ABSTRACT
Aim:
Humeral shaft fractures are one of the most common fractures of the upper extremity. Most humeral shaft fractures can be treated conservatively, but in some cases, surgical treatment is required. In this study, the characteristics of patients who needed surgical intervention due to unsuccessful conservative treatment and inability to achieve union were investigated.
Materials and Methods:
Data of 67 patients [female (n=41) and male (n=26)] in whom conservative treatment was initiated due to humeral shaft fracture were evaluated retrospectively. The data of the patients in whom treatment had to be switched to surgery during the follow-up period were analyzed. Age, gender, trauma type, fracture site and vitamin D levels on the day of the fracture were noted.
Results:
At the end of 54 (42-77) days, the treatment was switched to surgery due to nonunion in 14 patients. All of these patients were female, over the age of 60 years, and the humeral fractures in these patients were in the middle third of the humerus. The mean 25(OH) vitamin D [25(OH) D] level of these patients was 14 mg/dL (4-22 mg/dL).
Conclusion:
It is concluded that the conservative treatment is prone to fail if humeral shaft fracture is a proximal oblique or a mid-shaft one, if the patient is over the age of 60 years and female, and if 25(OH)D level of the patient is low.
INTRODUCTION
Humerus shaft fracture (HSF) is a common upper limb injury that makes up for 1-5% of all fractures1,2. In terms of incidence, HSFs usually show a bimodal distribution-the first peak is seen in young males aged 21-30 years mostly due to high-energy trauma, and the second peak is in older females aged 50-80 years due to low-energy trauma (most commonly due to fall from a standing height)3.
Although there is a lack of consensus regarding the most appropriate treatment for HSFs-conservative4 versus surgical intervention5, conservative methods, which include applying a coaptation splint followed by a Sarmiento functional brace6 or directly applying the functional brace7, are preferred more in the literature. Regarding the surgical treatment of HSFs, there is a list of absolute and relative indications that are commonly accepted by trauma surgeons (Table 1)8-10.
Age, gender, severity of trauma, presence of an open fracture and accompanying metabolic diseases are the factors that affect the union of the fracture2,3. In means of fracture type, some fracture patterns like short oblique fractures of humerus have relative indication for surgery, which means conservative treatment can be initiated primarily in these cases. In case of failure, such as nonunion in the follow-up, these fracture types may need surgical intervention. Throughout the follow-up period of conservative treatment, it is well known that patient compliance gradually decreases, and in case of necessity for a further surgical intervention when conservative treatment fails, surgery becomes much more demanding and technically challenging.
In this study, the characteristics of patients who needed surgical intervention due to unsuccessful conservative treatment and inability to achieve union were investigated. It was hypothesized that conservative treatment had a tendency to fail in proximal oblique shaft fractures. The effects of sex, age and vitamin D levels on the success or failure of conservative treatment were also evaluated.
GİRİŞ
Humerus şaft kırığı (HSK), tüm kırıkların %1-5’ini oluşturan yaygın bir üst ekstremite yaralanmasıdır1,2. HSK’ların insidansı genellikle bimodal bir dağılım gösterir-ilk zirve genellikle yüksek enerjili travmaya bağlı olarak 21-30 yaş arası genç erkeklerde görülürken, ikinci zirve 50-80 yaş arası yaşlı kadınlarda düşük enerjili travmaya bağlı olarak (genellikle ayakta durma yüksekliğinden düşme) meydana gelir3.
HSK’lar için konservatif4 tedavi ile cerrahi müdahale5 arasında en uygun tedaviye ilişkin henüz bir uzlaşı yoktur. Literatürde daha çok tercih edilen konservatif yöntemler, acil serviste uygulanan birleştirme alçısı ve ardından Sarmiento fonksiyonel alçı6 veya doğrudan fonksiyonel alçı uygulamayı içerir7. HSK’ların cerrahi tedavisi ile ilgili olarak, travma cerrahları tarafından yaygın olarak kabul edilen mutlak ve göreceli endikasyonlar listesi mevcuttur (Tablo 1)8-10.
