Orthopedics

CME Review Article 

Comparison of Initial Nonoperative and Operative Management of Radial Nerve Palsy Associated With Acute Humeral Shaft Fractures

Geng-yan Liu, MD; Chao-yue Zhang, PhD; Hong-wei Wu, MD

Abstract

Educational Objectives

As a result of reading this article, physicians should be able to:

Become familiar with the available treatment approaches for radial nerve palsy associated with humeral shaft fractures.

2. Understand the strengths and limitations of the current treatment approaches for radial nerve palsy associated with humeral shaft fractures.

3. Become familiar with the available evidence regarding the effectiveness of operative and nonoperative treatment for radial nerve palsy associated with humeral shaft fractures.

4. Understand when operative or nonoperative management of radial nerve palsy associated with humeral shaft fractures may be appropriate.

Abstract

Educational Objectives

As a result of reading this article, physicians should be able to:

Become familiar with the available treatment approaches for radial nerve palsy associated with humeral shaft fractures.

2. Understand the strengths and limitations of the current treatment approaches for radial nerve palsy associated with humeral shaft fractures.

3. Become familiar with the available evidence regarding the effectiveness of operative and nonoperative treatment for radial nerve palsy associated with humeral shaft fractures.

4. Understand when operative or nonoperative management of radial nerve palsy associated with humeral shaft fractures may be appropriate.

The optimal treatment approach for the initial management of radial nerve palsy associated with humeral shaft fractures has yet to be conclusively determined. The authors performed a systematic review of the literature to identify studies that compared the outcomes after initial nonoperative and operative management for radial nerve palsy associated with acute humeral shaft fractures. A meta-analysis of the data from these studies was also performed to determine whether recovery from radial nerve palsy was more favorable in one approach compared with the other. The primary outcome was recovery from radial nerve palsy and the secondary outcome was complaints after treatment. Nine articles (1 prospective observational and 8 retrospective) were included in the meta-analyses. Operative management showed no improved recovery from radial nerve palsy compared with nonoperative management. Nonoperative management was associated with a decreased risk of complaints relative to operative management. Recovery from radial nerve palsy associated with acute humeral shaft fractures is not influenced by the initial management approach. 

Drs Liu and Zhang are from the Department of Orthopedics, The Third Xiangya Hospital of Central South University, and Dr Wu is from the Department of Orthopedics, Hunan Cancer Hospital, Yuelu District, Changsha, China.

The material presented in any Vindico Medical Education continuing education activity does not necessarily reflect the views and opinions of Orthopedics or Vindico Medical Education. Neither Orthopedics nor Vindico Medical Education nor the authors endorse or recommend any techniques, commercial products, or manufacturers. The authors may discuss the use of materials and/or products that have not yet been approved by the US Food and Drug Administration. All readers and continuing education participants should verify all information before treating patients or using any product.

Correspondence should be addressed to: Chao-yue Zhang, PhD, Department of Orthopedics, The Third Xiangya Hospital of Central South University, 27th Ward, TongZipo Rd, Yuelu District, Changsha, China (zcy1958@medmail.com.cn).

Click here to take the CME quiz.

Humeral shaft fractures are typically the result of direct trauma and account for 1% to 7% of all fractures.1–3 A common complication of humeral shaft fractures is radial nerve palsy, which may occur at the time of injury or during reduction.4 Radial nerve palsy can be complete or partial4 and has been reported as a complication for between 2% and 17% of all humeral shaft fractures.4–6 The optimal strategy for the initial management of radial nerve palsy associated with humeral shaft fracture has yet to be conclusively determined and remains a controversial issue among surgeons.4,7,8

