-
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 -
The Cochrane Database of Systematic... Jun 2022Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely,... (Review)
Review
BACKGROUND
Fractures of the proximal humerus, often termed shoulder fractures, are common injuries, especially in older people. The management of these fractures varies widely, including in the use of surgery. This is an update of a Cochrane Review first published in 2001 and last updated in 2015.
OBJECTIVES
To assess the effects (benefits and harms) of treatment and rehabilitation interventions for proximal humeral fractures in adults.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trial registries, and bibliographies of trial reports and systematic reviews to September 2020. We updated this search in November 2021, but have not yet incorporated these results.
SELECTION CRITERIA
We included randomised and quasi-randomised controlled trials that compared non-pharmacological interventions for treating acute proximal humeral fractures in adults. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently selected studies, assessed risk of bias and extracted data. We pooled data where appropriate and used GRADE for assessing the certainty of evidence for each outcome. We prepared a brief economic commentary for one comparison.
MAIN RESULTS
We included 47 trials (3179 participants, mostly women and mainly aged 60 years or over) that tested one of 26 comparisons. Six comparisons were tested by 2 to 10 trials, the others by small single-centre trials only. Twelve studies evaluated non-surgical treatments, 10 compared surgical with non-surgical treatments, 23 compared two methods of surgery, and two tested timing of mobilisation after surgery. Most trials were at high risk of bias, due mainly to lack of blinding. We summarise the findings for four key comparisons below. Early (usually one week post injury) versus delayed (after three or more weeks) mobilisation for non-surgically-treated fractures Five trials (350 participants) made this comparison; however, the available data are very limited. Due to very low-certainty evidence from single trials, we are uncertain of the findings of better shoulder function at one year in the early mobilisation group, or the findings of little or no between-group difference in function at 3 or 24 months. Likewise, there is very low-certainty evidence of no important between-group difference in quality of life at one year. There was one reported death and five serious shoulder complications (1.9% of 259 participants), spread between the two groups, that would have required substantive treatment. Surgical versus non-surgical treatment Ten trials (717 participants) evaluated surgical intervention for displaced fractures (66% were three- or four-part fractures). There is high-certainty evidence of no clinically important difference between surgical and non-surgical treatment in patient-reported shoulder function at one year (standardised mean difference (SMD) 0.10, 95% confidence interval (CI) -0.07 to 0.27; 7 studies, 552 participants) and two years (SMD 0.06, 95% CI -0.13 to 0.25; 5 studies, 423 participants). There is moderate-certainty evidence of no clinically important between-group difference in patient-reported shoulder function at six months (SMD 0.17, 95% CI -0.04 to 0.38; 3 studies, 347 participants). There is high-certainty evidence of no clinically important between-group difference in quality of life at one year (EQ-5D (0: dead to 1: best quality): mean difference (MD) 0.01, 95% CI -0.02 to 0.04; 6 studies, 502 participants). There is low-certainty evidence of little between-group difference in mortality: one of the 31 deaths was explicitly linked with surgery (risk ratio (RR) 1.35, 95% CI 0.70 to 2.62; 8 studies, 646 participants). There is low-certainty evidence of a higher risk of additional surgery in the surgery group (RR 2.06, 95% CI 1.21 to 3.51; 9 studies, 667 participants). Based on an illustrative risk of 35 subsequent operations per 1000 non-surgically-treated patients, this indicates an extra 38 subsequent operations per 1000 surgically-treated patients (95% CI 8 to 94 more). Although there was low-certainty evidence of a higher overall risk of adverse events after surgery, the 95% CI also includes a slightly increased risk of adverse events after non-surgical treatment (RR 1.46, 95% CI 0.92 to 2.31; 3 studies, 391 participants). Open reduction and internal fixation with a locking plate versus a locking intramedullary nail Four trials (270 participants) evaluated surgical intervention for displaced fractures (63% were two-part fractures). There is low-certainty evidence of no clinically important between-group difference in shoulder function at one year (SMD 0.15, 95% CI -0.12 to 0.41; 4 studies, 227 participants), six months (Disability of the Arm, Shoulder, and Hand questionnaire (0 to 100: worst disability): MD -0.39, 95% CI -4.14 to 3.36; 3 studies, 174 participants), or two years (American Shoulder and Elbow Surgeons score (ASES) (0 to 100: best outcome): MD 3.06, 95% CI -0.05 to 6.17; 2 studies, 101 participants). There is very low-certainty evidence of no between-group difference in quality of life (1 study), and of little difference in adverse events (4 studies, 250 participants) and additional surgery (3 studies, 193 participants). Reverse total shoulder arthroplasty (RTSA) versus hemiarthroplasty There is very low-certainty evidence from two trials (161 participants with either three- or four-part fractures) of no or minimal between-group differences in self-reported shoulder function at one year (1 study) or at two to three years' follow-up (2 studies); or in quality of life at one year or at two or more years' follow-up (1 study). Function at six months was not reported. Of 10 deaths reported by one trial (99 participants), one appeared to be surgery-related. There is very low-certainty evidence of a lower risk of complications after RTSA (2 studies). Ten people (6.2% of 161 participants) had a reoperation; all eight cases in the hemiarthroplasty group received a RTSA (very low-certainty evidence).
