Original article 1
Evaluation of upper extremity function of displaced
diaphyseal humeral fractures in children treated by elastic
stable intramedullary nailing: preliminary results
Federico Canavesea, Lorenza Marengoa, Antoine Sambaa, Marie Rousseta,
Mounira Mansoura, Antonio Andreacchioc and Alain Dimegliob
The aim of this study was to retrospectively evaluate the
outcome of displaced humeral shaft fractures in children
and adolescents treated by elastic stable intramedullary
nailing (ESIN) and to evaluate upper extremity function
using the Quick-DASH questionnaire. Correction was
maintained over time in 14 of 16 patients. All patients were
pain free at last follow-up. Shoulder and elbow ranges of
motion were comparable with the noninjured side. The
mean Quick-DASH score was 1. This study reports good
functional outcomes in children with displaced humeral
shaft fractures surgically treated with ESIN, even in the
presence of residual deformity. ESIN enables stable
reduction, good rotational control, and good functional
Introduction
Humeral shaft fractures are relatively uncommon,
accounting for about 5.5% of all pediatric humeral frac-
tures [1], more frequently in patients younger than
3 years of age and older than 10 years of age [1–6].
Humeral shaft fractures can be treated nonsurgically in
babies and young children, but surgical treatment may
benefit older children and adolescents because of their
reduced remodeling potential and the tendency of such
injuries to displace [1,7–10]. However, the indications
and the type of surgical treatment remain controversial
issues in the literature [2,3,5,10,11–13].
Fractures that cannot be adequately reduced or main-
tained adequately aligned are candidates for surgical
management [5].
Elastic stable intramedullary nailing (ESIN) provides
stable fixation, good rotational stability, and relatively
easy insertion and removal [1,7,8]. Moreover, the ESIN
technique is minimally invasive, easy to learn, and has a
low complication rate [1,7,10]. However, although the
technique originally described by Ligier and colleagues is
used widely, none of the published studies dealing with
surgical management of humeral shaft fractures in chil-
dren have evaluated the clinical and radiological out-
comes of treatment using ESIN [2,7,10–12].
It has been shown that the Quick DASH questionnaire
can be used to measure disability and symptom severity
in a variety of arm disorders in children [14–16]. The
1060-152X Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.
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outcome. J Pediatr Orthop B 00:000–000 Copyright © 2016
Wolters Kluwer Health, Inc. All rights reserved.
Journal of Pediatric Orthopaedics B 2016, 00:000–000
Keywords: children, diaphysis, displaced,
elastic stable intramedullary nailing, humerus, surgical treatment
a
Department of Pediatric Surgery, University Hospital Estaing, Clermont Ferrand,
b
Faculty of Medicine, University of Montpellier, Montpellier, France and
c
Department of Pediatric Orthopedic Surgery, Regina Margherita Children’s
Hospital, Torino, Italy
Correspondence to Federico Canavese, MD, PhD, Department of Pediatric
Surgery, University Hospital Estaing, 1 Place Lucie et Raymond Aubrac, 63003
Clermont-Ferrand, France
Tel: + 33 4 73750293; fax: + 33 4 73750291;
e-mail: canavese_federico@yahoo.fr
questionnaire consists of 11 items, of which at least 10
have to be completed to calculate a Quick DASH score.
Each item has five response options, and the item scores
are used to calculate scale scores ranging from 0 (no
disability) to 100 (most severe disability).
The main aim of this study is to retrospectively evaluate
the clinical and radiographic outcomes of displaced
humeral shaft fractures in children and adolescents trea-
ted by ESIN and to evaluate upper extremity function
with the short version of the Disabilities of the Arm,
Shoulder and Hand outcome questionnaire (Quick
DASH).
Materials and methods
This study was approved by our institutional review
board. Medical records were reviewed to identify all
children who underwent surgical treatment for humeral
shaft fractures in a single center from September 2010 to
May 2014. In total, 38 consecutive children with humeral
shaft fractures were recorded, of whom 16 were surgically
treated by ESIN.
