Radiological Criteria for Rotational Reduction in Humeral Shaft Fractures
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Published:
Oct 10, 2021
Keywords:
Humerus fracture, diaphyseal fracture, intramedullary nail, radiological criteria, humeral retroversion, humerus surgery
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Abstract
Introduction: Humeral shaft fractures are frequent and surgical treatment is currently favored. Consolidation in malrotation is a complication that can lead to impaired function and long-term osteoarthritis. In minimally invasive techniques, it is difficult to manage intraoperative rotation as there is no direct view of the fracture reduction.
Objective: To describe radiological criteria for rotational reduction in humeral shaft fractures.
Materials and Methods: Retrospective study of humerus radiographs comparing radiological criteria of the distal humerus between radiographs with internal rotation (without proximal retroversion) and radiographswith external rotation (with physiological retroversion). Criteria studied: Overprojection of the lateral epicondyle over the capitellum of more than 50%; sclerosis of the lower border of the olecranon fossa (OF); sclerosis of the lateral border of the OF; and asymmetry of the OF.
Results: 200 radiographs were studied; 97% met the inclusion and exclusion criteria. Overprojection ofthe epicondyle over the capitellum was found in 83.3% of the cases. Sclerosis of the inferior border of the OF in 30%, sclerosis of the lateral border of the OF in 86.6%, and asymmetry of the OF in 80%. All criteria were statistically significant (p<0.001). When analyzing the 3 positive signs, we found a sensitivity of 70% and a specificity of 98%. The positive predictive value was 95.5% and the negative predictive value was 84.5%.
Conclusions: Correct humeral rotation is difficult to reproduce when performing minimally invasive surgeries in patients with a diaphyseal fracture. We describe 4 radiological criteria that allow inferring a correct humeral rotation.
Objective: To describe radiological criteria for rotational reduction in humeral shaft fractures.
Materials and Methods: Retrospective study of humerus radiographs comparing radiological criteria of the distal humerus between radiographs with internal rotation (without proximal retroversion) and radiographswith external rotation (with physiological retroversion). Criteria studied: Overprojection of the lateral epicondyle over the capitellum of more than 50%; sclerosis of the lower border of the olecranon fossa (OF); sclerosis of the lateral border of the OF; and asymmetry of the OF.
Results: 200 radiographs were studied; 97% met the inclusion and exclusion criteria. Overprojection ofthe epicondyle over the capitellum was found in 83.3% of the cases. Sclerosis of the inferior border of the OF in 30%, sclerosis of the lateral border of the OF in 86.6%, and asymmetry of the OF in 80%. All criteria were statistically significant (p<0.001). When analyzing the 3 positive signs, we found a sensitivity of 70% and a specificity of 98%. The positive predictive value was 95.5% and the negative predictive value was 84.5%.
Conclusions: Correct humeral rotation is difficult to reproduce when performing minimally invasive surgeries in patients with a diaphyseal fracture. We describe 4 radiological criteria that allow inferring a correct humeral rotation.
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How to Cite
Contreras, J. J., Azocar, C., Beltrán, M., Redlich, A., Sánchez, E., & Liendo, R. J. (2021). Radiological Criteria for Rotational Reduction in Humeral Shaft Fractures. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 86(5), 568-574. https://doi.org/10.15417/issn.1852-7434.2021.86.5.1379
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Clinical Research
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References
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https://doi.org/10.1177/230949901202000304
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https://doi.org/10.1371/journal.pone.0082075
12. Pidhorz L. Acute and chronic humeral shaft fractures in adults. Orthop Traumatol Surg Res 2015;101(1):S41-S49. https://doi.org/10.1016/j.otsr.2014.07.034
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14. Ying Li, Wang C, Wang M, Huang L, Huang Q. Postoperative malrotation of humeral shaft fracture after plating compared with intramedularing nailing. J Shoulder Elbow Surg 2011;20(6):947-54. https://doi.org/10.1016/j.jse.2010.12.016
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retroversion. Clin Orthop Relat Res 2008;466(3):661-9. https://doi.org/10.1007/s11999-007-0089-z
19. Fjalestad T, Stromsoe K, Salvesen P, Rostad B. Functional results of braced humeral diaphyseal fractures: why do 38% lose external rotation of the shoulder? Arch Orthop Trauma Surg 2000;120:281-5.
https://doi.org/10.1007/s004020050465
20. Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT. Functional bracing for comminuted extra-articular fracture of the distal third of the humerus. J Bone Joint Surg Br 1990;72(2):283-7.
