Injury: Kiran C. Mahabier, Lucas M.M. Vogels, Bas J. Punt, Gert R. Roukema, Peter Patka, Esther M.M. Van Lieshout

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Injury, Int. J.

Care Injured 44 (2013) 427–430

Contents lists available at SciVerse ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Humeral shaft fractures: Retrospective results of non-operative and operative


treatment of 186 patients
Kiran C. Mahabier a, Lucas M.M. Vogels a, Bas J. Punt b, Gert R. Roukema c, Peter Patka a,
Esther M.M. Van Lieshout a,*
a
Department of Surgery-Traumatology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
b
Department of Surgery-Traumatology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
c
Department of Surgery-Traumatology, Maasstad Hospital, Rotterdam, The Netherlands

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.

Introduction the Sarmiento brace as functional bracing therapy.4 Operative


approaches include intramedullary nailing, plate osteosynthesis
Fractures of the shaft of the humerus account for 1–3% of all and an external fixation.5
fractures1 and approximately 20% of all fractures involving the Both non-operative and operative treatment strategies have
humerus.2 The incidence is 14.5 per 100 000 per year, gradually their pros and cons. Although functional treatment is believed to
increasing from the fifth decade and reaching its peak of 60 per be associated with a very low rate of delayed union and excellent
100 000 per year in the ninth decade. In addition, a minor peak is functional results,6 in certain groups of patients functional bracing
seen in the third decade.1,3 does not provide sufficient immobilisation. For instance, non-
Both operative and non-operative treatments are used in the operative treatment in overweight patients results in a high rate of
management of humeral shaft fractures. Traditionally, the delayed union.7
treatment has generally been non-operative, nowadays using There is substantial controversy on the best approach of
humeral shaft fractures. Koch et al. for example stated that though
newer intramedullary techniques are probably less invasive and
technically less complicated, the Sarmiento brace remains the gold
* Corresponding author at: Erasmus MC, University Medical Centre Rotterdam,
Department of Surgery-Traumatology, Room H-822k, P.O. Box 2040, 3000 CA
standard and first treatment of choice.8 Schratz et al. on the
Rotterdam, The Netherlands. Tel.: +31 10 70 31050; fax: +31 10 70 32395. contrary favours intramedullary nailing.9 Schittko claimed that the
E-mail address: [email protected] (Esther M.M. Van Lieshout). operative therapy should be considered as the gold standard

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.

Overall (N = 186) Non-operative (N = 91) Operative (N = 95) P-value


a
Female 106 (57.0) 55 (60.4) 51 (53.7) 0.377c
Ageb (year) 60.8 (44.2–76.5) 60.6 (45.7–77.7) 61.1 (39.7–74.7) 0.424d
Left side affecteda 106 (57.0) 47 (51.6) 59 (62.1) 0.183c
Concomitant injuries 0.092c
Monotraumaa 155 (83.3) 79 (86.8) 76 (80.0)
Polytraumaa 29 (15.6) 10 (11.0) 19 (20.0)
Unkowna 2 (1.1) 2 (2.2) 0 (0.0)
Trauma mechanism 0.147c
Simple falla 134 (72.0) 69 (75.8) 65 (68.4)
High energya 32 (17.2) 10 (11.0) 22 (23.2)
Othera 13 (7.0) 8 (8.8) 5 (5.3)
Unknowna 7 (3.8) 4 (4.4) 3 (3.2)
a
Data are shown as number of patients with the percentages given within brackets.
b
Data are shown as median with the first quartile and third quartile given within brackets.
c
Pearson Chi-squared test.
d
Mann–Whitney U-test.

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.

Overall Non-operative Operative P-value

Radial nerve palsy


Trauma/fracture 13 (7.0) 8 (8.8) 5 (5.3)
Surgery 4 (2.2) N.A. 4 (4.2)
Total 17 (9.1) 8 (8.8) 9 (9.5) 0.053
Delayed union 35 (18.8) 18 (18.7) 18 (18.9) 0.580

Patient numbers are displayed, with the percentages given within brackets.
P-values were calculated with the Pearson Chi-squared test. N.A., not applicable.

operatively treated patients. Data of the current study (18.7% vs.


