Humeral Shaft Fractures


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Humeral Shaft Fractures


David J. Hak MD MBA FACS and Cyril Mauffrey MD FRCS FACS


University of Colorado, Denver Health Medical Center, Department of Orthopedic Surgery, Physical Medicine, and Rehabilitation, Denver, CO, USA


Clinical scenario



  • A 35‐year‐old man is brought to the Emergency Department following a motor vehicle accident.
  • He is complaining of right arm pain and has an obvious deformity of his right upper arm, which appears to be his only orthopedic injury.
  • After your resident attempts a reduction application of a hanging cast, the patient reports numbness and weakness in his radial nerve distribution.

Top three questions



  1. In adult patients with displaced humeral shaft fractures, does operative treatment result in improved function compared to nonoperative treatment?
  2. In adult patients with displaced humeral shaft fractures undergoing operative treatment, how does plate osteosynthesis compare to intramedullary nailing in terms of fracture union and complication rates?
  3. In adult patients sustaining humeral shaft fractures with radial nerve palsy, is there a difference in the recovery rate with primary radial nerve palsy, as compared to secondary radial nerve palsy (i.e. with fracture manipulation) radial nerve palsy?

Question 1: In adult patients with displaced humeral shaft fractures, does operative treatment result in improved function compared to nonoperative treatment?


Rationale


Nonoperative treatment has historically been the standard of care for isolated closed humeral shaft fractures. Similar to clavicle fractures, it has been assumed that the majority of fractures heal with a low level of complication, but level I evidence regarding the treatment of isolated closed humeral shaft fractures is lacking.


Clinical comment


Understanding the outcomes of operative and nonoperative treatment is important in order to recommend treatment and guide patients regarding their expected outcomes.


Available literature and quality of the evidence


To date, only a single level I study has compared operative with nonoperative treatment of humeral shaft fractures.1


Findings


Matsunaga and colleagues performed a prospective randomized study of 110 adult patients sustaining humeral shaft fractures treated with either minimally invasive bridge plating or nonoperative treatment with a functional brace. The primary outcome was the Disabilities of the Arm, Shoulder, and Hand (DASH) score at six months. Secondary outcome measures include the Short Form 36 (SF‐36) life‐quality questionnaire, Constant–Murley score for the shoulder, pain level, treatment complications, and radiographic results.1


Surgical treatment with bridge plating was statistically superior to conservative treatment with respect to the mean DASH at six months (mean scores: 10.9 ± 10.5 for bridge plating and 16.9 ± 18 for conservative treatment; p = 0.046), but this difference is of uncertain clinical benefit since other studies suggest that 10 points is the minimal clinically important difference.2,3 The union rate in the bridge plate group was significantly better than in the nonoperative group (100% vs 85% respectively; p <0.05). Mean residual angular displacement seen on the anteroposterior radiograph was significantly less in the bridge plate group (2.0° ± 4.7° vs 10.5° ± 8.9°; p <0.05). There was no difference between the groups with regard to the SF‐36 score, pain level, Constant–Murley score, or angular displacement seen on the lateral radiograph.


Resolution of clinical scenario



  • Operative treatment with bridge plating results in a superior mean DASH score at six months, but the clinical importance of this difference is uncertain.
  • Operative treatment using a minimally invasive bridge plating technique results in a significant higher union rate compared to nonoperative treatment.
  • This recommendation is based on only a single study with low external validity since it was conducted at a single center. There are two randomized clinical trials comparing surgical and nonsurgical treatment of humeral shaft fractures in progress.4,5
  • Given that the current evidence does not show significant functional differences between operative and nonoperative management, patient preferences such as time to return to activity and feelings toward surgical risk should be considered

Question 2: In adult patients with displaced humeral shaft fractures undergoing operative treatment, how does plate osteosynthesis compare to intramedullary nailing in terms of fracture union and complication rates?


Rationale


There is debate regarding the choice of humeral shaft fracture operative treatment. The main operative treatment options are plate fixation or intramedullary nailing. Plate fixation has traditionally been done through an open reduction approach, but a minimally invasive approach in which the plate is inserted through small incisions has gained popularity.


Clinical comment


A significant number of clinical studies have compared plate fixation or intramedullary nailing of humeral shaft fractures in an attempt to identify the optimal treatment option.


Available literature and quality of the evidence

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Humeral Shaft Fractures

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