The initial management of radial nerve palsy associated with humeral shaft fractures may be nonoperative or operative. Potential advantages of an initial nonoperative approach include the fact that radial nerve palsy often resolves spontaneously and that it avoids the risk of complications that may occur with surgery.4,5,8 Furthermore, proponents of an initial nonoperative approach suggest that delaying surgical exploration does not affect the outcome and that surgical treatment is easier once the fracture has healed.6 Potential advantages of an initial operative approach include the ability to define the extent and nature of the nerve injury (eg, nerve entrapment), the ability to stabilize the fracture, technical ease (vs later surgical exploration), and a reduced risk of nerve envelopment by scar tissue.4,6,8

Several nonrandomized, controlled studies have directly compared outcomes following initial nonoperative and operative management of radial nerve palsy associated with acute humeral shaft fractures, but no prospective, randomized trials have been performed. A meta-analysis examining this issue has been published6; however, the analyses did not exclusively compare the 2 types of initial management approaches. Hence, the current authors performed a systematic review of the available literature and then performed a meta-analysis of the data to determine whether recovery from radial nerve palsy was more favorable using one management approach over the other.

Materials and Methods

Literature Search Strategy

The authors searched Medline (inception to August 22, 2011), PubMed (inception to August 22, 2011), and the Cochrane Library (inception to August 22, 2011) using the terms radial nerve palsy, humeral shaft fracture, proximal humeral fractures, midshaft humeral fractures, distal humeral fractures, operative treatment, nonoperative treatment, functional bracing, intramedullary locking nail, locking plating, and surgical treatment. A cross-reference bibliography check was performed to ensure a complete list of potential studies. Only English-language studies were evaluated.

Selection Criteria

Studies. All randomized or quasirandomized (eg, allocation by hospital record number) studies that compared operative and nonoperative management of radial nerve palsy associated with traumatic humeral shaft fractures (ie, proximal, mid-shaft, and distal) were included.

Patients. Patients of either sex who had completed skeletal growth and had radial nerve palsy associated with 1 or more traumatic humeral shaft fractures were included. Nonoperative and operative treatment for radial nerve palsy associated with traumatic humeral shaft fractures were included. Pharmacological trials were excluded.

Outcomes. All clinical outcomes, including degree of nerve functional recovery, degree of fracture recovery (ie, complete, partial, or none), complications (eg, secondary neurolysis, malunion, and infection), free shoulder mobility (eg, range of motion), and complaints, were included.

Data Extraction and Quality Assessment

Eligible studies were selected by the first author (G.L.) and one reviewer (H.W.) using the search strategy and criteria already described. The initial decision on trial eligibility was based on citation details and, where available, the title. The following data were extracted from each eligible study: author’s last name; patient characteristics (ie, number, age, sex), type of injury that caused fracture (ie, high- or low-energy), fracture location and type; primary radial nerve palsy (ie, partial or complete), primary treatment, and length of follow-up. The main outcome, primary outcome, and secondary outcomes reported were collected. Qualitative details and raw data describing the study groups, interventions, complications (eg, secondary operation, infection, radial nerve paresis, and nonunion), and complaints, were also recorded. Quality assessment of the extracted data was performed by the reviewer by referring to a previously described approach with modification.9

Data Analysis

The authors used the [R] “rmeta” package (Free Software Foundation, Inc, Boston, Massachusetts) to perform the meta-analysis. Odds ratios (OR) and 95% confidence intervals (CIs) were determined for each study to assess the effect of treatment on functional recovery from radial nerve palsy associated with traumatic humeral nerve fracture. Functional recovery included whether full recovery (yes vs no) or free shoulder mobility (yes vs no) was obtained. Results from individual studies were combined using a fixed-effects model (Mantel-Haenszel) and a random-effects model (DerSimonian-Laird) to determine overall OR and 95% CI. Identical analysis was also performed to assess the effect of treatment on complaints after treatment (ie, whether complaints were more or less likely to occur. Complaints of different treatments included secondary neurolysis (yes vs no), malunion (yes vs no), and infection (yes vs no). Heterogeneity across the studies was determined by assessing the Q statistic. Funnel plots were constructed to assess publication bias. Statistical significance was indicated by a P value less than .05.

