What’s New in Orthopaedic Trauma

Proximal Humerus The treatment of proximal humeral fractures, especially in the elderly population, remains a complex decision based on fracture type, bone quality, and patient functional level. An observational cohort study from the Swedish Fracture Register of 31,761 fractures reported a low risk of early conversion to surgery in nonoperatively treated proximal humeral fractures1. The study included all patients ≥18 years of age from 2013 to 2021. The mean patient age was 70 years, and the majority of patients were female (76%). Conversion to surgery occurred at a rate of 3.7%; however, younger age and increased fracture severity were associated with higher conversion rates. The oldest patients in the cohort (≥80 years of age) and patients with the simplest fracture types (OTA/AO A1, A2, B1) had a conversion rate of <2%, whereas OTA/AO type-C fractures and fracture-dislocations had rates of conversion from 5% to 20%. This study reemphasized the importance of patient factors and fracture morphology in guiding the treatment of proximal humeral fractures with varying risks of treatment failure. With the 5-year follow-up results for the DelPhi multicenter randomized controlled trial (RCT), Fraser et al. reported improved outcomes for patients who were 65 to 74 years of age and for those with OTA/AO C2 fractures of the proximal humerus in favor of reverse total shoulder arthroplasty over open reduction and internal fixation (ORIF)2. This was consistent with their 24-month data. This most recent iteration included 65 patients available for follow-up. The mean Constant-Murley scores were 71.7 (95% confidence interval [CI], 67.1 to 76.3) for the reverse total shoulder arthroplasty group and 58.3 (95% CI, 50.6 to 65.9) for the ORIF group, indicating a significant difference of 13.4 (95% CI, 5.2 to 21.7). Subgroup analysis showed even more benefit for the reverse total shoulder arthroplasty group for patients with Type-C2 fractures (mean difference, 17.3 [95% CI, 7.5 to 27.0]) and for patients 65 to 74 years of age (mean difference, 15.7 [95% CI, 4.9 to 26.7]). Interestingly, for patients 75 to 85 years of age or patients with Type-B2 fractures, there was no significant difference observed, highlighting the importance of fracture personality and patient characteristics in treatment choice. Another multicenter RCT enrolled patients ≥70 years of age with 3 and 4-part proximal humeral fractures treated with either reverse shoulder arthroplasty or nonoperative management. The patients’ Constant-Murley scores at 1 year were reviewed, with a threshold of 10 set for the minimal clinically important difference (MCID)3. The Constant-Murley scores of the reverse shoulder arthroplasty group were 61.24 compared with 52.44 for the nonoperatively managed group, with a mean difference of 8.84 (p = 0.02). At the final follow-up, the study was slightly underpowered but was trending toward the MCID of 10 for the outcome improvement in the reverse shoulder arthroplasty group; however, a higher rate of complications was noted for the operatively managed group. The use of a fibular strut allograft has been extensively reported on as a possible adjunct to ORIF of the proximal humerus4. Alternatively, pectoralis major pedicle bone grafting compared with tricortical iliac crest grafting for Neer 4-part proximal humeral fractures has been evaluated via an RCT in patients 50 to 75 years of age with radiographic evidence of an impaired medial hinge5. Karslioglu et al.5 described using the clavicular head of the pectoralis major. The mean follow-up time was 24 months postoperatively, and both groups were equivalent in demographic characteristics as well as hip bone mineral density as measured by a dual x-ray absorptiometry (DXA) scan. Loss of reduction occurred in 17.6% of patients in the pectoralis major pedicle bone grafting group compared with 58.8% of patients in the iliac crest grafting group. This difference was significant. Osteonecrosis was observed in 5.9% of the pectoralis major pedicle bone grafting group and 29.4% of the tricortical iliac crest grafting group; however, the difference was not significant because of the underpowered nature of the study. There were no differences in American Shoulder and Elbow Surgeons (ASES) scores or Constant-Murley scores. Although limited by follow-up time and study size, this study demonstrated an alternative technique for medial column support. Although the importance of the medial calcar is frequently mentioned as it relates to proximal humeral fractures, the integrity of the lateral wall of the greater tuberosity was also shown in a biomechanical cadaveric study to be an important factor of stability in osteoporotic surgical neck fractures of the proximal humerus undergoing plate fixation6,7. Lateral wall incompetence led to decreased torsional stiffness, axial compression stiffness, and varus bending stiffness. Although this was a cadaveric study, it highlighted additional biochemical considerations in a region that is notoriously difficult to treat using nonoperative, internal fixation, or arthroplasty treatment modalities. Distal Humerus and Elbow Ten RCTs with a total of 512 patients were included in a meta-analysis reviewing intramedullary nailing compared with ORIF of the humerus8. Hurley et al.8 looked at rates of nonunion, reoperation, radial nerve palsy, and infection, and time to union. There was a nonsignificant difference in the rate of nonunion, a significant but not clinically relevant decrease in time to union with the intramedullary nail (10 weeks) compared with ORIF (11.9 weeks), and no significant difference in the rates of reoperation or radial nerve palsy. Additionally, the intramedullary nail group had a lower rate of infection (1.3%) compared with ORIF (5.3%) and shorter time of the operation (61 minutes) compared with ORIF (88 minutes). As such, the conclusions drawn from this study support surgeon preference and fracture morphology in determining fixation methods, as the Level-I data available do not substantiate one modality being superior to the