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Locking compression plate fixation in humeral shaft fractures: A comparative study to literature conservative treatment

      Highlights

      • The percentage of fracture healing in Sarmiento's cases is excellent, but it is difficult to be reproduced, and satisfactory results can also be achieved with operative treatment.
      • The incidence of malunions showed in conservative treatment may be completely avoided with ORIF (especially considering the varus deformity in conservative treatment).
      • The function is better in the immediate postoperative period, though we should remark that in the long term the function between the conservative and the surgical treatment is similar.
      • The incidence of postoperative radial nerve palsy is low and the recovery occurs in a reasonable time.

      Abstract

      Introduction

      Humeral shaft fractures represent about 3% of all fractures. While there are several treatment options for this type of fractures, there is no evidence in literature showing which is the best one. This study aims at analysing the outcomes for patients with humeral shaft fractures treated with Locking Compression Plate (LCP) fixation in our hospital and comparing them with the outcome for patients conservatively treated (according to data from Pubmed), in order to determine the best treatment option.

      Materials and Methods

      We treated surgically 220 humeral shaft fractures in our department from February 2005 to March 2012. Seventy-three of them met all the inclusion criteria for this study. All fractures were then classified according to the AO classification. The follow-up considered the radiographic healing of the fracture. All patients were treated with plate fixation (LCP - DePuySynthes Co). At the end of the four-year follow-up, the function was evaluated by means of the DASH score.
      A systematic review of the literature of the last 20 years was performed on MEDLINE (PubMed).

      Results

      We had 2 infections and 8 patients had postoperative nerve palsy which recovered in average time of 6.7 months. In addition, 4 fractures (5.48%) didn't heal within 6 months and they were considered as nonunions and healed after a second surgery. One of these 4 nonunions was infected. The mean DASH score was 18.24±19.18. No malunions were found. We identified 13 studies that were eligible for our systematic review. The mean non-union rate found was 17% in 2517 fractures with a follow-up that ranging from 67% to 100% of patients and a primary radial nerve palsy ranging from 0 to 115 patients. Malalignment rate ranged from 12.7 to 42%.

      Conclusions

      After taking into account both the conservative and the surgical treatment, for humeral shaft fractures we suggest the operative treatment, because the patient's function of the upper limb recovers quickly in the immediate postoperative period and the incidence of malunions may be avoided.