Yaş, cinsiyet, travma şiddeti, açık kırık varlığı ve eşlik eden metabolik hastalıklar kırığın iyileşmesini etkileyen faktörlerdir2,3. Kırık tipi açısından, humerusun kısa oblik kırıkları gibi bazı kırık tipleri cerrahi için göreli endikasyon taşır, yani bu durumlarda öncelikle konservatif tedavi başlatılabilir. Takipte kaynama olmaması gibi başarısızlık durumunda, bu kırık tipleri cerrahi müdahaleye ihtiyaç duyabilir. Konservatif tedavinin takip döneminde, hasta uyumunun giderek azaldığı iyi bilinmektedir ve konservatif tedavi başarısız olduğunda daha fazla cerrahi müdahaleye gereksinim duyulduğunda cerrahi daha zor ve teknik olarak zorlayıcı hale gelir.
Bu çalışmada, başarısız konservatif tedavi sonrası ve kaynama elde edilemeyerek cerrahi müdahaleye ihtiyaç duyan hastaların özellikleri araştırılmıştır. Konservatif tedavide distal oblik şaft kırıklarında başarısızlık eğilimi olduğu hipotez edilmiştir. Ayrıca, cinsiyet, yaş ve D vitamini düzeylerinin konservatif tedavi başarısı veya başarısızlığı üzerindeki etkileri de değerlendirilmiştir.
MATERIALS AND METHODS
The study was approved by the Tekirdağ Namık Kemal University of Local Ethics Committee (protocol no: 2023.77.04.13, date: 25/04/2023).
In this retrospective study, we evaluated 84 patients treated for HSFs between January 2008 and December 2018 in Tekirdağ Yaşam Hospital by reviewing archive and radiology files. Among these, 17 patients who were operated on for absolute indications were excluded from the study. The remaining 67 patients were conservatively managed at the beginning of the treatment before surgical intervention. All patient characteristics are presented in Table 2.
On the day of admission, 25(OH) vitamin D levels were measured for all patients using a blood test. After radiologic investigations [anteroposterior (AP) and lateral view radiographs of the shoulder and arm], all included patients were initially managed conservatively using a coaptation splint, which was applied in the emergency room. The next day, a custom brace was made for each patient according to the dimensions taken from the uninjured arm. After one week, the coaptation splint was removed and the custom-manufactured brace was applied. All patients were followed up for the next two weeks using serial weekly X-rays. Criteria for acceptable alignment were listed as less than 20° apex anterior or posterior angulation, less than 30° varus/valgus angulation, maximum 15° malrotation and 3 cm of shortening2. The data of the patients in whom treatment had to be switched to surgery during the follow-up period were analyzed. Age, gender, trauma type and fracture site were noted.
In Figure 1, the radiograph of a 67-year-old female patient at the time of first admission is seen and in Figure 2, the radiograph of the same patient is seen, showing deterioration in the fracture alignment and nonunion on the 29th day. In Figure 3, the radiograph of the patient taken at the end of 4 weeks after the operation is seen.
In Figure 4, the radiograph of another 64-year-old female patient at the time of first admission is seen. Figure 5 shows the radiograph of the same patient, demonstrating deterioration in the fracture alignment and nonunion. AP and lateral radiographs of the same patient 3 weeks after the operation are seen in Figure 6 and in Figure 7, respectively.
Statistical Analysis
A binary logistic regression model was used to examine the effects of age, sex, fracture site, and fracture type on the union status of fractures, and the Wald test was performed to evaluate the collective significance of the aforementioned variables. Furthermore, to determine the differences in fracture healing according to sex, fracture type, and age, the Fisher’s exact test was employed. A p value of <0.05 was used to determine statistical significance.
RESULTS
Sixteen of the fractures were located in the proximal third of the humerus, 39 in the middle third and 12 in the distal third. Eleven patients had fractures after major trauma like falling from height and the rest had fractures due to simple trauma or falls from a standing height. Out of the 67 patients, 53 healed without any complications and attained fracture union by the end of the 8-10-week period conservatively. Radiographically, callus formation was visible between 4 and 6 weeks for all 53 patients, and bony alignment was within the acceptable range in both AP and lateral radiographs.