Results

Literature Search

A total of 935 articles were identified by searching the 3 databases (Figure 1). Of these articles, 591 were subsequently excluded after title review. Abstracts for the remaining 196 articles were reviewed, and 185 were excluded. Hence, 9 articles were included in the systematic review and meta-analyses.10–18

Study flow diagram.

Figure 1: Study flow diagram.

Study Characteristics

Table 1 summarizes the characteristics of all studies included in the meta-analyses. The studies were published between 1972 and 2011 and included 1 prospective study17 and 8 retrospective studies.10–18 No randomized, controlled trials were included in the analyses. The studies included a total of 620 patients: 239 who received nonoperative treatment and 381 who received operative treatment. The quality of trial methodology was generally poor (Table 2).

Summary of Patients’ Baseline Characteristics for Each Study Included in the Meta-analysis

Table 1: Summary of Patients’ Baseline Characteristics for Each Study Included in the Meta-analysis

Methodological Quality Assessment Scheme for Trials Included in the Meta-analysisa

Table 2: Methodological Quality Assessment Scheme for Trials Included in the Meta-analysis

Primary Outcome: Recovery From Radial Nerve Palsy

A significant effect favored operative treatment in 2 studies. In the Packer et al15 study, the OR of having a favoring outcome during the initial operation was 12.80 (95% CI, 2.02–81.12). Denard et al11 also observed that initial operation was associated with better recovery (OR=4.50; 95% CI, 2.13–9.50). However, the overall fixed-effects model revealed that neither treatment approach was significantly favored over the other (OR=1.09; 95% CI, 0.73–1.64) (Figure 2). The random-effects model findings were consistent with the fixed-effects model findings (overall OR=0.88; 95% CI, 0.27–2.88) (Figure 3). Tests for heterogeneity were not statistically significant for either model (fixed-effect: χ2 [8]=39.73; P>.001; random-effect: χ2 [8]=39.61; P>.001).

Effect of operative treatment on full recovery of humeral shaft fractures in a fixed-effect model. Fixed-effects (Mantel-Haenszel) meta-analysis included the findings from 9 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was not statistically significant (OR=1.09; 95% CI=0.73–1.64). Test for heterogeneity: χ2(8)=39.73 (P<.001).

Figure 2: Effect of operative treatment on full recovery of humeral shaft fractures in a fixed-effect model. Fixed-effects (Mantel-Haenszel) meta-analysis included the findings from 9 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was not statistically significant (OR=1.09; 95% CI=0.73–1.64). Test for heterogeneity: χ2(8)=39.73 (P<.001).

Effect of operative treatment on full recovery of humeral shaft fractures in a random-effects model. Random-effects (DerSimonian-Laird) meta-analysis included the findings from 9 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was not statistically significant (OR=0.88; 95% CI=0.27- 2.88). Test for heterogeneity: χ2(8) =39.61 (P<.001). Estimated random-effects variance=2.26.

Figure 3: Effect of operative treatment on full recovery of humeral shaft fractures in a random-effects model. Random-effects (DerSimonian-Laird) meta-analysis included the findings from 9 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was not statistically significant (OR=0.88; 95% CI=0.27- 2.88). Test for heterogeneity: χ2(8) =39.61 (P<.001). Estimated random-effects variance=2.26.

Secondary Outcome: Complaints

Six of 9 studies compared the complaints between operative and nonoperative treatments. To assess whether initial operation increased complaints compared with nonoperation, the authors further assessed the association of complaints between different treatments. The overall fixed effects model revealed that nonoperative treatment was associated with a decreased risk of complaints (OR=0.50; 95% CI, 0.30–0.85) (Figure 4). A similar finding was observed using the random-effects model (Figure 5). Tests for heterogeneity were not statistically significant for either model (both: χ2 [5]=2.92; P=.713).

