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

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. Methods. From 2008 to 2017, 215 patients (mean age 57 yrs (17 to 18), 61% female (n = 130/215)) with a nonoperatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n = 165/215) after initial nonoperative management, with 23% (n = 50/215) uniting after surgery for nonunion. The EuroQol five-dimension three-level health index (EQ-5D-3L) was obtained via postal survey. Multiple regression was used to determine the independent influence of patient, injury, and management factors upon the EQ-5D-3L. An incremental cost-effectiveness ratio (ICER) of < £20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. Results. At a mean of 5.4 yrs (1.2 to 11.0), the mean EQ-5D-3L was 0.736 (95% confidence interval (CI) 0.697 to 0.775). Adjusted analysis demonstrated the EQ-5D-3L was inferior among patients who united after nonunion surgery (β = 0.103; p = 0.032). Offering routine fixation to all patients to reduce the rate of nonunion would be associated with increased treatment costs of £1,542/patient, but would confer a potential EQ-5D-3L benefit of 0.120/patient over the study period. The ICER of routine fixation was £12,850/QALY gained. Selective fixation based on a RUSHU < 8 at six weeks post-injury would be associated with reduced treatment costs (£415/patient), and would confer a potential EQ-5D-3L benefit of 0.335 per ‘at-risk patient’. Conclusion. Routine fixation for patients with humeral shaft fractures to reduce the rate of nonunion observed after nonoperative management appears to be a cost-effective intervention at five years post-injury. Selective fixation for patients at risk of nonunion based on their RUSHU may confer even greater cost-effectiveness, given the potential savings and improvement in health-related quality of life. Cite this article: Bone Jt Open 2022;3(7):566–572

Aims. Though most humeral shaft fractures heal nonoperatively, up to one-third may lead to nonunion with inferior outcomes. The Radiographic Union Score for HUmeral Fractures (RUSHU) was created to identify high-risk patients for nonunion. Our study evaluated the RUSHU’s prognostic performance at six and 12 weeks in discriminating nonunion within a significantly larger cohort than before. Methods. Our study included 226 nonoperatively treated humeral shaft fractures. We evaluated the interobserver reliability and intraobserver reproducibility of RUSHU scoring using intraclass correlation coefficients (ICCs). Additionally, we determined the optimal cut-off thresholds for predicting nonunion using the receiver operating characteristic (ROC) method. Results. The RUSHU demonstrated good interobserver reliability with an ICC of 0.78 (95% CI 0.72 to 0.83) at six weeks and 0.77 (95% CI 0.71 to 0.82) at 12 weeks. Intraobserver reproducibility was good or excellent for all analyses. Area under the curve in the ROC analysis was 0.83 (95% CI 0.77 to 0.88) at six weeks and 0.89 (95% CI 0.84 to 0.93) at 12 weeks, indicating excellent discrimination. The optimal cut-off values for predicting nonunion were ≤ eight points at six weeks and ≤ nine points at 12 weeks, providing the best specificity-sensitivity trade-off. Conclusion. The RUSHU proves to be a reliable and reproducible radiological scoring system that aids in identifying patients at risk of nonunion at both six and 12 weeks post-injury during non-surgical treatment of humeral shaft fractures. The statistically optimal cut-off values for predicting nonunion are ≤ eight at six weeks and ≤ nine points at 12 weeks post-injury

