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Archives of Orthopaedic and Trauma... Aug 2023Humeral 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... (Review)
Review
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.
Topics: Humans; Fracture Fixation, Internal; Fracture Fixation, Intramedullary; Humeral Fractures; Fracture Healing; Bone Plates; Radial Neuropathy; Humerus; Treatment Outcome
PubMed: 37093269
DOI: 10.1007/s00402-023-04836-8 -
Journal of Orthopaedic Surgery and... Sep 2021Distal humerus fractures (DHFs) constitute one-third of elbow fractures approximately. In this study, we aim to define and analyze the fracture lines and morphological...
BACKGROUND
Distal humerus fractures (DHFs) constitute one-third of elbow fractures approximately. In this study, we aim to define and analyze the fracture lines and morphological features of DHFs using mapping technique.
METHODS
One hundred and two DHFs were retrospectively reviewed. All the computed tomography (CT) data were used to manually reconstruct and virtually reduce the DHF fragments to fit a standard 3D model. Smooth curves were depicted accurately onto the surface of the template to represent the fracture lines. All the curves were overlapped onto the model to create the 3D fracture map and heat map.
RESULTS
Our analysis was based on 102 CT images of DHFs, contributed by 59 male and 43 female patients (mean age, 46 years; range, 18-93 years), and included 15 type A, 25 type B, and 62 type C fractures. On mapping, the hot zones were located in the radial fossa, coronoid fossa, olecranon fossa, and the external part of the trochlear. Conversely, the cold zones were noted in medial condyle, the medial side of the trochlear, and the anterolateral area on the supracondylar ridge.
CONCLUSIONS
Our study firstly shows the fracture lines and morphological features of distal humeral fractures by three-dimensional mapping technology. Distal humerus fracture lines are characteristic and highly related to the micro-architecture difference of distal humerus, which may provide some guidance for the treatment plan selection and surgical fixation design.
Topics: Elbow Joint; Epiphyses; Female; Fracture Fixation, Internal; Fractures, Bone; Humans; Humeral Fractures; Humerus; Male; Middle Aged; Retrospective Studies; Tomography, X-Ray Computed
PubMed: 34479569
DOI: 10.1186/s13018-021-02691-0 -
JAMA May 2020Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend.
OBJECTIVE
To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma.
INTERVENTIONS
Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44).
MAIN OUTCOME AND MEASURE
The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points).
RESULTS
Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy.
CONCLUSIONS AND RELEVANCE
Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01719887.
Topics: Adult; Aged; Aged, 80 and over; Bone Plates; Braces; Closed Fracture Reduction; Disability Evaluation; Female; Fracture Fixation, Internal; Fractures, Ununited; Humans; Humeral Fractures; Male; Middle Aged; Open Fracture Reduction; Recovery of Function
PubMed: 32396179
DOI: 10.1001/jama.2020.3182 -
Current Osteoporosis Reports Aug 2021Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure... (Review)
Review
PURPOSE OF REVIEW
Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures.
RECENT FINDINGS
There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.
Topics: Female; Femoral Fractures; Finite Element Analysis; Fracture Fixation; Humans; Humeral Fractures; Osteoporotic Fractures
PubMed: 34185266
DOI: 10.1007/s11914-021-00690-y -
PloS One 2018The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
The objective of this Health Technology Assessment was to evaluate effectiveness, complications and cost-effectiveness of surgical or non-surgical treatment for proximal, diaphyseal or distal fractures of the humerus in elderly patients. Secondary objectives were to evaluate the intervention costs per treatment of proximal humerus fractures (PHF) and to investigate treatment traditions of PHF in Sweden.