Effect of operative treatment on complaints of treatment in fixed effects model. Fixed-effects (Mantel-Haenszel) meta-analysis included the findings from 6 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was statistically significant (OR=0.50; 95% CI=0.30–0.85). Test for heterogeneity: χ2(5)=2.92 (P=.713).

Figure 4: Effect of operative treatment on complaints of treatment in fixed effects model. Fixed-effects (Mantel-Haenszel) meta-analysis included the findings from 6 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was statistically significant (OR=0.50; 95% CI=0.30–0.85). Test for heterogeneity: χ2(5)=2.92 (P=.713).

Effect of operative treatment on complaints of treatment in random-effects model. Random-effects (DerSimonian-Laird) meta-analysis included the findings from 6 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was statistically significant (OR=0.50; 95% CI=0.30–0.85). Test for heterogeneity: χ2(5) =2.92 (P=.713). Estimated random effects variance=0.

Figure 5: Effect of operative treatment on complaints of treatment in random-effects model. Random-effects (DerSimonian-Laird) meta-analysis included the findings from 6 studies. The odds ratio (OR) and upper and lower 95% confidence intervals (CIs) are shown for each study and for all studies combined (summary). The overall effect of treatment was statistically significant (OR=0.50; 95% CI=0.30–0.85). Test for heterogeneity: χ2(5) =2.92 (P=.713). Estimated random effects variance=0.

Funnel plot for the fixed-effects meta-analysis. No strong evidence of publication bias existed.

Figure 6: Funnel plot for the fixed-effects meta-analysis. No strong evidence of publication bias existed.

Funnel plot for the random-effects meta-analysis. No strong evidence of publication bias existed.

Figure 7: Funnel plot for the random-effects meta-analysis. No strong evidence of publication bias existed.

Publication Bias

Funnel plots revealed no strong evidence of publication bias for either the fixed-effects or random-effects models.

Discussion

The authors performed a systematic review and subsequent meta-analysis of data extracted from eligible studies to compare outcomes following initial nonoperative and operative management of radial nerve palsy associated with acute humeral shaft fractures. A total of 9 studies, involving a total of 620 patients, were identified. Meta-analysis of data extracted from these studies showed that no significant difference in recovery from radial nerve palsy between the initial management approaches and that nonoperation was associated with a decreased risk of complaints.

The current finding that recovery from radial nerve palsy did not significantly differ between the 2 management approaches is consistent with the finding from a previous systemic review.6 In contrast to the current analyses, Shao et al6 did not exclusively include data from studies directly comparing nonoperative and operative management. However, they found no significant difference in the rate of recovery between the initial expectant group (nonoperative group) and the early operation group (operated on within 3 weeks after injury).6

The current findings are also consistent with those reported in the only prospective study published to date, which compared outcomes following management of humeral midshaft fractures.17 Although the patients treated operatively in that prospective study had more favorable outcomes in terms of shoulder abduction strength, elbow flexion strength, functional hand positioning, and return to recreational activities after 6 weeks, no statistically significant differences were found between the 2 management approaches for any of the outcome measures at 1-year follow-up.17

Recovery from radial nerve palsy may be affected by several factors, including the cause of injury, extent of nerve injury, and location and type of fracture. Unfortunately, an insufficient number of patients in the current study did not allow the authors to perform meaningful subgroup analyses to determine whether the outcome of initial management is affected by these factors. A large-scale, randomized, controlled trial is needed to more comprehensively ascertain which patients with radial nerve injury associated with humeral shaft fractures are more likely to benefit from nonoperative initial management and which patients are more likely to benefit from initial operative management. The small-scale observational studies conducted to date do not allow for definitive conclusions to be drawn.

