An Excellent Study of Operative Versus Nonoperative Treatment of Humeral Shaft Fractures: Commentary on an article by Fabio Teruo Matsunaga, MD, PhD, et al.

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This article is an excellent attempt to address the clinical dilemma posed when a patient presents with a closed humeral midshaft fracture. In an era of increasingly aggressive surgical management of common fractures, we are frequently faced with the difficult task of predicting how patients will fare in the long term with nonoperative management. Experience has demonstrated that the chance of achieving union with a functional brace is anywhere from 77% to 100%1. Indeed, in this study by Matsunaga et al., nonoperative measures achieved union in 85% of patients. Operative management with a traditional open anterolateral approach is associated with blood loss, a risk of radial nerve palsy and infection, and a frequently substantial and noticeable scar. The technique of minimally invasive osteosynthesis, while previously reported on, has not gotten widespread attention in many parts of the world. The technique offers many potential advantages over the traditional anterolateral approach, including less blood loss, shorter incisions, and less muscle trauma2. Matsunaga et al. reported a 100% union rate and a low complication rate with this technique.
The real question that this study raises is what are the drivers of increasingly aggressive management of humeral fractures? One driver would be better patient-related outcome scores after operative treatment. The current study, while demonstrating a slightly higher Disabilities of the Arm, Shoulder and Hand (DASH) score at 6 months, did not show a difference of >10 points (which has been considered to be the minimal clinically important difference between groups). A second driver would be a wish to avoid the complications associated with nonoperative management. Certainly, the current trend of treating scaphoid fractures with surgery reflects a concern about successful management of the difficult problem of nonunion of that bone. In this study, 7 patients (13%) had a humeral shaft nonunion and 1 had a humeral shaft malunion after nonoperative management. All were managed successfully with conventional surgical treatment of the nonunion, with perhaps the greatest complication being the time that the patient spent undergoing brace treatment.
Although this study does not provide compelling evidence to support routine operative intervention, it does take the first step in the identification of which patients will benefit from early operative management. While the analysis of the nonoperative group did not show a correlation between nonunion and the risk factors (obesity and large breast mass) traditionally associated with various unsatisfactory results, subsequent studies may elucidate which factors predispose patients to early operative treatment. Finally, despite the current landscape of health care, the authors did not examine the cost associated with nonoperative management of a humeral shaft fracture, which can frequently take months to unite. While the surgical costs can be estimated, the ability of the patient to return to work may be an important factor in patient decision-making. The exact time to union and the patient’s return to employment were not evaluated in this study and, without these data, the cost of operative versus nonoperative management cannot be calculated.
The authors are to be congratulated on completing an exceedingly well-designed and well-controlled study and providing a critical first step in identifying the optimal management of this common fracture.
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