All patients were admitted through the emergency
department, and the following demographic and clinical
data were recorded: sex, age at the time of trauma,
mechanism of injury, side involved, presence or absence
of associated neurovascular injury, and whether the
fracture was closed or open.
DOI: 10.1097/BPB.0000000000000318
 2 Journal of Pediatric Orthopaedics B 2016, Vol 00 No 00
All patients underwent anteroposterior (AP) and lateral
radiographs of the humerus to assess the location (prox-
imal third, mid-diaphyseal, distal third), type (transverse,
oblique, spiral, comminuted), and degree of displace-
ment of the fracture (valgus, varus, recurvatum, pro-
curvatum, translation). Additional information such as
time from trauma to surgery, nail size, and length of
postoperative immobilization was collected from the
charts.
All children were treated according to the surgical tech-
nique described by Ligier et al. [8].
Inclusion criteria were patients with closed displaced,
unstable humeral shaft fracture without any associated
neurovascular injury, presence of physeal plates, and
surgical management by ESIN.
Exclusion criteria were nondisplaced fractures, open or
pathologic fractures, and absence of growth plates that
were visible on plain radiographs.
Radiographic evaluation
All patients underwent full-length AP and lateral radio-
graphs of the injured humerus.
The humeral shaft was defined as the portion of the
humerus between the area just distal to the surgical neck
to the area immediately proximal to the supracondylar
ridge. Only fractures that occurred within these anato-
mical landmarks and were managed surgically by ESIN
were included.
Using AP and lateral radiographs, fractures were classified
as oblique, transverse, or spiral on the basis of the rela-
tionship between the fracture line and the axis of the
humeral shaft. When three or more fracture fragments
were present, the fracture was classified as comminuted.
Angulation was defined as the angle between the axis of
the proximal and the distal fragments of the fracture.
Degree of valgus and varus angulation was assessed on
the AP radiographs. Valgus was defined as inward angu-
lation between the proximal and distal fragments. Varus
was defined as the opposite. Degree of recurvatum or
procurvatum angulation was assessed on the lateral
radiographs. Recurvatum was defined as a backward
thrust of the angle between the axis of the proximal and
distal fragments of the fracture. Procurvatum was defined
as the opposite. Values were expressed in degrees.
Translation was defined as the percentage of proximal
fragment not overlapping the distal fragment, with values
expressed as percentages.
Surgical technique
Surgery was recommended in patients older than 10 years
of age with displaced, unstable fracture of the humeral
diaphysis. No other treatment (i.e. conservative man-
agement) was attempted before surgery.
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All procedures were performed under general anesthesia.
Patients were placed supine on the operating table.
Fracture reduction was initially performed by traction
and closed manipulations under fluoroscopic control.
When reduction was achieved, two precontoured tita-
nium elastic nails (Synthes, Etupes, France) were intro-
duced through a 2–3 cm incision on the lateral side of the
distal humeral metaphysis. Each fracture was stabilized
using two same-diameter nails, where nail diameter was
equal to ∼ 40% of the diameter of the narrowest part of
the humeral shaft [17]. Nail entry point was at the inferior
third of the proximal humeral metaphysis; if the entry
point is too proximal, then hard cortical bone can make
nail insertion more challenging. Elastic nails must be
precontoured so that the apex of the bend will lie at the
fracture site. The nails are advanced beyond the fracture
site to stabilize the fracture while also providing rota-
tional control. A layered wound closure is performed,
leaving ∼ 0.5 cm of each nail remaining outside the bone.
After surgery, all patients are immobilized in a splint for a
period of 1–2 weeks, allowed to move the elbow several
times a day.
No other surgical technique was used to stabilize hum-
eral shaft fractures during the period studied.
Follow-up
All patients underwent regular clinical and radiographic
follow-up for at least 12 months after index surgery. At
each follow-up visit, full-length AP and lateral radio-
graphs of the affected humerus were obtained to assess
ongoing fracture consolidation and to detect complica-
tions such as secondary displacement, refracture, hard-
ware migration, nonunion, or malunion.
