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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 15  |  Issue : 1  |  Page : 43-48

A retrospective insight into patterns of humeral shaft fractures among Nigerians from radiological viewpoint


Department of Anatomy, School of Basic Medical Sciences, College of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria

Date of Web Publication19-Sep-2016

Correspondence Address:
Vitalis Chukwuma Ezeuko
Department of Anatomy, School of Basic Medical Sciences, College of Medical Sciences, University of Benin, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-2393.190819

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  Abstract 

Background: Fractures of the humeral shaft account for 1–3% of all fractures in adults and for 20% of all humeral fractures in some populations. Objective: This study was aimed at classifying the pattern of humeral shaft fractures among Nigerian using the Müller's AO classification system. Materials and Methods: The study was carried out retrospectively at the Department of Medical Records, National Orthopedic Hospital, Igbobi, Lagos State, Nigeria, using plain films from a total number of 206 patients comprising 140 males and 66 females. Humeral shaft fractures were classified according to Müller's classification into three main types with three groups in each type. Results: The result showed that the most frequent type of humeral shaft fractures was simple fractures (76.7% [158/206]) followed by wedge fractures (20.4% [42/206]), whereas the least frequent was the complex fractures (2.9% [6/206]). Among the simple diaphyseal humeral fractures, simple spiral fractures were the most frequent (41.8% [66/168). Among the wedge diaphyseal humeral fractures, spiral wedge fractures were the most frequent (90.5% [38/42]). All the complex diaphyseal humeral fractures were of irregular complex group (12C3; 100% [6/6]). Conclusion: This study showed to a great extent that there is a pattern for diaphyseal humeral fractures among Nigerians. It goes a long way in equipping surgeons, to allow resources to be allocated on the basis of projected frequency of different types of diaphyseal humeral fractures.

Keywords: Diaphyseal, fractures, humeral, Nigeria, pattern


How to cite this article:
Ezeuko VC, Esechie LE, Oigbochie VE, Ighalo EE. A retrospective insight into patterns of humeral shaft fractures among Nigerians from radiological viewpoint. J Exp Clin Anat 2016;15:43-8

How to cite this URL:
Ezeuko VC, Esechie LE, Oigbochie VE, Ighalo EE. A retrospective insight into patterns of humeral shaft fractures among Nigerians from radiological viewpoint. J Exp Clin Anat [serial online] 2016 [cited 2020 Dec 4];15:43-8. Available from: https://www.jecajournal.org/text.asp?2016/15/1/43/190819




  Introduction Top


The humeral diaphysis or shaft is the expanse between the proximal limit pectoralis major insertion and the distal metaphyseal flare of the humerus (Walker et al., 2011). Fractures of the humeral diaphysis account for 1–3% of all fractures in adults and for 20% of all humeral fractures in some populations (Emmett and Breck, 1958; Rose et al., 1982; Schemitsch et al., 2008).

Several authors had proposed different classification systems for humeral fractures (Oestern and Tscherne, 1984; Gustilo and Anderson, 1976; Gustilo et al., 1984). However, for research purposes, the most widely accepted classification system is those of Müller et al. (1990) and Orthopaedic Trauma Association Committee for Coding and Classification (1996). Müller et al. (1990) using alpha-numeric system assigned humeral shaft fractures into three main types: Type A (simple), Type B (wedge), and Type C (complex). The Orthopaedic Trauma Association (OTA) Committee for Coding and Classification extended this classification further into subtypes for further fracture details (Orthopaedic Trauma Association Committee for Coding and Classification, 1996).

Müller/OTA system is limited in clinical applicability. Furthermore, beyond identification of the three basic fracture types, it has poor interobserver reliability. However, it has remained useful for cataloging fractures for research purposes (Wainwright et al., 2000).

Unfortunately, the epidemiology of fractures of the humeral shaft has received little attention in Nigeria and as such there is no literature available on the pattern of fractures of the humeral shaft among Nigerians. Hence, this study was aimed at classifying the pattern of humeral shaft fractures among Nigerian using the Müller's AO classification system.

This study could be useful in facilitating the planning of treatment, defining priorities in training, and gaining an understanding of orthopedic traumatology (Tytherleigh-Strong et al., 1998), especially in developing countries where poor health-care system had led to the loss of lives and incapacitations of the citizens.