https://doi.org/10.1302/0301-620X.72B2.2312570
21. Wasmer G, Worsdorfer O. Management of humeral shaft fractures with Sarmiento cuff. Unfallheilkunde
1984;87(7):309-15. PMID: 6474620
https://doi.org/10.1016/j.jse.2017.10.028
2. Gallusser N, Barimani B, Vauclair F. Humeral shaft fractures. EFORT Open Rev 2021;6(1):24-34.
https://doi.org/10.1302/2058-5241.6.2000033
3. Tytherleigh-Strong G, Walls N, McQueen MM. The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 1998;80(2):249-53. https://doi.org/10.1302/0301-620x.80b2.8113
4. Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: a review. J
Shoulder Elbow Surg 2011;20(5):833-44. https://doi.org/10.1016/j.jse.2010.11.030
5. Clement ND. Management of humeral shaft fractures; non-operative versus operative. Arch Trauma Res
2015;4(2):e28013. https://doi.org/10.5812/atr.28013v2
6. Matsunaga FT, Tamaoki MJ, Matsumoto MH, Netto NA, Faloppa F, Belloti JC. Minimally invasive osteosynthesis
with a bridge plate versus a functional brace for humeral shaft fractures. J Bone Joint Surg Am 2017;99(7):583-92.
https://doi.org/10.2106/JBJS.16.00628
7. Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of
humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg 2013;22(3):387-95.
https://doi.org/10.1016/j.jse.2012.06.007
8. Benegas E, Ferreira Neto AA, Gracitelli ME, Malavolta EA, Assunção JH, Prada F, et al. Shoulder function
after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade
intramedullary nailing with minimally invasive plate osteosynthesis. J Shoulder Elbow Surg 2014;23(6):767-74.
https://doi.org/10.1016/j.jse.2014.02.010
9. Kulkarni SG, Varshneya A, Jain M, Kulkarni VS, Kulkarni GS, Kulkarni MG, et al. Antegrade interlocking nailing
versus dynamic compression plating for humeral shaft fractures. J Orthop Surg 2012;20(3):288-91.
https://doi.org/10.1177/230949901202000304
10. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane Database Syst Rev 2011;(6):CD005959. https://doi.org/10.1002/14651858.CD005959.pub2
11. Ma J, Xing D, Ma X, Gao F, Wei Q, Jia H, et al. Intramedullary nail versus dynamic compression plate fixation
in treating humeral shaft fractures: grading the evidence through a meta-analysis. PLoS One 2013;8(12):e82075.
https://doi.org/10.1371/journal.pone.0082075
12. Pidhorz L. Acute and chronic humeral shaft fractures in adults. Orthop Traumatol Surg Res 2015;101(1):S41-S49. https://doi.org/10.1016/j.otsr.2014.07.034
13. Kojima KE, Pires RES. Absolute and relative stabilities for fracture fixation: the concept revisited. Injury
2017;48(4):S1. https://doi.org/10.1016/S0020-1383(17)30766-0
14. Ying Li, Wang C, Wang M, Huang L, Huang Q. Postoperative malrotation of humeral shaft fracture after plating compared with intramedularing nailing. J Shoulder Elbow Surg 2011;20(6):947-54. https://doi.org/10.1016/j.jse.2010.12.016
15. Flury MP, Goldhahn J, Holzmann P, Simmen BR. Does Weber’s rotation osteotomy induce degenerative joint
disease at the shoulder in the long term. J Shoulder Elbow Surg 2007;16:735-41. https://doi.org/10.1016/j.jse.2007.02.130
16. Landis J, Koch G. The measurement of observer agreement for categorical data. Biometrics 1977;33(1):159-74.
PMID: 843571
17. Öztuna V, Öztürk H, Eskandari MM, Kuyurtar F. Measurement of the humeral head retroversion angle. A new
radiographic method. Arch Orthop Trauma Surg 2002;122(7):406-9. https://doi.org/10.1007/s00402-002-0398-3
18. Boileau P, Bicknell R, Mazzoleni N, Walch G, Urien JP. CT scan method accurately assesses humeral head
retroversion. Clin Orthop Relat Res 2008;466(3):661-9. https://doi.org/10.1007/s11999-007-0089-z
19. Fjalestad T, Stromsoe K, Salvesen P, Rostad B. Functional results of braced humeral diaphyseal fractures: why do 38% lose external rotation of the shoulder? Arch Orthop Trauma Surg 2000;120:281-5.
https://doi.org/10.1007/s004020050465
20. Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT. Functional bracing for comminuted extra-articular fracture of the distal third of the humerus. J Bone Joint Surg Br 1990;72(2):283-7.
https://doi.org/10.1302/0301-620X.72B2.2312570
21. Wasmer G, Worsdorfer O. Management of humeral shaft fractures with Sarmiento cuff. Unfallheilkunde
1984;87(7):309-15. PMID: 6474620