Upper limb
Concomitant injuries to the ipsilateral
shoulder in patients with a fracture of the
diaphysis of the humerus
T. M. P. O’Donnell,
J. V. McKenna,
P. Kenny,
P. Keogh,
S. J. O’Flanagan
From the Connolly
Memorial Hospital,
Blanchardstown,
Dublin, Ireland
T. M. P. O’Donnell, FRCSI,
FRCS(Orth & Trauma), Senior
Specialist Registrar
J. V. McKenna, FRCSI, MCh,
FRCS(Orth & Trauma), Senior
Specialist Registrar
P. Kenny, FRCSI, MCh,
FRCS(Orth & Trauma).
Consultant Orthopaedic
Surgeon
P. Keogh, FRCSI, MCh,
FRCS(Orth & Trauma),
Consultant Orthopaedic
Surgeon
S. J. O’Flanagan, FRCSI,
MCh, FRCS(Orth & Trauma),
Consultant Orthopaedic
Surgeon
Department of Orthopaedics
Connolly Memorial Hospital,
Blanchardstown, Dublin 15,
Ireland.
Correspondence should be sent
to Mr T. M. P. O’Donnell; e-mail:
[email protected]
©2008 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.90B1.
19215 $2.00
J Bone Joint Surg [Br]
2008;90-B:61-5.
Received 22 January 2007;
Accepted after revision 24
August 2007
Antegrade intramedullary nailing of fractures of the shaft of the humerus is reported to
cause impairment of the shoulder joint. We have reviewed 33 patients with such fractures
to assess how many had injuries to the ipsilateral shoulder. All had an MR scan of the
shoulder within 11 days of injury. The unaffected shoulder was also scanned as a control.
There was evidence of abnormality in 21 of the shoulders (63.6%) on the injured side; ten
had bursitis of the subacromial space, five evidence of a partial tear of the rotator cuff, one
a complete rupture of the supraspinatus tendon, four inflammatory changes in the
acromioclavicular joint and one a fracture of the coracoid process. These injuries may
contribute to pain and dysfunction of the shoulder following treatment, and their presence
indicates that antegrade nailing is only partly, if at all, responsible for these symptoms.
Fractures of the diaphysis of the humerus are
common. Many studies have examined both
the short- and long-term outcome of various
methods of treatment including functional
bracing,1-3 operative fixation with an
intramedullary (IM) nail,4-6 plate fixation
using either dynamic compression7-9 or bridging,10 minimally-invasive plating11 and external fixation.12 In recent years, plating has
gained popularity over nailing as a means of
internal fixation, partly because of the belief
that nailing may cause impairment of function
of the shoulder joint.6,7,13-18 However, the
exact nature and cause of this problem is
poorly understood. It has been suggested that
damage to the rotator cuff at the site of entry of
the nail may cause subacromial impingement17
which, in turn, may result in pain and stiffness
of the shoulder joint. Some early reports have
recorded an incidence of pain in the shoulder
as high as 41% following antegrade nailing.15
Once this complication was recognised,
greater care was taken to avoid damage to the
rotator cuff and to bury the nail adequately.
However, further studies still described a high
incidence of shoulder dysfunction.13-18Other
complications and re-operations may obscure
the true cause of shoulder pain.5,14,19 Fractures
of the shaft of the humerus treated with retrograde nailing have also been noted to have an
incidence of pain and dysfunction in the shoulder of between 7% and 12%.20,21
There are only a few reports dealing with
shoulder function after plate fixation of the
VOL. 90-B, No. 1, JANUARY 2008
humerus or non-operative treatment.8,22-24
These suggest that function does not fully
recover even without violation of the rotator
cuff. There has been no previous study examining the incidence of concomitant injury to
the ipsilateral shoulder in the presence of a
fracture of the diaphysis of the humerus,
although there have been several reports of dislocation in conjunction with fracture of the
shaft.25,26 We have investigated the incidence
of concomitant injury to the shoulder in association with fracture of the shaft of the
humerus by performing an MRI of both shoulders at the time of injury.
Patients and Methods
Between September 2002 and May 2004, all
patients seen with fractures of the diaphysis of
the humerus were recruited to this study.
