Atrophic pseudarthrosis of humeral diaphyseal fractures: medico-legal implications and methodological analysis of the evaluation.

Atrophic pseudarthrosis of humeral diaphyseal fractures: medico-legal implications and methodological analysis of the evaluation.

Authors

  • Giuseppe Basile Trauma Unit and Emergency Department, IRCCS Galeazzi Orthopedics Institute, Milano, Italy
  • Franco Maria Avato Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Italy
  • Alberto Passeri PhisicianSpecialist in Legal Medicine; via G. Garibaldi 110, 35043 Monselice (PD) - Italy
  • Riccardo Accetta Trauma Unit and Emergency Department, IRCCS Galeazzi Orthopedics Institute, Milano, Italy
  • Federico Amadei hand surgery and peripheral nerve center cof lanzo hospital
  • Arianna Giorgetti università di bologna
  • Daniele Castoldi Trauma Unit and orthopaedic Department, San Carlo Clinical Institute,Paderno Dugnano, Milano, Italy
  • Stefania Fozzato Trauma Unit and Emergency Department, IRCCS Galeazzi Orthopedics Institute, Milano, Italy

Keywords:

humeral pseudoartrhosis; humeral fractures; medico legal

Abstract

Humeral shaft fractures account for 1- 3% of all fractures and about 20-27% of those involving the humerus. In the past they were often conservatively treated, with an acceptable consolidation rate.

Open reduction and internal fixation (ORIF) is the best choice in polytrauma patients, in complex or pathological fractures and in those associated with vascular injuries.

Regardless the type of fixation used, these fractures can evolve into delayed union or pseudarthrosis (PSA). It should be noted that the humeral shaft itself has a high intrinsic healing potential, due to the blood supply provided by the surrounding muscles.

The aim of this work is to evaluate whether the causes that led to the development of atrophic pseudarthrosis in a humeral diaphyseal fracture are attributable to inadequate management of this fearful complication and to highlight the possible medico-legal repercussions.

We will try to verify whether the currently used forensic evaluation parameters of permanent disability are appropriate and adequate in relation to the complexity of such injuries. This complexity also includes the repercussions on the ergonomic efficiency of the entire limb, the relative possible postural alterations, the inevitable extension of the period of traumatic illness and the relative repercussions on the overall compromised structure of the subject.

 

Author Biography

Giuseppe Basile, Trauma Unit and Emergency Department, IRCCS Galeazzi Orthopedics Institute, Milano, Italy

Trauma Unit and Emergency Department, IRCCS Galeazzi Orthopedics Institute, Milano, Italy

References

Bajaj SK, Mohan NR, Kumar CS. Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures. Injury. 2004 May;35(5):523-7. doi: 10.1016/S0020-1383(03)00199-2. PMID: 15081332.

Chen YJ, Kuo YR, Yang KD, Wang CJ, Sheen Chen SM, Huang HC, Yang YJ, Yi-Chih S, Wang FS. Activation of extracellular signal-regulated kinase (ERK) and p38 kinase in shock wave-promoted bone formation of segmental defect in rats. Bone. 2004 Mar;34(3):466-77. doi: 10.1016/j.bone.2003.11.013. PMID: 15003794.

Cox G, Jones E, McGonagle D, Giannoudis PV. Reamer-irrigator-aspirator indications and clinical results: a systematic review. Int Orthop. 2011 Jul;35(7):951-6. doi: 10.1007/s00264-010-1189-z. Epub 2011 Jan 18. PMID: 21243358; PMCID: PMC3167404.

Dawson J, Kiner D, Gardner W 2nd, Swafford R, Nowotarski PJ. The reamer-irrigator-aspirator as a device for harvesting bone graft compared with iliac crest bone graft: union rates and complications. J Orthop Trauma. 2014 Oct;28(10):584-90. doi: 10.1097/BOT.0000000000000086. PMID: 24625833.

Delius M, Draenert K, Al Diek Y, Draenert Y. Biologicaleffects of shock waves: in vivo effect of high energypulses on rabbit bone. UltrasoundMedBiol. 1995;21(9):1219-25. doi: 10.1016/0301-5629(95)00030-5. PMID: 8849836.

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 Aug 11;33(8). doi: 10.3928/01477447-20100625-16. PMID: 20704103.

Emara KM, Diab RA, Emara AK. Recent biological trends in management of fracture non-union. World J Orthop. 2015 Sep 18;6(8):623-8. doi: 10.5312/wjo.v6.i8.623. PMID: 26396938; PMCID: PMC4573506.

EMEA. European Public Assessement Report. Procedure n. EMEA/H/C/293. (2000)

Fayaz HC, Giannoudis PV, Vrahas MS, Smith RM, Moran C, Pape HC, Krettek C, Jupiter JB. The role of stem cells in fracture healing and nonunion. Int Orthop. 2011 Nov;35(11):1587-97. doi: 10.1007/s00264-011-1338-z. Epub 2011 Aug 24. PMID: 21863226; PMCID: PMC3193959.