The results of the current meta-analyses are limited by several factors, most of which relate to the available evidence. First, the quality of the studies included was relatively low. Only a small number of studies were identified, and none were randomized, controlled trials. Second, the specific nonoperative and operative management approaches varied between studies (plate, nail, or undefined operative method) (Table 1), potentially reducing the ability to detect differences between management approaches. Third, only English-language studies were included in the meta-analyses; thus potentially pertinent studies published in the nonEnglish-language journals may have been missed.

Conclusion

The findings from the current systematic review and subsequent meta-analysis suggest that recovery from radial nerve palsy associated with acute humeral shaft fractures is not significantly influenced by the initial management approach (nonoperative or operative). Although instances of radial nerve palsy should be considered on a case-by-case basis, the authors suggest that initial nonoperative management should be favored when possible due to the reduced risk of complications associated with nonoperative management. Given the potential advantages of initial expectancy and to avoid unnecessary surgery, Shao et al6 recommended that a policy of initial expectancy must be considered. Nonoperative management, such as functional bracing, was also advocated in other reports.18 However, operative intervention is warranted if radial nerve palsy has not resolved within 6 months of the initial injury.5,6

References

  1. Brinker MR, O’Connor DP. The incidence of fractures and dislocations referred for orthopaedic services in a capitated population. J Bone Joint Surg Am. 2004; (86):290–297.
  2. Ekholm R, Adami J, Tidermark J, Hansson K, Törnkvist H, Ponzer S. Fractures of the shaft of the humerus. An epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006; (88):1469–1473.
  3. van Staa TP, Dennison EM, Leufkens HG, Cooper C. Epidemiology of fractures in England and Wales. Bone. 2001; (29):517–522. doi:10.1016/S8756-3282(01)00614-7 [CrossRef]
  4. DeFranco MJ, Lawton JN. Radial nerve injuries associated with humeral fractures. J Hand Surg Am. 2006; (31):655–663. doi:10.1016/j.jhsa.2006.02.013 [CrossRef]
  5. Shah A, Jebson PJ. Current treatment of radial nerve palsy following fracture of the humeral shaft. J Hand Surg Am. 2008; (33):1433–1434. doi:10.1016/j.jhsa.2008.05.029 [CrossRef]
  6. Shao YC, Harwood P, Grotz MR, Limb D, Giannoudis PV. Radial nerve palsy associated with fractures of the shaft of the humerus: a systematic review. J Bone Joint Surg Br. 2005; (87):1647–1652.
  7. Bishop J, Ring D. Management of radial nerve palsy associated with humeral shaft fracture: a decision analysis model. J Hand Surg Am. 2009; (34):991.e1–996.e1.
  8. Elton SG, Rizzo M. Management of radial nerve injury associated with humeral shaft fractures: an evidence-based approach. J Reconstr Microsurg. 2008; (24):569–573. doi:10.1055/s-0028-1090623 [CrossRef]
  9. Handoll HH, Ollivere BJ. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2010; (12):CD000434.
  10. Bostman O, Bakalim G, Vainionpää S, Wilppula E, Pätiälä H, Rokkanen P. Immediate radial nerve palsy complicating fracture of the shaft of the humerus: when is early exploration justified?Injury. 1985; 16(7):499–502. doi:10.1016/0020-1383(85)90181-0 [CrossRef]
  11. Denard A Jr, Richards JE, Obremskey WT, Tucker MC, Floyd M, Herzog GA. Outcome of nonoperative vs operative treatment of humeral shaft fractures: a retrospective study of 213 patients. Orthopedics. 2010; 33(8). doi:
  12. Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. The Holstein-Lewis humeral shaft fracture: aspects of radial nerve injury, primary treatment, and outcome. J Orthop Trauma. 2008; 22(10):693–697. doi:10.1097/BOT.0b013e31818915bf [CrossRef]
  13. Ekholm R, Ponzer S, Törnkvist H, Adami J, Tidermark J. Primary radial nerve palsy in patients with acute humeral shaft fractures. J Orthop Trauma. 2008; 22(6)):408–414. doi:10.1097/BOT.0b013e318177eb06 [CrossRef]
  14. Osman N, Touam C, Masmejean E, Asfazadourian H, Alnot JY. Results of non-operative and operative treatment of humeral shaft fractures. A series of 104 cases. Chir Main. 1998; 17(3):195–206.
  15. Packer JW, Foster RR, Garcia A, Grantham SA. The humeral fracture with radial nerve palsy: is exploration warranted?Clin Orthop Relat Res. 1972; 88:34–38. doi:10.1097/00003086-197210000-00005 [CrossRef]
  16. Sonneveld GJ, Patka P, van Mourik JC, Broere G. Treatment of fractures of the shaft of the humerus accompanied by paralysis of the radial nerve. Injury1987; (18):404–406. doi:10.1016/0020-1383(87)90287-7 [CrossRef]
  17. van Middendorp JJ, Kazacsay F, Lichtenhahn P, Renner N, Babst R, Melcher G. Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients. Eur J Trauma Emerg Surg. 2011; 37(3):287–296. doi:10.1007/s00068-011-0099-0 [CrossRef]
  18. Wallny T, Sagebiel C, Westerman K, Wagner UA, Reimer M. Comparative results of bracing and interlocking nailing in the treatment of humeral shaft fractures. Int Orthop. 1997; 21(6):374–379. doi:10.1007/s002640050189 [CrossRef]

