[Humeral diaphyseal fractures: functional bracing]

Humeral shaft fractures: retrospective results of non-operative and operative treatment of 186 patients

BACKGROUND

Humeral shaft fractures account for 1-3% of all fractures and 20% of the fractures involving the humerus. The aim of the current study was to compare the outcome after operative and non-operative treatment of humeral shaft fractures, by comparing the time to radiological union and the rates of delayed union and complications.

METHODS

All patients aged 16 years or over treated for a humeral shaft fracture during a 5-year period were included in this retrospective analysis; periprosthetic and pathological fractures were excluded. Radiographs and medical charts were retrieved and reviewed in order to collect data on fracture classification, time to radiographic consolidation and the occurrence of adverse events.

RESULTS

A total of 186 patients were included; 91 were treated non-operatively and 95 were treated operatively. Mean age was 58.7 ± 1.5 years and 57.0% were female. In 83.3% of the patients, only the humerus was affected. A fall from standing height was the most common cause of the fracture (72.0%). Consolidation time varied from a median of 11-28 weeks. The rate of radial nerve palsy in both groups was similar: 8.8% versus 9.5%. In 5.3% of the operatively treated patients, the palsy resulted from the operation. Likewise, delayed union rates were similar in both groups: 18.7% following non-operative treatment versus 18.9% following surgery.

CONCLUSION

The data indicated that consolidation time and complication rates were similar after operative and non-operative treatment. A prospective randomised clinical trial comparing non-operative with operative treatment is needed in order to examine other aspects of outcome, meaning shoulder and elbow function, postoperative infection rates, trauma-related quality of life and patient satisfaction.

[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.

Plate fixation or intramedullary fixation of humeral shaft fractures

BACKGROUND

The optimal approach to operative treatment of humeral shaft fractures remains debatable. Previously published trials have been limited in size and have been inconclusive regarding important patient outcome variables following treatment with either intramedullary nails or plates. We conducted a meta-analysis of available trials comparing treatment of humeral shaft fractures.

METHODS

We performed a literature search from 1967 to November 2007 in the main medical search engines and selected 4 randomized trials that compared nails and plates in patients with humeral shaft fractures and that reported on complications due to surgery. We statistically pooled patient data using standard meta-analytic approaches. Our primary outcome was the total complication rate, comprised of all complications listed in the articles included. Secondary outcomes included non-union, infection, nerve palsy, and reoperation rate. Methodology was assessed using the CLEAR NPT.

RESULTS

When pooling the data of the 4 trials (n = 203 patients), we did not find a statistically significant difference between implants in the rate of total complications, non-union, infection, nerve-palsy, or the need for reoperation. The studies included were small and had methodological limitations.

CONCLUSIONS

Our meta-analysis suggests stastistically insignificant differences between plates and nails in the treatment of humeral shaft fractures. Small sample sizes, study heterogeneity, and methodological limitations argue strongly for a definitive, large trial. We recommend that this trial should be a randomized controlled trial with appropriate allocation of patients and blinding of patients and care providers and outcome assessors, and that it should include patient-important outcomes.