Functional bracing yielded high nonunion rates for patients with humeral shaft fractures

Theodore A. Blaine, MD

This paper is an excellent and thought-provoking meta-analysis comparing functional bracing to surgical fixation of humeral shaft fractures. Functional bracing as popularized by Augustus Sarmiento, MD, has long been accepted as the initial treatment of choice for the majority of humeral shaft fractures; however, this study challenges that strategy based on the higher nonunion rates with functional bracing (17.4%) compared to open reduction and internal fixation (ORIF, 5.25%) or minimally invasive plate osteosynthesis (0.6%). Balancing this increased union rate with surgical fixation, however, is a higher incidence of radial nerve injury with ORIF (6.3%) compared to functional bracing (0.5%). 

Limitations of the study include the lack of objective (eg, range of motion) outcome measures, as well as patient-reported outcome measures. Also, the pattern and location of fracture in the humerus, both independent predictors of union, could not be recorded.  

While the authors do not make a specific recommendation on the management of humeral shaft fractures based on their findings, they do identify a higher nonunion rate with functional bracing than has generally been accepted. Therefore, in patients with humeral shaft fractures where there is concern for healing with functional bracing, surgeons may be more likely to consider surgical fixation.

Michael D. McKee, MD, FRCS(C)

The standard of care for the treatment of isolated humeral shaft fractures has traditionally been functional bracing. Given the high success rate of union (95% or more) reported by Augusto Sarmiento, MD, and others with closed treatment, the role for operative intervention has been limited to those fractures with specific indications (polytrauma, floating elbow, open wounds, etc.).

However, it is becoming increasing clear that functional bracing of humeral shaft fractures in 2023 has limitations, including a significantly higher rate of delayed and nonunion, functional impairment of the elbow and shoulder, and a prolonged time for return to full activity. The meta-analysis by Zavras and colleagues confirms these findings and, in addition to the recent randomized trials of surgery vs. no surgery for isolated humeral shaft fractures from Finland and Canada, lends support to a more liberal approach for primary fixation. While the precise method of operative fixation remains to be clarified, this article gives the orthopedist current, practical information with which to have an open, well-documented discussion with the patient and come to a joint decision about what is the best treatment for that individual.