Review Question - QID 214153

The patient has a proximal 1/3rd humeral shaft fracture with persistent fracture site motion after 6 weeks of conservative management. Given the significant risk of nonunion, he should be offered surgical management at this time.

The management of humeral shaft fractures remains very controversial. Conservative management with coaptation splint followed by Sarmiento bracing is still considered the standard of care in the majority of humeral shaft fractures. Union rates approach 80-90% with conservative management with the exception of certain fracture patterns more prone to nonunion (proximal 1/3rd shaft fractures, fracture-site distraction, and transverse fracture patterns). The decision to abort conservative management and convert to surgical fixation should be based on physical exam, patient symptoms, and radiographic findings. Persistent fracture site motion at 6 weeks is considered to be very highly predictive of progressing to nonunion and surgical management should be recommended for such patients.

Driesman et al. performed a retrospective cohort study to assess the presence of fracture site gross motion on physical examination to predict humeral shaft fracture progression to nonunion in patients managed nonoperatively. The authors reviewed 84 consecutive patients undergoing nonoperative treatment of a diaphyseal humeral shaft fracture. They noted that 73 patients (87%) healed their fracture by 6 months and 11 patients who went on to nonunion. The authors noted that if the humeral shaft fracture site was mobile at the 6-week follow-up visit, it identified future fracture nonunion with 82% sensitivity and 99% specificity. The authors concluded that knowledge of gross fracture motion at 6 weeks can be used in the shared decision-making model in counseling about early surgical options.

Carroll et al. performed a review of the management of humeral shaft fractures. They note that nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is arguably the standard of care for these fractures. They note specific criteria for surgical management to include polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. They describe the advantage and disadvantages of the various surgical managements including external fixation, open reduction internal fixation, and intramedullary nailing.

Figures A and B are the AP and lateral radiographs revealing a displaced proximal 1/3rd humeral shaft fracture. Figures C and D are the AP and lateral radiographs revealing improved alignment after closed reduction of the humeral shaft fracture. Figures E and F are the 6-week follow-up AP and scapular Y radiographs that reveal minimal bony callus with displacement of the fracture with the Sarmiento brace in place.

Incorrect Answers:
Answers 1, 2, 4, and 5: Given the persistent fracture site motion after 6 weeks of non-operative management, surgical intervention should be offered to the patient at this time.