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Objective: To describe humerus shaft fractures after low-energy gunshot wound (GSW) and compare with blunt injuries. We hypothesized that nerve injury, infection, and fracture union would be similar., Design: Retrospective., Setting: Urban Level 1 trauma center., Patients/participants: Four hundred three patients were treated for a humeral shaft fracture over 18 years. Sixty-two patients sustained injury due to GSW., Intervention: Primary open reduction and internal fixation was pursued in 59%, including 32% after GSW., Main Outcome Measurements: Rates of nerve injury, infection, and fracture union., Results: Patients with GSW were younger with a mean age of 30 years, more likely male (90%), with isolated injuries (84%), and less likely to have simple fractures (84%). Both groups experienced high rates of union (98% of GSW fractures vs. 99% of closed high-energy fractures). Deep infection occurred in 1 patient (1.6%) after GSW. Rates of deep infection in the closed and open blunt trauma fracture groups were similarly low at 1% and 4.5%, respectively. Nerve injury on presentation after GSW was more common than after low-energy and high-energy closed fractures (47% vs. 13% and 27%), but similar to blunt open fracture (52%). Despite higher rates of nerve injury, nerve recovery occurred at similarly high rates after both GSW and blunt injuries (78% vs. 86%)., Conclusions: Nerve injuries are more common after GSW, but most recover without intervention. Infection is uncommon after GSW, and secondary unplanned operations are rare. Initial nonoperative care of most GSW humerus fractures, even with radial nerve injury at the time of presentation, seems appropriate., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To investigate the association of obesity with fracture characteristics and outcomes of operatively treated pediatric supracondylar humerus fractures., Design: Retrospective multicenter., Setting: Two Level I pediatric hospitals., Patients: Patients (age <18 years) with operatively treated Gartland type III and type IV fractures 2010-2014., Intervention: Closed or open reduction and percutaneous pinning of supracondylar humerus fractures., Main Outcome Measure: Incidence of Gartland IV fracture, preoperative nerve palsy, open reduction and complication rates., Results: Patients in the obese group had a significantly higher likelihood of having a Gartland IV fracture (not obese: 17%; obese: 35%; P = 0.007). There was a significantly higher incidence of nerve palsy on presentation in the obese group (not obese: 20%; obese: 33%; P = 0.03). No significant differences were found between groups regarding incidence of open reduction, compartment syndrome, and rates of reoperation., Conclusions: The present study demonstrates that obese children with a completely displaced supracondylar humerus fractures have an increased risk of Gartland type IV and preoperative nerve palsy compared with normal weight children., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To clarify the incidence, associated conditions, and timing of fasciotomy for compartment syndrome (CS) in children with a supracondylar (SC) fracture of the humerus., Design: A retrospective trauma system database study., Setting: Accredited trauma centers in Pennsylvania., Patients: A statewide trauma database was searched for children 2-13 years of age admitted with a SC fracture between January 2001 and December 2015. Four thousand three hundred eight children met inclusion criteria., Intervention: Treatment of a SC fracture., Main Outcome Measurement: Diagnosis of CS/performance of a fasciotomy., Results: During the study period, 21 (0.49%) children admitted with a SC fracture of the humerus were treated with fasciotomy. CS/fasciotomy was more likely in males (P = 0.031), those with a nerve injury (P = 0.049), and/or ipsilateral forearm fracture (P < 0.001). Vascular procedure, performed in 18 (0.42%) children, was strongly associated with CS/fasciotomy (P < 0.001). Closed reduction and fixation of a forearm fracture was associated with CS (P = 0.007). Timing of SC fracture treatment did not influence outcome. Fasciotomy was performed subsequent to reduction in 13 subjects; mean interval between procedures was 23.4 hours (r = 4.5-51.3)., Conclusions: Risk factors for CS exist; however, they are not required for the condition to develop. CS may develop subsequent to admission and/or SC fracture treatment. In timing of operative management and hospitalization, the results support contemporary practice., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: The management of closed diaphyseal humerus fractures in the