Orthopedics

Feature Article 

Humeral Shaft Fracture Healing Rates in Older Patients

Frederic H. Pollock, MD; J. P. Maurer, DO; Aaron Sop, DO; Jonathan Callegai, DO; Mike Broce, BA; Maher Kali, MD; Jeffrey F. Spindel, DO

Abstract

Nonoperative treatment has become the standard of care for the majority of humeral shaft fractures. Published studies have mainly come from trauma centers with a young cohort of patients. The purpose of this study was to determine the nonunion rate of humeral shaft fractures in patients older than 55 years. A retrospective study was performed on a group of orthopedic trauma group treated at a level I trauma center during a 10-year period (2007–2017). Patients 55 years or older and treated for a humeral shaft fracture nonoperatively, with or without manipulation, were identified. Nonunion was defined by no bridging callus radiographically or by gross motion at the fracture at least 12 weeks from injury. There were 31 patients identified with humeral shaft fractures who met the inclusion criteria. The cohort included 21 (67.7%) females and 10 (32.3%) males with a mean age of 72.5 years (range, 55–92 years). Twenty-one fractures went on to union, and there were 10 nonunions, with no significant differences in the demographics or comorbidities. There was no correlation between AO/OTA fracture classification or fracture location and union status. There was a tendency toward higher risk of nonunion in proximal third humeral shaft fractures (45%) compared with middle (26%) and distal third (20%) humeral shaft fractures, although this was not statistically significant. The overall nonunion rate for humeral shaft fractures was 32% for patients older than 55 years. The authors found a significant correlation between age and union rate: as age increased, union rate decreased (R=−0.9, P=.045). The incidence of humeral shaft nonunion in patients older than 55 years was significantly higher than that of younger adults. To the authors' knowledge, this study is the first to report a significant correlation between nonunion and increased age. [Orthopedics. 2020;43(3);168–172.]

Abstract

Nonoperative treatment has become the standard of care for the majority of humeral shaft fractures. Published studies have mainly come from trauma centers with a young cohort of patients. The purpose of this study was to determine the nonunion rate of humeral shaft fractures in patients older than 55 years. A retrospective study was performed on a group of orthopedic trauma group treated at a level I trauma center during a 10-year period (2007–2017). Patients 55 years or older and treated for a humeral shaft fracture nonoperatively, with or without manipulation, were identified. Nonunion was defined by no bridging callus radiographically or by gross motion at the fracture at least 12 weeks from injury. There were 31 patients identified with humeral shaft fractures who met the inclusion criteria. The cohort included 21 (67.7%) females and 10 (32.3%) males with a mean age of 72.5 years (range, 55–92 years). Twenty-one fractures went on to union, and there were 10 nonunions, with no significant differences in the demographics or comorbidities. There was no correlation between AO/OTA fracture classification or fracture location and union status. There was a tendency toward higher risk of nonunion in proximal third humeral shaft fractures (45%) compared with middle (26%) and distal third (20%) humeral shaft fractures, although this was not statistically significant. The overall nonunion rate for humeral shaft fractures was 32% for patients older than 55 years. The authors found a significant correlation between age and union rate: as age increased, union rate decreased (R=−0.9, P=.045). The incidence of humeral shaft nonunion in patients older than 55 years was significantly higher than that of younger adults. To the authors' knowledge, this study is the first to report a significant correlation between nonunion and increased age. [Orthopedics. 2020;43(3);168–172.]

Ancient Egyptian texts dating back to 1600 BC document the treatment of humeral shaft fractures via immobilization by wrapping in linen until healing.1 Three cases were described in antiquity that were treated with a period of immobilization and went on to clinical healing. It is likely that none of these patients were elderly because the average life expectancy in antiquity is estimated to have been approximately 34 years.1–4 The treatment of humeral shaft fractures with immobilization remained relatively unchanged until the late 1970s AD.5

In 1977, Sarmiento et al2 presented a series of 51 humeral shaft fractures treated with a novel approach. Patients were treated with mobilization of the shoulder and elbow via a prefabricated polypropylene sleeve. They referred to this device as a “functional brace” because movement of the extremity was encouraged. Ninety-eight percent of the humeral shaft fractures healed uneventfully, with the exception of 1 pathologic fracture. The age of the patients in this group was not reported.