METHODS AND FINDINGS
The assessment contains a systematic review of clinical and health economic studies comparing treatment options for humerus fractures in elderly patients. The results regarding the effectiveness of treatments are summarized in meta-analyses. The assessment also includes a cost analysis for treatment options and an analysis of registry data of PHF. For hemiarthroplasty (HA) and non-operative treatment, there was no clinically important difference for moderately displaced PHF at one-year follow-up regarding patient rated outcomes, (standardized mean difference [SMD]) -0.17 (95% CI: -0.56; 0.23). The intervention cost for HA was at least USD 5500 higher than non-surgical treatment. The trend in Sweden is that surgical treatment of PHF is increasing. When functional outcome of percutaneous fixation/plate fixation/prosthesis surgery and non-surgical treatment was compared for PHF there were no clinically relevant differences, SMD -0.05 (95% CI: -0.26; 0.15). There was not enough data for interpretation of quality of life or complications. Evidence was scarce regarding comparisons of different surgical options for humerus fracture treatment. The cost of plate fixation of a PHF was at least USD 3900 higher than non-surgical treatment, costs for complications excluded. In Sweden the incidence of plate fixation of PHF increased between 2005 and 2011.
CONCLUSIONS
There is moderate/low certainty of evidence that surgical treatment of moderately displaced PHF in elderly patients has not been proven to be superior to less costly non-surgical treatment options. Further research of humerus fractures is likely to have an important impact.
Topics: Aged; Aged, 80 and over; Cost-Benefit Analysis; Female; Humans; Humeral Fractures; Male; Middle Aged; Orthopedic Procedures; Safety; Shoulder Fractures; Sweden; Technology Assessment, Biomedical; Treatment Outcome
PubMed: 30543644
DOI: 10.1371/journal.pone.0207815 -
Ugeskrift For Laeger Jan 2023The supracondylar humerus fracture is the most common elbow fracture in children. All orthopedic surgeons involved in pediatric trauma will at some point have to treat... (Review)
Review
The supracondylar humerus fracture is the most common elbow fracture in children. All orthopedic surgeons involved in pediatric trauma will at some point have to treat this injury. Severity ranges from simple fractures to limb threatening injuries. An in-depth knowledge of this injury is key to a successful treatment outcome. This review describes the diagnostic approach and current concepts for treatment of pediatric supracondylar humerus fractures.
Topics: Child; Humans; Humeral Fractures; Treatment Outcome; Retrospective Studies
PubMed: 36760153
DOI: No ID Found -
Joint Diseases and Related Surgery 2021This study aims to evaluate the clinical and functional results of patients treated with InSafeLOCK® humeral nail and iliac crest autograft for humeral nonunion.
OBJECTIVES
This study aims to evaluate the clinical and functional results of patients treated with InSafeLOCK® humeral nail and iliac crest autograft for humeral nonunion.
PATIENTS AND METHODS
A total of 15 patients (11 males, 4 females; mean age: 52.1±15.3 years; range, 31 to 78 years) who were followed conservatively for humeral fractures and operated with the InSafeLOCK® humeral nail and iliac bone graft in our center between June 2018 and January 2020 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, operative data, and pre- and postoperative Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), and Constant-Murley Scores (CMS) were recorded.
RESULTS
The mean time from injury to nonunion treatment was 10.9±1.6 months. Five patients had atrophic, eight patients had oligotrophic, and two patients had hypertrophic nonunion. Preoperatively, the mean DASH was 37.7±9.1, the mean CMS was 69.7±6.3, and the mean VAS was 3.8±0.7. In all patients, union was achieved. The mean operation time was 59.0±16.2 min. The mean postoperative DASH score was 16.1±8.7, CMS 87.4±3.4, and VAS score 0.8±0.7. Regarding the shoulder joint, the mean abduction was 164.7±11.3 degrees, the mean internal rotation was 82.0±6.8 degrees, the mean external rotation was 81.3±8.3 degrees, and the mean flexion was 162.0±12.1 degrees. During follow-up, complications such as vascular-nerve injury, reflex sympathetic dystrophy, screw migration or loosening, implant failure, and loss of reduction did not occur in any of our patients.
CONCLUSION
Considering the satisfactory functional and radiological results, the InSafeLOCK® humeral nail can be used safely in humeral nonunions.
