Injury: Kiran C. Mahabier, Lucas M.M. Vogels, Bas J. Punt, Gert R. Roukema, Peter Patka, Esther M.M. Van Lieshout
Injury: Kiran C. Mahabier, Lucas M.M. Vogels, Bas J. Punt, Gert R. Roukema, Peter Patka, Esther M.M. Van Lieshout
Injury: Kiran C. Mahabier, Lucas M.M. Vogels, Bas J. Punt, Gert R. Roukema, Peter Patka, Esther M.M. Van Lieshout
Injury
journal homepage: www.elsevier.com/locate/injury
A R T I C L E I N F O A B S T R A C T
Article history: Background: Humeral shaft fractures account for 1–3% of all fractures and 20% of the fractures involving
Accepted 31 July 2012 the humerus. The aim of the current study was to compare the outcome after operative and non-
operative treatment of humeral shaft fractures, by comparing the time to radiological union and the rates
Keywords: of delayed union and complications.
Humeral shaft fracture Methods: All patients aged 16 years or over treated for a humeral shaft fracture during a 5-year period
Treatment were included in this retrospective analysis; periprosthetic and pathological fractures were excluded.
Operative
Radiographs and medical charts were retrieved and reviewed in order to collect data on fracture
Non-operative
Consolidation time
classification, time to radiographic consolidation and the occurrence of adverse events.
Radial nerve palsy Results: A total of 186 patients were included; 91 were treated non-operatively and 95 were treated
Delayed union operatively. Mean age was 58.7 1.5 years and 57.0% were female. In 83.3% of the patients, only the
Complications humerus was affected. A fall from standing height was the most common cause of the fracture (72.0%).
Consolidation time varied from a median of 11–28 weeks. The rate of radial nerve palsy in both groups was
similar: 8.8% versus 9.5%. In 5.3% of the operatively treated patients, the palsy resulted from the operation.
Likewise, delayed union rates were similar in both groups: 18.7% following non-operative treatment versus
18.9% following surgery.
Conclusion: The data indicated that consolidation time and complication rates were similar after
operative and non-operative treatment. A prospective randomised clinical trial comparing non-operative
with operative treatment is needed in order to examine other aspects of outcome, meaning shoulder and
elbow function, postoperative infection rates, trauma-related quality of life and patient satisfaction.
ß 2012 Elsevier Ltd. All rights reserved.
0020–1383/$ – see front matter ß 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.injury.2012.08.003
428 K.C. Mahabier et al. / Injury, Int. J. Care Injured 44 (2013) 427–430
Table 1
Characteristics of the study population by type of treatment.
because of the development of new intramedullary and rotation- attending physician at each hospital and was based upon the
stable implants in addition to the classical osteosynthesis using a surgeon’s best judgement, knowledge and expertise.
plate.5 The trauma mechanism was classified as a simple fall, meaning
Therefore, the best treatment is still at debate and the type of a fall from persons height, high-energetic (e.g., a traffic-related
treatment highly depends on the physician’s personal view. The accident) or ‘other’.
current literature lacks an answer to the question whether Data were analysed using the Statistical Package for the Social
operative or non-operative treatment results in different clinical Sciences (SPSS) version 16.0 for Windows. Outcomes after
outcomes. The aim of the current study was to compare the operative and non-operative treatments were compared. Results
outcome after operative versus non-operative treatment of of categorical variables (gender, AO-types and sub-types, delayed
humeral shaft fractures, by comparing the time to radiological union, radial nerve palsy, injuries and trauma mechanism) were
union and the rates of delayed union and complications. analysed using the Chi-squared test. Results of numerical variables
(age and consolidation time) were analysed using the Mann–
Patients and methods Whitney U-test. All tests were two sided. P-values <0.05 were
considered statistically significant.
All patients aged 16 years or over treated for a humeral shaft
fracture in the Erasmus MC (Rotterdam, the Netherlands) between Results
January 2002 and December 2006, the Albert Schweitzer Hospital
(Dordrecht, the Netherlands) between January 2003 and December In total, 186 patients were included in this study. Table 1 shows
2007 and the Maasstad Hospital (Rotterdam, the Netherlands) the demographic data of this cohort for the patients in this study.
between January 2004 and December 2008 were included in this As many as 91 patients had been treated non-operatively. The
retrospective analysis. Patients with periprosthetic and pathologi- majority was female (60.4%) and the mean age was
cal fractures were excluded. 58.7 1.5 years. The operatively treated group consists of 95
The patients were identified from the radiology program PACS patients, 53.7% was female, with a median age of 61.1 years. No
(Picture Archiving and Communication System). Reports of all statistically significant difference could be found with respect to this
radiographs of the upper arm, including the shoulder and elbow, data between the groups.
were searched using ‘Humerus’ AND ‘Fracture’ as search terms. In the non-operatively treated group the left humerus was
Eligible patients with humeral shaft fractures were further affected in 51.6% of patients, which was not statistically different
identified by reading all radiology reports and reviewing all from the operative group (62.2%). In 83.3% of the patients, the
radiographs. humeral shaft injury was a solitary injury, and in 72% of patients
Humeral shaft fractures were defined as the area between the the fracture resulted after a simple fall. No statistical difference
surgical neck and the area immediately above the supracondylar was found between both groups. In the operative group 82.1% of
ridge. All fractures were classified using the Arbeitsgemeinschaft the patients were treated using intramedullary nailing, 11.6% using
für Osteosynthesefragen (AO)-system10 by reviewing the radio- plate osteosynthesis, 5.3% using external fixation and in one (1.1%)
graphs (K.C.M.). patient only cerclage wires were used.
