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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 37  |  Issue : 3  |  Page : 172-175

Functional and radiological outcome of isolated shaft of humerus fracture managed with functional cast brace


1 Department of Orthopaedics, JIPMER, Puducherry, India
2 Department of Orthopaedics, ABVIMS, Dr Ram Manohar Lohia Hospital, New Delhi, India

Date of Submission26-Oct-2022
Date of Acceptance21-Nov-2022
Date of Web Publication15-Dec-2022

Correspondence Address:
Sarvesh Kumar Pandey
Department of Orthopaedics, ABVIMS, Dr Ram Manohar Lohia Hospital, New Delhi 11001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jbjd.jbjd_35_22

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  Abstract 

Purpose: Functional Cast Bracing is a most common, universally following method of conservative management of shaft of humerus fracture. The objective of this study were to assess union rate, complications and risk factors associated with non-union of shaft of humerus fracture and same were evaluated with functional cast brace. Materials and Methods: The study was designed as a Descriptive observational study. Patients who presented with closed isolated shaft of humerus fracture as diagnosed by clinical and radiological were included in the study (n = 83). Patients were managed with closed reduction and “U” slab application for about 2nd weeks. On 3rd week of post injury “U” slabs were removed and functional cast braces were applied. Functional (Constant-Murley score) and radiological outcome were assessed on 4th, 6th and 12th weeks of post injury. Results: Total 83 patients were included in this study. Union rate was 84.4% (n = 70), non-union rate was 15.6%(n = 13) and the risk factors which associated with non-union were occupation (more in laboured, n = 9(37.5%)), socioeconomic status (more in lower socioeconomic status, n = 9(50%)), smoking (more in smoker, n = 9(60%)) and type of fracture (more in spiral fracture, n = 7(50%)). Conclusion: Union rate was (84.4%) more and non-union rate was less (15.6%) of shaft of humerus fracture managed with functional cast brace. Occupation, socioeconomic status, smoking and spiral type of fracture were associated with non-union.

Keywords: Constant-murley score, functional cast brace, socioeconomic status, U slab


How to cite this article:
Naresh G, Jaiswal S, Yadav AK, Pandey SK, Kamboj N, Rajan R, Khare R. Functional and radiological outcome of isolated shaft of humerus fracture managed with functional cast brace. J Bone Joint Dis 2022;37:172-5

How to cite this URL:
Naresh G, Jaiswal S, Yadav AK, Pandey SK, Kamboj N, Rajan R, Khare R. Functional and radiological outcome of isolated shaft of humerus fracture managed with functional cast brace. J Bone Joint Dis [serial online] 2022 [cited 2023 Feb 6];37:172-5. Available from: http://www.jbjd.in/text.asp?2022/37/3/172/363857




  Introduction Top


The incidence of the shaft of the humerus is 1% to 3% of all fracture.[1] Causes of the shaft of humerus fracture are a road traffic accident, fall from a height, sports injuries, direct blow and simple fall.[2] A most common cause of shaft of humerus fracture in males (20 to 30 years) are road traffic accident and fall from a height, in females (60 to 70 years) is fall from her standing height.[3] First time management of shaft of humerus fracture started in the Edwin Smith Papyrus, circa 1600 BC by Egyptians with splints made up of honey, alum and cloth.[4] Later Sarmiento developed functional brace therapy.[1] Complications of non-operative management were less like nonunion, malunion.[5] In most cases, union take places in 8 weeks to 14 weeks.[1] Nonunion more common in proximal 1/3 shaft of humerus fracture due to soft tissues interposition and unbalancing muscle forces at the fracture site. Nonunion rate less in middle and distal 1/3 shaft of a humerus fracture.[5] Secondary radial nerve injury(1%) due to functional brace is very rare.[1] Varus angulation (malunion) was less than 10 degrees in more than 85%.[1] Smoking increases the risk of nonunion.[6] Instability was more in women compared with men.[7] Limitations of the functional brace are polytrauma, brachial plexus injury and an open fracture of shaft of humerus.[4]

The study aims to assess the union rate, complication and risk factors associated with non-union of shaft of humerus fracture managed with functional cast brace.


  Materials and Methods Top


This descriptive observational study was conducted from July 2016 to December 2018 in a tertiary trauma care centre. This study was approved by institution review board. Patients of age more than 18 years, who presented with closed isolated shaft of humerus fracture as diagnosed by clinical and radiological were included in the study. After a detailed clinical history and examination, routine anteroposterior and lateral radiographs were taken.

