Aims

The primary aim of this study was to determine the rates of return to work (RTW) and sport (RTS) following a humeral shaft fracture. The secondary aim was to identify factors independently associated with failure to RTW or RTS.

Aims

The primary aim was to estimate the cost-effectiveness of routine operative fixation for all patients with humeral shaft fractures. The secondary aim was to estimate the health economic implications of using a Radiographic Union Score for HUmeral fractures (RUSHU) of < 8 to facilitate selective fixation for patients at risk of nonunion.

Aims. Fractures of the humeral shaft represent 3% to 5% of all fractures. The most common treatment for isolated humeral diaphysis fractures in the UK is non-operative using functional bracing, which carries a low risk of complications, but is associated with a longer healing time and a greater risk of nonunion than surgery. There is an increasing trend to surgical treatment, which may lead to quicker functional recovery and lower rates of fracture nonunion than functional bracing. However, surgery carries inherent risk, including infection, bleeding, and nerve damage. The aim of this trial is to evaluate the clinical and cost-effectiveness of functional bracing compared to surgical fixation for the treatment of humeral shaft fractures. Methods. The HUmeral SHaft (HUSH) fracture study is a multicentre, prospective randomized superiority trial of surgical versus non-surgical interventions for humeral shaft fractures in adult patients. Participants will be randomized to receive either functional bracing or surgery. With 334 participants, the trial will have 90% power to detect a clinically important difference for the Disabilities of the Arm, Shoulder and Hand questionnaire score, assuming 20% loss to follow-up. Secondary outcomes will include function, pain, quality of life, complications, cost-effectiveness, time off work, and ability to drive. Discussion. The results of this trial will provide evidence regarding clinical and cost-effectiveness between surgical and non-surgical treatment of humeral shaft fractures. Ethical approval has been obtained from East of England – Cambridge Central Research Ethics Committee. Publication is anticipated to occur in 2024. Cite this article: Bone Jt Open 2024;5(4):343–349

This study was carried out to determine the incidence of shoulder injuries in the ipsilateral shoulder of patients who attended our unit with fractures of the humeral diaphysis. This was a prospective study. 22 patients with fractures of the humeral diaphysis had an early (within 10 days of injury) MRI scan of the shoulder. The contralateral shoulder was also scanned as an internal control. There were 10 male and 12 female patients. The average age was 45 years. 20 were treated non-operatively, and 2 had retrograde intra-medullary nailing of the humerus. 6 patients in our study had a symmetrical MRI scan. The remaining 16 patients had some acute abnormality evident in the ipsilateral shoulder. 11 patients had a significant subacromial bursitis. 2 of these patients had a tear of the supraspinatus tendon. 1 patient had an undisplaced fracture of the coracoid process. The remaining 4 patients had significant AC joint inflammation, 3 being acute, the 4th being acute-on-chronic. This study shows a high incidence of asymmetrical MRI scans, indicating a definite shoulder injury sustained at the time of the fracture of the humeral diaphysis. We therefore surmise that shoulder pain and dysfunction post antegrade intra-medullary nailing of the humerus may not be due to iatrogenic causes, but may in fact result from concomitant ipsilateral shoulder injury. To our knowledge, this is the first study demonstrating such an association

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Humeral diaphysis fractures consist a rather frequent injury. The aim of our study is to evaluate the results of the treatment of humeral diaphysis fractures with the use of an interlocking intramedullary nail. During the period March 1999 – December 2001, 25 intramedullary nailings were performed in 24 patients with a humeral fracture (16 women and 8 men), aged 26–81 years (Average: 57.1 years) using a Russell-Taylor humeral nail. There were 16 cases of acute humeral fractures, 3 cases of pathologic fractures, and 6 cases of delayed union or non-union. Follow-up ranged from 6 to 36 months (Average: 20 months). Fracture union was recorded, and the results were evaluated according to the scoring system of Neer. No immediate postoperative complications were recorded. The final result was excellent in 9 cases (36%), good in 12 (48%), unsatisfactory in 3 (12%), while there was one failure (4%), where a reoperation was required. Fracture union was achieved within 4 months in 21 cases (84%), while 2 cases of delayed union and 2 non-unions were recorded. Interlocking intramedullary nailing offers a dependable solution in the treatment of humeral diaphysis fractures, providing a very satisfactory functional outcome and a high union rate. It offers an excellent option in the treatment of pathologic fractures of the humerus, as well as in severely comminuted fractures and humeral fractures in polytrauma patients