other. The HUMMER multicenter RCT analyzed functional and clinical outcomes following ORIF compared with intramedullary nailing of humeral shaft fractures. From 2012 to 2018, 245 patients, who were ≥18 years of age and had OTA/AO 12A or 12B fractures, were prospectively enrolled within 14 days of the injury, and the treatment modality was determined at the discretion of the surgeon9. Approximately twice as many patients were treated with an intramedullary nail relative to ORIF. The Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire scores were equivalent at 12 months, but the Constant-Murley scores and the shoulder range of motion were greater in the ORIF group. The implant-related complication rate was 2.6% (2 of 76) for the ORIF group and 14.2% (24 of 169) for the intramedullary nailing group. Additionally, the temporal radial nerve palsy rate was substantially higher in the ORIF group (10.5%) than the intramedullary nail group (0.6%). There was a nonsignificant trend toward a difference in the rate of nonunions: 5.7% in the ORIF group and 11.9% in the intramedullary nail group. Notably, many more patients were treated with an intramedullary nail than ORIF, and the study was underpowered for the primary and subgroup analyses. There were 121 surgeons who performed at least 1 surgery, further limiting the insight into surgeon expertise related to the procedures, possibly explaining the high rate of technical errors in the intramedullary nail group (nail prominence and screw prominence). The management of comminuted distal humeral fractures in the elderly population poses a clinical challenge, as these fractures may not be repairable. Between 2011 and 2019, 40 patients were randomized across 3 centers to semiconstrained total elbow arthroplasty or elbow hemiarthroplasty10. All patients were ≥60 years of age and were living independently, and the fracture was determined to not be able to be reconstructed on the basis of radiographs, computed tomographic (CT) scans, and intraoperative findings with regard to the quality and size of articular fragments. The final follow-up occurred at a minimum of 2 years. The study found no significant difference in the DASH score, the Mayo Elbow Performance Score (MEPS), the EuroQol-5 Dimensions (EQ-5D) index, or range-of-motion parameters as measured by a goniometer. Both procedures had similar rates of adverse events. Nearly 90% of patients were female, and the mean patient age was 74 years. As such, these results are difficult to generalize to a younger or predominantly male population. Additionally, although a strength of this study is surgeon expertise with each technique but the results may not be generalized as many centers may not possess this level of subspecialty experience, it is unclear if data can be extrapolated to surgeons or centers not commonly using elbow arthroplasty as a treatment. Forearm and Distal Radius Nonoperative management is a common treatment modality for distal radial fractures in elderly patients. The CAST study, a multicenter RCT, evaluated whether the type of fracture immobilization impacted outcomes of nonoperatively managed distal radial fractures in adults11. The rates of redisplacement following acceptable closed reduction and application of a volar-dorsal plaster splint or a circumferential below-the-elbow cast were recorded in 420 patients (213 splint, 207 cast) between 2020 and 2021 at 10 hospitals in The Netherlands. Of note, 420 was below their goal of 500 patients from a power analysis due to the exclusion of 110 patients for unacceptable initial reduction. The mean dorsal angulation at the time of reduction was approximately 5°. Radiographs were then reviewed at 1, 2, and 5 weeks after reduction for displacement parameters. During the 5-week review term, 47% of the splinted fractures and 49% of the casted fractures had displaced again (final displacement of >20° dorsal angulation). There were no meaningful differences between the cast group and the splint group with regard to pain, conversion to surgery, range of motion, or grip strength. Either immobilization modality is reasonable during the initial presentation prior to shared decision-making regarding the definitive treatment. Nonoperative management is a common and reasonable option in some patients with distal radial fractures, but understanding the clinical impact of malreduction or loss of reduction is important for informed decision-making. In a 1-year cohort study comparing radiographic parameters as they relate to clinical outcomes in distal radial fractures, 438 patients were prospectively enrolled across multiple centers12. Injuries were treated with casts or surgery, and radiographs after union had been achieved (>3 months) were used for radiographic assessment. The of the DASH range of motion, and grip strength at 1 year were their clinical There were patients with of patients treated was found to be the most associated with clinical scores were observed at dorsal and at patients had achieved a is the strength was impacted at of dorsal with a of compared with the the follow-up time of 1 year limited the of the final range of motion as well as the impact of parameters as articular patient based on fracture patient and functional is in guiding treatment to that the of the The management of fractures in the is than many with surgical as the modality compared with closed treatment. review and meta-analysis reviewed from to with cohort and 2 an of radial and fractures treated with either intramedullary nailing = or ORIF = for a total of patients with follow-up of 1 to 3 complication surgical infection, and rate were lower in the intramedullary nail group in all fractures. The time to grip and range of motion were found to be Notably, the intramedullary nail not the radial as as however, there was not a difference in The data were limited by a of and additional RCTs and in treatment and The study also not for differences or a for intramedullary nailing compared with ORIF but in a review of the data that the intramedullary nail be a treatment intramedullary for the treatment of fractures