Technique Spotlight: Nonoperative Management of Humeral Shaft Fractures

Indications

The majority of isolated humeral shaft fractures can be managed nonoperatively. It is widely accepted that acute, closed, isolated fractures in a cooperative, ambulatory patient will achieve union with nonoperative management without a significant angular deformity or any functional limitations. However, while indications for nonoperative management of humeral shaft fractures are a continual debate, it is widely accepted that the humerus can tolerate 15–20 degrees of angular deformity, 30 degrees of rotational malalignment, and 2–3 cm of shortening without compromising function.

Sarmiento et al. published the most notable study supporting nonoperative management of humeral shaft fractures in 2000. Humeral shaft fractures in 620 patients were treated nonoperatively with functional bracing including those with open fractures, segmental fractures, ipsilateral shoulder dislocation, and radial nerve palsies. They reported a union rate of 98% for closed fractures and 94% for open fractures. Eighty-seven percent healed in <16 degrees of varus angulation, and 98% of patients had a shoulder range-of-motion deficit of <25 degrees.

Toivanen et al. reviewed 93 consecutive patients with closed, humeral shaft fractures managed nonoperatively with functional bracing and reported nonunion rates based on fracture location and AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification. They noted a higher rate of nonunion in fractures of the proximal one-third (54%) and AO type A fractures (23%).

More recently, Papasoulis et al. reviewed 18 case series and reported nonunion rates based on location, AO type, and fracture configuration. They also observed higher nonunion rates in fractures of the proximal one-third (8.2%), AO type A fractures (15.4%), and long, oblique fractures (17.5%) ( Fig. 33.1 ), although these findings were not statistically significant. They also reported an overall union rate of 95% with an average time to union of 10–11 weeks. Varus malunion was the most common complication; however, the residual deformity was usually <20 degrees and did not affect cosmetic or functional outcome. They observed deficits in range of motion, most notably shoulder abduction, external rotation, and elbow extension; however, this rarely exceeded 10 degrees. Similar findings have been demonstrated in several other studies.

Despite historically high union rates and satisfactory functional outcomes reported with nonoperative treatment of humeral shaft fractures, more recent literature may contradict this paradigm. Serrano et al. recently published a multicenter retrospective review of 1182 patients initially treated with functional bracing for humeral shaft fractures and noted a 29% failure rate requiring surgical intervention. They showed that females and alcoholics were more likely to be converted to surgery. Proximal shaft, comminuted, segmental, and butterfly fractures were also linked with higher rate of conversion.

Likewise, two recently published prospective, randomized trials suggest higher union rates and better functional outcomes with surgical fixation compared with functional bracing. Khameneh et al. compared ORIF (open reduction internal fixation) with functional bracing and found a significantly faster time to union with operative treatment compared with functional bracing (13.9 vs. 18.7 weeks). Similarly, Matsunaga recently published results of minimally invasive osteosynthesis with bridge plating compared with functional bracing and reported lower nonunion rates (0% vs. 15%) and less coronal plane angulation (2 vs. 10.5 degrees) ( Table 33.1 ).