Aim: The retrospective evaluation of external fixation as a treatment of choice for fractures of humeral diaphysis. Material – Method: 24 patients with an equal number of fractures of humerus diaphysis (21 closed, 3 open) were treated with external fixation. Time to bony union, the seriousness and type of complications, the clinical, radiological and functional outcome were evaluated. The minimum time of follow up was six months. Results: Excellent 20, good 2, fair 1, poor 1. The cause of fair and poor results was limitation of shoulder motion. 22 fractures united within 2–5 months. Complications were 2 cases of non-union, 3 pin-track infections, 3 remanipulations. There was no case of deep infection at the fracture site and no iatrogenic injury of the radial nerve. Conclusion: The external fixation, used in the treatment of humerus fractures, is a semi-interventional method, easy to apply, well-tolerated by the patient and with very good functional results. It a very good alternative of both the conservative treatment and internal fixation

Conservative management remains the gold standard for many fractures of the humeral diaphysis with union rates of over 90% often quoted. Success with closed management however is not universal. Phase 1. A retrospective review of all conservatively managed fractures between 2001 and 2005 was undertaken to investigate a suspected high non-union rate and identify possible causes. The overall non-union rate was 39.2% (11 of 28 cases). There was no difference in axial distraction at presentation, however following application of cast there was significantly more distraction in the non-union group (1.2 v 5.09mm, p<0.01). Changes to practise. All humeral fractures were admitted, lightweight U-slabs were applied by a technician, distraction was avoided, patients abstained from NSAIDS, consultant reviewed radiographs before discharge and patients were converted early to functional brace. Phase 2. Prospective collection of data over the following two year period showed a decrease in the amount of distraction when first placed in cast (2.73 v 0.74, p<0.05), a reduction in NSAID use (89% v 38%, p<0.01) and earlier conversion to brace (37 v 20 days p<0.01). These changes to practise led to a dramatic reduction in non-union rate from 39.2% to 4.9% (p<0.01). Conclusion. Over-distraction at first application of cast is a causal factor in the development of non-union. Lightweight cast, avoidance of distraction, abstinence from NSAIDS and early conversion to functional brace is recommended. The initial surgical management of the patient who displays evidence of distraction will prevent evolution of non-union with conservative management. This will avoid lengthy delays in the treatment of the non-union and also help to prevent secondary stiffness in adjacent joints and disuse osteopenia

Introduced in 2005, the Opus Magnum (Arthrocare) anchor has been used in our unit for repair of rotator cuff tears. It is a non-screw type anchor which relies on the deployment of wings locked in the subchondral bone. In order to evaluate whether these anchors migrate after implantation we undertook radiographic examination of their placement at intervals. We attempted to assess whether loss of fixation could be secondary to osteoporosis. Between 2005 and 2006, 106 patients (59 female, 47 male) aged 35–84 years (average age 62 years) underwent arthroscopic repair of rotator cuff tears with a total of 229 anchors. A review of radiographs taken at six weeks and 12 months post-insertion was undertaken. Cortical index of the proximal humeral diaphysis was measured from the AP radiograph indicating bone density; this involved measuring humeral width and medullary cavity diameter at a fixed point of 10cm below the greater tuberosity of the humerus. At six weeks follow-up there were no anchor pull-outs seen on radiographs. At 12 months follow-up 10 of the 229 anchors were found to have pulled out of the bone, equating to a failure rate of 4%. Of these seven of the 10 patients were asymptomatic. The average cortical index was found to be significantly lower in the failure group. Bone quality at the greater tuberosity of the humerus can be insufficient to withstand the tensions developed in newer anchor technology, leading to anchor migration. We present evidence that radiographs may be sufficient to influence the clinician’s choice of anchorage device. An economic estimation of bone density would be a helpful predictor of pull-out strength of suture anchors, essentially a low cortical index would indicate that these anchors are more likely to fail. A routine radiograph at 12 months would also identify the asymptomatic anchor failures