were further in a review and meta-analysis of and patients, with of patients undergoing intramedullary of patients undergoing ORIF, and of patients undergoing Although outcomes and complication rates were similar between the intramedullary nail and ORIF complications included a rate of a nail with an at the compared with in the ORIF group. The rates of nerve palsy managed were As ORIF has been the for fractures, but the intramedullary nail a more alternative with the of that for of reduction and and with all in this review functional outcomes and clinical outcomes were to the review and meta-analysis by et further RCTs are Proximal the proximal or to be In a cohort study of patients who primary total hip arthroplasty from to 2020 in fracture occurred in patients had the rate of with an time rate of approximately whereas had similar rates to those of with time rate for both occurred after primary within the The noted that the risk of fracture was 3 greater with compared with and the review highlighted that of were related to There were to the however, and high of patients, surgeons not whether to use or not but also the of the or that they are The management of hip fractures was with groups comparing screw with screw The Fracture reviewed with fractures (OTA/AO and reverse fractures (OTA/AO at There were patients treated with an screw and patients treated with a screw compared with low and reduction were included in the patients reoperation for fixation Interestingly, the was not associated with The rates of reoperation were after screw and after screw fixation, with the of reoperation for fixation higher in both analysis [95% CI, to and analysis [95% CI, to Surgeons be using as their choice. to the study, the Fracture Register reviewed patients with OTA/AO and fractures, comparing and patients were with a mean age of years. of the patients were treated with and of the patients were managed with data demonstrated increased rates of reoperation at 1 year with the use of and at 3 years with the use of differences noted by fracture This was most with rate [95% CI, to = and toward with [95% CI, to = In a similar study by and patients ≥60 years of age treated for hip between and were evaluated after treatment with the nail nail or The nail was found to a higher rate of or screw nonunion, lateral and than screw The nail group had higher rates of fixation via or This was with both and with the in the risk of associated with the There was no difference between the nail and than higher rates of or noted in the group compared with the nail group. An alternative treatment using an support in hip fractures was at in The study prospectively enrolled patients and randomized to a or a nail with an support screw for hip fractures with loss of support (OTA/AO and were and at 2 to 3 weeks to for and loss of reduction of the There was no difference in the quality of reduction or quality noted between the et observed a loss of reduction with nail but a loss of reduction with the nail and support Additionally, the mean was greater with the group with the nail at compared with the group with nail and support screw at (p This study highlighted the of alternative for fracture With regard to hip fractures, time to surgery and patient factors The randomized study subgroup their results related to In the study, patients also had available for Of those patients, had on Of note, there was no difference between the group with on presentation and the group with to a of or were randomized to an group, in they surgery at a mean time of or to a group, in they surgery at a mean time of The risk of major complication was lower in the group than the group, whereas patients an had no benefit to at presentation was associated with a rate at days of in the group and in the group. The study into the the of surgical in patients with a hip fracture and at presentation and a to more similar to the The 2 trial is patients with to further insight into the management of these patients. Distal The management of distal fractures is of study. patients with OTA/AO or distal fractures for were to or between 2013 and There was no difference between and comparing radiographic in at 12 months, adverse and union rates. of study those patients with medial or patients, for toward improved outcomes compared with the study was not to the in these The importance of to following fractures is well compared with following distal fractures, or was reviewed in a review and meta-analysis from to on treatment with a lateral plate or intramedullary infection, and rates were available for and there was no significant difference in of the parameters. the available for review were and predominantly in and there was no RCT comparing the 2 the study the that early after fixation of distal fractures not an increased risk of more insight into the compared with for distal fractures were also reviewed, and a review and meta-analysis was performed on 5 with a total of et reviewed of total and total Although no difference was noted in or of patients treated with a were noted to complications compared with patients with treatment compared with = and total compared with = rates not but there were due to the of patients with Although these data that dual in the of may fixation, the study was limited in of by the size of the group and the of of that controlled for the fracture and compared with was with the of patients in the nailing group and in the nailing and and and were The nailing group had at both time and the difference the for the At 12 months, but not nailing also demonstrated a clinically important difference in The scores were for the nailing group and for the nailing group at weeks (p and for the nailing group and for the nailing group at 12 months (p mean differences of and both the The was compared with at weeks and compared with at 12 months (p for both The mean difference of at weeks not the however, the difference of at 12 months The study has to the of the use of but there was no functional to also insight into strength and range of (2 weeks) compared with weeks) after fractures were