Patients were questioned as to any problems in
the shoulder. Those with a history of pain,
stiffness, or previous surgery, including injection of the subacromial space, were excluded
from the study. Others excluded were those
with associated fractures of either the surgical
neck of the humerus or of the clavicle, an obvious injury to the acromioclavicular joint or
with multiple fractures from high velocity
trauma. Patients with a head injury, and who
required endotracheal intubation, were also
excluded because of their inability to give an
accurate history of their accident.
Patients were included whether they had
non-operative or operative treatment of their
61
62
T. M. P. O’DONNELL, J. V. MCKENNA, P. KENNY, P. KEOGH, S. J. O’FLANAGAN
fractures. All were seen within five days of injury. The
mechanism of the injury and hand dominance were
recorded. An MRI of both shoulders was carried out within
11 days of injury in all patients. The unaffected shoulder
was used as a control.
Statistical analysis. The results were collected and recorded
on a standard database (Microsoft Excel, Windows 2000;
Microsoft Corporation, Redmond, Washington). Statistical
analysis was performed using Student’s t-test to determine
whether factors such as age and gender could contribute
towards the results. Analysis of variance (ANOVA) was
used to analyse differences between the group with an ipsilateral shoulder injury and those without. A chi-squared
analysis of data was performed. A p-value ≤ 0.05 was considered significant. All data were provided with a 95% confidence interval (CI) when appropriate. Analysis of data
was performed using a commercially-available package by
SPSS for Windows 12.0 (SPSS Inc., Chicago, Illinois).
Results
During the period of the study, 43 patients attended with a
fracture of the diaphysis of their humerus. Ten patients
were excluded from the study; four had received a previous
injection of the subacromial space for impingement problems, two had associated fractures of the surgical neck of
humerus, one had an associated fracture of the ipsilateral
clavicle, and one had a grade 3 subluxation of the ipsilateral acromioclavicular joint.27 A further two patients
were excluded as they had head injuries and required
endotracheal intubation. This left 33 patients. Their mean
age was 36 years (19 to 57). There were 21 fractures of the
right humerus and 12 of the left. There were 30 patients
with right hand dominance, of whom 20 had fractures on
the right side. The mechanisms of injury and patterns of
fracture28 are shown in Table I.
All patients were treated initially in a U-slab cast. Subsequently eight required operation as a result of unacceptable
alignment. Of these, four had an open reduction and internal fixation with dynamic compression plating. The other
four had IM nailing; three by the retrograde technique
using a Marchetti-Vincenzi IM bundle nail (Zimmer, Warsaw, Indiana) and one with an antegrade Russell-Taylor IM
nail (Smith & Nephew Orthopaedics, Memphis, Tennessee). In the patient who had antegrade nailing, the MR scan
was carried out before surgery in order to avoid any interference with the rotator cuff.
Asymmetrical MR scans were seen in 21 of the 33
patients (63.6%), with the abnormality on the same side as
the fracture in all. A signal change suggestive of subacromial bursitis was seen in ten (Fig. 1), five had a partial tear
of the rotator cuff, one had a complete rupture of the
supraspinatus tendon, four had inflammation of the acromioclavicular joint (Fig. 2), of which three were acute and
one acute-on-chronic, and one had an undisplaced fracture
of the coracoid process (Figs 3 and 4). All of the MR scans
were reported by a single, experienced radiologist.
