ORIF yielded better outcomes than nonoperative treatment for humeral diaphyseal fractures
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Compared with nonoperative treatment, open reduction and internal fixation with a plate and screw construct yielded improved function at 6 weeks and 4 months in patients with humeral diaphyseal fractures, presented results showed.
“Humeral shaft fractures are fairly common and, unfortunately, our standard treatment with nonoperative care involving casts and slings still carries a symptomatic nonunion rate as high as 33% in the literature,” Prism Schneider, MD, PhD, FRCSC, said in her presentation at the Orthopaedic Trauma Association Annual Meeting.
From Nov. 13, 2009 to Feb. 4, 2020, Schneider and colleagues randomized 84 patients with isolated, closed humeral diaphyseal fractures to open reduction and internal fixation (ORIF) with a plate and screw construct and a matched cohort of 84 patients – also with isolated, closed humeral diaphyseal fractures – to nonoperative treatment, which included splinting followed by bracing.
According to the abstract, outcome measures included DASH score, short musculoskeletal functional assessment, Constant shoulder score, range of motion (ROM), time to union and radiographic factors.
At 6-week and 4-month follow-ups, the ORIF group had mean DASH scores of 33.8 and 21.6, respectively, while the nonoperative group had mean DASH scores of 56.5 and 31.6, respectively. However, at 12-month follow-up, researchers found no significant differences in mean DASH scores between the ORIF group (8.8) and the nonoperative group (11). ROM, time to union and complication rate were also better in the ORIF group up to 4 months, Schneider noted.
“For isolated, closed diaphyseal fractures of the humerus, regardless of age, BMI, type of fracture or smoking status, if you’re counseling your patient, this is still shared decision-making,” Schneider said. “If you go with nonoperative treatment, we now have fairly robust data support that the union make take 4 to 6 months. There is a 15.5% risk of nonunion requiring surgery, and shoulder strength and ROM may be limited up to 4 months,” she added.
Perspective
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I was interested in the results of Schneider’s randomized controlled trial (RCT) comparing operative vs. nonoperative treatment of humeral shaft fractures, as it seems that the operative management of these injuries is becoming more prevalent, especially among our more junior orthopedic colleagues. It is always interesting to see whether the literature supports our changing practice patterns that are often based more on anecdotal than actual evidence. I did find the title of the above article summarizing the study a little misleading, or more accurately, incomplete, as Schneider’s work did certainly show that early functional outcomes based on the DASH, SMFA and Constant scores were better at 6 weeks and 4 months among the operative cohort. But as is true with so many studies comparing operative to nonoperative management, there were no differences in functional outcome scores noted between the two groups at 1 year. However, these early outcomes differences are not insignificant, as these injuries tend to occur in younger patients, and improved functional outcomes could translate to earlier return to work, which is also a significant outcome, albeit more difficult to quantify. Although not noted in the preliminary abstract, Schneider did also report that her group noted improved ROM, decreased time to union and a lower complication rate in the operative group up to 4 months.
The results of this RCT are useful in helping to counsel patients regarding early outcomes of operative compared to nonoperative management, as well as time to union and the risk of nonunion requiring surgery. Any of us who treat humeral shaft fractures know that patients are certainly happier in the early course of their treatment when managed operatively, and it is definitely easier for both the patient and the surgeon to manage an operatively treated humerus. The question remains whether the early improvement in functional outcome outweighs the costs and risks of surgery when the outcomes at 1 year, or at least those measured in this study, are the same.
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