operatively treated across hospitals was evaluated in an RCT to for of the Score At months, the mean was in the early group and in the group. An analysis was also and from early was to be than motion and after surgical of fractures were also evaluated with an with fibular fractures, with or fixation, were and randomized to weeks of a range-of-motion and or to a splint, and with a for clinical and additional At 12 their The mean was higher in the early motion and group compared with the group This a clinically meaningful mean difference of (95% CI, to There were no reported and the benefit was at 24 weeks and at 1 year Loss and et al. a RCT the of at the time of for hip fractures between and reviewed the rate of over days 1 to as their primary noted no difference in rates for the group compared with for the group; = with in the treatment and in the (p = There was also no difference in loss or or At this it be that of at the time of has an on the of loss in patients with hip fracture included a review and meta-analysis of early surgery in patients The review included observational with a total of patients. All included a of based on the and were was noted that there was no significant difference in decrease after surgery, complications or and of of surgery was associated with complications than surgical [95% CI, to and early surgery the of Although the for increased intraoperative loss is the was not clinically important (mean difference, [95% CI, to = and there was an increased risk of complications from the basis of these surgery for the of an not in the and it is to to are the use of during was evaluated with an patients, years of were prospectively enrolled to either or with in a pain, total and time to were as primary the group was compared with the group, there were no differences in the outcomes related to mean scores compared with = compared with = or of compared with = The study the of whether the increased is the of an for the management of patients with hip fracture is also of An RCT with in patients with hip fracture undergoing arthroplasty compared with the group with patients were for pain, and occurred in of patients who compared with of patients who a [95% CI, to = was also noted that patients who more and also more than the patients who had a and In to intraoperative to for patients with hip fractures is also An RCT compared nerve group and to patients with hip fractures in the The study included and fractures in patients who were to 85 years of age and with scores Of note, patients index, were exclusion limiting to most American was evaluated in a of and then after the after the and then at multiple time to after the total of patients, in each group, were included in the with the majority of patients hip fractures or neck fractures the mean patient age was years. to the there was no significant difference in the however, at all time after the the nerve group (p in both and The nerve group also with regard to and The the of and be in the management of patients with hip fracture both and that to are infection is a complication in fracture meta-analysis of the from to and patients, evaluated the use of et found in both and the use of in open and closed fractures benefit in of decreased surgical infection, with and the most data in the available found that there was no difference in or infection with or the use of results were by the review of the trial relative to the by the results of the included centers in were compared with those at to centers in the and The patients enrolled in the RCT were compared with patients, and the analysis found that not are the results but they may even the of in a population of patients with and fractures. infection in was evaluated in a RCT comparing in and in as across centers in and the The study included patients with both open and closed fractures. was noted in closed fractures, the group the group [95% CI, to = with rates of infection of for the group and for the group. open fractures, there was no significant difference [95% CI, to = between the infection rates of the group and the group to surgical infection, infection remains a for An RCT by the was comparing with for 24 patients with infection evidence of were randomized to = or = Although the groups were slightly and there was from to there was for the use of compared with with to the rates of surgical procedures infection, nonunion, and treatment failure. patients, who the results from there was a of patients a high patients who had fractures, patients who were patients who had an infection, and patients who had a greater time between fixation and All of these and presentation in treatment more results are important the and of compared with and that are a reasonable in patients the The of reviewed a of related to the that a higher of In to in this 3 relevant to surgery are to this review after the with a each to further in an in this subspecialty nonoperative management of medial a randomized clinical In this RCT, and nonoperative management of medial fractures were evaluated between and 2021. There were with fractures Of the nonoperatively treated fractures, had nonunion, compared with union in the treatment group. well medial fractures, nonoperative management may be a reasonable treatment. The surgeon these data in the of the functional and medial There may be for nonoperative but the increased risk of not be nerve group for management in patients with hip a randomized In this patients were treated with either a iliac or a nerve group between 2020 and in a Although the nerve group group had the in as the iliac group, the time to the a was shorter (p in the nerve group group [95% CI, to than the iliac group [95% CI, to to be a for patients with undergoing fixation and with for in the results of the randomized controlled The management of closed fractures in the elderly population was evaluated via a RCT across 24 hospitals in and managed patients had elbow but no functional difference at 12 In patients, this evidence that nonoperative management may be a reasonable treatment and this study further shared decision-making.