      Keywords

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      References

        • Buckley R.E.
        • Moran C.G.
        • Apivatthakakul T.
        AO principles of fracture management.
        3rd Edition. Thieme, 2018
        • Sarmiento A.
        • Waddell J.P.
        • Latta L.L.
        Diaphyseal humeral fractures: treatment options.
        Instr Course Lect. 2002; 51: 257-269
        • Tartaglia N.
        • Vicenti G.
        • Carrozzo M.
        • et al.
        The treatment of distal third humeral diaphyseal fractures: is there still a place for the external fixation?.
        Musculoskelet Surg. 2016; 100: 45-51https://doi.org/10.1007/s12306-016-0419-y
        • Papasoulis E.
        • Drosos G.I.
        • Ververidis A.N.
        • Verettas D.A.
        Functional bracing of humeral shaft fractures. A review of clinical studies.
        Injury Int J Care Injured. 2010; 41: e21-e27
        • Changulani M.
        • Jain U.K.
        • Keswani Tulsi
        Comparison of the use of humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study.
        Int Orthop. 2007; 31: 391-395
        • Meekers F.S.
        • Broos P.L.
        Operative treatment of humeral shaft fractures. The Leuven experience.
        Acta Orthop Belg. 2002; 68: 462-470
        • Kumar R.
        • Singh P.
        • Chaundhary L.J.
        • Singh S.
        Humeral shaft fracture management, a prospective study; nailing or plating.
        J Clinical Orthop Trauma. 2012; 3: 37-42
        • Putti A.B.
        • Uppin R.B.
        • Putti B.B.
        Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures.
        J Orthop Surg (Hong Kong). 2009; 17: 139-141
        • McCormack R.G.
        • Brien D.
        • Buckley R.E.
        • McKee M.D.
        • Powell J.
        • Schemitsch E.H.
        Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial.
        J Bone Joint Surg Br. 2000; 82: 336-339
        • Chapman J.R.
        • Henley M.B.
        • Agel J.
        • Benca P.
        Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates.
        J Orthop Trauma. 2000; 14: 162-166
        • Bhandari M.
        • Devereaux P.J.
        • McKee M.D.
        • Schemitsch E.H.
        Compression plating versus intramedullary nailing of humeral shaft fractures: a meta- analysis.
        Acta Orthop. 2006; 77: 279-284
        • Heineman D.J.
        • Poolman R.W.
        • Nork Sean S.E.
        • Ponsen K.J.
        • Bhandari M
        Plate fixation or intramedullary fixation of humeral shaft fractures.
        Acta Orthop. 2010; 81: 218-225
        • Heineman D.J.
        • Bhandari M.
        • Nork S.E.
        • Ponsen K.J.
        • Poolman R.W.
        Treatment of humeral shaft fractures: meta-analysis reupdated.
        Acta Orthop. 2010; 81: 517
        • Rommens P.
        • Rüedi T.P.
        Humeral shaft fractures - intramedullary nail versus plate fixation.
        Orthopedic Trauma Directions. 2003; 01: 15-20
        • Müller M.E.
        • Nazarian S.
        • Koch P.
        • et al.
        The comprehensive classification of fractures of long bones.
        1st ed. Springer-Verlag, Berlin, Heidelberg, New York1990
        • Hunsaker F.G.
        • Cioffi D.A.
        • Amadio P.C.
        • Wright J.G.
        • Caughli B.
        The American Academy of Orthopaedic Surgeons outcomes instruments: normative values from the general population.
        J Bone Joint Surg Br. 2002; 84-A: 208-215
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        J Clin Epidemiol. 2009; 62: e1-34
        • Sarmiento A.
        • Zagorski J.B.
        • Zych G.A.
        • Latta L.L.
        • Capps C.A.
        Functional bracing for the treatment of fractures of the humeral diaphysis.
        J Bone Joint Surg Am. 2000; 82-A: 478-486
        • Koch P.P.
        • Gross D.F.
        • Gerber C.
        The result of functional (Sarmiento) bracing of humeral shaft fractures.
        J Shoulder Elbow Surg. 2002; 11: 143-150
        • Mahabier K.C.
        • Vogels L.M.M.
        • Punt B.J.
        • Roukema G.R.
        • Patka P.
        • Van Lieshout E.M.M.
        Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients.
        Injury Int J Care Injured. 2013; 44: 427-430
        • Fjalestad T.
        • Stromsoe K.
        • Salvesen P.
        • et al.
        Functional result of braced humeral diaphyseal fractures: why do 38% lose external rotation of the shoulder?.
        Arch Orthop Trauma Surg. 2000; 120: 281-285
        • Ekholm R.
        • Tidermark J.
        • Törnkvist H.
        • Adami J.
        • Ponzer S.
        Outcome after closed functional treatment of humeral shaft fractures.
        J Orthop Trauma. 2006; 20: 591-596
        • Rutgers M.
        • Ring D.
        Treatment of diaphyseal fractures of the humerus using a functional brace.
        J Orthop Trauma. 2006; 20: 597-601
        • Toivanen J.A.
        • Nieminen J.
        • Laine H.J.
        • Honkonen S.E.
        • Järvinen M.J.
        Functional treatment of closed humeral shaft fractures.
        Int Orthop. 2005; 29: 10-13https://doi.org/10.1007/s00264-004-0612-8
        • Denard Jr., A.
        • Richards J.E.
        • Obremskey W.T.
        • Tucker M.C.
        • Floyd M.
        • Herzog G.A.
        Outcome of nonoperative vs operative treatment of humeral shaft fractures: a retrospective study of 213 patients.
        Orthopedics. 2010; 33 (Published 2010 Aug 11. doi:10.3928/01477447-20100625-16)https://doi.org/10.3928/01477447-20100625-16
