Eleanor Christianson

OBJECTIVES: To report the injury profile of gunshot wounds (GSWs) to the humerus along with treatment, fracture-related infection (FRI), and nonunion. METHODS: Design: Retrospective review. Setting: Multicenter, 12 academic hospitals. Patient Selection Criteria: All patients ≥18 years old who presented to the emergency room with GSW-related humerus fractures (Orthopaedic Trauma Association classifications 11–13, types A-C) were included from January 2016 to October 2021. Patients were compared based on surgical management (SM) and nonsurgical management (NoSM). Outcome Measures and Comparisons: Data on patient demographics, injury presentation, treatment received, and outcomes including FRI and nonunion were collected. FRI was split into confirmatory and suggestive diagnoses. Multivariable logistic regression evaluated differences between the SM and NoSM groups in FRI after controlling for indicators of injury severity. RESULTS: Six hundred fifty-four patients were included with a mean age of 31 years (range: 18–74 years). Five hundred seventy-five patients (88%) were male, and 512 (79%) were Black or African American. Intra-articular fractures were more likely to be managed surgically (SM: 33.4%, NoSM: 17%, P < 0.0001). The rate of vascular injury was significantly higher in SM patients (SM: 16.8%, NoSM: 5.4%, P < 0.001); this was also true for nerve injury (SM: 45.6%, NoSM: 23.9%, P < 0.0001). Among all 654 patients, there was a significant difference in confirmatory FRI (SM: 5.4%, NoSM: 0.4%, P = 0.004) and suggestive FRI (SM: 19.9%, NoSM: 4.4%, P < 0.0001). In the subgroup of 307 patients with at least 90 days of follow-up, a significant difference was observed in suggestive FRI (SM: 22.5%, NoSM: 2.4%, P < 0.0001), but not in confirmatory FRI (SM: 6.8%, NoSM: 1.2%, P = 0.080). The rate of nonunion did not differ significantly between groups in the full cohort (SM: 8.4%; NoSM: 5.3%, P = 0.148) and subgroup with at least 90 days of follow-up (SM: 14.4%; NoSM: 12.9%, P = 0.739). After controlling for indicators of injury severity, the SM group had a significantly higher odds of suggestive FRI than the NoSM group both in the overall cohort (adjusted odds ratio = 2.54; 95% confidence interval: 1.14–5.64; P = 0.023) and among patients with at least 90 days of follow-up (adjusted odds ratio = 5.62; 95% confidence interval: 1.22–25.8; P = 0.027). CONCLUSIONS: In this study, humerus GSWs managed with surgery were associated with a higher prevalence of suggestive FRI, vascular injury, and nerve injury than GSWs managed without surgery; management (surgery vs. no surgery) was not associated with risk of nonunion. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background/Objectives: Bone nonunion remains a clinical challenge in orthopedic surgery with significant impacts on mental and physical wellbeing for patients. There are several previously established risk factors of nonunion that are connected to nutrition, but this has yet to be substantially explored. This review seeks to assess all studies that present associations between nutrition and nonunion to understand the potential for clinical relevance in nonunion prevention. Methods: Case–control and cohort studies comparing nonunion risk based on nutritional factors were gathered through PubMed in July 2024. Data were extracted with dual verification through Covidence and assessed for bias using the Newcastle–Ottawa Scale. Results: A total of 21 studies were included in this literature review. Vitamin D deficiency was a significant risk factor of nonunion in six studies and not significant in six other studies. Albumin was significant in three of the five studies addressing this lab value. Iron deficiency anemia was significant in a study assessing its impact on nonunion. Calcium was not significant in the one study mentioned. ICD-10-coded malnutrition was significant in one of the two studies. Sarcopenia, nutritional care plans, and dietitian-diagnosed malnutrition were statistically significant clinical indicators for predicting nonunion, but food insecurity was insignificant. Conclusions: Vitamin D, calcium, albumin, iron deficiency anemia, sarcopenia, and clinically diagnosed malnutrition have all been associated with an increased risk of nonunion in observational studies and should be considered when preventing nonunion development.