  Materials and Methods Top


The study was carried out retrospectively at the Department of Medical Records, National Orthopedic Hospital, Igbobi, Lagos State, Nigeria, using plain films of X-ray (both anteroposterior and lateral views) that were taken between 2009 and 2014 from a total number of 206 patients of ages from birth to 95 years (0–95 years), comprising 140 males and 66 females.

The plain films that were selected for the study were strictly those of Nigerians based on the information given by the subjects and filled in their case notes.

Information that was gathered from the patients' case notes included age of the patients, gender of the patients, side affected, and cause of the fracture. The causes were grouped into three: Those that occurred as a result of the fall, those occurred as a result of road traffic accident (RTA), and those that occurred as a result of other causes (these included birth injuries, pathological, industrial machines, and machete cut). The subjects were socioeconomically grouped according to their ages into children (17 years and below), young (18–39 years), middle age (40–64 years), and elderly (65 years and above).

Diaphyseal humeral fractures were classified according to Müller et al. (1990) into three main types with three groups in each type as shown in [Figure 1].
Figure 1: Müller AO classification of diaphyseal humeral fractures (Müller et al., 1990)

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The results were presented in tabular formats showing percentage frequencies and fractional frequencies. Comparisons of the patterns of diaphyseal humeral fractures were made between the sexes, sides affected, age groups, and causes of the fractures.


  Results Top


[Table 1] presents the humeral diaphyseal fracture pattern among the subjects studied. The most frequent type of diaphyseal humeral fractures was simple fractures (12A; 76.7% [158/206]) followed by wedge fractures (12B; 20.4% [42/206]), whereas the least frequent was the complex fractures (12C; 2.9% [6/206]).
Table 1: Diaphyseal humeral fracture pattern among the subjects studied

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Among the simple diaphyseal humeral fracture cases [Table 1], simple spiral fractures was the most frequent (12A2; 41.8% [66/168]) followed by simple transverse fractures (12A3; 36.7% [58/158]), whereas simple oblique fractures was the least frequent (12A1; 21.5% [34/158]).

Among the wedge diaphyseal humeral fracture cases [Table 1], spiral wedge fractures were the most frequent (12B2; 90.5% [38/42]), whereas bending wedge (12B1) and fragmented wedge (12B3) fractures had equal frequency (4.8% [2/42] each).

All the complex diaphyseal humeral fracture cases [Table 1] were of irregular complex group (12C3; 100% [6/6]).

[Table 2] presents a comparison of the pattern of diaphyseal humeral fractures between males and females. The most frequent type of diaphyseal humeral fractures was simple fractures (80.0% [112/140] in males and 69.7% [46/66] in females) followed by wedge fractures (17.1% [24/140] in males and 27.3% [18/66] in females), whereas the least frequent type was the complex fractures (2.9% [4/140] in males and 3.0% [2/66] in females).
Table 2: Comparison of the pattern of diaphyseal humeral fractures between males and females

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Among the simple diaphyseal humeral fracture cases [Table 2], simple spiral fractures were the most frequent in males (41.1% [46/112]) followed by simple transverse fractures (33.9% [38/122]), whereas simple oblique fractures were the least frequent (25.0% [28/112]). In females, both simple spiral and simple transverse fractures had higher but equal frequencies (43.5% [20/46]) compared to simple oblique fractures (13.0 [6/46]).

Among the wedge diaphyseal humeral fracture cases [Table 2], spiral wedge fractures were the most frequent in males (91.7% [22/24]) followed by bending wedge fractures (8.3% [2/24]); there was no incidence of fragmented wedge. In females, spiral wedge fractures were the most frequent in males (88.9% [16/18]) followed by fragmented wedge (11.1% [2/18]); there was no incidence of bending wedge.

All the complex diaphyseal humeral fracture cases [Table 2] were of irregular complex group both in males (4/4) and females (2/2).