AUTHORS' CONCLUSIONS
There is high- or moderate-certainty evidence that, compared with non-surgical treatment, surgery does not result in a better outcome at one and two years after injury for people with displaced proximal humeral fractures. It may increase the need for subsequent surgery. The evidence is absent or insufficient for people aged under 60 years, high-energy trauma, two-part tuberosity fractures or less common fractures, such as fracture dislocations and articular surface fractures. There is insufficient evidence from randomised trials to inform the choices between different non-surgical, surgical or rehabilitation interventions for these fractures.
Topics: Adult; Aged; Arthroplasty, Replacement, Shoulder; Female; Fracture Fixation; Humans; Male; Quality of Life; Randomized Controlled Trials as Topic; Shoulder Fractures
PubMed: 35727196
DOI: 10.1002/14651858.CD000434.pub5 -
The American Journal of Occupational... 2017People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in... (Review)
Review
People with musculoskeletal disorders of the shoulder commonly experience pain, decreased strength, and restricted range of motion (ROM) that limit participation in meaningful occupational activities. The purpose of this systematic review was to evaluate the current evidence for interventions within the occupational therapy scope of practice that address pain reduction and increase participation in functional activities. Seventy-six studies were reviewed for this study-67 of Level I evidence, 7 of Level II evidence, and 2 of Level III evidence. Strong evidence was found that ROM, strengthening exercises, and joint mobilizations can improve function and decrease pain. The evidence to support physical modalities is moderate to mixed, depending on the shoulder disorder. Occupational therapy practitioners can use this evidence to guide daily clinical decision making.
Topics: Bursitis; Exercise Therapy; Humans; Humeral Fractures; Muscle Stretching Exercises; Musculoskeletal Diseases; Neck Pain; Occupational Therapy; Range of Motion, Articular; Rotator Cuff Injuries; Shoulder Impingement Syndrome; Shoulder Pain; Treatment Outcome
PubMed: 28027039
DOI: 10.5014/ajot.2017.023127 -
The Journal of Bone and Joint Surgery.... Dec 2005The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed... (Meta-Analysis)
Meta-Analysis Review
The management of radial nerve palsy associated with fractures of the shaft of the humerus has been disputed for several decades. This study has systematically reviewed the published evidence and developed an algorithm to guide management. We searched web-based databases for studies published in the past 40 years and identified further pages through manual searches of the bibliography in papers identified electronically. Of 391 papers identified initially, encompassing a total of 1045 patients with radial nerve palsy, 35 papers met all our criteria for eligibility. Meticulous extraction of the data was carried out according to a preset protocol. The overall prevalence of radial nerve palsy after fracture of the shaft of the humerus in 21 papers was 11.8% (532 palsies in 4517 fractures). Fractures of the middle and middle-distal parts of the shaft had a significantly higher association with radial nerve palsy than those in other parts. Transverse and spiral fractures were more likely to be associated with radial nerve palsy than oblique and comminuted patterns of fracture (p < 0.001). The overall rate of recovery was 88.1% (921 of 1045), with spontaneous recovery reaching 70.7% (411 of 581) in patients treated conservatively. There was no significant difference in the final results when comparing groups which were initially managed expectantly with those explored early, suggesting that the initial expectant treatment did not affect the extent of nerve recovery adversely and would avoid many unnecessary operations. A treatment algorithm for the management of radial nerve palsy associated with fracture of the shaft of the humerus is recommended by the authors.