The remaining 14 patients (20.89%), in whom conservative treatment had failed, were subsequently treated surgically. The average duration for determining the failure of conservative management and opting for surgery was 41 days (38±14 days). The reasons for failure were malalignment and lack of adequate callus formation in the follow-up radiographs. Eventually, all 14 patients were treated with open reduction and internal fixation using plate and screws. Postoperatively, the patients were followed for 2 weeks, all fractures healed and showed radiographic union at the end of 10 weeks postoperatively. As for the complications, superficial wound infections, which were healed with a 15-day antibiotic treatment and dressings, were detected in two patients. In three patients, 30° of decrease in elbow total arc range of motion, which recovered with a 20-day physical therapy conducted at home and in the hospital, developed.
In terms of fracture location, 25% of the proximal one-third (n=4/16), 89.74% of the middle third (n=35/39), and 100% of the distal third (n=12/12) fractures were united using a functional brace. There was a statistically significant difference between the healing rates in the proximal and middle third fractures (p=0.039) and the proximal and distal third fractures (p=0.043) but the difference in the healing rates for the middle and distal third fractures was statistically not significant (p=0.051).
When comparing the conservatively treated (n=53) and surgically treated (n=14) groups, we found that the former had relatively younger patients (44±12 years), while the mean age for the surgically treated ones was 61±11 years, which was statistically significant (p=0.040). On the other hand, the mean vitamin D3 levels at the time of admission were significantly low in the surgically treated group compared to the conservatively treated group [14 mg/dL (16±8 mg/dL) versus 29 mg/dL (44±14 mg/dL); p=0.036].
When stratified according to sex, all male patients had bony unions while 33.3% of women had nonunion. On comparing different age groups, we found that all patients in age group of 16-59 years had union while 35% of the patients aged >60 years had no union. Additionally, there was no significant relationship between union status and trauma type, such as major or minor (p=0.061).
The Wald test performed to determine the effects of age, sex, and vitamin D levels revealed that a one-year increase in the age variable reduced the probability of fracture union by 0.836 times (b=-0.18, odds ratio=0.836, p=0.048). Furthermore, we found a significant relationship between fracture union status and sex (p=0.011) and age (p=0.044).
DISCUSSION
Functional treatment (in the form of splinting/bracing) is an integral part of the conservative management of HSFs, which usually yields satisfactory results by allowing appropriate stabilization to ensure fracture healing and patient compliance11. Although obesity and nonconformity of the patient to brace therapy are the primary impediments to conservative treatment10,11, functional bracing is the first choice of treatment for HSFs10-12. In our study sample, all patients were first started with conservative treatment with splints followed by functional bracing, unless absolutely indicated for surgery. However, Denard et al.5 stated that closed treatment of humerus fractures had a significantly higher rate of nonunion and malunion, and surgical treatment was better than conservative treatment without significant complication. In contrast, only 20.89% of our patients had nonunion or malunion with conservative management, which corroborates the choice of conservative treatment as the first-line treatment for HSF.
However, despite the success of conservative treatment for HSFs, many studies have pointed out that oblique fractures of the humerus, especially in the proximal one-third, require surgical intervention4,12,13. In our study, all of our patients who underwent surgery due to malunion or nonunion had oblique fractures in the proximal humerus. Furthermore, Koch et al.14 stated that transverse fractures of the humerus are more prone to nonunion and often require surgery. However, in our study, transverse fractures healed adequately with conservative treatment, whereas the oblique fracture group required surgery.
Notably, previous studies with concurring evidence about proximal oblique HSFs being more prone to nonunion with conservative methods have also highlighted the role of the patient’s age as important for nonunion15,16. In contrast, Ali et al.4 found that nonunion could occur in this particular fracture type, irrespective of the patient’s age. In our study, patients over the age of 60 years were particularly prone to nonunion after sustaining a proximal oblique HSF.