polytrauma patient varies widely. The aim of this study was to compare outcomes of operative and nonoperative management in this patient population., Design: Single-center, retrospective cohort analysis., Setting: Urban, Level 1 trauma center., Patients: Seventy-one patients with closed diaphyseal humerus fractures, and Injury Severity Score (ISS) of ≥17, treated between 2006 and 2011 were identified., Intervention: Patients were treated operatively versus nonoperatively with a functional brace by surgeon preference., Main Outcomes: Primary outcome was union. Secondary outcomes included time to union, time to release to weightbearing, and complications other than nonunion., Results: There was no statistical difference between age, Injury Severity Score, or fracture type between the 2 cohorts. There was a statistically higher incidence of associated orthopaedic injury, and more specifically, lower extremity injury in the group treated with operative intervention. There was no difference in union rates (95% operative, 94% nonoperative), time to union (17 weeks operative, 15 weeks nonoperative), or complication rates between the 2 groups. Time to release to weightbearing was 3 weeks shorter in the operative group (9.3 weeks operative, 12.8 weeks nonoperative)., Conclusions: Polytrauma patients with closed diaphyseal humerus fractures can be treated successfully with equivalent union rates, time to union, and complication rates when selected for conservative management techniques. The decision to undertake operative management of closed diaphyseal humerus fractures in the polytraumatized patient is multifaceted and should consider patient expectations, demographics, injury profile, and ambulatory status., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To compare the risk of major complications after either minimally invasive plate osteosynthesis (MIPO) or intramedullary nailing (IMN) of humeral shaft fractures., Design: Retrospective, case-match controlled study., Setting: A major metropolitan tertiary referral trauma center in Australia., Patients: Thirty patients with fractures of the humeral shaft., Intervention: Either MIPO or IMN were performed on 15 patients each with traumatic humeral shaft fractures., Primary Outcome Measure: The cumulative risk of 3 major complications associated with these procedures: nonunion, infection, and iatrogenic radial nerve injury., Results: An overall major complication rate of 53% was observed in the patients treated with IMN; one complication (7%) was identified in those managed with humeral MIPO, a nonunion. Complications after IMN included 4 patients (27%) with nonunion, 3 patients (20%) with iatrogenic radial nerve injuries, and 1 patient (7%) with a wound infection. Statistical analysis revealed a significant between-group difference (P = 0.01) in the cumulative rate of major complications. When each of these complications was considered independently, no statistically significant difference was demonstrated., Conclusions: This study suggests that humeral MIPO results in a significantly lower pooled major complication rate than that of IMN, and it should therefore be considered an attractive alternative to IMN in those patients requiring surgical stabilization of a traumatic humeral shaft fracture., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives: To determine the rate of iatrogenic radial nerve palsy (RNP) after surgical repair of established humeral shaft nonunion (HSNU)., Design: Retrospective chart review., Setting: Level I trauma center., Patients/participants: Fifty-four patients with HSNU, 10 (18.5%) of whom developed an iatrogenic RNP after nonunion repair., Intervention: HSNU repair with compression plate stabilization with or without autogenous bone graft., Main Outcome Measurements: Postoperative iatrogenic RNP., Results: Ten (18.5%) patients developed iatrogenic radial nerve palsies: 8 experienced complete resolution (mean, 2.5 months) and 2 experienced partial resolution. There were no statistically significant differences between patients who developed nerve palsy and those who did not in regard to age, gender, tobacco use, diabetic status, previous RNP, initial management (operative vs. nonoperative), surgical approach, presence of infected nonunion, number of previous surgeries, or operative time (P > 0.05)., Conclusions: The occurrence of iatrogenic RNP for patients undergoing surgical repair of an HSNU was 18.5%. According to historical data, this rate is nearly 3 times higher than for those undergoing open reduction and internal fixation of either acute humeral shaft fractures or HSNUs., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of Levels of Evidence.

