Review Question - QID 220162

This patient has a transverse humeral shaft fracture. Contemporary literature has found that surgical management with closed reduction and intramedullary nail fixation is associated with lower infection rates when compared to open reduction and internal fixation (ORIF) (Answer 4).

Humeral shaft fractures are common injuries, representing 20% of all humerus fractures. These injuries have a bimodal distribution with respect to patient age. In young patients, these injuries are typically the result of high-energy trauma, whereas in older patients, they occur secondary to low-energy falls. Historically, many of these injuries were managed nonoperatively with splinting and subsequent functional bracing. Contemporary literature, however, has suggested unacceptably high nonunion rates and lower rates of patient satisfaction following nonoperative management. As a result, interest has been resurgent regarding the operative management of these injuries. Multiple reduction and fixation techniques can be utilized by surgeons, including, but not limited to, traditional open reduction and internal fixation (ORIF), closed reduction with intramedullary nail fixation (IMN), and minimally invasive plate osteosynthesis (MIPO).

Hurley et al. performed a meta-analysis of randomized controlled trials comparing IMN and ORIF for humeral shaft fractures. Their study ultimately included 10 RCTs with 512 patients. Overall, the authors found that time to union was quicker following IMN versus ORIF, and that IMN was associated with a lower postoperative infection rate and intraoperative time. The authors found no difference in reoperation rate or postoperative radial nerve palsy.

Den Hartog et al. performed a randomized controlled trial comparing ORIF and IMN for humeral shaft fractures. Their study included 76 patients treated with ORIF and 169 treated with IMN. The authors found that ORIF was associated with faster patient recovery but more temporary nerve palsies. On the other hand, IMN was associated with a higher rate of hardware-related complications and operations. Overall, the authors concluded that ORIF appeared superior to IMN for these injuries.

Colasanti et al. performed a systematic review and meta-analysis of individualized treatment strategies for humeral shaft fractures. Overall, 25 studies reporting on 1908 patients were included. The authors found that nonoperative management was associated with the highest nonunion rates, and that IMN was associated with the lowest deep infection rate. Furthermore, MIPO was associated with a lower postoperative radial nerve palsy rate than IMN or ORIF.

Incorrect Answers
Answer 1: nonoperative management of these injuries is associated with higher rates of nonunion compared to all contemporary surgical techniques.
Answer 2: patients treated with MIPO experience a lower rate of transient radial nerve palsy compared to traditional ORIF.
Answer 3: patients treated with IMN are more likely to experience hardware-related complications.
Answer 5: total operative time is higher for ORIF compared to IMN.