Table I. AO classification28 and mechanism of injury of
patients with acute fractures
Patient
AO classification
Mechanism of injury
1*
2
3*
4†
5*
6
7‡
8*
9
10*
11‡
12*
13
14†
15
16‡
17†
18*
19
20
21§
22
23*
24¶
25
26*
27
28*
29†
30
31‡
32†
33
A1
A1
A1
A1
A2
A2
A2
A2
A2
A2
A2
A2
A2
A2
A2
A3
A3
A3
A3
A3
A3
B1
B1
B2
B2
B2
B2
B2
C1
C1
C1
C2
C2
Motor vehicle accident
Motor vehicle accident
Motor vehicle accident
Pedestrian accident
Motor vehicle accident
Motor vehicle accident
Motor vehicle accident
Pedestrian accident
Pedestrian accident
Fall from height
Fall from height
Fall from height
Fall from height
Sports injury
Sports injury
Motor vehicle accident
Motor vehicle accident
Fall from height
Fall from height
Sports injury
Sports injury
Motor vehicle accident
Fall from height
Motor vehicle accident
Motor vehicle accident
Pedestrian accident
Fall from height
Fall from height
Motor vehicle accident
Fall from height
Fall from height
Fall from height
Fall from height
*bursitis of the sub-acromial space
†partial tear of the rotator cuff
‡ inflammation of the acromioclavicular joint
§ complete rupture of the supraspinatus tendon
¶ fracture of the coracoid process
There was no statistically significant relationship
between either the type (chi-squared test, p = 0.132) or
mechanism (chi-squared test, p = 0.1459) of injury and an
ipsilateral shoulder injury. The chi-squared test showed no
statistically significant relationship between any independent factors such as age (p = 0.1535), gender (p = 01348),
type (p = 0.1383) or mechanism (p = 0.1595) of injury
between those with, and those without an ipsilateral injury.
Discussion
The treatment of fractures of the shaft of the humerus
remains controversial. The rationale for non-operative
treatment largely stems from the work of Sarmiento et al2
and Klenerman.29 Sarmiento et al2 had a rate of union in
closed injuries of 98%, with all patients achieving a satisfactory return of function. However, most authors have had
difficulty in replicating these results.3,30-33 Klenerman29
demonstrated that there is little loss of function with up to
THE JOURNAL OF BONE AND JOINT SURGERY
CONCOMITANT INJURIES TO THE IPSILATERAL SHOULDER IN PATIENTS WITH A FRACTURE OF THE DIAPHYSIS OF THE HUMERUS
63
Fig. 1
Fig. 2
MR scan showing florid bursitis of the sub-acromial space (arrow).
MR scan showing inflammation of the acromioclavicular joint (arrow).
Fig. 3
Fig. 4
Anteroposterior radiograph showing minimally-displaced fracture of
the coracoid process ten days after injury.
MR scan showing a minimally-displaced fracture of the coracoid process (arrow).
3 cm of shortening, 30˚ of varus angulation, and 20˚ of
angulation in the anteroposterior (AP) plane.
Internal fixation is indicated following failure to maintain satisfactory alignment with conservative treatment. It
may be necessary in victims of polytrauma who need stabilisation to aid in nursing care or to assist in movement.
Other indications include pathological fractures and associated vascular injury. Where there is damage to neurological structures, particularly the radial nerve, some advocate
early exploration34-37 but others disagree, noting the high
rate of spontaneous recovery, and advise a policy of expectancy.38-44 An obvious advantage of fixation is that once the
limb is stabilised it can be used early without external support, and allows the patient the comfort of sleeping in the
supine position.5,20 Additionally, the angular deformity so
often seen with conservative treatment1-3,29 is effectively
prevented.
Where internal fixation is indicated, most of the recent
literature has recommended dynamic compression plating
rather than antegrade nailing,7-9 since there is a high
reported incidence of shoulder dysfunction, pain and nonunion after nailing.7,13,14 A fracture may occur around the
end of the locked nail.45 However, nailing offers the advantage of less soft-tissue injury, a lower rate of infection and
no need for exposure of the radial nerve.5 It is preferred by
some for open fractures, comminuted fractures, pathological fractures, and those associated with osteoporosis.5,6,46,47 Other studies have demonstrated no difference in
VOL. 90-B, No. 1, JANUARY 2008
64
T. M. P. O’DONNELL, J. V. MCKENNA, P. KENNY, P. KEOGH, S. J. O’FLANAGAN
outcome between plating and nailing for open or comminuted fractures,10,48 but the numbers have been small.
Gardner et al49 described a series of patients with osteo–
porosis who sustained fractures of the shaft of the humerus
and had good results following treatment with a hybrid
locking plate system.
Ajmal et al,13 in a review of 33 patients, found an incidence of nonunion of 30% after locked antegrade IM nailing. Pain was experienced either in the shoulder or at the
fracture site in 56% of patients, and 41% had poor shoulder function. Only 51% were satisfied with the outcome
and 42% needed further surgery. Chapman et al8 observed
a significant restriction of movement and increased pain in
the shoulder after nailing compared with plate fixation in a
prospective randomised trial.
