Humeral Shaft Fractures: What Is the Best Treatment?

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Chapter 54 Humeral Shaft Fractures: What Is the Best Treatment?

Fractures of the humeral shaft represent approximately 5% of all fractures.¹ The majority of humeral shaft fractures are currently treated without surgery in North America and Europe, a fact reflected in the following quote: “Because closed methods of treatment for humeral shaft fractures have a high rate of success, open reduction is rarely indicated.”² The indications for operative reduction and fixation of humeral diaphysis fractures, first defined by Bandi³ in 1964 and now found in most articles and textbooks, include failed conservative management (unable to maintain adequate reduction), open fracture, bilateral humeral shaft fractures, fractures with vascular injury/compromise, polytrauma victim with humeral shaft fracture, pathologic fracture, ipsilateral humeral shaft and forearm fractures (floating elbow), and segmental fractures.⁴ These recommendations are based on expert opinion rather than comparative outcome studies.

OPTIONS

Options for treatment of humeral diaphysis fractures include operative and nonoperative techniques. Nonoperative modalities include hanging cast, coaptation splint (also known as functional bracing), and plaster U splint (“sugar-tong splint”). No evidence exists to support one of these methods over the other. Once there is indication for operative intervention, the surgeon can choose between open reduction and internal fixation with plate and screws, intramedullary nailing (statically locked and nonlocked), and external fixation.

OPERATIVE VERSUS NONOPERATIVE MANAGEMENT

Currently, no prospective trials have compared the outcomes of operative and nonoperative treatment of these fractures. In one study, Ekholm and coauthors ⁵ report on a cohort of 78 patients evaluated retrospectively after conservative treatment of humeral shaft fractures with fracture brace treatment. The nonunion rate overall was 10% but increased to 20% for AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) type A fractures of the midshaft and more proximal diaphysis. Outcome scores were worse for those who went on to nonunion and required open reduction and internal fixation. Even in those who healed successfully with nonoperative care, only 50% reported full recovery. The authors conclude that plate fixation should be considered for some fracture subtypes (Level V).

Operative Management: Compression Plating versus Statically Locked Intramedullary Nail

Since the advent of intramedullary nails designed for humeral shaft fractures, controversy has existed regarding the superiority of compression plating versus statically locked nailing of these fractures.⁶ Advantages of nailing include a remote entry point preserving the biological environment for fracture healing; intramedullary reaming and fixation, eliminating risk for injury to the radial nerve (as long as no nerve interposition occurs); load sharing by the device; and more rapid surgery with less blood loss and muscle damage. In contrast, the advantages of plate fixation include a direct approach to the fracture site with no violation of the proximal humerus and, more importantly, the rotator cuff; no risk of shoulder impingement from prominent subacromial hardware; direct visualization and protection of the radial nerve depending on fracture level and approach; the possibility of rigid compressive fixation; and the opportunity for bone grafting or radial nerve exploration, or both, if needed. Both options permit rapid mobilization of the shoulder and elbow.

A number of prospective, randomized studies have compared plating and nailing of humeral shaft fractures. Rodrigues-Merchan ⁷ compared open reduction and compression plating with closed reduction and intramedullary fixation with Hackethal nails in 40 patients who did not respond successfully to conservative treatment. Given the lack of interlocking, the nailing group required 6 months of postoperative bracing. All except one of the former group required reoperation for hardware removal. No nonunions occurred, and delayed union and functional results were identical in both groups. The author concludes that the treatments were equivalent in healing and functional outcome, but that the nailing group required systematic hardware removal and prolonged bracing.

Chiu and colleagues ⁸ randomized 91 patients to 3 groups: open reduction and plate fixation, with and without bone graft, and closed reduction and nailing with flexible Enders nails without interlocking. Surgical time, blood loss, and length of stay were lowest in the nailing group. Time to union was increased in the group undergoing plating without bone graft. Overall, complications were more likely to occur in the plating without bone graft and the nailing groups, including a statistically greater rate of nonunion when compared with plating with bone graft. Infection and iatrogenic nerve injury were similar in all three groups. All patients reported satisfactory results according to functional parameters set out by the authors. The authors conclude that, in cases where operative time was a consideration (e.g., patient with polytrauma injuries), Enders nailing appeared superior. Overall, union was best assured with plating plus bone graft.

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