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Overview of humeral-shaft related studies

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Specific to the subject
 Humeral shaft fractures: Intramedullary nailing compared with compression plating
 Humeral shaft fractures: Intramedullary nail versus plate fixation
Of interest to the subject
 Fracture healing
 OTD Classic article review: Sarmiento A (1977): Functional bracing of fractures of the shaft of the humerus
 Humeral-shaft fractures - Intramedullary nail compared with compression plating (UPDATE to September 2007 report)
General relevance
 Treatment of traumatic open wounds
 Classic article review: Riska EB, Myllynen P (1982): Fat Embolism in Patients with Multiple Injuries
 OTD classic article review: Engelberg R, Martin DP, Agel J, et al (1996): Musculoskeletal Function Assessment Instrument: Criterion and Construct Validity
 Open long-bone fractures: Early versus delayed debridement as a prognostic factor for infection
 Long-bone fractures: Does post-fracture NSAID use increase the risk of nonunion?
 Open fractures: Rates of infection and nonunion in primary versus delayed wound closure
 OTD classic article review: Marko Godina: Early microsurgical reconstruction of complex trauma of the extremities (1986)
 Fracture healing: The effect of low intensity pulsed ultrasound (LIPUS)
 OTD classic article review: Gustilo RB, Anderson JT (1976): Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones
 Open fractures: Timing of wound debridement
Humeral shaft fractures: Intramedullary nailing compared with compression plating

Orthopedic Trauma Directions 2007; 05; 11-18

Summary

Evidence from three randomized controlled trials suggests that treatment of acute humeral shaft fractures with intramedullary nailing (IMN) compared with dynamic compression plating leads to comparable results with respect to rates of nounion, infection, and iatrogenic nerve injury. There appeared to be an increase in risk of reoperation with IMN, which was significant when data were pooled across studies. There was conflicting evidence in regard to the mean time to union. Additional methodologically rigorous randomized controlled trials with larger populations are necessary to establish the long term safety and efficacy of these two operative treatments and to evaluate the superiority of one treatment over another. One researcher [Bhandari] estimates that such a trial would require between 1150 and 2180 patients to have sufficient power to demonstrate a 25% relative risk reduction for reoperation [see appendix].

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Humeral shaft fractures: Intramedullary nail versus plate fixation

Orthopedic Trauma Directions 2003; 01; 15-20

Summary

Taken together, these reports suggest that intramedullary nailing resulted in more complications compared with plate fixation for humeral shaft fractures, particularly when the antegrade approach was used. These reports do not provide strong evidence for the superiority of either fixation method with regard to fracture union, prevention of infection, or overall upper extremity function.

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Fracture healing

Orthopedic Trauma Directions 2009; 06; 01-10

Summary
In a review of five case series and two retrospective cohort studies, nearly 50% of patients had their hardware removed without a clear indication. Approximately half of patients who underwent hardware removal for pain experienced pain relief, although some patients did experience increased pain after removal. It is unclear whether the indication for hardware removal affects resultant pain relief. Improved function was also observed in a few select studies. While generally safe, the available evidence does not support a general recommendation for hardware removal after fracture healing. Well-designed comparative
studies are needed to determine whether there is any benefi t of hardware removal for patients, particularly those without a clear indication for removal.

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OTD Classic article review: Sarmiento A (1977): Functional bracing of fractures of the shaft of the humerus

Orthopedic Trauma Directions 2008; 01; 33-40

Author Summary

Results from 49 patients with 59 humeral shaft fractures treated with a functional plastic sleeve demonstrated rapid and uneventful healing. Good alignment of the fractures was maintained, union rate was high, and the majority of patients demonstrated good range of motion. Early functional activity to the entire extremity appears to contribute to timely and uninterrupted osteogenesis.

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Humeral-shaft fractures - Intramedullary nail compared with compression plating (UPDATE to September 2007 report)

Orthop. trauma dir. 2010; 05; 19–29

Summary

Evidence from four randomized controlled trials (RCT) suggests that treatment of acute humeral shaft fractures with intramedullary nailing (IMN) compared with dynamic compression plating leads to comparable results with respect to rates of nounion and infection. There appeared to be an increase in risk of reoperation and iatrogenic nerve injury with IMN, which was significant when data were pooled across studies. There was conflicting evidence in regard to the mean time-to-union. Additional methodologically rigorous randomized controlled trials with larger populations are necessary to establish the long-term safety and efficacy of these two operative treatments and to evaluate the superiority of one treatment over another. One researcher [Bhandari] estimates that such a trial would require between 1150 and 2180 patients to have sufficient power to demonstrate a 25% relative risk reduction for reoperation [see appendix references].

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Treatment of traumatic open wounds

Orthopedic Trauma Directions 2010; 01; 11-18

Summary
Limited evidence from two small randomized controlled trials and one retrospective cohort study suggest negative pressure wound therapy (NPWT) might reduce infection rate, drainage time, and time to wound closure when compared with standard-pressure dressing methods for high-energy orthopedic trauma. All three studies found NPWT to be more effective than standard treatment for the primary outcomes studied; however, each study evaluated a different type of wound and reported a different primary outcome. Evidencebased conclusions are difficult given the relatively small sample sizes and selection of treatment based on patient presentation in the cohort study. A methodologically rigorous multicenter randomized controlled trial may provide sufficient sample size to effectively compare similar wounds and treatments for these types of high-energy trauma.