Summary of Patients’ Baseline Characteristics for Each Study Included in the Meta-analysis

Study No. of Patients Age Range, y No. of Women/Men No. of Low-/High-Energy Injuriesa Fracture Location (No.) Fracture Type (No.) Primary Radial Nerve Palsy Primary Treatment (No.) Follow-up
Packer et al15 31 5–88 15/16 25/6 Proximal (5) Middle (22) Distal (4) Closed (31) Complete (24) Partial (7) Unclear op method (24) Nonop (7) 1–24 mo
Bostman et al10 59 13–79 14/45 24/35 Proximal (1) Middle (30) Distal (28) Open (10) Closed (49) Complete (59) Unclear op method (39) Nonop (20) 3 y
Sonneveld et al16 17 3–74 7/10 12/5 Middle (16) Distal (1) Closed (16) Open (1) Complete or partial (17) Dynamic compression plate (op) (14) Collar and cuff (nonop) (3) 3–36 mo
Wallny et al18 89 11–92 39/50 NA Proximal (43) Middle (39) Distal (7) NA Complete or partial (12) Locking nails (op) (45) Functional bracing (nonop) (44) 1- 4 y
Osman et al14 104 17–103 44/60 68/36 Primary (31) Middle (54) Distal (19) NA Complete or partial (11) Plates, wires, or nail (op) (72) Sling and plaster splint (nonop) (32) 18 mo
Ekholm et al12 33 16–91 19/14 23/10 Proximal (3) Middle (18) Distal (12) Closed (33) Complete or partial (33) Plate, nail, or screw (op) (15) Nonop (18) 6 y
Ekholm et al13 27 16–91 18/9 17/10 Distal (27) Closed (27) Complete or partial (6) Plate, nail or screw (op) (7) Nonop (20) 6.3 y
Denard et al11 213 Mean: 36.4 (nonop) vs 34.9 (op) 97/116 95/118 NA NA NA Compression plating (op) (150) Functional bracing (nonop) (63) 3–41 mo
Van Middendorp et al17 47 17–86 23/24 NA Middle (47) NA Primary (3) Locking nails (op) (33) Functional brace (nonop) (14) 1 y

Methodological Quality Assessment Scheme for Trials Included in the Meta-analysisa

