Lower rates of nonunions, malunions found
Although nonsurgical management has been the longstanding treatment for closed humeral shaft fractures, a study presented at the 2009 annual meeting of the Orthopaedic Trauma Association demonstrated that surgical management significantly reduces the incidence of both nonunions and malunions.

“Our goal was to compare surgical versus nonsurgical treatment of humerus shaft fractures and examine the incidence of malunion, nonunion, infection, range of motion, and radial nerve injury based on recent experience,” said Anthony Denard Jr., co-author and fourth year medical student at Meharry Medical College.

Better outcomes with ORIF
The researchers conducted a retrospective chart and radiographic review of 246 patients treated at two Level I trauma centers between January 2001 and December 2005. Of these patients, 156 (63 percent) were treated with open reduction and internal (plate and screw) fixation (ORIF) (Fig. 1) and 90 (37 percent) were treated with a functional brace (Fig. 2); 33 patients (13.4 percent) were lost to follow-up (ORIF: 6 patients; brace: 27 patients).

Most of the injuries resulted from motor vehicle collisions (49.3 percent) and falls (22 percent). The sex, age, and comorbidities of the patients were very similar except for the use of tobacco. The surgical group had 32 percent tobacco users versus 4 percent in the brace group.

The researchers found a statistically significant difference in the rate of nonunion between the brace and surgical groups (23 percent versus 9 percent; p=0.0128). “The 23 percent nonunion rate in the brace group is higher than has been historically reported,” said principal investigator William T. Obremskey, MD, MPH. “It may be that we have lost the art of brace treatment or that patients do not tolerate immobilization very well.

“The 9 percent nonunion rate in the surgical group is relatively high and may be due to the large percentage of patients using tobacco,” he said.

The brace group also had a higher incidence of malunion compared to the surgical group (13 percent versus 1 percent; p=0.0011). But the investigators did not find any appreciable differences in postsurgical range of motion or the need for secondary surgery between the two groups.

The rate of infection was higher for patients in the surgical group than in the brace group; the one infection in the brace group resulted from the injury itself, a low-energy gunshot wound. All but one radial nerve palsies from injury or treatment completely resolved.

“Historically, the rates of nonunion for brace treatment have been reported to be less than 5 percent. But most authors have not been able to replicate those studies and have reported a rate of nonunion between 6 percent and 29 percent with bracing,” Mr. Denard said.

“Studies focusing on surgical treatment usually have shown a rate of nonunion of less than 5 percent,” he stated.

Advising patients on treatment
“We should give patients the best information we have and help them make good decisions,” said Dr. Obremskey. “I can tell them there is a 5 percent to 10 percent chance that the fracture won’t heal with an operation and a 20 percent to 25 percent chance that it will not heal with a brace.

“Over the long term, there’s no real difference in range of motion or incidence of permanent nerve injury. The worst risk of an operation is permanent nerve injury and that risk is small but it isn’t zero,” he said. “Patients and surgeons need to weigh risks and results of surgical and brace treatment of this injury to make a reasonable decision.”

“Operative versus nonoperative treatment of humeral shaft fractures: A retrospective review of 213 patients from two Level I trauma centers”

The authors report the following disclosures: Dr. Obremskey—Medtronic, Osteogenix, Synthes; Mr. Denard—no conflicts; Michael C. Tucker, MD—Southern Fracture Consortium.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org