In 2000, Sarmiento et al3 followed up with an extensive multicenter study of 922 patients with humeral shaft fractures treated with a functional brace. In the 620 patients followed, 465 (75%) of the fractures were closed and 155 (25%) were open. There was a 2% nonunion rate for closed fractures and 6% nonunion rate for open fractures. The average age of the patients was 36 years (range, 16–38 years) at the time of injury.

Functional bracing remains the treatment of choice for most closed, isolated diaphyseal fractures of the humerus.4 Relative indications for operative fixation include obesity and large breasts because these make brace treatment difficult.5 Surgical fixation has been recommended for patients with vascular injury, open fracture, associated forearm fractures, and polytrauma.5 Concomitant radial nerve injury is generally treated expectantly in closed fractures, followed by electromyography to access nerve recovery.6,7 A recent study comparing minimally invasive bridge plating vs functional bracing concluded that surgical treatment in young adult patients was of uncertain benefit.8

Elderly patients may lose their independence if they have a painful and impaired upper extremity.9 Hence, it is important to understand the union rate of humeral fractures treated with functional bracing in older patients.

Materials and Methods

Radiograph and chart review received institutional research ethical committee approval. The billing department of a single specialty orthopedic trauma group produced a list of patients with a charge code for humeral shaft fractures treated by closed treatment with or without manipulation from April 2007 through April 2017. This group was the basis of this study at a level I trauma center.

The inclusion criteria were (1) humeral shaft fracture treated definitively with a functional brace, (2) age of at least 55 years at the start of treatment, and (3) follow-up of at least 12 weeks. Chart review was undertaken to establish age, smoking history, sex, and medical comorbidities. Patients were excluded from the study if they converted to operative treatment for any reason before 12 weeks.

The initial search for the billing code of humeral shaft fractures at the orthopedic trauma group during a 10-year period yielded 385 fractures in 367 patients. Selecting those who were 55 years or older at the initial injury decreased the number to 55 fractures. There were 40 who were followed for at least 12 weeks. Of these, 9 elected operative treatment. This left 31 fractures that made up this study.

Charts and radiographs of 31 patients were reviewed by a panel of orthopedic surgeons (F.H.P., J.P.M., A.S.). All humeral fractures were classified by anatomic location of the shaft fracture and by AO/OTA classification system. A nonunion of the humerus was defined as no bridging callus or gross motion at the fracture site at 12 weeks, and this was chosen for several reasons. Driesman et al10 recently studied a group of humeral shaft fractures and found that no healing at 6 weeks was highly predictive of no further healing and subsequent non-union. Similarly, the current authors also found no cases that had no healing by 12 weeks that went on to heal by 6 months (Figures 12).

Anteroposterior initial (A), preoperative (B), and postoperative (C) radiographs of a 72-year-old woman who had a standing slip and fall injury. She had a closed AO/OTA type 12-B3 right proximal humeral fracture. This patient was a nonsmoker with type 2 diabetes mellitus and hypothyroidism. She was cooperative with the use of a prefabricated polyethylene brace for 6 months. By 6 months, it was evident that a nonunion was present. At 7 months, she underwent repair of the nonunion and had uneventful healing of the humeral fracture.

Figure 1:

Anteroposterior initial (A), preoperative (B), and postoperative (C) radiographs of a 72-year-old woman who had a standing slip and fall injury. She had a closed AO/OTA type 12-B3 right proximal humeral fracture. This patient was a nonsmoker with type 2 diabetes mellitus and hypothyroidism. She was cooperative with the use of a prefabricated polyethylene brace for 6 months. By 6 months, it was evident that a nonunion was present. At 7 months, she underwent repair of the nonunion and had uneventful healing of the humeral fracture.

Anteroposterior initial (A), preoperative (B), and postoperative (C) radiographs of a 68-year-old man who tripped and fell, sustaining an injury to the left humerus. The radiographs revealed an AO/OTA type 12-A1 midshaft left humeral fracture. He had no history of cigarette use. There was a history of hypertension and atrial fibrillation. At 7 months, the patient had evidence of an established humeral nonunion. He declined surgical fixation. After 3.5 years, he decided to proceed with operative fixation. The patient underwent repair of the left humerus nonunion. He is currently in the early postoperative period.