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. Methods. From 2008 to 2017, all patients with a humeral diaphyseal fracture were retrospectively identified. Patient demographics and injury characteristics were recorded. Details of pre-injury employment, sporting participation, and levels of return post-injury were obtained via postal questionnaire. The University of California, Los Angeles (UCLA) Activity Scale was used to quantify physical activity among active patients. Regression was used to determine factors independently associated with failure to RTW or RTS. Results. The Work Group comprised 177 patients in employment prior to injury (mean age 47 years (17 to 78); 51% female (n = 90)). Mean follow-up was 5.8 years (1.3 to 11). Overall, 85% (n = 151) returned to work at a mean of 14 weeks post-injury (0 to 104), but only 60% (n = 106) returned full-time to their previous employment. Proximal-third fractures (adjusted odds ratio (aOR) 4.0 (95% confidence interval (CI) 1.2 to 14.2); p = 0.029) were independently associated with failure to RTW. The Sport Group comprised 182 patients involved in sport prior to injury (mean age 52 years (18 to 85); 57% female (n = 104)). Mean follow-up was 5.4 years (1.3 to 11). The mean UCLA score reduced from 6.9 (95% CI 6.6 to 7.2) before injury to 6.1 (95% CI 5.8 to 6.4) post-injury (p < 0.001). There were 89% (n = 162) who returned to sport: 8% (n = 14) within three months, 34% (n = 62) within six months, and 70% (n = 127) within one year. Age ≥ 60 years was independently associated with failure to RTS (aOR 3.0 (95% CI 1.1 to 8.2); p = 0.036). No other factors were independently associated with failure to RTW or RTS. Conclusion. Most patients successfully return to work and sport following a humeral shaft fracture, albeit at a lower level of physical activity. Patients aged ≥ 60 yrs and those with proximal-third diaphyseal fractures are at increased risk of failing to return to activity. Cite this article: Bone Jt Open 2022;3(3):236–244

Aims. The primary aim of this study was to develop a reliable, effective radiological score to assess the healing of humeral shaft fractures, the Radiographic Union Score for HUmeral fractures (RUSHU). The secondary aim was to assess whether the six-week RUSHU was predictive of nonunion at six months after the injury. Patients and Methods. Initially, 20 patients with radiographs six weeks following a humeral shaft fracture were selected at random from a trauma database and scored by three observers, based on the Radiographic Union Scale for Tibial fractures system. After refinement of the RUSHU criteria, a second group of 60 patients with radiographs six weeks after injury, 40 with fractures that united and 20 with fractures that developed nonunion, were scored by two blinded observers. Results. After refinement, the interobserver intraclass correlation coefficient (ICC) was 0.79 (95% confidence interval (CI) 0.67 to 0.87), indicating substantial agreement. At six weeks after injury, patients whose fractures united had a significantly higher median score than those who developed nonunion (10 vs 7; p < 0.001). A receiver operating characteristic curve determined that a RUSHU cut-off of < 8 was predictive of nonunion (area under the curve = 0.84, 95% CI 0.74 to 0.94). The sensitivity was 75% and specificity 80% with a positive predictive value (PPV) of 65% and a negative predictive value of 86%. Patients with a RUSHU < 8 (n = 23) were more likely to develop nonunion than those with a RUSHU ≥ 8 (n = 37, odds ratio 12.0, 95% CI 3.4 to 42.9). Based on a PPV of 65%, if all patients with a RUSHU < 8 underwent fixation, the number of procedures needed to avoid one nonunion would be 1.5. Conclusion. The RUSHU is reliable and effective in identifying patients at risk of nonunion of a humeral shaft fracture at six weeks after injury. This tool requires external validation but could potentially reduce the morbidity associated with delayed treatment of an established nonunion. Cite this article: Bone Joint J 2019;101-B:1300–1306

