Outcomes With Surgery vs Functional Bracing for Patients With Closed, Displaced Humeral Shaft Fractures and the Need for Secondary Surgery

Abstract

IMPORTANCEExisting evidence indicates that surgery fails to provide superior functional outcome over nonoperative care in patients with a closed humeral shaft fracture. However, up to one-third of patients treated nonoperatively may require secondary surgery.OBJECTIVE To compare the 2-year outcomes of patients who required secondary surgery with the outcomes of patients with successful initial treatment. DESIGN, SETTING, AND PARTICIPANTSThis 2-year follow-up of the Finnish Shaft of the Humerus (FISH) randomized clinical trial comparing surgery with nonoperative treatment (functional brace) was completed in January 2020. Enrollment in the original trial was between November 2012 and January 2018 at 2 university hospital trauma centers in Finland. A total of 321 adult patients with closed, displaced humeral shaft fracture were assessed for eligibility. After excluding patients with cognitive disabilities, multimorbidity, or multiple trauma and those refusing randomization, 82 patients were randomized.INTERVENTIONS Interventions were surgery with plate fixation (n = 38; initial surgery group) or functional bracing (n = 44); the latter group was divided into the successful fracture healing group (n = 30; bracing group) and the secondary surgery group (n = 14) with fracture healing problems. MAIN OUTCOMES AND MEASURESThe primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 2 years (range, 0 to 100 points; 0 denotes no disability, 100 extreme disability; minimal clinically important difference, 10 points). RESULTSOf 82 randomized patients, 38 (46%) were female. The mean (SD) age was 48.9 (17.1) years. A total of 74 patients (90%) completed the 2-year follow-up. At 2 years, the mean DASH score was 6.8 (95% CI, 2.3 to 11.4) in the initial surgery group, 6.0 (95% CI, 1.0 to 11.0) in the bracing group, and 17.5 (95% CI, 10.5 to 24.5) in the secondary surgery group. The between-group difference was −10.7 points (95% CI, −19.1 to −2.3; P = .01) between the initial and secondary surgery groups and −11.5 points (95% CI, −20.1 to −2.9; P = .009) between the bracing group and secondary surgery group.CONCLUSIONS AND RELEVANCE Patients contemplating treatment for closed humeral shaft fracture should be informed that two-thirds of patients treated with functional bracing may heal successfully while one-third may experience fracture healing problems that require secondary surgery and lead to inferior functional outcomes 2 years after the injury.

Factors Associated with Patient-Reported Outcomes Following a Humeral Shaft Fracture: Nonunion Results in a Poorer Outcome Despite Union after Surgical Fixation

“…Broadbent et al 18 also observed that humeral diaphyseal nonunion was associated with a worse Neer score up to 1-year postinjury. Reporting 2-year follow-up of the Finnish Shaft of Humerus (FISH) randomized clinical trial, Rämö et al 20 found that functional outcomes among 14 patients who united after nonunion surgery were inferior to those who underwent successful initial operative or nonoperative management. Our results add to this growing body of evidence that poorer function and HRQoL may persist for years following a humeral shaft nonunion.…”

“…15,18,21 Longer-term patient-reported outcomes after a humeral diaphyseal fracture and the legacy of humeral shaft nonunion surgery are incompletely understood. 20 The authors are aware of only 2 smaller studies assessing factors associated with functional outcome, 18,19 and neither examines the effect of nonunion in the longer term.…”

Routine fixation of humeral shaft fractures is cost-effective

“… 24 In the absence of any clear benefit, it has been difficult to justify the operative risks and increased costs associated with routine fixation for patients with these injuries. However, considering the differential nonunion rate between nonoperative and operative management, 6 , 7 and the increasing body of evidence that humeral shaft nonunion leads to inferior patient-reported upper limb function and health-related quality of life even after successful nonunion surgery, 8 , 9 there may be longer-term advantages to operative fixation that have been previously underappreciated. This study attempts to quantify the longer-term utility of reducing the risk of humeral shaft nonunion, by offering early surgery to all patients.…”

“…recalcitrant nonunion rate negligible); initial operative management involving plate and screw fixation would generate fracture union (i.e. nonunion rate after initial fixation negligible); longer-term HRQoL (according to the EQ-5D-3L) would be equivalent after initial nonoperative and initial operative management, provided union had been achieved; 3 , 4 , 8 , 9 and any difference in longer-term HRQoL (according to the EQ-5D-3L) resulting from nonunion after nonoperative management would be present throughout the preceding five years.…”

“…One of the principal differences between these two management strategies is the rate of nonunion, which is reported to be less than 3% after open reduction and compression plating, 5 and 15% to 17% after nonoperative management. 6 , 7 Given the potential impact of humeral shaft nonunion upon longer-term patient-reported outcomes, 8 , 9 one of the most compelling arguments for offering fixation to more patients may lie in mitigating the detrimental effects of this complication upon patient function and health-related quality of life (HRQoL). Health economic analyses have been recommended as essential in rationalizing humeral shaft fracture management.…”