Figure 2:

Anteroposterior initial (A), preoperative (B), and postoperative (C) radiographs of a 68-year-old man who tripped and fell, sustaining an injury to the left humerus. The radiographs revealed an AO/OTA type 12-A1 midshaft left humeral fracture. He had no history of cigarette use. There was a history of hypertension and atrial fibrillation. At 7 months, the patient had evidence of an established humeral nonunion. He declined surgical fixation. After 3.5 years, he decided to proceed with operative fixation. The patient underwent repair of the left humerus nonunion. He is currently in the early postoperative period.

Results

The study group included 31 patients with a closed humeral shaft fracture. There were 21 (67.7%) females and 10 (32.3%) males with mean age of 72.5 years (range, 55–92 years) (Table 1). There were no significant differences in the demographics or comorbidities between the union and nonunion groups. However, patients with hypothyroidism had a higher occurrence of nonunions (P=.067).

Patient Demographics and Fracture Classification and Distribution

Table 1:

Patient Demographics and Fracture Classification and Distribution

Of the 31 closed humeral shaft fractures, 21 progressed to union status and 10 were classified as nonunions. Additionally, there were differences noted in union rates depending on the fracture location; however, these were not statistically significant. The nonunion rate was 45% in proximal third, 26% in midshaft, and 20% in distal third humeral shaft fractures (P=.488). Furthermore, there was no significant difference in nonunion rate by AO/OTA fracture classification11: type A, 27%; type B, 50%; type C, 20% (P=.436). The overall nonunion rate was 32% for patients 55 years and older. This nonunion rate was significantly higher than the rate seen in historic studies. Interestingly, the authors found a significant correlation between age and union rate in prior studies. As age increased, the union rate decreased (R=−0.9, P=.045) (Figure 3).

Average age by union status of the published cohort studies.

Figure 3:

Average age by union status of the published cohort studies.

Discussion

Despite a limited number of published studies of nonsurgical treatment for humeral shaft fractures in older adults, there are several suggestions of impaired healing in this group found in the literature. The authors used the following studies for historical comparison (Table 2). Zagorski et al12 had 170 patients with a nonunion rate of 1.6% at an average age of 36 years. Similarly, Sarmiento et al3 published their largest series with a nonunion rate of 2% at an average age of 36 years. Matsunaga et al8 reported a nonunion rate of 15% at an average age of 40 years. Ali et al13 reported 156 closed humeral shaft fractures with brace treatment; the nonunion rate was 17% at an average age of 54 years. In the current study, the nonunion rate was 32% at a mean age of 74 years. The authors found a clear trend that the older the mean patient age, the lower the union rate (Figure 3).

Summary of Research Studies With Reported Age and Union Status

Table 2:

Summary of Research Studies With Reported Age and Union Status

Ring et al14 retrospectively reviewed humeral shaft fractures that were operatively treated for nonunion during a 10-year period. They identified that midshaft and proximal humeral shaft fractures treated with a fracture brace are more likely to result in nonunion than distal third fractures. Ali et al13 retrospectively reviewed more than 200 humeral shaft fractures that were treated nonoperatively with fracture bracing. They too demonstrated that proximal third humerus fractures are less likely to heal, with a nonunion rate of 24%. These results coincide with the current findings that proximal third fractures treated with fracture bracing tend to have a higher non-union rate.

Large series of humeral fracture studies are often from trauma centers that predominantly treat younger patients. The mechanism of injury in young patients is often different from that in the older group. The literature includes studies of fractures in young patients with often wild injury patterns, including arm wrestling15 and throwing grenades.16,17 Regardless of mechanism, there has been much success with nonoperative treatment in this younger population. Although the mechanism of injury of the current patient population was almost entirely due to falls, studying older patients with this injury is difficult because they often return to their communities and are lost to follow-up.

Many fractures occur in a bimodal age distribution. Younger patients sustain fractures from significant energy dissipated on the skeleton. Older patients sustain fractures with minimal trauma because of balance issues and osteoporosis. The orthopedic treatment is often different in these 2 groups for fractures such as femoral neck or shoulder fractures depending on age. Perhaps age may be a factor to be considered in the care of humeral shaft fractures.