The primary aim was to assess the reliability of ultrasound in the assessment of humeral shaft fracture healing. The secondary aim was to estimate the accuracy of ultrasound assessment in predicting humeral shaft nonunion. Twelve patients (mean age 54yrs [20–81], 58% [n=7/12] female) with a non-operatively managed humeral diaphyseal fracture were prospectively recruited and underwent ultrasound scanning at six and 12wks post-injury. Scans were reviewed by seven blinded observers to evaluate the presence of sonographic callus. Intra- and inter-observer reliability were determined using the weighted kappa and intraclass correlation coefficient (ICC). Accuracy of ultrasound assessment in nonunion prediction was estimated by comparing scans for patients that united (n=10/12) with those that developed a nonunion (n=2/12). At both six and 12wks, sonographic callus was present in 11 patients (10 united, one developed a nonunion) and sonographic bridging callus (SBC) was present in seven patients (all united). Ultrasound assessment demonstrated substantial intra- (6wk kappa 0.75, 95% CI 0.47-1.03; 12wk kappa 0.75, 95% CI 0.46-1.04) and inter-observer reliability (6wk ICC 0.60, 95% CI 0.38-0.83; 12wk ICC 0.76, 95% CI 0.58-0.91). Absence of sonographic callus demonstrated a sensitivity of 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (accuracy 92%). Absence of SBC demonstrated a sensitivity of 100%, specificity 70%, PPV 40% and NPV 100% (accuracy 75%). Of three patients at risk of nonunion based on reduced radiographic callus formation (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (and united) and the other two had non-bridging or absent sonographic callus (both developed a nonunion). Ultrasound assessment of humeral shaft fracture healing was reliable and predictive of nonunion, and may be a useful tool in defining the risk of nonunion among patients with reduced radiographic callus formation

Proximal humeral shaft fractures are commonly treated with long straight locking plates endangering the radial nerve distally. The aim of this study was to investigate the biomechanical competence in a human cadaveric bone model of 90°-helical PHILOS plates versus conventional straight PHILOS plates in proximal third comminuted humeral shaft fractures. Eight pairs of humeral cadaveric humeri were instrumented using either a long 90°-helical plate (group1) or a straight long PHILOS plate (group2). An unstable proximal humeral shaft fracture was simulated by means of an osteotomy maintaining a gap of 5cm. All specimens were tested under quasi-static loading in axial compression, internal and external rotation as well as bending in 4 directions. Subsequently, progressively increasing internal rotational loading until failure was applied and interfragmentary movements were monitored by means of optical motion tracking. Flexion/extension deformation (°) in group1 was (2.00±1.77) and (0.88±1.12) in group2, p=0.003. Varus/valgus deformation (°) was (6.14±1.58) in group1 and (6.16±0.73) in group2, p=0.976. Shear (mm) and displacement (°) under torsional load were (1.40±0.63 and 8.96±0.46) in group1 and (1.12±0.61 and 9.02±0.48) in group2, p≥0.390. However, during cyclic testing shear and torsional displacements and torsion were both significantly higher in group 1, p≤0.038. Cycles to catastrophic failure were (9960±1967) in group1 and (9234±1566) in group2, p=0.24. Although 90°-helical plating was associated with improved resistance against varus/valgus deformation, it demonstrated lower resistance to flexion/extension and internal rotation as well as higher flexion/extension, torsional and shear movements compared to straight plates. From a biomechanical perspective, 90°-helical plates performed inferior compared to straight plates and alternative helical plate designs with lower twist should be investigated in future paired cadaveric studies

Methods. Between 2005 and 2012, 50 patients (23 female, 27 male) with nonunion of the humeral shaft were included in this retrospective study. The mean age was 51.3 years (14 to 88). The patients had a mean of 1.5 prior operations (. sd. 1.2;1 to 8). All patients were assessed according to a specific risk score in order to devise an optimal and individual therapy plan consistent with the Diamond Concept. In 32 cases (64%), a change in the osteosynthesis to an angular stable locking compression plate was performed. According to the individual risk an additional bone graft and/or bone morphogenetic protein-7 (BMP-7) were applied. Results. A successful consolidation of the nonunion was observed in 37 cases (80.4%) with a median healing time of six months (IQR 6). Younger patients showed significantly better consolidation. Four patients were lost to follow-up. Revision was necessary in a total of eight (16%) cases. In the initial treatment, intramedullary nailing was most common. . Discussion. The use of locking compression plates in combination with autologous cancellous bone graft has been shown to be a safe and effective treatment. In more complex cases, the use of the Masquelet technique and BMP-7 may be indicated at the first revision operation. Take home message: Our results suggest the Diamond Concept is a successful treatment strategy for nonunions of the humeral shaft. Cite this article: Bone Joint J 2016;98-B:81–7