It has also been reported that the only criterion to ensure union in an HSF, regardless of its type according to the AO classification16, is the fracture location within the shaft-proximal or not11. We also observed that patients with fractures in the proximal third of the humerus were likely to go into nonunion. It is uncertain why proximal third humerus fractures, especially the oblique type, do not unite conservatively and require surgery. Walker et al.10 reasoned that this area was between the insertion points of two strong muscles, deltoid and pectoralis major, which tend to distract the fracture site by pulling in different directions. Therefore, if rotational alignment is maintained but there is a gap between the fracture ends, muscle interposition must be taken into consideration. It is well established that if there is a significant gap between fracture ends, the fracture tends to go into atrophic nonunion.
Similar to our study, Decomas and Kaye17 also performed a multifactorial analysis of nonunion in HSF patients and confirmed that obesity, a history of cigarette smoking, metabolic bone disease, cardiovascular disease, short oblique fractures, open fractures, and fractures of the proximal third of the shaft were potential risk factors. Accordingly, they claimed that handling these patients by conservative treatment increased the risk of nonunion; hence, they should be managed surgically and directly17. Our results also corroborate these findings that HSFs in the proximal one-third tend to go into nonunion when managed conservatively, especially in older patients.
Study Limitations
We did not account for the patient’s medical history, such as accompanying illnesses that can impair fracture healing, namely diabetes mellitus, hypothyroidism, obesity, and smoking habits. A lack of information about these information limits the applicability of our results. Furthermore, the fractures were not classified according to the AO classification. Larger studies comparing the nonunion cases by their fracture classifications and incorporating more factors related to the patient’s personal characteristics are required to verify these results.
TARTIŞMA
Fonksiyonel tedavi (alçıya alma/alçılama şeklinde) HSK’ların konservatif yönetiminin ayrılmaz bir parçasıdır ve bu sayede genellikle kırık kaynamasını ve hastanın uyumunu sağlamak için uygun stabilizasyona izin vererek tatmin edici sonuçlar elde edilir11. Obezite ve hastanın alçı tedavisine uyumsuzluğu, konservatif tedavi için başlıca engeller olsa da10,11, fonksiyonel alçı tedavisi HSK’lar için tercih edilen ilk tedavi seçeneğidir10-12. Çalışmamızdaki örneklemde, tüm hastalar öncelikle konservatif tedavi ile alçıya alma ile başlatılmış ve ameliyat için mutlak endikasyon olmadıkça fonksiyonel alçı kullanılarak yönetilmiştir. Ancak, Denard ve ark.5 kırık konservatif tedavi yönetiminin kırık kaynamama ve malunion açısından cerrahi tedaviden önemli ölçüde daha yüksek bir orana sahip olduğunu belirtmiş ve cerrahi tedavinin belirgin komplikasyon olmaksızın konservatif tedaviden daha iyi olduğunu ifade etmişlerdir. Buna karşılık, hastalarımızın yalnızca %20,89’unun konservatif yönetimle yanlış kaynama veya kırık kaynamaması yaşadığı, bu da HSK’lar için ilk tercih olarak konservatif tedaviyi destekleyen bir seçenek olduğunu göstermektedir.
Ancak, HSK’ların konservatif yöntemlerle tedavisinin başarılı olmasına rağmen, birçok çalışma özellikle proksimal üçte birdeki oblik humerus kırıklarının cerrahi müdahale gerektirdiğini belirtmiştir4,12,13. Çalışmamızda da, yanlış kaynama veya kırık kaynaması nedeniyle cerrahiye yönelik tedavi uygulanan tüm hastalarımızın proksimal humerusta oblik kırıkları vardı. Ayrıca, Koch ve ark.14 humerusun transvers kırıklarının yanlış kaynama açısından daha yatkın olduğunu ve genellikle cerrahi gerektirdiğini belirtmiştir. Ancak, çalışmamızda, transvers kırıklar konservatif tedavi ile iyi kaynama gösterirken, oblik kırık grubunda cerrahiye ihtiyaç duyulmuştur.