[Table 3] presents a comparison of the pattern of diaphyseal humeral fractures between the right and left sides. The most frequent type of diaphyseal humeral fractures was simple fractures (79.5% [70/88] on the right humerus and 74.6% [88/118] on the left humerus) followed by wedge fractures (18.2% [16/88] on the right humerus and 22.0% [26/118] on the left humerus), whereas the least frequent type was the complex fractures (2.3% [2/88] on the right humerus and 3.4% [4/118] on the left humerus).
Table 3: Comparison of the pattern of diaphyseal humeral fractures between the right and left sides

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Among the simple diaphyseal humeral fracture cases [Table 3], simple spiral fractures were the most frequent (37.1% [26/70] on the right humerus and 45.5% [40/88] on the left humerus) followed by the simple transverse fractures (34.3% [24/70] on the right humerus and 38.6% [34/88] on the left humerus), whereas simple oblique fractures were the least frequent (28.6% [20/70] on the right humerus and 15.9% [14/88] on the left humerus).

Among the wedge diaphyseal humeral fracture cases [Table 3], spiral wedge fractures were the most frequent (75.0% [12/16] on the right humerus and 100.0% [26/26] on the left humerus). On the right humerus, both bending wedge and fragmented wedge fracture had lower but equal frequencies (12.5% [2/16] each).

All the complex diaphyseal humeral fracture cases [Table 3] were of irregular complex group both on the right (2/2) and left (4/4) sides.

[Table 4] presents a comparison of the pattern of diaphyseal humeral fractures among the various age groups. The most frequent type of diaphyseal humeral fractures was extra-articular fractures (85.0% [34/40] among the children, 85.4% [70/82] among the young ones, 65.5% [38/58] among the middle-aged, and 61.5% [16/26] among the elderly). This was followed by wedge fractures (15.0% [6/40] among the children, 12.2% [10/82] among the young, 27.6% [16/58] among the middle-aged, and 38.5% [10/26] among the elderly). The least frequent among the young (2.4% [2/82]) and middle-aged (6.9% [4/58]) was complex fractures. There was no incidence of complex fractures among the children and the elderly.
Table 4: Comparison of the pattern of diaphyseal humeral fractures among the various age groups

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Among the children with simple diaphyseal humeral fractures [Table 4], simple spiral fractures were the most frequent (64.7% [22/34]), while simple oblique and simple transverse fractures both had equal frequencies (17.6% [6/34] each). Among the young with simple diaphyseal humeral fractures [Table 4], simple spiral fractures (42.9% [30/70]) were the most frequent followed by simple transverse fractures (40.0% [28/70]), whereas simple oblique fractures (17.1% [12/70]) were the least frequent. Among the middle-aged with simple diaphyseal humeral fractures [Table 4], simple transverse fractures (42.1% [16/38]) were the most frequent followed by simple spiral fractures (31.6% [12/38]), whereas simple oblique fractures (26.3% [10/38]) were the least frequent. Among the elderly with simple diaphyseal humeral fractures [Table 4], simple transverse fractures (50.0% [8/16]) were the most frequent followed by simple oblique fractures (37.5% [6/16]), while simple spiral fractures (12.5% [2/16]) were the least frequent.

All the children, young and elderly with wedge diaphyseal humeral fractures [Table 4] had spiral wedge fractures (6/6 for the children, 10/10 for the young, and 10/10 for the elderly). Among the middle-aged with wedge diaphyseal humeral fractures [Table 4], spiral wedge fractures were the most frequent (75.0% [12/16]), whereas bending wedge and fragmented wedge fractures both had equal frequencies (12.5% [2/16] each).

There was no incidence of complex diaphyseal humeral fractures among the children and the elderly. Furthermore, all the young and middle-aged that had complex diaphyseal humeral fractures [Table 4] had irregular complex fractures (2/2 for the young and 4/4 for the middle-aged).