The current standard for treatment of humeral shaft fractures is in a functional humeral brace. Aims: To further assess the union rate for this mode of treatment and to delineate and any fracture type less likely to go on to union. Retrospective radiographic and clinical review of 199 consecutive acute adult humeral shaft fractures. 43 operated on acutely (including all open fractures). Remaining 156 fractures treated in a humeral brace. Non union was determined as delayed fracture fixation or no evidence of union at 1 year. Union rate 82.9% with 88.5% follow-up. 16 of the 24 non unions were proximal third (all but one spiral/oblique): 71.4% union rate. Middle third fractures 87.3% and distal third shaft fractures 88.9 % union rate. Union rate of fractures with 3+ parts inclusive of all regions of the shaft was 95.6%. The union rate in this study is not as high as has previously been reported for functional brace treatment. A lower threshold for intervention in proximal third spiral/oblique humeral shaft fractures may be indicated. Fracture site comminution is a very good prognostic indicator

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 cost-effectiveness of using a Radiographic Union Score for HUmeral fractures (RUSHU)<8 to facilitate selective fixation for patients at risk of nonunion. From 2008-2017, 215 patients (mean age 57yrs [17–81], 61% female) with a non-operatively managed humeral diaphyseal fracture were retrospectively identified. Union was achieved in 77% (n=165/215) after non-operative management, with 23% (n=50/215) uniting after nonunion surgery. The EuroQol Five-Dimension (EQ-5D) Health Index was obtained via postal survey. An incremental cost-effectiveness ratio (ICER) <£20,000 per quality-adjusted life-year (QALY) gained was considered cost-effective. At a mean of 5.4yrs (1.2–11.0), the mean EQ-5D was 0.736. Multiple regression demonstrated that uniting after nonunion surgery was independently associated with an inferior EQ-5D (beta=0.103, p=0.032). Routine fixation for all patients to reduce the nonunion rate would be associated with increased treatment costs (£1,542/patient) but confer a potential EQ-5D benefit of 0.120/patient. The ICER of routine fixation was £12,850/QALY gained. Selective fixation, based upon a RUSHU<8 at 6wks post-injury, would be associated with reduced treatment costs (£415/patient) and confer a potential EQ-5D benefit of 0.335 per ‘at-risk patient’. Routine fixation for patients with humeral shaft fractures, to reduce the nonunion rate observed after non-operative management, appears to be cost-effective at 5yrs post-injury. Selective fixation for patients at risk of nonunion based upon the RUSHU may confer greater cost-effectiveness, given the potential savings and improvement in EQ-5D

Introduction: Humeral shaft fractures account for 1–3% of all fractures. Little is known about additional epidemiological data on this specific fracture type. The aim of this study was to investigate the epidemiology of humeral shaft fractures in patients 16 years or older in Stockholm during the years 1998–99. Patients and Methods: All patients 16 years or older with a humeral shaft fracture admitted to any of six major hospitals in the County of Stockholm during the two years 1998–99 were included in the study. A total of 401 fractures in 397 patients were found. Three hundred and sixty-one of the fractures were traumatic and were classified according to the Orthopaedic Trauma Association (OTA) classification system. The remaining 40 fractures were pathological (n=34) or peri-implant fractures (n=6). Open fractures were classified using the Gustilo classification system. Data regarding the injury mechanism, age, gender, side of the injury and occurrence of possible radial nerve injury were collected from the medical charts. The overall incidence and the age-specific incidence were calculated on the basis of data from Statistics Sweden. Results: The incidence was 14.5 per 100 000 persons per year with a gradually increasing age-specific incidence from the fifth decade in both genders and reaching an incidence of almost 60 per 100 000 persons and year in the ninth decade. The majority of fractures were closed ones sustained after simple falls among elderly patients. The age distribution among females was characterised by a peak in the eighth decade while the age distribution among males was more even. Type A (simple) fractures were by far the most common and the majority of the fractures were located in the middle and proximal parts of the humeral shaft. The incidence of radial palsy was 8%. Fracture localisation in the middle and distal part of the shaft was associated with an increased risk for having radial nerve palsy. Only 2% of the fractures were open and 8% were pathological. Discussion: These recent epidemiological data on humeral shaft fractures are representative of a society with a limited amount of high-energy trauma, including penetrating trauma, which probably reflects the situation in the majority of European countries. Our results can be used to facilitate the future treatment of patients with this particular fracture