Complete fracture healing was defined as a full return to
activities of daily living and sports.
Functional evaluation
One year after the index surgery, patients were asked to
complete the short version of the Disabilities of the Arm,
Shoulder and Hand outcome questionnaire (Quick
DASH) at the outpatient clinic or by telephone. Quick
DASH is a self-reported questionnaire consisting of 11
items corresponding to different activities of daily living
and symptoms experienced by the patient. The patient
rates each item according to their perceived degree of
severity, ranging from 1 (no discomfort or symptoms) to 5
(major discomfort or severe symptoms). The final score is
calculated according to the algorithm [(sum of responses
N/N) − 1] × 25, where N is the number of responses. The
Quick DASH score ranges from 0 (no disability) to 100
points (most severe disability) and can be used to eval-
uate overall upper limb performance [18,19].
Data were expressed as frequencies and percentages,
with means and SDs as appropriate. Statistical analysis
was carried out using Student’s t-test and the threshold

for statistical significance was set at a P-value of less
than 0.05.
Results
The study included a total of 16 patients [12 males (75%)
and four females (25%); male : female ratio: 3 : 1] invol-
ving 16 displaced humeral shaft fractures (Table 1). The
average age of the patients at the time of injury was
12.3 ± 2.6 years (range: 6.9–15.3). The right side was
involved in 11 cases (69%) and the left side was involved
in five (31%). Mechanism of injury was direct in eight
cases and indirect in eight cases. All were isolated closed
fractures without any neurovascular compromise. No
patients had neurapraxia-type radial nerve injury.
Fracture type was transverse in seven cases (44%), obli-
que in one case (6%), spiroid in six cases (38%), and
comminuted in two cases (12%). Fracture location was
proximal third of the humerus in four cases (25%), mid-
diaphyseal in six cases (37%), and distal third of the
humerus in six cases (37%).
Before surgery, the mean valgus angulation was 28° ± 19°
(range: 3–62), the mean varus angulation was 10° ± 4°
(range: 5–15), and the mean procurvatum angulation was
17° ± 9° (range: 5–35). No patient showed recurvatum
displacement. The mean presurgery translation was
79 ± 22% (range: 33–100) (Table 2).
After surgery, the mean valgus angulation was 2° ± 4°
(range: 0–10), the mean varus angulation was 3° ± 4°
(range: 0–10), and the mean procurvatum angulation was
4° ± 5° (range: 0–15). The mean postsurgery translation
was 10 ± 14% (range: 0–38) (Table 2).
At last follow-up, the mean valgus angulation was 1° ± 2°
(range: 0–6), the mean varus angulation was 5° ± 7°
(range: 0–6), the mean procurvatum angulation was
4° ± 6° (range: 0–13), and the mean translation was 4 ± 9
(range: 0–33) (Table 2).
Correction was maintained over time, except in one
patient, who showed secondary displacement 10 days
after index surgery and therefore underwent a further
reduction and stabilization by ESIN and one patient who
developed postoperative humeral osteomyelitis and
therefore required early hardware removal.
The mean age at surgery, the male : female ratio, the
mean angulation and translation, the mean follow-up, and
the mean Quick DASH score of the patients are reported
in Table 3.
Surgical treatment, follow-up, and complications
All patients were surgically treated within 3–48 h from
the time of fracture. All fractures were reducible by
external maneuvers under an radiographic image inten-
sifier and stabilizable by ESIN. All patients were older
than 6 years of age: three fractures (19%) were treated in
patients aged 6–11 years old and 13 fractures (81%) were
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Diaphyseal humeral fractures in children Canavese et al. 3
treated in children aged older than 11 years. Overall, 34
titanium elastic nails (Synthes) were used (two nails per
fracture plus an extra two nails in the secondary disloca-
tion case). The mean follow-up duration was
25 ± 12 months (range: 12–56).