Foster RJ, Dixon GL Jr, Bach AW, Appleyard RW, Green TM. Internal fixation of fractures and non-unions of the humeral shaft. Indications and results ina multi-center study. J Bone Joint Surg Am. 1985 Jul;67(6):857-64. PMID: 4019533.

Frölke JP, Patka P. Definition and classification of fracture non-unions. Injury. 2007 May;38 Suppl2:S19-22. doi: 10.1016/s0020-1383(07)80005-2.

Han F, Peter L, Lau ET, Thambiah J, Murphy D, Kagda FH. Reamer Irrigator Aspirator bone graft harvesting: complications and outcomes in an Asian population. Injury. 2015 Oct;46(10):2042-51. doi: 10.1016/j.injury.2015.07.027. Epub 2015 Jul 29. PMID: 26253387.

Harkin FE, Large RJ. Humeral shaft fractures: union outcomes in a large cohort. J ShoulderElbowSurg. 2017 Nov;26(11):1881-1888. doi: 10.1016/j.jse.2017.07.001. PMID: 29054684.

Jakma TS, Röling MA, Punt B, Reynders-Frederix P. More adverse events than expected in the outcome after use of the reamer-irrigator-aspirator. Eur J Trauma Emerg Surg. 2014 Jun;40(3):337-41. doi: 10.1007/s00068-013-0345-8. Epub 2013 Oct 22. PMID: 26816069.

Kanakaris NK, Morell D, Gudipati S, Britten S, Giannoudis PV. Reaming Irrigator Aspirator system: early experience of its multipurpose use. Injury. 2011 Sep;42 Suppl4:S28-34. doi: 10.1016/S0020-1383(11)70009-2. PMID: 21939800.

Khan SN, Cammisa FP Jr, Sandhu HS, Diwan AD, Girardi FP, Lane JM. The biology of bone grafting. J Am AcadOrthop Surg. 2005 Jan-Feb;13(1):77-86. PMID: 15712985.

Kiran M, Jee R. Ilizarov's method for treatment of nonunion of diaphyseal fractures of the humerus. Indian J Orthop. 2010 Oct;44(4):444-7. doi: 10.4103/0019-5413.69319. PMID: 20924488; PMCID: PMC2947734.

Kumar MN, Ravindranath VP, Ravishankar M. Outcome of locking compression plates in humeral shaft nonunions. Indian J Orthop. 2013 Mar;47(2):150-5. doi: 10.4103/0019-5413.108899. PMID: 23682176; PMCID: PMC3654464.

Liu JW, Chao LH, Su LH, Wang JW, Wang CJ. Experience with a bone bank operation and allograft bone infection in recipients at a medical centre in southern Taiwan. J HospInfect. 2002 Apr;50(4):293-7. doi: 10.1053/jhin.2002.1192. PMID: 12014903.

Mahabier KC, Vogels LM, Punt BJ, Roukema GR, Patka P, Van Lieshout EM. Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients. Injury. 2013 Apr;44(4):427-30. doi: 10.1016/j.injury.2012.08.003. Epub 2012 Aug 29. PMID: 22938959.

Maresca A, Sangiovanni P, Cerbasi S, Politano R, Fantasia R, Commessatti M, Pascarella R. Why a surgicallytreatedhumeralshaftfracturebecame a nonunion: review of 11 years in two trauma centers. MusculoskeletSurg. 2017 Dec;101(Suppl 2):105-112. doi: 10.1007/s12306-017-0509-5. Epub 2017 Oct 19. PMID: 29052035.

Marti RK, Verheyen CC, Besselaar PP. Humeral shaft nonunion: evaluation of uniform surgical repair in fifty-one patients. J Orthop Trauma. 2002 Feb;16(2):108-15. doi: 10.1097/00005131-200202000-00007. PMID: 11818806.

Martini L, Giavaresi G, Fini M, Borsari V, Torricelli P, Giardino R. Earlyeffects of extracorporeal shock wave treatment on osteoblast-likecells: a comparative studybetweenelectromagnetic and electrohydraulicdevices. J Trauma. 2006 Nov;61(5):1198-206. doi: 10.1097/01.ta.0000203575.96896.34. PMID: 17099529.

Murray Wr, Lucas Db, Inman Vt. Treatment Of Non-Union Of Fractures Of The Long Bones By The Two-Plate Method. J Bone Joint SurgAm. 1964 Jul;46:1027-48. PMID: 14192498.

Pugh DM, McKee MD. Advances in the management of humeral nonunion. J AmAcadOrthopSurg. 2003 Jan-Feb;11(1):48-59. doi: 10.5435/00124635-200301000-00007. PMID: 12699371.