Patients were given a U-plaster of Paris slab for 2 week after the closed reduction was done. On 3rd week of post injury “U” slabs were removed and functional cast braces were applied. Functional (Constant-Murley score) and radiological outcome were assessed on 4th, 6th and 12th weeks of post injury. Rehabilitation program consisting of active exercises of the hand, wrist, elbow and shoulder along with shoulder mobilisation exercises at least 30 min and 2 times daily was advised after brace removal. They were instructed to use cc sling intermittently for another 2 weeks for protection and after which activities were permitted as per tolerance. Functional assessment was done by Constant-Murley Score which consists of the following 4 major categories assessing shoulder functions subjectively and objectively. Components of constant-Murley score are pain (score: 15), activity of daily living (score: 20), range of movements (score: 40) and strength (score: 25). Pain and daily living activity are subjective parameters whereas Range of motion and strength are objective parameters.

The final outcome calculated on the basis of the Constant-Murley score (CMS) which was categorized into poor (score: 0-55), moderate (score: 56-70), good (score: 71-85), excellent (score: 86-100) [see [Table 1]].[8]
Table 1: Grade of constant-murley score

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Radiological assessment was done by anterioposterior and lateral view of arm to see three cortices union in both views and angle measured between proximal and distal fragment in both views to see the malunion at fracture site.

Statistical analysis

The sample size was estimated by using the statistical formula and analysis was done by using statistical software SPSS for Windows, version 24. The distribution of data on categorical variables such as sex, gender, occupation, comorbidities mode of injury, Muller’s fracture type, limb involved, Constant-Murley score grade and the radiological profile was expressed as frequency and percentage.

The data on discrete/ continuous variables such as age, the level of pain, level of activity of daily living, Range of Motion, Strength, Constant-Murley score was expressed as mean with standard deviation or median with range. All statistical analysis was carried out a 5% level of significant and p value <0.05 was considered as significant.


  Results Top


A total of 83 patients were included in this study. Out of 83 patients, 70 patients (84.4%) had union and 13 (15.6%) patients had non-union at fracture site. Risk factors associated with non-union were labour, socioeconomic status, smoking and type of fracture and 6(7%) patients had malunion at the end of 12 weeks.

Labour as occupation patients had more non-union, n = 9(37.5%) with p value was 0.011 which was significant. Lower socioeconomic status patients had non-union of 50%. Patients who had habit of smoking had non-union of 60% and patients who were presented with spiral type of fracture pattern had non-union of 50%. Socioeconomic status, smoking and type of fracture had same p value of 0.00 which was significant. The average union time for fracture in male was 7.5weeks and 8.1 weeks in female.

Constant-murley score (CMS)

At 6 weeks, 67(80.7%) patients had poor CMS and 16(19.3%) patients had fair CMS and no patients had good and excellent CMS at 6 weeks. 13 patients had nonunion and 54 patients had union out of 67 patients who had poor CMS at 6 weeks. All patients had a union who had fair CMS at 6 weeks.

At 12 weeks, 13(15.7%) patients had poor CMS, 15(18.1%) patients had fair CMS, 43(51.8%) patients had good CMS and 12(14.5%) patients had excellent CMS at 12 weeks. All patients had nonunion who had poor CMS at 12 weeks. All patients who had fair, good and excellent CMS had a union at 12 weeks.


  Discussion Top


In total 83 patients which were recruited in this study, union rate was 84.4% and non-union rate was 15.6% and 6(7%) patients had malunion at end of 12 weeks which was managed with functional cast brace.

[Table 2] shows the risk factors associated with non-union were occupation, socioeconomic status, smoking and type of fracture. Labour as occupation patients had more non-union, n = 9(37.5%). Lower socioeconomic status patients had non-union of 50%. Patients who had habit of smoking had non-union of 60% and patients who were presented with spiral type of fracture pattern had non-union of 50%.
Table 2: Risk factors associated with non-union

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CMS was assessed at 4, 6 and 12 week, [Figure 1] shows trend of improved score from poor to good score from 4 to 12 weeks. At 4 weeks more patients had poor score and at 12 weeks more patients had good score.
Figure 1: Comparison of CMS at 4, 6 and 12 weeks