There was no radiographic evidence of delayed union
and no cases of hardware migration. One case of infection
was identified. Note that the patient suffered a fall and
developed secondary displacement 10 days after index
surgery. This patient underwent hardware removal,
closed reduction, and fracture stabilization by ESIN
under general anesthesia and C-arm fluoroscopy. After
reduction, a splint was applied to immobilize the upper
extremity for 4 weeks. The patient was allowed to
resume full physical and sport activities 6 months after
the last reduction. One case of refracture presented
4 months after index surgery. The patient underwent
closed reduction under general anesthesia and C-arm
fluoroscopy. After reduction, a splint was applied to
immobilize the upper extremity for 4 weeks. The patient
was allowed to resume full physical and sport activities
6 months after closed reduction.
None of the patients showed signs of growth arrest or
disturbances on the basis of radiological and clinical
assessment during follow-up. Clinically, arm length was
equal in all children.
Functional outcome
All patients were pain free at the last follow-up. Shoulder
and elbow ranges of motion were comparable with the
noninjured side.
The mean Quick DASH score was 1 ± 5 (range: 0–18.2):
14 patients had a score of 0 (93%) and one had a score of
1.2 (7%) (Table 3). One patient with mental retardation
could not answer the questionnaire (Table 1).
Functional outcome did not differ significantly between
patients according to fracture type, fracture location, and
presence of residual valgus or varus deformity (P > 0.05).
All children were able to return to daily life and sport
activities without discomfort or residual pain.
Discussion
Humeral shaft fractures are relatively uncommon in
pediatric populations, and few studies have focused on
the treatment of these fractures in children. To the best
of our knowledge, the functional outcome of surgical
treatment of humeral shaft fractures in children has never
been investigated.
This study reviewed 16 patients treated by ESIN for
displaced humeral shaft fractures. All fractures healed,
but one patient had residual valgus of 10° and four had
residual recurvatum deformity of at least 10° (Fig. 1).
Nevertheless, functional outcome was good in all patients
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4 Journal of Pediatric Orthopaedics B 2016, Vol 00 No 00

Table 1 Characteristics of patients and fractures included in the study
Fracture Preoperative displacement Postoperative displacement Displacement at last FU

Coronal Sagittal Coronal Sagittal Coronal Sagittal

plane plane plane plane plane plane Quick DASH
N Sex Side Age Location Type (deg.) (deg.) Translation (%) (deg.) (deg.) Translation (%) (deg.) (deg.) Translation (%) Complication score
1 F Left 6.9 Proximal Transverse 0 15 (PC) 100 0 13 (PC) 0 0 13 (PC) 0 0
1/3rd
2 M Right 15 Distal Spiral 22 (VG) 9 (PC) 100 0 0 0 0 0 0 0
1/3rd
3 M Left 15.1 Middle Oblique 40 (VG) 3 (PC) 66 0 10 (PC) 0 0 0 0 0
1/3rd
4 M Right 12.5 Proximal Transverse 32 (VG) 13 (PC) 77 0 0 0 0 0 0 0
1/3rd
5 F Right 12.4 Distal Transverse 62 (VG) 22 (PC) 75 0 0 33 0 10 (PC) 0 0
1/3rd
6 F Right 12.2 Middle Spiral 15 (VR) 5 (PC) 55 (50) 10 (VR) 5 (PC) 38 0 0 19 Secondary 0
1/3rd [20 (VR)]* [15 (PC)] displacement
7 M Right 12.3 Proximal Transverse 40 (VG) 20 (PC) 73 0 15 (PC) 0 0 10 (PC) 0 0
1/3rd
8 M Right 8.7 Distal Spiral 13 (VR) 0 57 3 (VR) 4 (PC) 20 3 (VR) 0 0 0
1/3rd
9 M Right 7.7 Middle Spiral 5 (VR) 28 (PC) 45 0 0 30 0 0 10 0
1/3rd
10 M Left 13.3 Distal Spiral 10 (VG) 14 (PC) 100 8 (VG) 4 (PC) 0 6 (VG) 0 0 NA (mental