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Classic article review: Riska EB, Myllynen P (1982): Fat Embolism in Patients with Multiple Injuries

Orthopedic Trauma Directions 2009; 06; 29-33

Author summary
Of 459 patients treated in the intensive care unit (ICU) from 1975–1978, 211 patients with multiple injuries and fractures of the long bones and pelvis/spine were treated emergently using internal fi xation in a primary stage. The main outcome of interest was clinical fat embolism syndrome (grade III), a severe and potentially life-threatening condition that is common following long-bone and pelvic fractures. Early operative fi xation resulted in a low rate of grade III fat embolism and, therefore, may effectively prevent subsequent morbidity and mortality in this patient population.

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OTD classic article review: Engelberg R, Martin DP, Agel J, et al (1996): Musculoskeletal Function Assessment Instrument: Criterion and Construct Validity

Orthopedic Trauma Directions 2009; 03; 25-27

Authors’ summary/background
The Musculoskeletal function assessment (MFA) instrument is a 100-item, self-reported, health status measure designed for use in a clinical setting on a broad range of patients with musculoskeletal disorders of the extremities. This study sought to test both its criterion and construct validity, an important aspect of creating a health status instrument. The criterion validity was tested against physicians’ ratings of patient function and against various clinical
measures. Construct validity was evaluated using medical records, demographic data, other standard health instruments, and by comparing patients based on their various health issues. Both types of validity were affirmed by significant correlations between the MFA scores and the criteria evaluated.

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Open long-bone fractures: Early versus delayed debridement as a prognostic factor for infection

Orthopedic Trauma Directions 2008; 06; 11-18

Summary

Limited data from three retrospective cohort studies suggests that there may be no significant association between time to debridement and rate of infection in open long-bone fractures. However, the studies included did not control for possible confounding factors that may bias study results, such as antibiotic use and fracture type. Methodologically rigorous studies which control for such factors should be conducted to confirm that adherence to the 6-hour debridement window does not appear to affect infection rates.

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Long-bone fractures: Does post-fracture NSAID use increase the risk of nonunion?

Orthopedic Trauma Directions 2007; 03; 23-30

Summary

Evidence from four studies indicates that nonsteroidal antiinflammatory drug (NSAID) use in the post-fracture period of long-bone healing increases the risk of nonunion, with adjusted relative risk estimates ranging from 3.15–10.74. While three of the studies showed this risk to be statistically significant, one study did not. Additional methodologically rigorous prognostic studies which delineate NSAID type, dosage, and timing are necessary to establish the long
term risk of NSAID use on the incidence of nonunion in long-bone fractures.

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Open fractures: Rates of infection and nonunion in primary versus delayed wound closure

Orthopedic Trauma Directions 2007; 02; 19-26

Summary

There is conflicting evidence from three retrospective cohort studies regarding infection and nonunion rates when comparing primary with delayed wound closure in open fractures. One study of open tibial fractures suggests that delayed, secondary closure may result in a significant decrease in nonunion and infections compared with primary closure. These findings were not replicated in two other studies, however. Comparisons across studies were difficult
as different types of fractures and fixation methods were included in each study. In addition, distribution of fracture types and fixation methods may have differed between primary and delayed closure groups. Methodologically rigorous comparative studies which control for confounding factors (eg, injury severity, fracture type and grade, fixation method) are needed to determine whether there are real differences in outcomes between primary and delayed
wound closure.

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OTD classic article review: Marko Godina: Early microsurgical reconstruction of complex trauma of the extremities (1986)

Orthopedic Trauma Directions 2006; 05; 29-36

Summary

The success rate of the microsurgical procedure was much higher in the early treatment group (99.25 %) than in the delayed and late treatment groups (88% and 91.5% respectively). The planning of the microvascular free-tissue transfer and the transfer itself were much easier immediately after the injury, largely due to the absence of fibrosis. Patients in the early treatment group had better outcomes with respect to number of microsurgical procedure failures, postoperative infections, bone healing time and average length of hospital stay.

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Fracture healing: The effect of low intensity pulsed ultrasound (LIPUS)

Orthopedic Trauma Directions 2005; 06; 01-08

Summary

Studies show that low intensity pulsed ultrasound therapy results in a statistically significant shorter mean time to fracture healing compared with controls.
Further randomized controlled trials are needed to determine the optimal role of this therapy, alone and in combination with other interventions, across fracture types, sites, and severities.

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OTD classic article review: Gustilo RB, Anderson JT (1976): Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones

Orthopedic Trauma Directions 2005; 01; 23-29

Author summary

  1. Open fractures require emergency treatment including adequate debridement and copious irrigation.
  2. Primary closure is indicated for type I and II fractures. Delayed primary closure, including split thickness skin grafts and appropriate flaps, should be used in type III open fractures.
  3. Internal fixation by plates or intramedullary nails should not be used. External skeletal fixation by skeletal traction or pins above and below the fracture site incorporated in a plaster cast are recommended.
  4. Open fractures associated with arterial injury requiring repair should be treated by skeletal traction whenever possible instead of primary internal fixation.
  5. Antibiotics should be administered before and during surgery. If the wound is closed primarily, the antibiotics are stopped on the third postoperative day.
    If the wound is closed secondarily, the antibiotics are continued for another three days after this procedure.

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Open fractures: Timing of wound debridement

Orthopedic Trauma Directions 2005; 01; 15-22

Summary

Studies have shown promising results that early or immediate wound debridement for open fractures may be better than delayed wound debridement.
Time-to-union was shorter, and fewer infections were reported in the groups who had early debridement. Functional outcomes may favor immediate debridement. The proportion of delayed unions or nonunions varied by study. These results should be interpreted with caution as the studies did not have consistent definitions of immediate versus delayed wound debridement, and the fracture grades varied. Additional studies are recommended to verify and further clarify these results.

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