        • Matsunaga F.T.
        • Tamaoki M.J.
        • Matsumoto M.H.
        • Netto N.A.
        • Faloppa F.
        • Belloti J.C.
        Minimally Invasive Osteosynthesis with a Bridge Plate Versus a Functional Brace for Humeral Shaft Fractures: a Randomized Controlled Trial.
        J Bone Joint Surg Am. 2017; 99: 583-592https://doi.org/10.2106/JBJS.16.00628
        • Harkin F.E.
        • Large R.J.
        Humeral shaft fractures: union outcomes in a large cohort.
        J Shoulder Elbow Surg. 2017; 26: 1881-1888https://doi.org/10.1016/j.jse.2017.07.001
        • Dielwart C.
        • Harmer L.
        • Thompson J.
        • Seymour R.B.
        • Karunakar M.A.
        Management of Closed Diaphyseal Humerus Fractures in Patients With Injury Severity Score ≥17.
        J Orthop Trauma. 2017; 31: 220-224https://doi.org/10.1097/BOT.0000000000000768
        • Serrano R.
        • Mir H.R.
        • Sagi H.C.
        • et al.
        Modern Results of Functional Bracing of Humeral Shaft Fractures: a Multicenter Retrospective Analysis.
        J Orthop Trauma. 2020; 34: 206-209https://doi.org/10.1097/BOT.0000000000001666
        • Rämö L.
        • Sumrein B.O.
        • Lepola V.
        • et al.
        Effect of Surgery vs Functional Bracing on Functional Outcome Among Patients With Closed Displaced Humeral Shaft Fractures: the FISH Randomized Clinical Trial.
        JAMA. 2020; 323: 1792-1801https://doi.org/10.1001/jama.2020.3182
        • Ekholm R.
        • Adami J.
        • Tidermark J.
        • et al.
        Fractures of the shaft of the humerus. An epidemiological study of 401 fractures.
        J Bone Joint Surg Br. 2006; 88-B: 1469-1473
        • Tytherleigh-Strong G.
        • Walls N.
        • McQueen M.M.
        The epidemiology of humeral shaft fractures.
        J Bone Joint Surg Br. 1998; 80-B: 249-253
        • Shao Y.C.
        • Harwood P.
        • Grotz M.R.
        • Limb D.
        • Giannoudis P.V.
        Radial nerve palsy associated with fractures of the shaft of the humerus. A systematic review.
        J Bone Joint Surg Br. 2005; 87-B: 1647-1652
        • Wang J.P.
        • Shen W.J.
        • Chen W.M.
        • Huang Y.S.
        • Chen T.H.
        Iatrogenic radial nerve palsy after operative management of humeral shaft fractures.
        J Trauma. 2009; 66: 800-803
        • van de Wall B.J.M.
        • Ochen Y.
        • Beeres F.J.P.
        • et al.
        Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies.
        J Shoulder Elbow Surg. 2020; 29: 1493-1504https://doi.org/10.1016/j.jse.2020.01.072
        • Tingstad E.M.
        • Wolinsky P.R.
        • Shyr Y.
        • Johnson K.D.
        Effect of immediate weightbearing on plated fractures of the humeral shaft.
        J Trauma. 2000; 49: 278-280
        • An Z.
        • Zeng B.
        • He X.
        • Chen Q.
        • Hu S.
        Plating osteosynthesis of mid-distal humeral shaft fractures: minimally invasive versus conventional open reduction technique.
        Int Orthop. 2010; 34: 131-135
        • Paris H.
        • Tropiano P.
        • Clouet D'orval B.
        • Chaudet H.
        • Poitout D.G
        [Fractures of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature].
        Rev Chir Orthop Reparatrice Appar Mot. 2000; 86: 346-359
        • Brunner A.
        • Thormann S.
        • Babst R.
        Minimally invasive percutaneous plating of proximal humeral shaft fractures with the Proximal Humerus Internal Locking System (PHILOS).
        J Shoulder Elbow Surg. 2012; 21: 1056-1063
        • Obremskey W.T.
        • Denard A.
        • Tucker M.C.
        Operative versus nonoperative treatment of humeral shaft fractures: a retrospective review of 213 patients from two level I trauma centers.
        AAOS. 2009; (now December)
        • De Carolis O.
        • Mori C.M.
        • Vicenti G.
        • Carrozzo M.
        • Abate A.
        • Caiaffa V.
        A lifelong story: case report of a humeral shaft nonunion successfully treated after 30 years.
        Injury. 2018; 49: S43-S47https://doi.org/10.1016/j.injury.2018.11.031
        • Sarmiento A.
        • Horowitch A.
        • Aboulafia A.
        • et al.
        Functional bracing for comminuted extra-articular fractures of the distal third of the humerus.
        J Bone Joint Surg Br. 1990; 72: 283-287
        • Zagorski J.B.
        • Latta L.L.
        • Zych G.A.
        • Finnieston A.R.
        Diaphyseal fractures of the humerus. Treatment with prefabricated braces.
        J Bone Joint Surg Am. 1998; 70-A: 607-610
        • Van Middendorp J.J.
        • Kazacsay F.
        • Lichtenhahn P.
        • Renner N.
        • Babst R.
        • Melcher G.
        Outcome following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients.
        Eur J Trauma Emerg Surg. 2011; 37: 287-296
        • Rommens P.M.
        • Kuechle R.
        • Th Bord
        • Lewens T.
        • Engelmann R.
        • Blum J.
        Humeral nailing revisited - Review.
        Injury Int J Care Injured. 2008; 39: 1319-1328
        • Rommens P.M.
        • Kuechle R.
        • Bord T.
        • et al.
        Humeral nailing revisited - Author's reply.
        Injury Int J Care Injured. 2010; 41: e18-e19
        • Vicenti G.
        • Antonella A.
        • Filipponi M.
        • et al.
        A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: results after 5 years.
        Injury. 2019; 50: S80-S88https://doi.org/10.1016/j.injury.2019.01.051