Özellikle proksimal üçte birdeki oblik HSK’ların konservatif yöntemlerle yanlış kaynama açısından daha yatkın olduğu konusunda önceki çalışmaların da benzer kanıtları vardır ve bu durumda hastanın yaşı önemli bir faktör olarak belirtilmiştir15,16. Buna karşılık, Ali ve ark.4 bu özel kırık tipinde, hastanın yaşı gözetilmeksizin yanlış kaynama oluşabileceğini bulmuşlardır. Çalışmamızda, 60 yaşın üzerindeki hastalar, proksimal oblik HSK geçirdikten sonra yanlış kaynamaya yatkındılar.
Ayrıca, AO sınıflandırmasına göre kırığın tipine bakılmaksızın HSK’larda kaynamayı sağlamak için tek kriterin şaftın içindeki kırık yerinin proksimalde olup olmaması olduğu rapor edilmiştir11. Biz de çalışmamızda proksimal üçte birdeki kırıkların yanlış kaynama eğiliminde olduğunu gördük. Proksimal üçte birdeki kırıkların, özellikle oblik tipi, konservatif olarak kaynamamaya yatkındır. Ancak, neden proksimal üçte bir humerus kırıkları, özellikle oblik tipi, konservatif olarak kaynamaz ve cerrahi gerektirir henüz belirsizdir. Walker ve ark.10 bunun nedeninin bu bölgenin deltoid ve pectoralis major adlı iki güçlü kasın eklem yerlerinin arasında olması ve bu kasların farklı yönlere doğru çekerek kırık bölgesini dağıtma eğiliminde olması olduğunu belirtmişlerdir. Dolayısıyla, rotasyonel hizalama korunsa da kırık uçları arasında boşluk olması durumunda, kas araya girme durumunun dikkate alınması gerektiği belirtilmektedir. Önemli bir boşluk olduğunda, kırık atrofik bir yanlış kaynama eğilimindedir. Çalışmamızdaki sonuçlar, özellikle proksimal bir üçte bir humerus kırıklarının konservatif olarak yönetilmesi durumunda eğilimin yanlış kaynama yönünde olduğunu ve özellikle yaşlı hastalarda bu durumun daha da belirgin olduğunu doğrulamaktadır.
Çalışmamıza benzer şekilde, Decomas ve Kaye17 HSF hastalarında kaynama olmama durumunu çoklu faktöriyel analiz ile inceleyerek obezite, sigara içme öyküsü, metabolik kemik hastalığı, kardiyovasküler hastalık, kısa oblik kırıklar, açık kırıklar ve şaftın proksimal üçte birindeki kırıkların potansiyel risk faktörleri olduğunu doğrulamışlardır. Buna göre, bu hastaların konservatif tedavi ile yönetilmesinin kaynama olmama riskini artırdığını ve dolayısıyla cerrahi olarak doğrudan yönetilmeleri gerektiğini belirtmişlerdir17. Sonuçlarımız da benzer şekilde, özellikle yaşlı hastalarda, HSF’lerin proksimal üçte birindeki kırıkların konservatif yönetimi durumunda kaynama olmama eğiliminde olduğunu doğrulamaktadır.
Çalışmanın Kısıtlılıkları
Çalışmamızda hastaların kırık kaynamasını etkileyebilecek diabetes mellitus, hipotiroidizm, obezite ve sigara içme gibi hastalıklar gibi hastanın tıbbi geçmişi göz önünde bulundurulmamıştır; bu bilgilerin eksikliği sonuçlarımızın uygulanabilirliğini sınırlar. Ayrıca, kırıklar AO sınıflandırmasına göre sınıflandırılmamıştır. Kırık iyileşmesi konusunda non-union olgularını kırık sınıflarına göre karşılaştıran daha büyük çalışmalara ve hastanın kişisel özellikleri ile ilgili daha fazla faktörü içeren çalışmalara ihtiyaç vardır.
CONCLUSION
Our results confirm that oblique HSFs (short or long) in the proximal or middle one-third regions tend to become absolute indications for surgical management, especially if the patient is female and above the age of 60 years. In such patients, clinicians can promptly opt for surgery without using conservative methods to ensure bony union and recovery.