Topics: Adult; Aged; Bone Nails; Bone Screws; Bone Transplantation; Female; Fracture Fixation, Intramedullary; Fractures, Ununited; Humans; Humeral Fractures; Ilium; Male; Middle Aged; Radiography; Range of Motion, Articular; Retrospective Studies; Shoulder Joint; Upper Extremity
PubMed: 34145823
DOI: 10.52312/jdrs.2021.81535 -
Orthopaedics & Traumatology, Surgery &... Feb 2023Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be... (Review)
Review
Aseptic humeral shaft nonunions are rare lesions, with less than 700 cases per year in France. This low frequency explains why they are difficult to manage. They can be hypertrophic or atrophic, with or without a defect. The diagnosis is made based on radiographs and/or CT scan images. Nonunion is suspected early on when a patient presents with abnormal motion at the fracture site 6 weeks after the initial injury event in the context of conservative treatment or has large residual displacement after initial treatment or an open fracture. The treatment for hypertrophic nonunion consists in applying stable, rigid fixation, most often using a large-fragment plate with 4.5 mm screws, combined with cancellous autograft. When combined with the osteoperiosteal decortication first described by Judet, it produces union in 98% of cases. Intramedullary (IM) nail fixation with an autograft is another possibility. In atrophic nonunions, resecting the ends and ensuring the soft tissues have good vitality will generally lead to fracture union. Nonunions with critical size defects (larger than 5 cm), which have a high risk of infection, are a treatment challenge that requires stable fixation and recourse to more complex treatments like the two-step induced membrane technique or vascularized fibular graft. In all cases, to avoid complex repeat revision, internal fixation with plate or IM nail must be combined with a bone graft in situ to maximize the chances of union.
Topics: Humans; Humeral Fractures; Fractures, Ununited; Fracture Fixation, Internal; Humerus; Bone Plates; Bone Transplantation; Treatment Outcome; Retrospective Studies; Fracture Healing
PubMed: 36942794
DOI: 10.1016/j.otsr.2022.103462 -
BMC Surgery Oct 2021Currently, the reduction and support of comminuted medial cortex of humeral fracture remains a challenge, Therefore, a novel reduction and fixation technique that...
BACKGROUND
Currently, the reduction and support of comminuted medial cortex of humeral fracture remains a challenge, Therefore, a novel reduction and fixation technique that employs an anteromedial small locking plate was explored in this study, and its viability and the associated complications were assessed.
METHODS
Fifteen cases of proximal humeral fractures with medial instability (five cases were classified as three-part and ten as four-part by Neer classification) were treated by the proposed reduction technique using an anteromedial small locking plate. Subsequently, the radiological and clinical outcomes were evaluated over an average follow-up period of 18.53 months.
RESULTS
The average operation time was 108 min (range, 70-130 min), and the mean fracture union time in all patients was 12.13 weeks (range, 8-16 weeks). Complications such as infection and neurovascular injury were not observed. Postoperative X-ray showed avascular necrosis and screw penetration in one patient, while screw penetration, varus malunion, or significant reduction loss was not found in the other cases. The mean Constant score was 79.8 (range, 68-92) during the final visit.
CONCLUSIONS
The use of an anteromedial small locking plate improved the reduction efficiency, reconstructed the medial support, and alleviated the occurrence of complications in proximal humeral fractures with medial instability.
Topics: Bone Plates; Bone Screws; Fracture Fixation, Internal; Humans; Humeral Fractures; Shoulder Fractures; Treatment Outcome
PubMed: 34719385
DOI: 10.1186/s12893-021-01388-9 -
Annals of the Royal College of Surgeons... Oct 2020Following open reduction and internal fixation for a proximal humerus fracture a 71-year-old man re-presented with wound changes consistent with infection and elevated...
Following open reduction and internal fixation for a proximal humerus fracture a 71-year-old man re-presented with wound changes consistent with infection and elevated inflammatory markers. No significant improvement was seen with concomitant intravenous antibiotics and multiple debridement procedures. This case was further complicated by soft tissue breakdown at the site of a left thigh haematoma also requiring debridement. Surgical site infections represent the most common cause of morbidity postoperatively. This case highlights the importance of considering a number of differential diagnoses. A diagnosis of pyoderma gangrenosum prompted systemic corticosteroid therapy giving rapid clinical improvement.
Topics: Aged; Debridement; Diagnosis, Differential; Fracture Fixation, Internal; Humans; Humeral Fractures; Male; Open Fracture Reduction; Pyoderma Gangrenosum; Thigh
PubMed: 32347737
DOI: 10.1308/rcsann.2020.0091