1/3rd retardation)
11 M Right 15.3 Middle Transverse 38 (VG) 35 (PC) 100 0 4 (PC) 0 0 4 (PC) 0 0
1/3rd
12 M Right 14.9 Middle Comminuted 11 (VR) 20 (PC) 90 0 3 (PC) 0 9 (VR) 13 (PC) 33 Osteomyelitis 0
1/3rd
13 M Left 13 Proximal Transverse 7 (VR) 0 33 0 0 0 0 0 0 0
1/3rd
14 M Right 13.8 Middle Transverse 3 (VG) 27 (PC) 100 10 (VG) 7 (PC) 17 15 (VG) 19 (PC) 0 Refracture 18.2
1/3rd (3 months after
index surgery)
15 M Right 12.7 Distal Spiral 10 (VR) 10 (PC) 100 0 2 (PC) 20 0 0 0 0
1/3rd
16 F Left 11.3 Distal Comminuted 9 (VG) 15 90 6 (VR) 0 0 5 (VR) 0 0 0
1/3rd

FU, follow-up; NA, not applicable; PC, procurvatum; VG, valgus; VR, varus.
 Diaphyseal humeral fractures in children Canavese et al. 5

Table 2 Fracture displacement: preoperative, postoperative, and Surgical options include the use of ESIN, Kirschner
last follow-up values
wires, external fixation, or screw and plate fixation [2,
Preoperative Postoperative Last follow-up 10–12].
Valgus displacement 28 ± 19 2±4 1±2
Varus displacement 10 ± 4 3±4 5±7 Sahu [11] reviewed a group of 68 children aged between
Procurvatum displacement 17 ± 9 4±5 4±6 2 and 14 years old presenting a closed fracture of the
Translation (%) 79 ± 22 10 ± 14 4±9
humeral shaft and found that 64 fractures were treated
All values except translation are expressed in degrees (mean ± SD). with Kirschner wires that were used to achieve a closed
intramedullary fixation. Similarly, Qidwai [12] reviewed
29 humeral shaft fractures in adolescents and adults
Table 3 Patient demographics
(range: 14–60 years) treated by closed fixation with
Mean age at Mean follow-up Mean quick multiple intramedullary Kirschner wires. Both studies
surgery (years) Male : female ratio (months) DASH score
reported the technique to be simple, quick to perform,
12 ± 3 3:1 25 ± 12 1±5 safe, and reliable in providing stable fixation, mostly in
transverse and short oblique fractures of the humeral
shaft [11,12].

as the humerus is a nonweight-bearing bone and better
tolerates frontal and sagittal plane residual deformity.
Treatment of displaced humeral shaft fractures is often
conservative, especially in younger patients. Residual
varus up to 23° and procurvatum up to 20° are considered
acceptable in patients younger than 10 years of age [3,6,
8]. However, these values tend to decrease as children
become older, and there is ongoing debate over the
appropriate indications and type of surgical treatment. In
our group of patients, residual deformity was less than 10°
in both the frontal and the sagittal plane.
Machan and Vinz reviewed 222 humeral shaft fractures in
children and found that surgical treatment was performed
in 10% of patients with open fractures or inadequate
reduction and in cases of polytraumatism. They con-
cluded that individual therapeutic procedure depends on
the age of the patient and on the pattern of fracture [2].
Garg and colleagues reviewed 13 patients ranging in age
from 4.8 to 16.7 years with displaced humeral shaft
fractures treated by ESIN. Twelve of the 13 patients
(92.3%) could resume full sports activities with no lim-
itations or discomfort. They reported two cases of nail
migration (7.7%) [5]. However, for three patients of this
series, follow-up was less than 8 months (1.4, 5 and
7.9 months) [5]. Similarly, Maruthi et al. [13] reviewed
seven children aged between 9 and 15 years with dis-
placed humeral shaft fractures treated by ESIN, and
reported that the ESIN technique provides stable fixa-
tion with minimal soft tissue stripping at the fracture site,
and enables early mobilization of the extremity.
