Rodriguez-Merchan [27] prospectively studied 40 patients with closed transverse fractures of the diaphysis of the humerus without associated nerve palsies. All failed nonoperative treatment and were operated with either compression plating (PLT) or intramedullary fixation (IMN) with Hackethal nail. The patients were not randomized but the treatment was left to the surgeon’s preference. The patients were reviewed with an average follow-up of 18 months. The patients in the IMN group required with one exception a second anesthesia to remove the symptomatic nails and had to be protected in the brace for 6 months. Patients in the PLT group performed the same rehabilitation protocol but did not use the postoperative brace. All fractures treated with IMN healed with a delayed union in one case. All the fractures treated by PLT healed with one exception who showed delayed union. The author concluded that there were no differences between the two groups and that either PLT or IMN can be used. Disadvantages of the IMN group included the need to use a postoperative brace and the need of a second procedure to remove the device.

Chapman et al. [28] performed a prospective randomized study including 84 patients which underwent IMN (n = 38) or PLT (n = 46). The devices implanted were either an antegrade humeral nail (Russell Taylor, Smith and Nephew) or a dynamic locking compression plate (DCP Synthes). The results were studied with a 13-month follow-up. Fracture healing by 16 weeks was present in 42 of 43 PLT, compared with 33 out of 38 in the IMN group (p = nonsignificant). Shoulder pain and decreased shoulder motion were significantly more frequent after IMN (p = 0.007). A decreased range of motion of the elbow was significantly (p = 0.003) more frequent after PLT of distal third fractures. The same patients did not experience increased elbow pain. The prevalence of other complications was not significantly different between the two groups. The authors concluded that both treatments can provide predictable methods for the treatment of these fractures.

McCormack et al. [29] prospectively randomized 44 patients with fractures of the shaft of the humerus to either intramedullary nail (IMN) or plating (DCP). After a minimum 6-month follow-up, there were no differences in shoulder and elbow function and pain and time to return to normal activity. Shoulder impingement was present in one case after plating and six after IMN. Complications were found in three DCP group patients compared with 13 in the IMN group. Secondary surgery was needed in 7 IMN nail patients but only one in the DCP group. The author concluded that DCP remained the best treatment for humeral shaft fractures, while IMN may have specific indications but is technically more demanding and shows a higher complication rate.

Changulani et al. [30] compared results of humerus IMN and DCP. Forty-seven patients with a diaphyseal fracture of the shaft were prospectively randomized. The IMN group included 23 patients, while in the DCP group there were 24 patients. Antegrade nailing was routinely employed and DCP plating was applied through an anterolateral or posterior approach. The outcome measurements included union time, union rate, functional outcome, and incidence of complications. Functional outcome assessed with the American Shoulder and Elbow Surgeons Score (ASES) showed no differences between the two groups. Union rate was similar, and time to union was significantly lower for IMN. Complications such as infection were higher with DCP. Shortening of the arm and restriction of shoulder movements due to impingement were more frequent with IMN compared with DCP. The authors concluded that IMN may be preferable because of shorter union time and lower incidence of infection. There were no differences between the two groups in terms of rate of union and functional results.

Raghavendra and Bhalodiya [31] prospectively studied 36 patients with fractures of the shaft of the humerus. The follow-up was from 1 to 2 years. There were two groups, each one of 18 patients. There were no differences in union time between the two groups but patients with an interlocking nail underwent more bone grafting procedures to achieve the union (six vs two). A good to excellent result was achieved by 12 patients in the DCP (66 %) compared to 4 patients (25 %) in the nailing group. Locked nailing was associated with a significant reduction of shoulder function (p = 0.003) and overall results (p = 0.02). The authors concluded that there was no difference between the two groups in terms of time to union. However compression plating was preferable because of better preservation of joint function and lesser need for secondary bone grafting.

Putti et al. [32] randomized 34 patients with humeral shaft fractures to either antegrade IMN (n = 16) or DCP (n = 18). Fractures were classified according to the AO system (type A in 19 cases, type B in 15 cases). The outcome evaluation included functional results, union, and complications. The minimum follow-up was 24 months. The functional scores according to American Shoulder and Elbow Surgeons (ASES) were not significantly different. Complication rates were higher in IMN group versus DCP groups (50 % vs 17 %, p = 0.038) and the nonunion rate was 0 % versus 6 % (ns). Two patients in the IMN group sustained an iatrogenic fracture at the time of insertion. Two had a radial nerve palsy and one patient needed nail removal for shoulder impingement. Three patients had adhesive capsulitis. The authors concluded that the complication rate was higher in the IMN group, while functional outcomes were similar in the two groups.

Khan et al. [33] compared two groups of 30 patients each treated with intramedullary interlocking nail and plating with DCP. In the IMN group 11 patients had moderate to severe shoulder dysfunctions and 8 of them were above 50 years of age. In the DCP group only one patient had severe shoulder dysfunction (p = 0.001). There was no significant difference in infection rate and palsy between the two groups. The authors concluded that antegrade nailing may not be suitable in elderly patients as it can cause significant shoulder dysfunction.