[Table 5] presents a comparison of the pattern of diaphyseal humeral fractures caused by falls and those as caused by RTAs, which were the two major causes of diaphyseal humeral fractures recorded. The most frequent type of diaphyseal humeral fractures was simple fractures (87.1% [54/62] caused by falls and 72.9% [86/118] caused by RTAs) followed by wedge fractures (12.9% [8/62] caused by falls and 23.7% [28/118] caused by RTAs), whereas the least frequent type was complex fractures (0.0% [0/62] caused by falls and 3.4% [4/118] caused by RTAs).
Table 5: Comparison of the pattern of diaphyseal humeral fractures between the main causes

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Among the simple diaphyseal humeral fractures caused by falls [Table 5], simple spiral fractures were the most frequent (51.9% [28/54]) followed by simple transverse fractures (25.9% [14/54]), whereas the least frequent was simple oblique fractures (22.2% [12/54]). Among the simple diaphyseal humeral fractures caused by RTAs [Table 5], simple transverse fractures were the most frequent (46.5% [40/86]) followed by simple spiral fractures (32.6% [28/86]), whereas the least frequent was simple oblique fractures (20.9% [18/86]).

All the wedge diaphyseal humeral fractures caused by falls [Table 5] were spiral wedge fractures (8/8). Among the wedge diaphyseal humeral fractures caused by RTAs [Table 5], whereas spiral wedge was the most frequent (85.8% [24/28]), bending wedge and fragmented wedge fractures had equal frequencies (7.1% [2/28] each).

No complex humeral diaphyseal fractures were caused by falls, whereas all the complex humeral diaphyseal fractures caused by RTAs were irregular complex fractures (4/4) [Table 5].


  Discussion Top


Epidemiological study of the diaphyseal humeral fracture has received no attention in Nigeria. The study presents a pattern of diaphyseal humeral fractures among Nigerians. The most frequent type of diaphyseal humeral fractures was simple fractures followed by wedge fractures, whereas the least frequent was complex fractures. This pattern was seen in both sexes, on both sides, in both causes and in all age groups. This pattern is similar with the earlier studies by Tytherleigh-Strong et al. (1998) in the United Kingdom and Ekholm et al. (2006) in Sweden.

This study also showed that among the simple fracture cases, simple spiral fractures were the most frequent followed by simple transverse fractures, whereas simple oblique fractures were the least frequent. This is the noted observed in both males and females, on both right and left sides, in children and young and in diaphyseal humeral fractures caused by falls. This pattern also agrees with studies by Tytherleigh-Strong et al. (1998) and Ekholm et al. (2006).

Among the middle-aged with simple fractures and in simple fractures caused by RTAs, a different pattern was observed; the most frequent was simple transverse fractures followed by simple spiral fractures, whereas the least was simple oblique fractures. This similarity in patterns between diaphyseal humeral fractures caused by RTAs and middle-aged could be attributed to the high level of mobility among this age group and their higher predisposition to RTAs. This is catchy when considering an earlier study that had established RTAs as the most frequent cause of humeral shaft fractures among Nigerians and that humeral shaft fractures occur most frequently between 21 and 40 years (Ezeuko et al., 2015). Other studies had noted that middle age consists of agile, active, and very mobile age range associated with increase transit from place to place, increase in risk-taking, and it is the age range associated with increased use of alcohol and drug intoxication (Kumar et al., 2008; Silas et al., 2012; Ezeuko et al., 2014).

Among the elderly with simple fractures, the most frequent was simple transverse fractures followed by simple oblique fractures, whereas the least frequent was simple spiral fractures. This variation in the pattern of diaphyseal humeral fractures could perhaps be due to the alteration of biomechanical properties seen in elderly bone (Tytherleigh-Strong et al., 1998).

This study shows that among the wedge diaphyseal humeral fracture cases, spiral wedge fractures were the most frequent. Studies by Tytherleigh-Strong et al. (1998) and Ekholm et al. (2006) noted that spiral wedge was the most frequent of wedge fractures followed by bending wedge while fragmented wedge was the least frequent.

All the complex diaphyseal humeral fracture cases noted in this study were of irregular variety. This is at variance with the studies by Tytherleigh-Strong et al. (1998) and Ekholm et al. (2006) who in their respective findings indicated that complex spiral fractures were the most frequent form of complex fractures followed by complex segmental fractures, whereas complex irregular fractures were the least frequent.