Aim: To describe and evaluate the use of the limited contact plate in complex humeral shaft fractures. Certain sub-groups of humeral shaft fractures can be very difficult to treat. These ‘complex fractures’ include fractures in very osteoporotic bone, those associated with shoulder or elbow prosthesis, non-unions and those associated with intra articular extensions and dislocations. The AO limited contact plate (LCP) is a new form of fixation whether the screw heads lock into the holes in the plate. The plate is not designed to cause compression and does not need to lie perfectly adjacent to the bone. Methods: A prospective study of six consecutive complex humeral shaft fractures treated with LCP plate. Rate of union, complications, and subjective and objective outcome (DASH scores) are analyzed. Results: Union occurred in 9/10 patients. The final patient is progressing to union. There were no serious complications. Good subjective and objective outcome in all patients. Conclusion: This heterogeneous series of complex and complicated humeral shaft fractures all pose significant management problems. Treatment with the LCP plate demonstrated good results with no significant complications. This completely new rational for treatment seems particularly suitable for the treatment of complex or complicated humeral shaft fractures

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome. Setting: Six major hospitals in Stockholm County. Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome. Patients: All 27 patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 consecutive patients with 361 traumatic humeral shaft fractures. Intervention: Nonoperative or operative treatment according to the decision of the attending orthopedic surgeon. Main Outcome Measurements: Recovery of the radial nerve, fracture healing and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA). Results: The Holstein-Lewis humeral shaft fracture constituted 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared to other types of humeral shaft fractures, 22% versus 8% (p< 0.05). The fractures of six of the seven operatively treated patients healed after the primary surgical procedure while one fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All six radial nerve palsies (two patients treated nonoperatively and four operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively. Conclusion: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function is excellent regardless of the primary treatment modality, i.e. operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative

Proximal humeral shaft fractures are commonly treated with long straight plates or intramedullary nails. Helical plates might overcome the downsides of these techniques as they are able to avoid the radial nerve distally. The aim of this study was to investigate in an artificial bone model: (1) the biomechanical competence of different plate designs and (2) to compare them against the alternative treatment option of intramedullary nails. Twenty-four artificial humeri were assigned in 4 groups and instrumented as follows: group1 (straight 10-hole-PHILOS), group2 (MULTILOCK-nail), group3 (45°-helical-PHILOS) and group4 (90°-helical-PHILOS). An unstable proximal humeral shaft fracture was simulated. Specimens were tested under quasi-static loading in axial compression, internal/external rotation and bending in 4 directions monitored by optical motion tracking. Axial displacement (mm) was significantly lower in group2 (0.1±0.1) compared to all other groups (1: 3.7±0.6; 3: 3.8±0.8; 4: 3.5±0.4), p<0.001. Varus stiffness in group2 (0.8±0.1) was significantly higher compared to groups1+3, p≤0.013 (1: 0.7±0.1; 3: 0.7±0.1; 4: 0.8±0.1). Varus bending (°) was significantly lower in group2 compared to all other groups (p<0.001) and group4 to group1, p=0.022. Flexion stiffness in group1 was significantly higher compared to groups2+4 (p≤0,03) and group4 to group1, p≤0,029 (1: 0.8±0.1; 2: 0.7±0.1; 3: 0.7±0.1; 4: 0.6±0.1). Flexion bending (°) in group4 was higher compared to all other groups (p≤0.024) and lower in group2 compared to groups1+4, p≤0.024. Torsional stiffness remained non significantly different, p≥0.086. Torsional deformation in group2 was significantly higher compared to all other groups, p≤0.017. Shear displacement remained non significantly different, p≥0.112. From a biomechanical perspective, helical plating with 45° and 90° may be considered as a valid alternative fixation technique to standard straight plating of proximal third humeral fractures. Intramedullary nails demonstrated higher axial and bending stiffness as well as lower fracture gap movements during axial loading compared to all plate designs. However, despite similar torsional stiffness they were associated with higher torsional movements during internal/external rotation as compared to all investigated plate designs

