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Scoring of radiographic cortical healing with the radiographic humerus union measurement predicts union in humeral shaft fractures

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The purpose of this study is to determine if the radiographic humerus union measurement (RHUM) is predictive of union in humeral shaft fractures treated nonoperatively.


All patients with long bone fracture nonunion presenting to a single surgeon were enrolled in a prospective registry. This registry was queried to identify patients with humeral shaft fractures treated nonoperatively and developed nonunion. The nonunion cohort was matched to a three to one gender- and age-matched control group that were treated nonoperatively for a humeral shaft fracture and achieved union. Two fellowship-trained orthopedic traumatologists blinded to eventual union scored radiographs obtained 12 weeks after injury using the RHUM. A binomial logistic regression determined the effect of the RHUM on the likelihood of developing union.


Nine patients with humeral shaft fractures treated nonoperatively with radiographs 12 weeks after injury that developed nonunion were identified. These patients were matched to 27 controls. Logistic regression demonstrated the RHUM was a significant predictor of healing 12 weeks after humeral shaft fracture treated nonoperatively (p = 0.014, odds ratio 9.434, 95% CI for OR 1.586–56.098). All patients with RHUM below 7 went on to nonunion. All patients with RHUM above 8 healed. Three of seven patients (43%) with RHUM of 7 or 8 healed.


The RHUM demonstrated an increased likelihood of achieving union 12 weeks after injury. Orthopedic surgeons can counsel patients that fractures with RHUM scores of 6 or below are in danger of developing nonunion and can target interventions appropriately.

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  1. 1.

    Court-Brown CM, Caesar B (2006) Epidemiology of adult fractures: a review. Injury. https://doi.org/10.1016/j.injury.2006.04.130

  2. 2.

    Kim SH, Szabo RM, Marder RA (2012) Epidemiology of humerus fractures in the United States: Nationwide emergency department sample, 2008. Arthritis Care Res 64(3):407–414. https://doi.org/10.1002/acr.21563

  3. 3.

    Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA (2000) Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Jt Surg Am 82(4):478–486

  4. 4.

    Foulk DA, Szabo RM (1995) Diaphyseal humerus fractures: natural history and occurrence of nonunion. Orthopedics 18:333–335

  5. 5.

    Christiano AV, Goch AM, Burke CJ, Leucht P, Konda SR, Egol KA (2019) Radiographic humerus union measurement (RHUM) demonstrates high inter- and intra-observer reliability in assessing humeral shaft fracture healing. HSS J. https://doi.org/10.1007/s11420-019-09680-4

  6. 6.

    Corrales LA (2008) Variability in the assessment of fracture-healing in orthopaedic trauma studies. J Bone Jt Surg 90(9):1862. https://doi.org/10.2106/JBJS.G.01580

  7. 7.

    Whelan DB, Bhandari M, Stephen D et al (2010) Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. J Trauma 68(3):629–632. https://doi.org/10.1097/TA.0b013e3181a7c16d

  8. 8.

    Bhandari M, Chiavaras MM, Parasu N et al (2013) Radiographic union score for hip substantially improves agreement between surgeons and radiologists. BMC Musculoskelet Disord 14(1):70. https://doi.org/10.1186/1471-2474-14-70

  9. 9.

    Patel SP, Anthony SG, Zurakowski D et al (2014) Radiographic scoring system to evaluate union of distal radius fractures. J Hand Surg Am. https://doi.org/10.1016/j.jhsa.2014.05.022

  10. 10.

    Van Houten AH, Heesterbeek PJC, Van Heerwaarden RJ, Van Tienen TG, Wymenga AB (2014) Medial open wedge high tibial osteotomy: can delayed or nonunion be predicted? Clin Orthop Relat Res 472(4):1217–1223. https://doi.org/10.1007/s11999-013-3383-y

  11. 11.

    Ross KA, O’Halloran K, Castillo RC et al (2018) Prediction of tibial nonunion at the 6-week time point. Injury. https://doi.org/10.1016/j.injury.2018.07.033

  12. 12.

    Frank T, Osterhoff G, Sprague S, Garibaldi A, Bhandari M, Slobogean GP (2016) The Radiographic Union Score for Hip (RUSH) identifies radiographic nonunion of femoral neck fractures. Clin Orthop Relat Res. https://doi.org/10.1007/s11999-015-4680-4

  13. 13.

    Kreder HJ (2013) Tibial nonunion is worse than having a myocardial infarction: commentary on an article by Mark R. Brinker, MD, et al.: “The devastating effects of tibial nonunion on health-related quality of life”. J Bone Jt Surg 95(24):e1991. https://doi.org/10.2106/JBJS.M.01180

  14. 14.

    Antonova E, Le TK, Burge R, Mershon J (2013) Tibia shaft fractures: costly burden of nonunions. BMC Musculoskelet Disord 14(1):42. https://doi.org/10.1186/1471-2474-14-42

  15. 15.

    McMichael JC, Israel H, Moed BR (2013) The musculoskeletal function assessment: establishing normative data. J Orthop Trauma. https://doi.org/10.1097/BOT.0b013e3182840d7c

  16. 16.

    Egol KA, Gruson K, Spitzer AB, Walsh M, Tejwani NC (2009) Do successful surgical results after operative treatment of long-bone nonunions correlate with outcomes? Clin Orthop Relat Res 467(11):2979–2985. https://doi.org/10.1007/s11999-009-0883-x

  17. 17.

    Fisher N, Driesman AS, Konda S, Egol KA (2018) Patient reported pain after successful nonunion surgery. J Orthop Trauma. https://doi.org/10.1097/bot.0000000000001032

  18. 18.

    Christiano AV, Pean CA, Konda SR (2016) Egol KA. The Nicotine Effect. Iowa Orthop J, Predictors of Patient Reported Pain After Lower Extremity Nonunion Surgery, p 36

  19. 19.

    Driesman AS, Fisher N, Karia R, Konda S, Egol KA (2017) Fracture site mobility at 6 weeks after humeral shaft fracture predicts nonunion without surgery. J Orthop Trauma. https://doi.org/10.1097/BOT.0000000000000960

  20. 20.

    Yang JS, Otero J, McAndrew CM, Ricci WM, Gardner MJ (2013) Can tibial nonunion be predicted at 3 months after intramedullary nailing? J Orthop Trauma 27(11):599–603. https://doi.org/10.1097/BOT.0b013e31828f5821

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No sources of funding were obtained for this study.

Author information

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Anthony Christiano, Christian Pean and Sanjit Konda. The first draft of the manuscript was written by Anthony Christiano, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Correspondence to Anthony V. Christiano.

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The authors report no conflict of interest or sources of funding related to the contents of the manuscript.

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Our study was approved by the appropriate institutional research ethics committee and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

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Christiano, A.V., Pean, C.A., Leucht, P. et al. Scoring of radiographic cortical healing with the radiographic humerus union measurement predicts union in humeral shaft fractures. Eur J Orthop Surg Traumatol (2020). https://doi.org/10.1007/s00590-020-02635-0

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  • RHUM
  • Humerus fracture
  • Radiographic union
  • Nonunion