Electronic Letters to:

Upper Limb: T. M. P. O’Donnell, J. V. McKenna, P. Kenny, P. Keogh, and S. J. O’Flanagan Concomitant injuries to the ipsilateral shoulder in patients with a fracture of the diaphysis of the humerus J Bone Joint Surg Br 2008; 90-B: 61-65 [Abstract] [Full text] [PDF]

eLetters: Submit a response to this article

Electronic letters published:

Authors' reply:

Turlough O'Donnell, John V. McKenna, Patrick F. Kenny, Peter Keogh, Shay J. O'Flanagan   (26 February 2008)

Anterograde intramedullary nail of diaphyseal humeral fractures can cause shoulder pain

Nick J Little, K Dalzell, BA Rogers.   (15 February 2008)

Authors' reply: 26 February 2008
Turlough O'Donnell, Orthopaedic Surgeon Connolly Memorial Hospital, Blanchardstown, Dublin, John V. McKenna, Patrick F. Kenny, Peter Keogh, Shay J. O'Flanagan Send letter to journal: Re: Authors' reply: Todonn{at}indigo.ie Turlough O'Donnell, et al.	Sir, We thank Dr Little and his colleagues for their interest in our paper and we would like to make the following points in response. Firstly, Bhandari's meta-analysis did indeed show a 90% reduction in the relative risk for shoulder pain following plating over nailing. The author summed up, however, by saying that the results were unclear and inconclusive, and that large trials were needed to elucidate the probem. Therefore, while noted, it is impossible to read any significance into his findings. Secondly, there are many studies (Changulani et al,1 Chiu et al,2 Flinkkila et al,3 McCormack et al4), referred to in our paper, showing no difference in shoulder function and pain comparing plating and nailing. Is Dr Little suggesting that all of these studies are insignificant, incorrect in their conclusions, or both? Thirdly, we did not actually suggest that antegrade nailing was not responsible for shoulder pain post IM nailing. The message we tried to convey was that in over 60% of patients with humeral diaphyseal fractures, there is a concomitant injury to the shoulder. We hypothesised that shoulder pain may be due to violation of an ALREADY pathologically abnormal shoulder with the nail, and not, as was traditionally thought, due to creating an entry point for the nail in a pristine rotator cuff. We hope to have cleared up any confusion. T. O'Donnell, Orthopaedic Surgeon, J.V. McKenna, P.F. Kenny, P. Keogh, S.J. O'Flanagan, Connolly Memorial Hospital, Blanchardstown, Dublin, Ireland. 1. Changaluni M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop 2007;31:391-5. 2. Chiu FY, Chen CM, Lin CF, et al. Closed humeral shaft fractures: a prospective evaluation of surgical treatment. J Trauma 1997;43:947-51. 3. Flinkkila T, Hyvonen P, Lakovaara M, et al. Intramedullary nailing of humeral shaft fractures. A retrospective study of 126 cases. Acta Orthop Scand 1999;70:133-6. 4. McCormack RG, Brien D, Buckley RE, et al. Fixation of fracture of shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective randomised trial. J Bone Joint Surg [Br] 2000;82-B:336-9.
Anterograde intramedullary nail of diaphyseal humeral fractures can cause shoulder pain 15 February 2008
Nick J Little, Orthopaedic Registrar Waitako Hospital, Hamilton, NZ, K Dalzell, BA Rogers. Send letter to journal: Re: Anterograde intramedullary nail of diaphyseal humeral fractures can cause shoulder pain njlittle{at}gmail.com Nick J Little, et al.	Sir, We read this paper with interest. We note that the aims of the study were to assess associated ipsilateral shoulder injuries after diaphyseal humeral fracture, and the conclusion that anterograde nailing is only partly, if at all, responsible for shoulder pain following treatment. We would like to make the following points. 1. This current study demonstrates that 63.6% of shoulders show an MRI-demonstrable abnormality following ipsilateral diaphyseal humeral fracture. 2. The meta-analysis of plate versus intra-medullary nail fixation of humeral fractures by Bhandari et al1 stated that plate fixation affords a 74% relative risk reduction for re-operation. More importantly, they demonstrated that plate fixation results in a 90% relative risk reduction in shoulder pain and impingement. Although the study suggests that further larger randomised trials would be of benefit, these findings cannot be ignored. 3. If 63.6% of all shoulders with ipsilateral humeral fractures demonstrate a co-comittant shoulder injury, why is it that those that are treated with an intra-medullary nail have more shoulder pain than those treated with plates? Therefore it cannot be suggested from this study alone that intramedullary nailing is only partly, if at all, responsible for shoulder pain and symptoms. N.J. Little, Orthopaedic Registrar, K. Dazell, Orthopaedic Registrar, B.A Rogers, Orthopaedic Registrar, Waikato Hospital, Hamilton, New Zealand. 1. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop 2006;77:279–84.