Nailing vs. open reduction internal fixation yield comparable results for humeral fracture

Tim Lenters, MD

A recent Duke University paper with robust methodology performed a meta-analysis of 10 randomized controlled trials of IMN vs. ORIF for humeral shaft fracture. The study demonstrated less infection (1% vs. 5%) and quicker surgery (61 minutes vs. 88 minutes) in the IMN group. Other measures, including incidence of radial nerve palsy (3% vs. 4%), reoperation and time to union, were not clinically significant. Given concerns of reaming the radial nerve without direct exposure during use of IMN, the nerve injury findings were important to highlight.

Of interest to the reader would be analysis of patient-reported outcomes and range of motion data due to concerns about iatrogenic rotator cuff injury with IMN. Unfortunately, heterogeneity in reported outcome measures prevented compilation of data. Shoulder surgeons continue to care for patients who develop shoulder pain after use of IMN. Standard shoulder outcome metrics should be utilized in future comparisons of these two surgical techniques (such as American Shoulder and Elbow Surgeons and range of motion data).

As such, we are left with a solid recommendation that applies to most surgical procedures that we offer patients: Do what you do best. Factors such as age, activity level and fracture pattern (ie, long oblique, transverse, butterfly fragment) also should be considered.

Vani J. Sabesan, MD

This is a new study published examining an age-old question on optimal fixation for humeral shaft fractures. The authors took a new spin in this meta-analysis using only level-1 randomized controlled trials to understand outcomes and optimal surgical treatment for humeral shaft fractures, ORIF vs. IMN treatment. In their outcomes, they report comparable rates of union, reoperations and radial nerve palsies for IMN vs. ORIF for humeral shaft fractures. While both IMN and ORIF present as viable options for humeral shaft fractures, they found a slightly faster union time (10 weeks vs. 11.9 weeks) and lower infection rates (1.2% vs. 5.3%) associated with IMN group. They did have moderate heterogeneity for variables in the study.

From a clinical standpoint, these results reaffirm that both surgical treatment options have good outcomes with minimal complication rates, but factors such as fracture pattern, patient preferences and goals, and potential for complications need to be carefully weighed. Although IMN is a more minimally invasive technique and appears to offer benefits in specific aspects, understanding the patient specific factors, broader clinical context and individual patient need are paramount.