeral shaft fracture literature: a systematic review.

With a lack of standardization among outcome measures in fracture literature, cross-study comparisons remain limited. This systematic review aimed to identify trends in outcome measures reported by studies of the treatment of humeral shaft fractures. A systematic review was performed of studies reporting clinical outcomes of humeral shaft fractures indexed in PubMed. Extracted data included demographics, fracture characteristics, treatment modalities, outcomes, patient reported outcome measures (PROMs), and journal characteristics. Cochran-Armitage tests and linear regressions were used to identify data trends. Pearson chi-square and Kruskal-Wallis tests were used for comparisons between studies. This review included 197 studies with outcomes of 15,445 humeral shaft fractures. 126 studies reported PROMs and 37 different PROMs were used. The Constant Score was most commonly reported (34% of studies), followed by ASES Score (21%), MEPS (21%), and DASH Score (20%). There was a significant increase in PROM usage over time (p = 0.016) and in articles using three or more PROMs (p = 0.005). The number of PROMs were significantly greater in prospective cohort studies and RCTs (p = 0.012) compared to retrospective cohort studies and case series (p = 0.044 for both). Post-treatment shoulder motion was reported in 43% of studies and 34% reported elbow motion. 86% of studies reported complications as an outcome parameter. Time to union and nonunion rate were published in 69% and 88% of studies, respectively. This study identified increasing PROM usage over time and disparities in the reporting of outcomes in humeral shaft fracture literature requiring further validation and standardization of available outcome measures.

The effect of plate location on radial nerve palsy recovery time associated with humeral shaft fractures.

This study aims to investigate the influence of plate placement on nerve regeneration in humerus fractures accompanied by radial nerve injury. A retrospective analysis was conducted on a cohort of 94 patients with humerus fractures and concomitant radial nerve injury treated between January 2018 and November 2022. After applying exclusion criteria, 31 patients were included in the study. Clinical outcomes were assessed by comparing demographic data, surgical duration, radial nerve recovery time, the Mayo Elbow Performance Score (MEPS), Disabilities of the Arm Shoulder and Hand (DASH), and the Medical Research Council (MRC) scale. Two distinct groups were established: lateral plating and anteromedial (AM) plating. These groups demonstrated comparability regarding age, gender, and body mass index (BMI). No statistically significant differences were observed between the groups concerning MEPS and MRC. The AM plating group notably exhibited shorter surgical durations, faster recovery times, and lower DASH scores. According to the findings of this investigation, in cases of humerus fractures accompanied by radial nerve injury, AM plating may be preferable over lateral plating due to its association with reduced surgical durations and expedited nerve recovery.

Combining robotics and 3D printing facilitates closed reduction of humeral shaft fractures using a minimally invasive plate as a reduction template: A proof-of-concept study.

Minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures (HSFs) has limitations due to malreduction and radiation exposure. To address these limitations, we integrated robotics and 3D printing by incorporating plates as reduction templates. The innovative technology facilitated closed reduction of HSFs in the operating theatre using 18 models with cortical marking holes. The dataset of the precontoured plate was imported into 3D planning software for virtual fixation and screw path planning. The models were divided into half to simulate transverse fractures. During the operation, the software generated drilling trajectories for robot navigation, and precise plate installation achieved automatic fracture reduction. The evaluation results of reduction accuracy revealed variations in length, apposition, alignment, and rotation that meet the criteria for anatomic reduction. High interoperator reliabilities were observed for all parameters. The proposed technology achieved anatomic reduction in simulated bones.