Ultrasound assessment of humeral shaft nonunion risk: a feasibility and proof of concept study

William M Oliver, Jamie Nicholson, Katrina R Bell, Thomas H. Carter, Timothy O White, Nicholas Clement, Andrew Duckworth, A Hamish R W Simpson

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Purpose: To determine the feasibility and reliability of ultrasound in the assessment of humeral shaft fracture healing, and estimate the accuracy of 6wk ultrasound in predicting nonunion.

Methods: Twelve adults with a non-operatively managed humeral shaft fracture were prospectively recruited and underwent ultrasound scanning at 6wks and 12wks post-injury. Seven blinded observers evaluated sonographic callus appearance to determine intra- and inter-observer reliability. Nonunion prediction accuracy was estimated by comparing images for patients that united (n=10/12) with those that developed a nonunion (n=2/12).

Results: The mean scan duration was 8mins (5-12) and all patients tolerated the procedure. At 6wks and 12wks, sonographic callus (SC) was present in 11 patients (10 united, one nonunion) and sonographic bridging callus (SBC) in seven (all united). Ultrasound had substantial intra- (weighted kappa: 6wk 0.75; 12wk 0.75) and inter-observer reliability (intraclass correlation coefficient: 6wk 0.60; 12wk 0.76). At 6wks, absence of SC demonstrated sensitivity 50%, specificity 100%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% in nonunion prediction (overall accuracy 92%). Absence of SBC demonstrated sensitivity 100%, specificity 70%, PPV 40% and NPV 100% in nonunion prediction (overall accuracy 75%). Of three patients at risk of nonunion (Radiographic Union Score for HUmeral fractures <8), one had SBC on 6wk ultrasound (that subsequently united) and the others had non-bridging/absent SC (both developed nonunion).

Conclusions: Ultrasound assessment of humeral shaft fracture healing was feasible, reliable and may predict nonunion. Ultrasound could be useful in defining nonunion risk among patients with reduced radiographic callus formation.
Original languageEnglish
Number of pages10
JournalEuropean Journal of Orthopaedic Surgery and Traumatology
Early online date29 Sept 2023
Publication statusE-pub ahead of print - 29 Sept 2023

Keywords / Materials (for Non-textual outputs)

  • Humeral shaft
  • fracture
  • ultrasound
  • callus
  • nonunion prediction


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