Introduction: Metastatic bone disease of the humerus may be associated with disabling pain and loss of function. Surgery must provide good local tumor control, immediate mechanical stability, and a short rehabilitation period. Between 1980 and 2000, the authors operated 59 patients with metastatic disease of the humerus. The current study summarizes the principles of the surgical technique and functional and oncological outcomes. Materials and Methods: There were 33 females and 26 males. Indications for surgery included pathological fracture (40), impending fracture (11), and intractable pain (6). Anatomic locations of humeral metastases included: around the proximal humeral metaphysic and head (Type I) – 18, humeral diaphysis (Type II) – 39, and humeral condyles (Type III) – 2. Types I and III metastases were treated with resection and endoprosthetic reconstruction. Type II metastases were treated with intralesional tumor removal and cemented nailing. Postoperatively, 31 patients were treated with radiation therapy, 35 with chemotherapy, and 14 with immunotherapy. Follow-up of the study patients included physical examination, radiological evaluation and functional evaluation according to the American Musculoskeletal Tumor Society system. Results: Patients who had cemented nailing had better overall function, emotional acceptance, hand positioning, and lifting ability than patients who underwent endoprosthetic reconstruction. Pain alleviation and dexterity were comparable in both groups. All patients had a stable extremity and overall function of 56 patients (95%) was > 68% of normal upper extremity function. Only two patients (3%) had a local tumor recurrence. Conclusions: An aggressive surgical approach in patients who have humeral metastases and meet the criteria for surgical intervention is beneficial; it provides durable reconstruction and is associated with good function and local tumor control in most patients

Purpose of the study: The aim of this work was to assess results after treatment by nailing of nonunion of the humeral shaft. In particular, we focused on consolidation and factors predictive of failure. Material and method: A prospective study was conducted in 13 consecutive patients presenting aseptic nonunion of the humeral diaphysis. There were five cases after orthopedic treatment and eight cases after internal fixation. Two patients had iterative nonunions. Locked nailing was performed with three successive types of nails: the Seidel nail in four cases, the Russel Taylor nail in seven, and the ACE nail in two. Anterograde nailing was used for the first three cases and retrograde nailing for the others. All patients were followed regularly in our department. Last follow-up was one to seven years after nailing. Results: Five nonunions (38%) did not consolidate after locked nailing. Consolidation was achieved in the other patients after four to 18 months. The anatomic result was good in these patients. Between the success and failure groups, there was no significant difference in age, gender, type of fracture, first intention treatment, delay from fracture to nailing, type or diameter of the nail, surgical access or not to the fracture site during nailing, or duration of complementary fixation. Anterograde nail insertion, used in our first three patients in this series, appeared to affect shoulder function. The retrograde route was used in other patients and did not appear to have any impact on the elbow itself or the elbow region. Discussion: This clinical study was unable to identify clinical factors explaining failures but did provide several arguments suggesting that defective primary stability of the initial fixation could be incriminated in the failures. Conclusion: Centromedullary locked nailing is a simple technique with potential for resolving difficult problems of nonunion. Good functional outcome can be obtained when consolidation is achieved. Rather than abandoning this technique, it would be advisable to conduct further research to determine what factors are determinant in its failures

Aims

This study aims to describe a new method that may be used as a supplement to evaluate humeral rotational alignment during intramedullary nail (IMN) insertion using the profile of the perpendicular peak of the greater tuberosity and its relation to the transepicondylar axis. We called this angle the greater tuberosity version angle (GTVA).

Purpose: It is known that severe distention of the inferior glenohumeral ligament (IGHL) during anteror-inferior shoulder instability is an important factor of poor functional prognosis after arthroscopic stabilisation. O. Gagey proposed a clinical test to assess laxity of the IGHL. The purpose of this study was to assess the laxity of the IGHL using a dynamic radiological test (AP view in passive abduction of the glenohu-meral joint) and to correlate findings with arthroscopic observations. Material and methods: We performed a prospective study in 21 patients scheduled for arthroscopic stabilisation for anteroinferior shoulder instability. Mean age was 24.6 years, 17 men and 4 women. The test was performed in the supine position with a strictly AP view of the shoulder. Bilateral comparative images were obtained. The shoulder was brought to forced passive abduction in neutral rotation without general anaesthesia or locoregional anaesthesia. The angle between the axis of the humeral diaphysis and the line passing through the inferior border of the glenoid cavity and the lateral border of the scapular tubercle was measured. Vuillemin has demonstrated that this test is reliable and reproducible. During arthroscopy performed for diagnostic and therapeutic purposes, the degree of distension was quantified using the Detrisac classification of four stages. We considered that stages 3 and 4 were frank pathological distension. We used the threshold of 15° for the difference between the healthy and pathological side for the radiological test. We assessed the ability to demonstrate severe laxity of the IGHL. Results: For differences in abduction less than 15°, the test sensitivity was 77%, specificity 91%, positive predictive value 87% and negative predictive value 84%. Discussion: A careful physical examination and appropriate complementary tests are essential for the evaluation of anteroinferior instability of the shoulder joint in order to obtain a precise diagnosis and search for contraindications for arthroscopic cure. The rate of recurrence after arthroscopic stabilisation remains above that obtained with open techniques. It has been demonstrated that major laxity of the IGHL constitutes a relative contraindication for arthroscopic stabilisation. Radiographic measurements provide precise information for evaluating the laxity of the IGHL. Taking a positive threshold of 15° difference identifies 87% of the cases of Detrisac stage 3 or 4 ligament distension. Conclusion: We propose a preoperative complementary test using standard x-rays together with our dynamic radiological test of passive shoulder abduction. If the difference between the healthy and pathological side is greater or equal to 15°, the therapeutic strategy should include not only reinsertion of the rim but also retight-ening the ligament complex, or open stabilisation