The conservative management if isolated humeral shaft fractures is a long, drawn out, painful process for the patient. For the clinician, it involves multiple clinic attendances and repeated radiographic assessment and brace alteration. The primary reason for conservative management is the excellent results, but a very definite secondary consideration is the high incidence of shoulder pathology after I.M. nailing. This is thought to be due to rotator cuff pathology at the time of surgery. We question the validity of this second argument. Ten consecutive humeral shaft fractures attending our unit had an MRI of both shoulders carried out during the initial stages of their injury. Two of the ten had retrograde nailing and the remainder was managed conservatively. While there was no patient with an occult coracoid fracture in association with the shaft fracture. We found eight out of ten to have significant signal changes in the subacromial space on the side of the fracture only. We conclude that there is a significant occult injury to the shoulder at the time of humeral shaft fracture and this may in fact represent a cause for the high incidence of shoulder pain post fracture

Thirty-eight patients with nonunion of the humeral shaft underwent a comprehensive assessment including completion of three patient-based functional outcome surveys as well as the determination of the Constant shoulder and Mayo elbow scores. Treatment consisted of compression plating with or without bone grafting. Smokers were found to have significantly longer time to union as compared to nonsmokers (25.1 weeks vs. 16.2 weeks, p< 0.001). Our results also demonstrated that increased time to union had a significant negative effect on the patient-reported functional outcome scores. To evaluate the functional outcome and identify prognostic factors that influence the healing time of surgically treated humeral shaft nonunions. Time to consolidation of operatively treated humeral shaft nonunions was significantly longer in smokers versus non-smokers. Time to union was negatively associated with the patient-reported functional outcome scores. The long-term functional outcome following surgical treatment of humeral shaft nonunions is dependent upon the time to consolidation. Smoking is a significant remediable risk factor for delayed union following surgical repair of humeral shaft nonunion. We identified thirty-eight patients (mean age fifty-five years) treated surgically for nonunion of the humeral shaft at a mean follow-up of sixty months. All patients underwent a comprehensive assessment including the completion of the SF-36, the DASH, the SMFA and the determination of the Constant shoulder and Mayo elbow scores. Seventeen (44.7%) patients were classified as ‘smokers’ and twenty-one (55.3%) were ‘non-smokers’. All nonunions united with a mean time of 16.2 weeks for non-smokers and 25.1 weeks for smokers (p< 0.001). Time to union was negatively associated with the Physical Function portion of the SF-36 (p=0.01), the DASH (p=0.01), and the Arm and Hand Function part of the SMFA (p=0.005). The only other factor that had a significant negative effect on the functional outcome scores was the presence of one or more comorbid factors (SF-36, p< 0.001; DASH, p< 0.001; SMFA, p< 0.001). Patient-oriented and surgeon based scores were found to correlate well (range r=0.545 to r=0.916, p< 0.001 for all combinations)