Furthermore, brace treatment of humeral fractures can be difficult to manage in older patients because there are often mobility and cognitive issues. This group is often dependent on ambulation aids such as canes and walkers that make brace use difficult. Idoine et al18 reported that a younger trauma group (average age, 38 years) had a low failure rate with anterior-approach humeral plating with immediate weight bearing. Such treatment or intramedullary rod fixation may help older patients maintain mobility and independence.

This study had some limitations. By the nature of the retrospective review, the data may have been skewed from bias. Surgeon bias may have existed to treat fractures operatively vs nonoperatively because no set protocol was in place and treatment was at the discretion of the attending orthopedic trauma surgeon. Selection bias may have also influenced treatment decisions. Certain fracture patterns may have been treated nonoperatively initially and then the treatment plan changed to operative fixation secondary to surgeon preference or patient request.

Furthermore, the current study has relatively low numbers. These patients are difficult to follow because they may have changes in their community status and location. A larger data set may demonstrate risk factors such as fracture location, fracture type, and other comorbidities that have a larger significance in the development of nonunion.

Conclusion

The incidence of nonunion in patients older than 55 years was found to be significantly higher than that reported in historical orthopedic literature. Furthermore, there was a significant correlation between increasing age and nonunion of humeral shaft fractures. This information can help inform clinicians about the potential advantages of early operative fixation of humeral shaft fractures in older patients. Future studies may help identify risk factors for humeral fracture nonunion in the elderly. This is a difficult group of patients to follow. With a mean age of 72.5 years, many of these patients had multiple orthopedic and medical comorbidities. A multicenter study to confirm these results would be helpful.

To the authors' knowledge, this is the first study demonstrating that age-dependent treatment of humeral shaft fractures may be advisable. Because it appears that older patients are more likely to have a nonunion of their diaphyseal fracture when treated with a functional brace, early operative stabilization may be warranted. Future multicenter, prospective, randomized studies comparing operative vs nonoperative treatment of humeral shaft fractures are recommended.

References

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Patient Demographics and Fracture Classification and Distribution

CharacteristicNo. (%)P

Nonunion (N=10)Union (N=21)
Female6 (60.0)15 (71.4).685
Diabetes mellitus4 (40.0)6 (28.6).685
Hypertension2 (20.0)9 (42.9).262
Congestive heart failure1 (10.0)4 (19.0)1.000
Anemia1 (10.0)4 (19.0)1.000
Hypothyroidism4 (40.0)2 (9.5).067
Renal failure0 (0.0)5 (23.8).147
Coronary artery disease3 (30.0)5 (23.8)1.000
Age <67 y2 (20.0)7 (33.3).677
Smoker2 (20.0)4 (19.0)1.000
Married8 (80.0)13 (61.9).428
AO/OTA classification
  A5 (50.0)13 (61.9)
  B4 (40.0)4 (19.0)
  C1 (10.0)4 (19.0).436
Location
  Distal third1 (10.0)4 (19.0)
  Midshaft4 (40.0)11 (52.4)
  Proximal third5 (50.0)6 (28.6).488

Summary of Research Studies With Reported Age and Union Status

Study (Year)Average Age, ySDNo. of PatientsNo. of UnionsNo. of Nonunions% Union
Zagorski et al12 (1988)36170167398.2
Sarmiento et al3 (2000)366206011996.9
Matsunaga et al8 (2017)40.317.24639784.8
Ali et al13 (2015)541381142482.6
Current (2018)72.510.231211067.7
Authors

The authors are from the Orthopedic Trauma Group (FHP, JPM, AS, JC) and the Center for Health Services and Outcomes Research (MB, MK), Charleston Area Medical Center, Charleston; and the West Virginia School of Osteopathic Medicine (JFS), Lewisburg, West Virginia.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Maher Kali, MD, Center for Health Services and Outcomes Research, Charleston Area Medical Center, 3200 MacCorkle Ave SE, Charleston, WV 25304 ( maher.kali@camc.org).

Received: November 14, 2018
Accepted: March 18, 2019
Posted Online: February 20, 2020

10.3928/01477447-20200213-03

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