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Toivonen JAK et al.[9] studied 93 patients with the shaft of humerus fracture treated with functional cast brace .72 patients had a union (77%) without any complication and in 21 patients had a complication (nonunion) because the total number of patients is relatively high compared with our study and more 50% of fracture occurred in middle in 1/3 of the shaft of the humerus. Kapil Maniet al.[10] studied 108 patients who had a shaft of humerus fracture managed with functional cast brace. Average union time was 12.16 weeks and nonunion rate was 2.8%, because 2/3 patients were male and most of the patients were a young adult. Crespo AMet al.[11] Studied 72 patients who had a shaft of humerus fracture managed with functional cast brace. Union rate was 92% and the nonunion rate was 8%. Average union time was 15 weeks. Union rate was more (92%) due to less number of sample sizes. Westrick Eet al.[12] Studied 69 patients who had a shaft of the humerus fracture managed with functional cast brace. Nonunion rate was 23%. Patients who had a history of RTA were 46(67%) and patients with other mechanisms of injury were 23(33%). In this study, the high rate of a nonunion was due to the high energy mode of injury and soft tissue interference between fractures fragments same like this study. Nonunion associated with tobacco smoking and uncontrolled DM like our study in which smoking was associated with nonunion. Neuhauset al.[7] Total number of patients with the shaft of humerus fracture included in this study was 79. 63 (80%) patients had a union and 16 (20%) patients had nonunion. A total number of patients associated with smoking were 19 out of 79 and 8 patients with a history of smoking had nonunion at the end of 6 weeks. So, smoking associated with nonunion. Ringet al.[13] Studied 33 patients with the shaft of humerus fracture managed with functional cast brace. All patients had good and excellent CMS as a functional outcome.

Union rate was high and non-union rate was low which was comparable with above studies and the risk factor for non-union was evaluated in this study. Other factors like age, sex, mode of injury, site and side of injury were not associated with non-union.


  Conclusion Top


We concluded that union rate was high and non-union rate was low of isolated shaft of humerus fracture managed with functional cast brace and the association of non-union with risk factors was established in this study.

Financial support and sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

The authors declare that they have no conflict of interest.

Ethical approval

The study was done in accordance with the ethical standards of the institutional research committee (Jawaharlal Institute of Postgraduate Medical Education and Research [JIPMER]), Puducherry, India. Project number: JIP/IEC/2016/ and with the 1964 Helsinki declaration and comparable ethical standards.

Consent to participate

Informed consent was taken from all individual participants included in this study.

Consent to publish

Patients were signed informed consent regarding publishing their data and photographs.



 
  References Top

1.
Papasoulis E, Drosos GI, Ververidis AN, Verettas DA Functional bracing of humeral shaft fractures. A review of clinical studies. Injury 2010;41:e21-27.  Back to cited text no. 1
    
2.
Pal JN, Biswas P, Roy A, Hazra S, Mahato S Outcome of humeral shaft fractures treated by functional cast brace. Indian J Orthop 2015;49:408-17.  Back to cited text no. 2
    
3.
Pidhorz L Acute and chronic humeral shaft fractures in adults. Orthop Traumatol Surg Res 2015;101:S41-9.  Back to cited text no. 3
    
4.
Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M Humeral shaft fractures: A rev. J Shoulder Elbow Surg 2011;20:833-44.  Back to cited text no. 4
    
5.
Attum B, Obremskey W Treatment of Humeral Shaft Fractures: A Critical Analysis Review. JBJS Rev 2015;3:1.  Back to cited text no. 5
    
6.
Pehlivan O Functional treatment of the distal third humeral shaft fractures. Arch Orthop Trauma Surg 2002;122:390-5.  Back to cited text no. 6
    
7.
Neuhaus V, Menendez M, Kurylo JC, Dyer GS, Jawa A, Ring D Risk factors for fracture mobility six weeks after initiation of brace treatment of mid-diaphyseal humeral fractures. J Bone Joint Surg Am 2014;96:403-7.  Back to cited text no. 7
    
8.
Constant CR, Murley AH A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 1987;160:4-3.  Back to cited text no. 8
    
9.
Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Järvinen MJ Functional treatment of closed humeral shaft fractures. Int Orthop 2005;29:10-3.  Back to cited text no. 9
    
10.
Kapil Mani KC, Gopal Sagar DC, Rijal L, Govinda KC, Shrestha BL Study on outcome of fracture shaft of the humerus treated non-operatively with a functional brace. Eur J Orthop Surg Traumatol 2013;23:323-8.  Back to cited text no. 10
    
11.
Crespo AM, Konda SR, Egol KA Set it and forget it: Diaphyseal fractures of the humerus undergo minimal change in angulation after functional brace application. Iowa Orthop J 2018;38: 73-7.  Back to cited text no. 11
    
12.
Westrick E, Hamilton B, Toogood P, Henley B, Firoozabadi R Humeral shaft fractures: Results of operative and non-operative treatment. Int Orthop 2017;41:385-95.  Back to cited text no. 12
    
13.
Ring D, Chin K, Taghinia AH, Jupiter JB Nonunion after functional brace treatment of diaphyseal humerus fractures. J Trauma 2007;62:1157-8.  Back to cited text no. 13
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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