Objective: The purpose of this study was to report the long-term outcome and complications of surgically fixated lateral unicondylar distal humerus fractures., Design: Retrospective Review., Setting: Two level 1 Trauma Centers, Massachusetts General Hospital and Brigham and Women's Hospital., Patients/participants: Between 2002 and 2014, 24 patients treated with open reduction and internal fixation for lateral unicondylar distal humerus fractures (OTA/AO type B1 fractures) were retrospectively reviewed., Intervention: Open reduction and internal fixation., Main Outcome Measurements: Union rates, early complications, functional outcome, and the range of elbow motion were evaluated. Disabilities of the arm, shoulder, and hand, Mayo elbow Performance Index, satisfaction, pain scale, and American Shoulder and Elbow Surgeons., Results: The mean age of patients was 46 ± 23 years at the time of surgery. The average final flexion/extension arc of motion was 108°. Reoperations were performed in 9 of 24 elbows after an average 21 ± 31 months. Twenty of the 24 patients were available for the clinical follow-up at an average of 70 months (range: 16-144 months). Disabilities of the arm, shoulder, and hand averaged at 10.8 ± 11.7 points, satisfaction at 9.5 ± 1.2, American Shoulder and Elbow Surgeons score at 88.5 ± 13.3 points at final follow-up. Based on the functional classification proposed by Jupiter, 16 demonstrated good to excellent results, 2 fair and 2 poor result., Conclusions: Outcome of open reduction and internal fixation of isolated lateral column distal humerus fractures can result in high union rates with acceptable outcome scores and high patient satisfaction despite a high reoperation rate., Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objectives: This study was performed to determine (1) the incidence of humeral shaft fractures within the Medicare noncancer population, (2) the trends in utilization of humeral shaft fixation techniques by plate-and-screw devices and intramedullary nails, (3) differences in procedure times, and (4) the outcomes of individuals as measured by rate of secondary operations and 1-year mortality., Design/setting: Retrospective comparative cohort analysis. A cancer-free Medicare part B claims sample derived from a 5% sample from the years 1993 to 2007 was analyzed., Patients/intervention: Our cohorts were generated by diagnostic and procedural codes for humeral shaft fractures., Main Outcome Measurement: The incidence of humeral shaft fracture and trend in operative fixation were evaluated for all years of data. Surgical times were assessed by anesthesia Current Procedural Terminology codes. Outcomes and complications were assessed by Current Procedural Terminology codes. The proportion of individuals experiencing complications and 1-year mortality were compared by proportion hazards., Results: We identified 1385 claims for humeral shaft fractures over 15 years, with an adjusted rate of between 12.0 and 23.4 fractures per 100,000 beneficiaries. We identified 511 individuals who received surgical treatment for humeral shaft fractures, 451 of whom had complete 1-year follow-up data. Nail fixation was more prevalent than plate fixation most years and had shorter anesthesia time by 27.1 minutes (P < 0.0001). There were no significant differences in the complication rates between the 2 groups as measured by incidence of secondary operations and 1-year mortality., Conclusions: Intramedullary nails are used for the majority of operative humeral shaft fractures among Medicare beneficiaries. Nailing has a shorter mean operative time. The 2 surgical techniques had no significant differences in terms of risk of secondary procedures and 1-year mortality., Level of Evidence: : Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Objective: The primary aim was to describe the epidemiology of the Holstein-Lewis humeral shaft fracture, its association with radial nerve palsy, and the outcome regarding recovery from the radial nerve palsy and fracture healing. The secondary aim was to analyze the long-term functional outcome., Setting: Six major hospitals in Stockholm County., Design: Descriptive study. Retrospective assessment of radial nerve recovery and fracture healing. Prospective assessment of functional outcome., Patients: Twenty-seven patients with a 12A1.3 humeral shaft fracture according to the OTA classification satisfying the criteria of a Holstein-Lewis fracture in a population of 358 patients with 361 traumatic humeral shaft fractures., Intervention: Nonoperative or operative treatment according to the decision of the attending orthopaedic surgeon., Main Outcome Measurements: Recovery of the radial nerve, fracture healing, and functional outcome according to the Short Musculoskeletal Function Assessment (SMFA)., Results: The Holstein-Lewis humeral shaft fracture constitutes 7.5% of all humeral shaft fractures and was associated with an increased risk of acute radial nerve palsy compared with other types of humeral shaft fractures, 22% versus 8% (P < 0.05). The fractures of 6 of the 7 operatively treated patients healed after the primary surgical procedure while 1 fracture healed after revision surgery. The fractures of all patients treated nonoperatively healed without any further intervention. All 6 radial nerve palsies (2 patients treated nonoperatively and 4 operatively) recovered. The functional outcome according to the SMFA was good with no differences between the nonoperatively and operatively treated patients: SMFA dysfunction index 7.6 and 9.7, respectively, and SMFA bother index 6.1 and 6.8, respectively., Conclusions: The Holstein-Lewis humeral shaft fracture was associated with a significantly increased risk of acute radial nerve palsy. The overall outcome regarding fracture healing, radial nerve recovery, and function was very good regardless of the primary treatment modality, that is, operative or nonoperative treatment. The indication for primary operative intervention in this fracture type appears to be relative.