Topics: Algorithms; Humans; Humeral Fractures; Paralysis; Practice Guidelines as Topic; Prognosis; Radial Nerve; Radial Neuropathy; Recovery of Function; Treatment Outcome
PubMed: 16326879
DOI: 10.1302/0301-620X.87B12.16132 -
The Archives of Bone and Joint Surgery Aug 2022The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN).... (Review)
Review
BACKGROUND
The two techniques most utilized in the surgical treatment of humeral shaft fractures are open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Although there have been multiple comparative clinical studies comparing outcomes for these two treatments, studies have not suggested one approach to be superior to the other. The purpose of this study is to perform a systematic literature review and meta-analysis of studies that evaluated the treatment of humeral shaft fractures with either ORIF or intramedullary nail.
METHODS
We conducted this meta-analysis utilizing stricter inclusion and broader exclusion criteria to examine these two common approaches. We examined those articles which have compared first-time, closed fractures of the humeral diaphysis in adults in fracture patterns that could be treated equivalently by intramedullary nail or plate fixation. The primary outcome of interest was nonunion, and studies that did not report nonunion rates were excluded.
RESULTS
There were a total of 1,926 abstracts reviewed and a total of three articles were included in the final analysis after screening. There was no significant difference in the incidence of nonunion between plating (2/111, 1.8%) and nailing (4/104, 3.9%) (). The mean difference in average time to union for plated fractures and nailed fractures was 1.11 weeks (95% CI 0.82 to 1.40) which was statistically significant (). There was a significant difference in the incidence of radial nerve palsy (12/111, 10.8%) for plating compared to nailing (0/104, 0%) (). There was no difference in incidence of post-operative infection between the two groups intramedullary nailing ().
CONCLUSION
The results of this analysis demonstrate an increased risk of iatrogenic radial nerve injury, and a significantly shorter time to union when treating humeral shaft fractures with plating as compared to intramedullary nailing. There was no difference in the rates of nonunion or delayed union. Based on the evidence, both plating and nailing can achieve a similar treatment effect on humeral shaft fractures.
PubMed: 36258745
DOI: 10.22038/ABJS.2021.59413.2947 -
Journal of Orthopaedics 2021The purpose of this systematic review was to (1) define the cumulative humerus fracture rate after BT and (2) compare how often fracture rate was reported compared to... (Review)
Review
BACKGROUND
The purpose of this systematic review was to (1) define the cumulative humerus fracture rate after BT and (2) compare how often fracture rate was reported compared to other complications.
METHODS
A systematic review was performed using the PRISMA guidelines.
RESULTS
39 studies reported complications and 30 reported no complications. Of the 39 studies that reported complications, 5 studies reported fracture after BT (n = 669, cumulative incidence of 0.53%). The overall non-fracture complication rate was 12.9%.
DISCUSSION
Due to the relatively high incidence of fracture, surgeons should ensure that this complication is disclosed to patients undergoing BT.
PubMed: 34880569
DOI: 10.1016/j.jor.2021.11.014 -
Orthopaedic Journal of Sports Medicine May 2022Arm wrestling is a popular sport in which various injuries have occurred, even in children. (Review)
Review
BACKGROUND
Arm wrestling is a popular sport in which various injuries have occurred, even in children.
PURPOSE
To analyze reported fracture-separation of the medial humeral epicondyle (MHE) caused by arm wrestling to determine its mechanism and provide a current overview.
STUDY DESIGN
Systematic review; Level of evidence, 4.
METHODS
The PubMed and Web of Science databases were searched using the terms "arm wrestling" and "humeral fracture" or "medial humeral epicondyle fracture"; and "sports" and "humeral fracture" or "medial humeral epicondyle fracture," following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The inclusion criteria were English full-text articles on arm wrestling-induced MHE fracture that described patient characteristics and presented appropriate images. Studies with a lack of appropriate images or detailed description of the injury situation were excluded. The patient characteristics were evaluated, and the ratios of treatment selection and outcomes were evaluated using the chi-square test.