Ring D, Perey BH, Jupiter JB. The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients. J Bone Joint SurgAm. 1999 Feb;81(2):177-90. doi: 10.2106/00004623-199902000-00005. PMID: 10073581.

Rosen H. The treatment of nonunions and pseudarthroses of the humeral shaft. OrthopClin North Am. 1990 Oct;21(4):725-42. PMID: 2216404.

Rubel IF, Kloen P, Campbell D, Schwartz M, Liew A, Myers E, Helfet DL. Open reduction and internal fixation of humeral nonunions : a biomechanical and clinical study. J Bone Joint SurgAm. 2002 Aug;84(8):1315-22. doi: 10.2106/00004623-200208000-00004. PMID: 12177259.

Sagi HC, Young ML, Gerstenfeld L, Einhorn TA, Tornetta P. Qualitative and quantitative differences between bone graft obtained from the medullary canal (with a Reamer/Irrigator/Aspirator) and the iliac crest of the same patient. J Bone Joint SurgAm. 2012 Dec 5;94(23):2128-35. doi: 10.2106/JBJS.L.00159. PMID: 23224383.

Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint SurgAm. 2000 Apr;82(4):478-86. doi: 10.2106/00004623-200004000-00003. PMID: 10761938.

Schaden W, Fischer A, Sailler A. Extracorporeal shock wave therapy of nonunion or delayed osseous union. ClinOrthopRelat Res. 2001 Jun;(387):90-4. doi: 10.1097/00003086-200106000-00012. PMID: 11400900.

Segonds JM, Alnot JY, Masmejean E. Pseudarthroses et retards de consolidationaseptiques de la diaphysehumérale: à propos de 30 castraités par plaque et autogreffeosseuse [Aseptic non-union of humeralshaftfracturestreated by plating and bone grafting]. RevChirOrthopReparatriceApparMot. 2003 Apr;89(2):107-14. French. PMID: 12844054.

Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Järvinen MJ. Functional treatment of closed humeral shaft fractures. Int Orthop. 2005 Feb;29(1):10-3. doi: 10.1007/s00264-004-0612-8. Epub 2004 Dec 21. PMID: 15611875; PMCID: PMC3456948.

Tomić S, Bumbasirević M, Lesić A, Mitković M, Atkinson HD. Ilizarov frame fixation without bone graft for atrophic humeral shaft nonunion: 28 patients with a minimum 2-year follow-up. J Orthop Trauma. 2007 Sep;21(8):549-56. doi: 10.1097/BOT.0b013e31814612c8. PMID: 17805022.

Wang CJ, Chen HS, Chen CE, Yang KD. Treatment of nonunions of long bone fractures with shock waves. ClinOrthopRelat Res. 2001 Jun;(387):95-101. doi: 10.1097/00003086-200106000-00013. PMID: 11400901.

Westrick E, Hamilton B, Toogood P, Henley B, Firoozabadi R. Humeralshaftfractures: results of operative and non-operative treatment. IntOrthop. 2017 Feb;41(2):385-395. doi: 10.1007/s00264-016-3210-7. Epub 2016 May 6. PMID: 27150488.

Wozney JM, Rosen V, Celeste AJ, Mitsock LM, Whitters MJ, Kriz RW, Hewick RM, Wang EA. Novel regulators of bone formation: molecular clones and activities. Science. 1988 Dec 16;242(4885):1528-34. doi: 10.1126/science.3201241. PMID: 3201241.

Xu ZH, Jiang Q, Chen DY, Xiong J, Shi DQ, Yuan T, Zhu XL. Extracorporeal shock wave treatment in nonunions of long bone fractures. Int Orthop. 2009 Jun;33(3):789-93. doi: 10.1007/s00264-008-0553-8. Epub 2008 Apr 25. PMID: 18437381; PMCID: PMC2903117.

Giolla P. “Valutazione del danno alla persona in responsabilità civile”, Giuffrè, Milano, 1968

Ronchi E., Morini O. "Reflections on the subject of an earlier state in the assessment of biological damage ", It. Journal of Legal Medicine 14, 574, 1992

Grandi M., Farneti A., Mangili F." Food for thought on the subject of biological and property damage ", Study Days on Damage to Health, Pisa 12-13 May 1989, CEDAM, pp. 193 -197, 1990

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01-07-2022

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1.
Basile G, Avato FM, Passeri A, Accetta R, Amadei F, Giorgetti A, et al. Atrophic pseudarthrosis of humeral diaphyseal fractures: medico-legal implications and methodological analysis of the evaluation. . Acta Biomed [Internet]. 2022 Jul. 1 [cited 2024 Jul. 17];93(3):e2022176. Available from: https://mattioli1885journals.com/index.php/actabiomedica/article/view/12733