Objectives: Evaluation of patients with a second hip fracture, which means a fracture of the contralateral hip., Design: Retrospective database analysis., Settings: Academic teaching hospital., Patients: All patients who were admitted for their second hip fractures between November 1999 and September 2001 and had their first hip fracture treated in our institution., Intervention: In this study, we epidemiologically analyzed the fracture types, the interval between the two fractures, general status of the patients, type of operation performed, and the postfracture independence level., Results: This survey comprises 84 patients (65 females and 19 males). Their ages ranged from 57 to 91 years (mean: 79) and 58 to 93 years (mean: 82) for the first and the second operation, respectively. The interval between the operations ranged from 2 to 297 months (mean: 35 months, median: 30 months). Twenty-three patients had subcapital fractures in both hips. In 54 patients, bilateral intertrochanteric fractures were noted. Only 7 patients had a previous subcapital fracture and a second intertrochanteric fracture. The general status of the patients' health was defined by the number of pre-existing major medical conditions and was found to be between 0 and 4 (mean: 2.15). Thirty-two patients (38%) had additional fractures somewhere between 1 and 8 years prior to the hip fracture (vertebra, proximal humerus, or distal radius). Sixty-eight and 56 out of the 84 patients reached the same mobility status after the first and second operation, respectively., Conclusions: A tendency was found for the second hip fracture to be of the same type as the previous one. Most patients showed a good potential for rehabilitation and for maintaining their prefall functional level.

Objectives: To examine the epidemiology and results of treatment of fractures of the distal humeral metaphysis., Design: Observational cohort study., Setting: An orthopaedic trauma unit, which provides all the fracture care for a well-defined catchment population., Patients/participants: A consecutive series of 320 patients with distal humeral fractures admitted to the unit between January 1988 and June 1997., Intervention: We adopted a protocol of open reduction and fixation of all displaced fractures (greater than 5 mm of displacement in any plane) in patients who were medically fit for anesthesia. Postoperative immobilization was a cylinder cast for 6 weeks. Patients with undisplaced fractures or who were medically unfit were also treated nonoperatively in cylinder casts for 6 weeks., Main Outcome Measurements: Epidemiological examination of patient subgroups and the incidence of complications of treatment., Results: The overall incidence of distal humeral fractures in adults during this time was 5.7 cases per 100,000 in the population per year with an almost equal male to female ratio. There was a bimodal age distribution, simple falls were the most common overall cause of fracture, and the majority of the fractures were extra-articular (AO/OTA type A) or complete articular fractures (AO/OTA type C). The risk of complications during treatment was generally low in most patients, and the majority healed their fractures uneventfully. Overall, 90.6% of fractures united within 12 weeks and just under half of the remaining 9.4% patients with union complications healed without requiring further operative intervention by 24 weeks. The risk of union complications was higher following high-energy injuries, open fractures, and nonoperative treatment. Although the AO/OTA classification was not predictive of union complications, the "low" transcondylar (type A2.3 and A3) and simple intercondylar fracture (type C1.3) configuration had a greater risk of union complications than the "high" subtype. The rate of infection, myositis ossificans, and other implant-related complications were higher following operative treatment of type C fractures than type A and B fractures., Conclusions: The epidemiology of a consecutive unselected series of adult distal humeral fractures is defined in this study. The majority of these fractures are best treated surgically by rigid open reduction and internal fixation, except for "low" Type A and C fractures, which have a higher risk of union complications. The role of total elbow arthroplasty to treat these more complex injuries requires further evaluation.

The fracture patterns of 3,350 children with 3,413 limb fractures admitted to one center from 1986 to 1990 were analyzed retrospectively. The overall boy-to-girl ratio was 2.7:1, rising to 5.5:1 in the adolescent group. Distal radius fracture was the most common fracture (19.87%), followed by supracondylar fracture of the humerus (16.64%) and forearm shaft fracture (13.36%). Specific age group breakdown showed that supracondylar fracture of the humerus was the most common fracture occurring in the age groups 0 to 3 years and 4 to 7 years, accounting for 28.94 and 31.18% of all limb fractures, respectively. Fracture of the distal radius occurred in 27.06% of the 8 to 11 year age group and 23.31% of the 12 to 16 year group. Open fractures were uncommon (2.17%), and greenstick fractures were found only in 5.27% of this hospital series. The nondominant arm was found to have more fractures although the number was not statistically significant. Seasonal variation in incidence occurred, with more cases in the summer and autumn months. The open reduction rate in the treatment varied from 10.15% in the 0 to 3 year age group to 33.95% in the 12 to 16 year group. Forty-five percent of the 0 to 3 year age group were discharged from hospital within 24 h, contrasting with 30% in the other age groups. Overall incidence of fractures requiring hospital treatment was estimated to range from 35 per 10,000 in the 0 to 3 year age group to 62, 60, and 57 per 10,000 in the 4 to 7, 8 to 11, and 12 to 16 year groups, respectively.