Abstract
Background
Orthopedic surgeons use radiographs to determine degrees of fracture healing, guide progression of clinical care, and assist in determining weight bearing and removal of immobilization. However, no gold standard exists to determine the progression of healing of humeral shaft fractures treated non-operatively.
Purpose
The purpose of this study was to determine whether a scale comparable to the modified Radiographic Union Score for Tibial (RUST) fractures applied to non-operatively treated humeral shaft fractures can increase interobserver reliability in determining fracture healing.
Methods
A retrospective review was undertaken by three orthopedic traumatologists and one musculoskeletal radiologist, who evaluated 50 sets of anteroposterior and lateral radiographs, presented at random, of non-operatively treated humeral shaft fractures at various stages of healing from 17 patients. The radiographs were scored using a modified RUST scale called the Radiographic Humerus Union Measurement (RHUM). Observers were blinded to the time from injury. After a 4-week washout period, observers again scored the same radiographs. Observers classified each fracture as either healed or not healed based on the combination of radiographs. Inter- and intraobserver reliability of the RHUM were determined using an intraclass correlation coefficient (ICC). Interobserver reliability of determining a healed fracture was calculated using Cohen’s kappa (κ) statistics. A receiver operator characteristic curve was conducted to determine the RHUM score predictive of a fracture being considered healed.
Results
ICC demonstrated almost perfect interobserver reliability (ICC, 0.838; ICC 95% CI, 0.765 to 0.896) and intraobserver reliability (ICC range, 0.822 to 0.948) of the RHUM. κ demonstrated substantial agreement between observers in considering a fracture healed (κ = 0.647). Receiver operating characteristic (ROC) curve demonstrated that a RHUM of 10 or higher is an excellent predictor of the observer considering the fracture healed (area under the ROC curve = 0.946, specificity = 0.957, 95% CI specificity, 0.916 to 0.979).
Conclusions
This cortical scoring system has excellent interobserver reliability in humeral shaft fractures treated non-operatively. Consistent with previous cortical scoring systems, a RHUM score of 10 or above can be considered radiographically healed.
Similar content being viewed by others
References
Bhandari M, Guyatt GH, Swiontkowski MF, Tornetta P, Sprague S, Schemitsch EH. A lack of consensus in the assessment of fracture healing among orthopaedic surgeons. J Orthop Trauma. 2002;16(8):562–566.
Busse JW, Bhandari M, Einhorn TA, et al. Trial to re-evaluate ultrasound in the treatment of tibial fractures (TRUST): a multicenter randomized pilot study. Trials. 2014;15:206.
Chiavaras MM, Bains S, Choudur H, et al. The Radiographic Union Score for Hip (RUSH): the use of a checklist to evaluate hip fracture healing improves agreement between radiologists and orthopedic surgeons. Skeletal Radiol. 2013;42(8):1079–1088.
Corrales LA. Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Joint Surg Am. 2008;90(9):1862–1868.
Court-Brown CM, Aitken S, Hamilton TW, Rennie L, Caesar B. Nonoperative fracture treatment in the modern era. J Trauma. 2010;69(3):699–707.
Foulk DA, Szabo RM. Diaphyseal humerus fractures: natural history and occurrence of nonunion. Orthopedics. 1995;18:333–335.
Fowler J, Dubina AG, Castillo RC, et al. Prediction of tibial nonunions at 3 months after intramedullary nailing. Annual Meeting of the Orthopaedic Trauma Association [Abstract #110]; 15-18 Oct 2014; Tampa, FL.
Giganti M, Liuni F, Celi M, et al. Changes in serum levels of TNF-alpha, IL-6, OPG, RANKL and their correlation in fragility fractures and high energy fractures. J Biol Regul Homeost Agents. 2012;26(4):671–680.
Guimarães J, Duarte M, Fernandes M, et al. The effect of autologous concentrated bone-marrow grafting on the healing of femoral shaft non-unions after locked intramedullary nailing. Injury. 2014;5:7–13.
Hammer RR, Hammerby S, Lindholm B. Accuracy of radiologic assessment of tibial shaft fracture union in humans. Clin Orthop Relat Res. 1985;199:233–238.
Kim SH, Szabo RM, Marder RA, Marder A. Epidemiology of humerus fractures in the United States : nationwide emergency department sample, 2008. Arthritis Care Res (Hoboken). 2012;64(3):407–414.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–174.
Litrenta J, Tornetta III P, Mehta S, et al. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in metadiaphyseal fractures. J Orthop Trauma. 2015;29(11):516–520.
Marsh D. Concepts of fracture union, delayed union, and nonunion. Clin Orthop Relat Res. 1998;355:S22–30.
Patel SP, Anthony SG, Zurakowski D, et al. Radiographic scoring system to evaluate union of distal radius fractures. J Hand Surg Am. 2014;39(8):1471–1479.
Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Jt Surg Am. 2000;82(4):478–486.
Tape T. The area under an ROC curve: interpreting diagnostic tests. Available at: http://gim.unmc.edu/dxtests/roc3.htm. Accessed 3 May 2016.
Tawonsawatruk T, Hamilton DF, Simpson AH. Validation of the use of radiographic fracture-healing scores in a small animal model. J Orthop Res. 2014;32(9):1117–1119.
Tower S, Beals R, Duwelius P. Resonant frequency analysis of the tibia as a measure of fracture healing. J Orthop Trauma. 1993;7(6):552–557.
Van Houten AH, Heesterbeek PJC, Van Heerwaarden RJ, Van Tienen TG, Wymenga AB. Medial open wedge high tibial osteotomy: can delayed or nonunion be predicted? Clin Orthop Relat Res. 2014;472(4):1217–1223.
Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, et al. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma. 2010;68(3):629–632.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
Anthony V. Christiano, MD, Abraham M. Goch, MD, Christopher J. Burke, MD, Philipp Leucht, MD, PhD, and Sanjit R. Konda, MD, declare that they have no conflicts of interest. Kenneth A. Egol, MD, reports royalties and personal fees as a consultant from Exactech, royalties from Wolters-Kluwer and Slack, Inc., and grants from DePuy Synthes outside the submitted work.
Human/Animal Rights
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.
Informed Consent
Informed consent was waived from all patients for being included in this study.
Required Author Forms
Disclosure forms provided by the authors are available with the online version of this article.
Rights and permissions
About this article
Cite this article
Christiano, A.V., Goch, A.M., Burke, C.J. et al. Radiographic Humerus Union Measurement (RHUM) Demonstrates High Inter- and Intraobserver Reliability in Assessing Humeral Shaft Fracture Healing. HSS Jrnl 16 (Suppl 2), 216–220 (2020). https://doi.org/10.1007/s11420-019-09680-4
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11420-019-09680-4