McCormack et al9 found no difference in shoulder and
elbow scores, shoulder pain, or range of movement
between nailing and plate fixation in a prospective randomised trial. Lin and Hou5 reported good functional outcome in a group of 38 patients treated with antegrade
nailing. Flinkkilä et al50 studied the recovery of shoulder
function, comparing patients who had antegrade nailing
with those who were plated. They concluded that symptoms, the range of movement and isometric strength do not
fully recover after uncomplicated antegrade nailing or plate
fixation, although there was a higher rate of shoulder pain
which was not statistically significant in the group treated
by nailing.
It has been suggested that injury to the rotator cuff during insertion of the nail is not the main reason for residual
problems in the shoulder joint. Changulani et al48 compared the use of IM nails with dynamic compression plating
in a series of 47 patients. Function of the shoulder was
found to be similar in both groups. The rate of union was
also similar, although the time to union was significantly
shorter in the group who had nailing. They also found a
higher rate of infection in the group which were plated.
Bhandari et al51 undertook a meta-analysis of randomised
trials, comparing compression plate fixation with nailing.
Fixation with a plate appeared to reduce the risk of reoperation and shoulder impingement, although it was concluded that the cumulative evidence was unclear and inconclusive.
Some studies have compared antegrade nailing with
other forms of treatment other than plate fixation. Scheerlinck and Handelberg52 found a reduction in movement
and in the power of abduction with antegrade compared
with retrograde nailing. Chiu et al22 observed no difference
between Ender nailing and plate fixation with regard to
movement of the shoulder.
Most authors have considered impingement of the rotator cuff as the most important factor contributing to problems in the shoulder joint.19,50 Other technical factors
which are thought to cause poor recovery include massive
injury of the rotator cuff with inadequate repair, promi-
nence of the head of the nail or the locking screws, axillary
nerve injury, and intra-operative comminution of the
humeral head.5 Incision into the supraspinatus tendon is
made in order to gain access for insertion of the nail. This is
near a so-called ‘critical zone’ in the tendon, which has been
believed to have a poor blood supply, leading to problems
with healing.19 Further studies have shown this area to be
hypervascular, and that even degenerative ruptures of this
zone heal following surgical treatment.53-55 O’Brien et al56
described using a transrotator cuff approach for arthroscopic surgery and found that this healed without causing
problems. Other reports support the idea that antegrade
nailing, when carried out correctly, is not the cause of
impairment of function.50 It has been speculated that softtissue injury, pain, or immobilisation may play an important role.5,57 Insertion of a nail through the rotator cuff may
worsen the effect of these factors and make post-operative
rehabilitation more difficult. Nailing may be associated
with complications which require repeated incisions
through the rotator cuff, and this can lead to serious problems.14,15
We recognise that there are weaknesses to this study. The
patients were not randomised into groups for different
modes of treatment. We did not carry out functional shoulder and elbow scores at follow-up, which would have
allowed us to attach clinical significance to our findings. All
the MR scans were interpreted by a single radiologist, albeit
an experienced one, who was not blinded to the side of
injury. However, we have clearly demonstrated the high incidence of shoulder injury associated with this fracture, using
the highly sensitive method of MR scanning. We do recognise, however, that there have been studies reporting a higher
incidence of shoulder pain and dysfunction following antegrade IM nailing compared with plate fixation. It seems that
shoulder pain and dysfunction after antegrade IM nailing is
a multifactorial problem, and not solely a result of surgical
access to the humeral head through the rotator cuff. Most of
the pathology detected on MR scanning probably pre-dated
the injury to the humeral diaphysis, although no patient in
the series had a history of shoulder problems. It is known
that a certain incidence of asymptomatic rotator cuff disease
exists in the population.55 Part of the problem leading to
pain may be violation of the rotator cuff through an already
damaged cuff or subacromial space, albeit in patients with
asymptomatic disease. In addition, in patients with asymptomatic acromioclavicular disease, the fall itself may exacerbate preceding pathology. Further prospective studies are
required to fully elucidate these problems.
The authors would like to acknowledge Dr S. Eustale, Consultant in musculo–
skeletal radiology, Cappagh Hospital, for his assistance.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
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