Introduction and Objectives: In this retrospective study, we have evaluated the results of treatment of non-unions of the humeral diaphysis using plate osteosynthesis. Materials and Methods: This is a retrospective study covering the years 1997–2002, with a total of 135 fractures of the humeral shaft: 84% were treated orthopaedically and 16% surgically by means of plate osteosynthesis. We present 14 cases of humeral non-union, all of which occurred after orthopaedic treatment, and 12 of which were surgically treated by means of plate osteosynthesis (the other 2 declined surgical treatment). The most common cause of fracture was accidental fall, and of the 12 cases, 11 were female, and 1 was male. Mean age was 67.6 years. Initial orthopaedic treatments included the following: in 9 cases U-splint + sling, in 1 case U-splint + Velpeau sling, in 2 cases hanging cast + Poulipen. Of these, the initial bandaging was replaced with braces after 2.5-3 months. Definitive surgical treatment was delayed an average of 8.1 months. We used the Müller-AO fracture classification system. There were 4 cases with 12B12, 3 cases with 12A12, 1 case with 12A11, 1 case with 12B22, 1 case with 12B11, 1 case with 12B21, and 1 case with 12A21. Surgical treatment was performed in 7 cases with LD-DCP plates, in 3 cases with DCP plates, in 1 case with a T-plate, and in 1 case with a straight plate. Corticocancellous bone grafts were transferred from the iliac crest in 9 of 12 cases. Results: Bone healing was achieved in 11 of 12 surgical cases (one case without radiographic consolidation due to detachment of the plate due to trauma). In 2 cases there was a limitation of shoulder abduction at 85° and elbow extension -10°. In one case, there was repeat treatment due to failure of osteosynthesis. In two of the surgical cases, definitive BA will be measured upon completion of rehabilitation. Complications included 2 temporary radial palsies that recovered both motor and sensory function, one distal detachment of the plate due to previous trauma that had borderline BA and was non-painful. There was one case in which consolidation did not occur and where the humeral artery was injured iatrogenically during surgery (the same one that required repeat surgical intervention). There was one case of infection of the site of osteosynthesis due to Pseudomonas aeruginosa, which responded well to initial antibiotic treatment, and no material needed to be removed. Discussion and Conclusions: Plate osteosynthesis is an effective treatment for non-unions of the humeral shaft and yields good joint mobility and few complications (similar to the results of other treatment methods) and must be performed by experienced surgeons

Aims

This is a multicentre, prospective assessment of a proportion of the overall orthopaedic trauma caseload of the UK. It investigates theatre capacity, cancellations, and time to surgery in a group of hospitals that is representative of the wider population. It identifies barriers to effective practice and will inform system improvements.

Aims

The optimal choice of management for proximal humerus fractures (PHFs) has been increasingly discussed in the literature, and this work aimed to answer the following questions: 1) what are the incidence rates of PHF in the geriatric population in the USA; 2) what is the mortality rate after PHF in the elderly population, specifically for distinct treatment procedures; and 3) what factors influence the mortality rate?

Aims

The aim of this study was to assess orthopaedic oncologic patient morbidity resulting from COVID-19 related institutional delays and surgical shutdowns during the first wave of the pandemic in New York, USA.

Objectives

To date, no study has considered the impact of acromial morphology on shoulder range of movement (ROM). The purpose of our study was to evaluate the effects of lateralization of the centre of rotation (COR) and neck-shaft angle (NSA) on shoulder ROM after reverse shoulder arthroplasty (RSA) in patients with different scapular morphologies.

Objectives

This investigation sought to advance the work published in our prior biomechanical study (Journal of Orthopaedic Research, 2016). We specifically sought to determine whether there are additional easy-to-measure parameters on plain radiographs of the proximal humerus that correlate more strongly with ultimate fracture load, and whether a parameter resembling the Dorr strength/quality characterisation of proximal femurs can be applied to humeri.