  Conclusion Top


This study showed to a great extent that there is a pattern for diaphyseal humeral fractures among Nigerians. This type of epidemiologic studies offers important data that contribute to improvement in fracture management. It also goes a long way in equipping surgeons, not only for an intrinsic but also to allow resources to be allocated on the basis of projected frequency of different types of diaphyseal humeral fractures. The ability to predict the level of admissions to a trauma center is valuable for administrative and training purposes.[16]

Acknowledgment

Staff of Medical Records, National Orthopedic Hospital, Igbobi, Lagos State, Nigeria.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Ekholm R., Adami J., Tidermark J., Hansson K., Törnkvist H., Ponzer S. (2006). Fractures of the shaft of the humerus: An epidemiological study of 401 fractures. J Bone Joint Surg Br 88B: 1469-73.  Back to cited text no. 1
    
2.
Emmett J.E., Breck L.W. (1958). A review and analysis of 11,000 fractures seen in a private practice of orthopaedic surgery, 1937-1956. J Bone Joint Surg Am 40A: 1169-75.  Back to cited text no. 2
    
3.
Ezeuko V.C., Anetor-Oforghor E., Enogieru A.B., Ogbeide O.U. (2014). An insight to patterns of femoral diaphyseal fractures among adult Nigerians: University of Benin Teaching Hospital experience. J Anat Sci 5(2):33-8.  Back to cited text no. 3
    
4.
Ezeuko V.C., Ehimigbai A.R., Esechie E.L. (2015). Assessment of some demographic risk factors associated with diaphyseal humeral fractures among Nigerians. Burns Trauma 3(3):6.  Back to cited text no. 4
    
5.
Gustilo R.B., Anderson J.T. (1976). Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analysis. J Bone Joint Surg Am 58A: 453-8.  Back to cited text no. 5
    
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Gustilo R.B., Mendoza R.M., Williams D.N. (1984). Problems in the management of Type III (Severe) open fractures: A new classification of Type III open fractures. J Trauma 24:742-6.  Back to cited text no. 6
    
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Kumar A., Lalwani S., Agrawal D., Rautji R., Dogra T.D. (2008). Fatal road accidents and their relationship with head injuries: An epidemiological survey of five years. Indian J Neurotrauma 5(2):63-7.  Back to cited text no. 7
    
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Müller M.E., Nazarian S., Koch P., Schatzker J. (1990). The Comprehensive Classification of Fractures of Long Bones. Springer, New York.  Back to cited text no. 8
    
9.
Oestern H.J., Tscherne H. (1984). Pathophysiology and classification of soft tissue injuries associated with fractures. In: Tscherne H., Gotzen L., editors. Fractures with Soft Tissue Injuries. Springer-Verlag, Berlin, Heidelberg, New York, p. 1-9.  Back to cited text no. 9
    
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Orthopaedic Trauma Association Committee for Coding and Classification. (1996). Fracture and dislocation compendium. J Orthop Trauma 10 Suppl 1:36-41.  Back to cited text no. 10
    
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Rose S.H., Melton L.J., Morrey B.F., Ilstrup D.M., Riggs B.L. (1982). Epidemiologic features of humeral fractures. Clin Orthop168:24-30.  Back to cited text no. 11
    
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Schemitsch E.H., Bhandari M., Talbot M. (2008). Fractures of the humeral shaft. In: Skeletal Trauma: Basic Science, Management and Reconstruction. 4th ed. Saunders, Philadelphia, p. 1593-4.  Back to cited text no. 12
    
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Silas O.A., Adoga A.A., Echejo G.O., Dauda A.M., Manasseh M.N., Olu-Silas R.A. (2012). Pattern of injuries associated with deaths following road traffic accidents as seen in a tertiary health centre Jos University Teaching Hospital (JUTH), Jos, North Central, Nigeria. J Health Sci 2(2):5-7.  Back to cited text no. 13
    
14.
Tytherleigh-Strong G., Walls N., McQueen M.M. (1998). The epidemiology of humeral shaft fractures. J Bone Joint Surg Br 80B: 249-53.  Back to cited text no. 14
    
15.
Wainwright A.M., Williams J.R., Carr A.J. (2000). Interobserver and intraobserver variation in classification systems for fractures of the distal humerus. J Bone Joint Surg 82:636-42.  Back to cited text no. 15
    
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Walker M., Palumbo B., Badman B., Brooks J., Van Gelderen J., Mighell M. (2011). Humeral shaft fractures: A review. J Shoulder Elbow Surg 20:1-12.  Back to cited text no. 16
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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