Study Treatment Concealedb Withdrawn Partic Inclc Baseline Characd Blinded to Treatment
Care Programs Identicale Inclus/Exclus Criteriaf Outcome Measures
Active Surveillh
Outcome Assessors Partic Treatment Providers Defined Validg
Packer et al15 0 0 0 0 0 0 0 0 1 1 0
Bostman et al10 0 0 0 0 0 0 0 0 1 1 0
Sonneveld et al16 0 0 0 0 0 0 0 1 1 1 0
Wallny et al18 1 0 1 0 0 0 0 1 1 1 0
Osman et al14 0 1 0 0 0 0 0 1 1 1 0
Ekholm et al12 0 0 1 0 0 0 0 1 1 1 0
Ekholm et al13 0 0 1 0 0 0 0 1 1 1 0
Denard et al11 0 0 1 0 0 0 0 1 1 1 1
van Middendorp et al17 0 1 1 0 0 0 0 1 1 1 1

Instructions

  1. Review the stated learning objectives at the beginning of the CME article and determine if these objectives match your individual learning needs.

  2. Read the article carefully. Do not neglect the tables and other illustrative materials, as they have been selected to enhance your knowledge and understanding.

  3. The following quiz questions have been designed to provide a useful link between the CME article in the issue and your everyday practice. Read each question, choose the correct answer, and record your answer on the CME Registration Form at the end of the quiz.

  4. Type or print your full name and address and your date of birth in the space provided on the CME Registration Form.

  5. Indicate the total time spent on the activity (reading article and completing quiz). Forms and quizzes cannot be processed if this section is incomplete. All participants are required by the accreditation agency to attest to the time spent completing the activity.

  6. Complete the Evaluation portion of the CME Regi stration Form. Forms and quizzes cannot be processed if the Evaluation portion is incomplete. The Evaluation portion of the CME Registration Form will be separated from the quiz upon receipt at Orthopedics. Your evaluation of this activity will in no way affect the scoring of your quiz.

  7. Send the completed form, with your $15 payment (check or money order in US dollars drawn on a US bank, or credit card information) to: Orthopedics CME Quiz, PO Box 36, Thorofare, NJ 08086, OR take the quiz online. Visit www.Healio.com/EducationLab/Orthopedics for details.

  8. Your answers will be graded, and you will be advised whether you have passed or failed. Unanswered questions will be considered incorrect. A score of at least 80% is required to pass. If a passing score is achieved, Vindico Medical Education will issue an AMA PRA Category 1™ certificate within 4–6 weeks.

  9. Be sure to mail the CME Registration Form on or before the deadline listed. After that date, the quiz will close. CME Registration Forms received after the date listed will not be processed.

Instructions

CME Accreditation

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Vindico Medical Education and Orthopedics. Vindico Medical Education is accredited by the ACCME to provide continuing medical education for physicians.

Vindico Medical Education designates this Journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

This CME activity is primarily targeted to orthopedic surgeons, hand surgeons, head and neck surgeons, trauma surgeons, physical medicine specialists, and rheumatologists. There is no specific background requirement for participants taking this activity.

Full Disclosure Policy

In accordance with the Accreditation Council for Continuing Medical Education’s Standards for Commercial Support, all CME providers are required to disclose to the activity audience the relevant financial relationships of the planners, teachers, and authors involved in the development of CME content. An individual has a relevant financial relationship if he or she has a financial relationship in any amount occurring in the last 12 months with a commercial interest whose products or services are discussed in the CME activity content over which the individual has control.

Drs Liu, Zhang, and Wu have no relevant financial relationships to disclose. Dr Aboulafia, CME Editor, has no relevant financial relationships to disclose. Dr D’Ambrosia, Editor-in-Chief, has no relevant financial relationships to disclose. The staff of Orthopedics have no relevant financial relationships to disclose.

Unlabeled and Investigational Usage

The audience is advised that this continuing medical education activity may contain references to unlabeled uses of FDA-approved products or to products not approved by the FDA for use in the United States. The faculty members have been made aware of their obligation to disclose such usage.

10.3928/01477447-20120725-10

Sign up to receive

Journal E-contents