Aims: Analyse our results of the treatment of humeral shaft fractures treated solely with functional brace. Methods: The patients 16 years or more in age admitted in Tampere University Hospital because of fracture of diaphysis of the humerus between January1997 and December 2000 were included in this study. The fractures were treated solely using functional brace. Results: There were 94 closed fractures with 38 (42%) male and 52 (58%) female patients whose ages were between 16 and 90 (median 50) years in this study. The fracture configuration was spiral (A1) in 54 (60%), transverse in 31 (34%) (A3) and comminuted in 5 (6%) (C1). The fractures located in the proximal third of the diapysis of the humerus in 12 (13%), in the middle third in 57 (63%), and in distal third in 21 (23%) of the patients. From 90 fractures 69 (81%) consolidated without problems. In 6 fractures of the 12 (50%) at the proximal third, 48 of the 57 (87%), and 17 of the 21 (85%) bony union achieved using functional brace. There was significant difference with respect of consolidation between proximal and middle third (p< 0.01) and between proximal and distal third (p< 0.05) of the humeral shaft. There was no significant difference between fractures of middle and distal third of the diaphysis of the humerus. From spiral, transverse and comminuted fractures, 22of the 28 (78%), 28 of the 31 (90%), 5 of the 5 (100%) consolidated without problems using functional brace. Conclusion: The management of middle and distal third humeral shaft fractures solely with functional brace is justified. Our series indicated that consolidation is achieved also in transverse fractures, even though those fractures have often been considered as a relative indication for operation

The aim of this audit was to assess the union rate of humeral shaft fractures treated conservatively in a functional brace in our unit, compared to a “gold standard” of 98% as reported by Sarmiento (JBJS 1977). A retrospective clinical and radiographic review of 155 closed humeral shaft fractures managed with a humeral brace from 2005–2012 was performed. Pathological fractures and patients under 18 were excluded. The mean age was 60 (18–94) with 45 males and 72 females. 15 (10%) patients under 18 and 8 (5%) pathological fractures were excluded; 15 (10%) patients were lost to follow up. Of the remaining 117 fractures, 83 (71%) went on to union and 34 (29%) developed a non-union. Mean time to union was 131 days (47–622). 80% of distal fractures and 75% of midshaft fractures united but only 58% of proximal fractures went on to unite. There was no significant difference in union rates between multi fragmentary (> 3 parts) and simple fracture patterns (69% vs 71% respectively). Our study suggests that a lower threshold for operative intervention of proximal third humeral shaft fractures may be required

Background: The purpose of this retrospective study was to analyze the results of closed intramedullary fixation of pathological humeral shaft fractures with unreamed humeral nail (UHN). Patients & Methods: Nine patients who had ten pathological fractures of the humeral shaft secondary to metastatic disease were included in the study. All fractures were stabilized with unreamed humeral nailing with use of a closed anterograde technique. The mean patient age was sixty-three (range, fifty to 78), male to female ratio 1:8 and left humerus was involved in five, right in three patients and one patient had bilateral pathological humeral shaft fracture. Results: The blood loss was unremarkable in seven patients (8 procedures). Two patients were given totally 3 units of pack cells after the surgery and these were the only patients who had additional surgeries during the same operation due to their additional pathological fractures. The mean duration of hospitalization after the operation was 6.5 days (range, two to 16 days). All of the ten extremities had a return to nearly normal function within 6 weeks after nailing. Relief of pain was rated as good in all but one patient. Seven patients received adjuvant therapy during the 3 months period before and after the procedure. Five patients died at a mean of 3.5 months (range, one to 9 months). There were no early or late complications related to surgery except one patient who developed cellulitis after the surgery. The fracture was united in all of the extremities in patients who survived for at least 3 months and had radiographs available. Conclusion: Unreamed humeral nailing of the pathological humeral shaft fractures provides immediate stability and pain relief, minimum morbidity and early return of function to the extremity

Helical plates are preferably used for proximal humeral shaft fracture fixation and potentially avoid radial nerve irritation as compared to straight plates. Aims:(1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus. (2) to assess and compare their distances to adjacent anatomical structures at risk. MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated. None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1-3) in group1, 7(2-11) in group2, 14(7-25) in group3 and 6(3-8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8-28) in group1, 11(7-18) in group2, 3(2-4) in group3 and 6(3-8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18-23) in group1, 7(6-7) in group2, 4(3-5) in group3 and 7(6-7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021. MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Anterior parts of the deltoid insertion will be detached using 90°-helical and ALPS implants in MIPO-technique