Sénès and Catena reviewed 22 children surgically treated
for displaced metaphyseal and diaphyseal humerus frac-
tures: 11 treated with Kirschner wires and 11 treated with
ESIN. They reported a relatively short recovery period,
minimal surgical damage to soft tissues compared with

Fig. 1

Fracture of the middle third of the humeral shaft (a); postoperative radiographs (b); and final result after hardware removal (c).

Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 6 Journal of Pediatric Orthopaedics B 2016, Vol 00 No 00
open reduction, and limited immobilization in the
immediate postoperative period [10].
However, none of the studies published to date dealing
with the surgical management of fractures of the humeral
shaft in children have evaluated the functional outcome
of surgical treatment [5,10–12]. In addition, Sénès and
Catena [10] reviewed both metaphyseal and diaphyseal
fractures, Sahu [11] included patients as young as 2 years
of age, Qidwai [12] mixed pediatric with adult patients,
Garg et al. [5] treated fractures with retrograde and
anterograde ESIN, and Maruthi et al. [13] reported results
with only a short follow-up.
Quick DASH is a region-specific outcome instrument
developed as a measure of self-rated, upper-extremity dis-
ability and symptoms [19] that also serves to evaluate
functional outcome in patients with displaced humeral shaft
fractures. Here, functional outcome was good in all patients,
even in those with residual valgus and varus deformity.
To the best of our knowledge, this is the first study to use a
standardized rating scale, that is, the Quick DASH ques-
tionnaire, to measure functional outcome in children and
adolescents with displaced humeral shaft fractures. The
Quick DASH questionnaire has the advantage of enabling
a reproducible comparison of postsurgery functional out-
come over time in patients with this type of fracture,
including the capacity to detect and differentiate small and
large changes in disability [18,19]. It has been shown that
the Quick DASH questionnaire can be used to measure
disability and symptom severity in a variety of arm dis-
orders in children [14–16,20,21]. Canavese and colleagues
used it to evaluate the functional outcome of proximal
humerus fractures, Colovic and colleagues used it to assess
elbow function after supracondylar fractures, Bae and col-
leagues used it in children with established malunion of
the clavicle, and Behr and colleagues used it to evaluate
scaphoid nonunion in skeletally immature adolescents
[14–16,20,21].
We encountered some limitations in the analysis of our
results. First, although there is no set age limit, the Quick
DASH questionnaire was developed for adults. However,
87.8% of our patients were older than 8 years of age and
thus able to fully understand the questions and answer
independently [18–21]. In addition, the DASH ques-
tionnaire has already been used to measure disability and
symptom severity in a variety of arm disorders in children
[14–16,20,21].
Second, this is a retrospective study with a limited
number of patients. Although the overall number of
fractures is lower than that in previous papers, the
number of surgically treated patients was comparable
with the average number of cases in other published
studies [2,5,10,13]. In addition, the patients formed a
homogeneous group in terms of age and type of fracture.
Copyright r 2016 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Conclusion
This study reports good functional outcomes in children
with closed isolated fractures of the humeral shaft surgi-
cally treated with ESIN. Outcomes were good in all
patients, even in the presence of residual frontal and
sagittal plane deformity. Residual deformities less than
10° can be tolerated on both the sagittal and the frontal
plane.
ESIN enables stable reduction, good rotational control,
and good functional outcome. Rotational malalignment
needs to be avoided, whereas residual frontal (valgus or
varus) and sagittal (procurvatum or recurvatum) mala-
lignment can be tolerated as it does not interfere sig-
nificantly with upper extremity function.
We advocate using a standardized rating scale to homo-
geneously compare functional outcome and facilitate
comparisons of clinical outcomes in different patient
populations. Future studies are needed on a larger num-
ber of patients to confirm the preliminary findings of our
work.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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