Information about the affected side, the consolidation period Fig. 1 shows a detailed overview of fractures by AO subgroups.
and presence of a delayed union were collected from the This shows that type A humeral shaft fractures were found most
radiographs, radiology reports and the patient’s hospital records. frequently (50.0% of the patients) and type C was the least common
Radiological consolidation was defined as cortical bridging of at (8.1% of the patients). In the non-operatively treated group, the A1
least three out of four cortices and was expressed in weeks from spiral fracture was the most common subtype (28.6%) and in the
the day of the fracture. Delayed union was defined as a failure to operatively treated group the A3 transverse fracture (26.3%).
heal at 24 weeks post fracture with no progress towards healing Table 2 shows the time it took to achieve radiological
seen on the most recent radiographs.11 consolidation in weeks from the day of the fracture per AO type
The medical charts of all patients were reviewed and the and sub-type. In the non-operatively treated group, the time to
following items were retrieved: age, gender, trauma mechanism, achieve radiological consolidation ranged from a median of
other injuries besides the humeral shaft fracture, type of treatment 11 weeks in the AO type A2 subgroup to 15 weeks in the B2 and A3
and radial nerve palsy. The type of treatment was non-operative or subgroups. In the operative group, time to consolidation
operative. The decision between the two was made by the ranged from a median of 12 weeks (A2 sub-type) to 28 weeks
K.C. Mahabier et al. / Injury, Int. J. Care Injured 44 (2013) 427–430 429
Table 3
Origin of radial nerve palsy and delayed union in patients with humeral shaft
fractures by type of treatment.
Patient numbers are displayed, with the percentages given within brackets.
P-values were calculated with the Pearson Chi-squared test. N.A., not applicable.
function, pain, postoperative infection rates, numbers of patients 8. Koch PP, Gross DF, Gerber C. The results of functional (Sarmiento) bracing of
humeral shaft fractures. Journal of Shoulder and Elbow Surgery 2002;11(2):
returning to their previous work and residual deformity. 143–50.
9. Schratz W, Worsdorfer O, Klockner C, Gotze C. Treatment of humeral shaft
Conflict of interest statement fracture with intramedullary procedures (Seidel nail, Marchetti-Vicenzi nail,
Prevot pins) [Behandlung der Oberarmschaftfraktur mit intramedullaren
Verfahren (Seidel-Nagel, Marchetti-Vicenzi-Nagel, Prevot-Pins)]. Unfallchirurg
The authors state that no conflict of interest, financially or 1998;101(1):12–7.
otherwise, exist. 10. Fracture dislocation compendium. Orthopaedic trauma association committee
for coding and classification. Journal of Orthopaedic Trauma 1996;10(Suppl.
1):v–ix. 1–154.
Funding source 11. Anglen JO, Archdeacon MT, Cannada LK, Herscovici Jr D. Avoiding complications
in the treatment of humeral fractures. Journal of Bone and Joint Surgery
2008;90(7):1580–9.
No funding was obtained for this study.
12. Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the
treatment of fractures of the humeral diaphysis. Journal of Bone and Joint Surgery
References 2000;82(4):478–86.
13. Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Jarvinen MJ. Functional
1. Ekholm R, Adami J, Tidermark J, Hansson K, Tornkvist H, Ponzer S. Fractures of treatment of closed humeral shaft fractures. International Orthopaedics
the shaft of the humerus. An epidemiological study of 401 fractures. Journal of 2005;29(1):10–3.
Bone and Joint Surgery British Volume 2006;88(11):1469–73. 14. Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clinical Ortho-
2. Rose SH, Melton 3rd LJ, Morrey BF, Ilstrup DM, Riggs BL. Epidemiologic features paedics and Related Research 2004;419:46–50.
of humeral fractures. Clinical Orthopaedics and Related Research 1982;(168): 15. Ekholm R, Tidermark J, Tornkvist H, Adami J, Ponzer S. Outcome after closed
24–30. functional treatment of humeral shaft fractures. Journal of Orthopaedic Trauma
3. Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral 2006;20(9):591–6.
shaft fractures. Journal of Bone and Joint Surgery British Volume 1998;80(2): 16. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral frac-
249–53. tures. Journal of Hand Surgery 2006;31(4):655–63.
4. Sarmiento A, Latta LL. Humeral diaphyseal fractures: functional bracing [Funk- 17. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy
tionelle Behandlung bei Humerusschaftfrakturen]. Unfallchirurg 2007;110(10): associated with fractures of the shaft of the humerus: a systematic review.
824–32. Journal of Bone and Joint Surgery British Volume 2005;87(12):1647–52.
5. Schittko A. Humeral shaft fractures [Humerusschaftfrakturen]. Chirurg 18. Ruedi TP. Ao Principles of Fracture Management. Thieme; 2001.
2004;75(8):833–46. [quiz 847]. 19. Zagorski JB, Latta LL, Zych GA, Finnieston AR. Diaphyseal fractures of the
6. Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace humerus. Treatment with prefabricated braces. Journal of Bone and Joint Surgery
treatment of diaphyseal humerus fractures. Journal of Trauma 2007;62(5): 1988;70(4):607–10.
1157–8. 20. Rosenberg N, Soudry M. Shoulder impairment following treatment of diaphy-
7. Jensen AT, Rasmussen S. Being overweight and multiple fractures are indications seal fractures of humerus by functional brace. Archives of Orthopaedic and
for operative treatment of humeral shaft fractures. Injury 1995;26(4):263–4. Trauma Surgery 2006;126(7):437–40.