Although good to excellent results have been reported using each of these different treatment modalities, functional fracture bracing has become the most common treatment for closed humeral shaft fractures [6].

It is important to stress here that virtually nearly all transverse to short oblique humeral shaft fractures are amenable to nonoperative management and recommendations by some authors for immediate surgical intervention are not at all supported by orthopedic evidence (there is only level II study evidence and one randomized controlled trial underway); the Cochrane analysis from 2012 is even more characteristic [7–9]: six completed studies that appeared to meet the Cochrane inclusion criteria. After scrutiny, all six studies were excluded: five were retrospective studies and one was a prospective study without randomization. There is no evidence available from randomized controlled trials to ascertain whether surgical intervention of humeral shaft fractures gives a better or worse outcome than no surgery. One sufficiently powered good quality randomized controlled trial comparing surgical (MIPO plating) versus nonsurgical intervention (bracing) for treating humeral shaft fractures in adults is actually ongoing, and it is likely that the results from this and two other ongoing randomized trials will help inform practice in due course [9]. In addition a level III comparative study of extra-articular distal-third diaphyseal humeral fractures brings into play complications: the authors concluded that although operative treatment resulted in more predictable alignment and a potentially quicker functional return, the operative risks were not insignificant and included loss of fixation; infection, which is concerning; and postoperative radial nerve palsy, which is of serious concern [10]. Among the 19 patients treated surgically, a 26 % complication rate was reported. Comparatively, in the group that underwent brace treatment, the end result in each case was a healed fracture with excellent functional outcome, with only minor skin complications due to local brace irritation. Advocates for surgical treatment should acknowledge that even in cases in which brace treatment is a challenge, the literature does not support the superiority of operative treatment [10]. Our current strategy for conservative management of humeral shaft fractures begins with immediate immobilization of the injured extremity via a coaptation splint and/a cuff and collar shoulder sling to provide initial fracture stability, pain control, and resolution of the swelling. Once the soft tissue envelope is adequate, typically after 7–10 days, the initial splint is exchanged for a functional brace that provides circumferential soft tissue compression. When fitted properly, the brace extends medially from 2.5 cm beneath the axilla to 1 cm proximal to the medial epicondyle. On the lateral aspect of the arm, the brace should be placed so that it spans from just below the lateral acromion to a point just above the lateral epicondyle [11]. Velcro straps that are fashioned around the brace are tightened periodically as the swelling subsides to maintain the constant compressive environment during fracture healing. Adequate placement of the orthosis will provide nearly unhindered range of motion of the shoulder and elbow. Active motion of these joints should begin as soon as tolerated. The use of the brace is typically continued for a period of approximately 8 weeks, at which time it is discontinued after clinical and radiological confirmation of fracture healing. In the largest clinical analysis to date, Sarmiento et al. reported on 922 patients treated with a functional brace for both closed and open humeral shaft fractures [11]. In total, 67 % of patients were available for follow-up, and among these patients, 98 % of all closed injuries and 94 % of all open fractures healed. Frequently debated concerns regarding closed management of humeral shaft fractures pertain to the amount of angulation that is acceptable for a good outcome and the proper management of an associated radial nerve injury [1]. Fjalestad et al. added a further concern in treating humeral shaft fractures conservatively, a substantial deficit in external rotation in the shoulder using standardized CT scan [12]. With regard to angular deformities, given the mobility afforded by the shoulder and elbow, malunions of the humeral shaft are well tolerated with minimal functional impairment [1, 10, 11, 13]. Parameters in the acceptable range therefore have included up to 30° of varus angulation, 20° of anterior bowing, and up to 15° of internal rotation; beyond these limits, cosmetic deformity and functional impairment may show clinically [11, 14]. In terms of neurological sequelae, injury to the radial nerve with neurapraxia is the most frequently encountered nerve deficit associated with humeral fractures and is found in up to a fifth of all patients [15]. Spontaneous recovery over a period of 4 months occurs in 70–92 % of patients managed expectantly; therefore, its presence is not an indication for open management and nerve exploration [14–16]. Conversely, nerve loss after application of a brace or closed reduction of the fracture is sometimes considered a relative indication for nerve exploration; however, no studies document improvement with such management, and most authors continue to recommend against operative intervention [17].