18.9%, respectively) are consistent with the literature data.
Fig. 1. Distribution of the humeral shaft fractures into AO types and subtypes by Increased delayed union rates as suggested previously15 could
type of treatment.
not be confirmed in the current study.
Due to the high variability in fracture sub-types, our study
(B3 sub-type), which did not differ statistically from the non- lacked adequate statistical power to show statistically significant
operative group. difference in time to radiographic healing between both groups.
Overall, 17 of the patients (9.1%) developed radial nerve palsy For the B3 type fractures, a trend was seen, suggesting that the time
(Table 3). No statistically significant difference was found between to radiographic healing was shorter in the non-operative group
the two groups. In the non-operatively treated group, this (median 12 weeks) than in the operative group (median 28 weeks).
originated from the trauma or fractures themselves in eight In the current study, 9.1% of the patients had radial nerve palsy.
patients. In the operatively treated group, radial nerve palsy Rates between 2% and 17% are described in the literature,16 but a
originated from the trauma or fracture in 13 patients. In four review by Shao et al. reported an average rate of 11.8%.17 Even
patients, it occurred after surgery. though primary radial nerve palsy is considered by many an
Delayed union occurred in 18.8% of the patients, that is, in 18 absolute indication for surgery5 the data of our study do not
patients treated non-operatively and in 18 patients treated support this, as radial nerve palsies occurred equally frequent in
operatively (P > 0.05; 14 treated with intramedullary nailing, both groups. In the operatively treated group, less radial nerve
two with plate osteosynthesis, one with an external fixator and one palsies were seen as a result of the fracture or the trauma (8.8% vs.
with cerclage wires). 5.3%). Spontaneous recovery is seen in 70.7% of the patients treated
conservatively for the palsy, and after including surgical manage-
Discussion ment the overall recovery rate is 88.1%, as reported by Shao et al.
The retrospective nature and the lack of randomisation was a
The aim of the current retrospective study was to compare the limitation of our study. The decision between operative and non-
outcome after operative versus non-operative treatment of humeral operative treatment was made by the attending surgeon, based
shaft fractures, by comparing the time to radiological union and the upon his preferences and previous experience. Given the low and
rates of delayed union and complications. In this series of 186 similar rates of delayed union in both groups, it is tempting to
patients, no statistically significant differences were found in the speculate that the surgeons were quite good at identifying which
time to radiological consolidation between the two groups, in the fractures should be operated on. Whether or not this is true should
rates of delayed union or occurrence of radial nerve palsy. be studied in more detail.
The demographic data of the current study are to a large extent Data on other essential aspects of outcome were unavailable.
in agreement with published epidemiologic studies on humeral Possible residual deformity of the arm or impaired function could
shaft fractures.1,3 In the most recent epidemiologic study, the be a disadvantage of non-operative treatment compared with
average age of patients with a humeral shaft fracture was 62.7 operative treatment. Rotational or axial malalignment up to 20–
years1; the average age of the patients in our study was 58.7 years. 258 and shortening less than 2 cm are regarded as acceptable
Data from previous studies showed delayed union rates of 2– following non-operative treatment.13,18,19 Surgery could improve
23%12,13 after non-operative treatment versus 15–30%14 for the alignment of the fracture site, but it is unclear at this moment if
improved alignment also results in better functional outcome. As a
Table 2 disadvantage of surgery shoulder impairment is often mentioned,
Consolidation time in weeks from day of humeral shaft fracture per AO type and
though impaired shoulder function may also occur following non-
subtypes by type of treatment.
operative treatment.20 Moreover, infections after surgery, the time
Overall Non-operative Operative P-value and ability to full resumption of activities of daily living and
A All 14 (11–18) 13 (8–18) 14 (11–19) 0.169 patient satisfaction with the outcome are all important factors that
A1 14 (10–18) 13 (9–18) 16 (11–18) 0.381 should be taken into consideration in the treatment of humeral
A2 11 (8–13) 11 (6–13) 12 (10–20) 0.221 shaft fractures.
A3 15 (12–22) 15 (11–22) 14 (12–23) 0.890
B All 15 (12–22) 14 (11–21) 17 (13–23) 0.166
B1 16 (12–21) 14 (9–18) 18 (14–23) 0.065 Conclusion
B2 15 (12–21) 15 (14–26) 14 (11–20) 0.173
B3 22 (12–31) 12 (9–22) 28 (23–34) 0.034 In conclusion, the current study revealed similar time to
C All 22 (16–24) No data 22 (16–24) N.A.
consolidation and rates of delayed union and radial nerve palsy
C1 20 (16–24) No data 20 (16–24) N.A.
C2 No data No data No data N.A. after non-operative and operative treatment of humeral shaft
C3 22 (22–22) No data 22 (22–22) N.A. fractures. A randomised clinical trial comparing non-operative
Data are shown as median with the first quartile and third quartile given within
with operative treatment is needed in order to examine all aspects
brackets. P-values were calculated with the Mann–Whitney U-test. N.A., not of outcome, taking into account consolidation time, delayed union
applicable. and radial nerve palsy rates as well as the shoulder and elbow
430 K.C. Mahabier et al. / Injury, Int. J. Care Injured 44 (2013) 427–430

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in the treatment of humeral fractures. Journal of Bone and Joint Surgery
2008;90(7):1580–9.
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treatment of fractures of the humeral diaphysis. Journal of Bone and Joint Surgery
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