The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures
Introduction
Diaphyseal fractures of the humerus may constitute up to 5% of all fractures, with the vast majority being amendable to non-operative treatment [1]. Patients typically fall into a bimodal age distribution consisting of mostly young males 21−30 years of age, and older females 60−80 years of age [2]. Published guidelines for non-operative treatment include alignment with less than 20° of angulation in the anterior-posterior plane, less than 30° of varus−valgus angulation, less than 15° of malrotation, and less than 3 cm of shortening [3]. Operative indications include open fractures, vascular injury, articular extension, polytrauma, floating elbow, progressive radial nerve deficits, brachial plexus injury, significant soft tissue injuries prohibiting bracing, pathologic fractures, and failed non-operative management [1].
Complications of non-operative treatment include non-union, malunion, and persistent radial nerve deficits [4], [5], [6], [7], [8]. More than 40% of these fractures treated non-operatively may heal in greater than 5° of varus/valgus malalignment, while up to 30% may heal in greater than 5° of anterior or posterior angulation [4], [7]. Residual angulation can result in loss of motion, with up to 40% of patients may losing shoulder motion and 24% of patients having less elbow motion [4]. As a result of lost motion and malunion, up to 35% of patients may experience pain with daily activities [9].
Validated patient reported functional outcomes scores have significantly evolved over the past 20 years and are now important measures of patient outcomes in orthopaedic surgery [10],[11]. Although malunion or residual angular deformity and range of motion (ROM) measures continue to play a role in measuring patient outcomes, these objective findings may or may not always correlate with patient reported outcomes. The purpose of this study was to determine if residual angulation in healed humeral diaphyseal fractures treated without surgery would correlate with patient reported functional outcome scores. The study hypothesis was that increasing residual angular deformity of the humeral diaphysis would result in worse extremity specific functional outcomes.
Section snippets
Methods
Patients treated from 2004 to 2011 for humeral shaft fractures were retrospectively identified for three surgeons at a level 1 trauma centre. All skeletally mature patients at least 1 year post-injury at the time of study participation were included in the study. Patients were excluded if they were treated surgically, were deceased, did not have available contact information, diagnosed with dementia, had subsequent but unrelated trauma or surgery to the injured extremity, and non-English
Results
Thirty-two patients were successfully recruited with an average age 45 ± 22 [range 18−84], and average time from injury to study follow up being 47 ± 29 months [range 12−104]. The average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed angular deformity in the sagittal plane measured on average 8 ± 5.7° [range 0−18], and 15 ±7.9° [range 2−27] in the coronal plane. See Table 1 for patient demographics.
There was no significant correlation between residual
Discussion
It is generally accepted that humeral diaphyseal fractures with less than 20° of angulation in the sagittal plane and less than 30° in the coronal plane [3], in the absence of other surgical indications, can be managed without surgery. However, non-anatomic healing of the humeral shaft results in compensation from the shoulder and elbow joints, and in many patients measureable differences in ROM can be detected [4]. The purpose of this study was to determine if increasing residual angulation
Conclusion
Residual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.
Conflicts of interest
The authors have no financial disclosures or conflicts of interest to report.
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