RESULTS
Included were 27 studies with a total of 68 patients, all boys with a mean age of 14.6 ± 1.24 years (based on n = 65, with 3 patients excluded from this calculation as no definitive age was provided). Boys aged 14 to 15 years accounted for 72% (49/68) of the cases. Fracture occurred suddenly during arm wrestling in 63 boys, while the other 5 boys experienced antecedent medial elbow pain. The match status at the time of injury, provided for 46 patients, was varied. In 31 boys with known match details, injury occurred when a participant suddenly added more force to change the match status. Eight patients displayed anterior and/or proximal displacement of the MHE fragment. Treatment was nonoperative in 25 patients and operative in 38 patients (n = 63, excluding 5 unknown patients). In 35 patients followed up for ≥3 months (mean, 17.6 ± 12.3 months), outcomes were not significantly different between the operative and nonoperative groups.
CONCLUSION
MHE fracture-separation caused by arm wrestling occurred mostly in boys aged 14 to 15 years regardless of the match status. The likely direct cause is forceful traction of the attached flexor-pronator muscles. A relative mechanical imbalance during adolescence may be an underlying cause. A sudden change from concentric to eccentric contraction of the flexor-pronator muscles increases the likelihood of fracture occurrence.
PubMed: 35528993
DOI: 10.1177/23259671221087606 -
Shoulder & Elbow Feb 2022Distal humeral hemiarthroplasty has been performed for a variety of indications with the most common being management of distal humeral fractures. This systematic review... (Review)
Review
BACKGROUND
Distal humeral hemiarthroplasty has been performed for a variety of indications with the most common being management of distal humeral fractures. This systematic review evaluates the outcomes and complications of distal humeral hemiarthroplasty for this pathology.
METHODS
We searched PubMed, EMBASE, and MEDLINE for studies reporting indications and outcomes of patients undergoing distal humeral hemiarthroplasty. Study screening, risk of bias assessment, and data extraction were performed. Summery statistics were provided.
RESULTS
We included 11 studies ( = 163) in this review. In all studies, the indication for distal humeral hemiarthroplasty was the presence of an intraarticular, comminuted, unreconstructable fracture. The mean post-operative MEPS, FullDASH, and QuickDASH (SD) scores were 83.6 (6.1) points, 25.4 (10.3), and 15.7 (7.4) points, respectively. The mean post-operative range of motion (SD) was 106° (11°) in the flexion and extension arc and 153° (19°) in the protonation and supination arc. The overall rate of adverse events and complication was 63%. The rate for major complications was 11%. The mean total revision rate was 4% (0% to 15) and total re-operation rate was 29% (0% to 88%).
CONCLUSION
Distal humeral hemiarthroplasty is a suitable option for unreconstructable distal humeral fractures and offers good functional outcomes with acceptable complication rates.
PubMed: 35154405
DOI: 10.1177/17585732211023100 -
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 -
BioMed Research International 2017The study aims to compare minimally invasive percutaneous plate osteosynthesis (MIPO) and open reduction internal fixation (ORIF) in the treatment of proximal humeral... (Meta-Analysis)
Meta-Analysis Review
Comparison of Minimally Invasive Percutaneous Plate Osteosynthesis and Open Reduction Internal Fixation on Proximal Humeral Fracture in Elder Patients: A Systematic Review and Meta-Analysis.
OBJECTIVE
The study aims to compare minimally invasive percutaneous plate osteosynthesis (MIPO) and open reduction internal fixation (ORIF) in the treatment of proximal humeral fracture in elder patients.
METHOD
PubMed, Medline, EMbase, Ovid, Cochrane Library, China National Knowledge Infrastructure (CNKI), Wangfang, and VIP Database for Chinese Technical Periodicals were searched to identify all relevant studies from inception to October 2016. Data were analyzed with Cochrane Collaboration's Review Manage 5.2.
RESULTS
A total of 630 patients from 8 publications were included in the systematic review and meta-analysis. The pooled results showed that MIPO was superior to ORIF in the treatment of proximal humeral fracture in elder patients. It was reflected in reducing blood loss, operation time, postoperative pain, or fracture healing time of the surgery and in improving recovery of muscle strength. Concerning complications, no significant difference was seen between MIPO and ORIF.
CONCLUSION
The MIPO was more suitable than ORIF for treating proximal humeral fracture in elder patients.
Topics: Aged; Aged, 80 and over; Female; Fracture Fixation, Internal; Humans; Humeral Fractures; Male; Minimally Invasive Surgical Procedures
PubMed: 28698871
DOI: 10.1155/2017/3431609