[Humeral shaft fractures]

Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study

Purpose

The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery.

Methods

From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type.

Results

Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001).

Conclusion

Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group.

Trial registration

NTR3617 (registration date 18-SEP-2012).

Supplementary Information

The online version contains supplementary material available at 10.1007/s00068-022-01890-6.

HUMeral shaft fractures: measuring recovery after operative versus non-operative treatment (HUMMER): a multicenter comparative observational study

Background

Fractures of the humeral shaft are associated with a profound temporary (and in the elderly sometimes even permanent) impairment of independence and quality of life. These fractures can be treated operatively or non-operatively, but the optimal tailored treatment is an unresolved problem. As no high-quality comparative randomized or observational studies are available, a recent Cochrane review concluded there is no evidence of sufficient scientific quality available to inform the decision to operate or not. Since randomized controlled trials for this injury have shown feasibility issues, this study is designed to provide the best achievable evidence to answer this unresolved problem. The primary aim of this study is to evaluate functional recovery after operative versus non-operative treatment in adult patients who sustained a humeral shaft fracture. Secondary aims include the effect of treatment on pain, complications, generic health-related quality of life, time to resumption of activities of daily living and work, and cost-effectiveness. The main hypothesis is that operative treatment will result in faster recovery.

Methods/design

The design of the study will be a multicenter prospective observational study of 400 patients who have sustained a humeral shaft fracture, AO type 12A or 12B. Treatment decision (i.e., operative or non-operative) will be left to the discretion of the treating surgeon. Critical elements of treatment will be registered and outcome will be monitored at regular intervals over the subsequent 12 months. The primary outcome measure is the Disabilities of the Arm, Shoulder, and Hand score. Secondary outcome measures are the Constant score, pain level at both sides, range of motion of the elbow and shoulder joint at both sides, radiographic healing, rate of complications and (secondary) interventions, health-related quality of life (Short-Form 36 and EuroQol-5D), time to resumption of ADL/work, and cost-effectiveness. Data will be analyzed using univariate and multivariable analyses (including mixed effects regression analysis). The cost-effectiveness analysis will be performed from a societal perspective.

Discussion

Successful completion of this trial will provide evidence on the effectiveness of operative versus non-operative treatment of patients with a humeral shaft fracture.

Trial registration

The trial is registered at the Netherlands Trial Register (NTR3617).

[Therapy of humeral shaft fractures]

Fractures of the humeral shaft are less frequent than those of the proximal humerus. The formerly recommended treatment of humeral shaft fractures was conservative according to Böhler. This still remains an adequate concept of treatment but according to a change in the technical possibilities and the demands of patients and physicians on fast restoration of function and low pain, there is a trend towards surgical stabilization of humeral shaft fractures. The implant of choice is discussed controversially and consists of various types of nails versus plating. The technique of nailing is antegrade or retrograde and depends on the localization of the fracture. In our opinion good indications for plating are combined fractures of the proximal humerus and the shaft as well as very distal humeral shaft fractures. A primary lesion of the radial nerve is no imperative indication for exploration and different studies have shown the same results for exploration after 2 or 3 months if there is no spontaneous remission.

Percutaneous fixation of comminuted fractures of the humerus: initial experience at Al Razi hospital, Kuwait

OBJECTIVE

To present initial experience of 12 cases of percutaneous plating of the comminuted fractures of the humerus using minimal access surgery and standard low-contact dynamic compression plate.

PATIENTS AND METHODS

Twelve patients (11 males and 1 female) with an average age of 29.8 years (range 17-46 years) with comminuted diaphyseal fractures of the humerus were treated by minimal access surgery using standard AO/ASIF implants. Fracture was reduced indirectly either by manipulation or by a femoral distractor. Image intensifier was used to monitor the reduction and fixation. The plate was fixed on the anterior surface of the humerus using proximal and distal minimal incision on the anterior aspect of the upper arm.

RESULTS

All fractures were united, and all patients had a good range of motion in the adjacent joints. In 1 patient, there was a transient neurological deficit.

CONCLUSION

Percutaneous fixation of comminuted fractures of the humeral shaft is an alternative to standard open surgery, reducing the surgical impact and giving an excellent functional result.