Revisiting the debate on operative vs nonoperative management of humeral shaft fractures

Abstract

Operative management of humeral shaft fractures demonstrates superior early functional recovery (6-month Disabilities of the Arm, Shoulder, and Hand scores) and significantly lower nonunion rates (63.9% reduction) compared to functional bracing, particularly in complex cases, while conservative treatment remains viable for low-demand patients. Surgical techniques, including open reduction internal fixation, intramedullary nailing, and minimally invasive plate osteosynthesis, offer trade-offs between anatomic precision and complication risks (e.g., radial nerve injury vs rotator cuff damage), with over 90% of radial nerve injuries resolving spontaneously. Ultrasound-guided diagnosis (89% sensitivity, 95% specificity) optimizes decision-making for nerve entrapment. Individualized treatment selection, prioritizing fracture complexity and patient needs, is critical to balance accelerated rehabilitation with minimized complications.

Key Words: Operative; Nonoperative; Functional brace; Humeral shaft fractures; Disabilities of the Arm, Shoulder, and Hand

Core Tip: Historically, humeral shaft fractures were predominantly managed through conservative methods. However, with advancements of open reduction internal fixation and intramedullary nailing, the rate of surgical intervention has gradually increased. But according to the previous literature, there were not consistent conclusions about conservative and surgical treatments. While conservative treatment avoids surgical complications and functional bracing has outstanding results, both operative and nonoperative follow-up periods and the potential for complications like nonunion, malunion, and loss of reduction are still debated. Patients in the surgery group benefit from early functional activities, but there is a risk of infection, nonunion, and failure of the internal fixation. Compared with conservative treatment, the surgery group has similar Disabilities of the Arm, Shoulder, and Hand scores at 12 months. Hematopoiesis is further disrupted by disturbed intraoperative soft tissue, and nonunion can result from potential instability in conservative treatment approaches.

INTRODUCTION

The optimal management of humeral shaft fractures remains controversial in orthopedic practice. Historically, nonoperative approaches dominated treatment paradigms for closed fractures due to perceived low complication rates[1]. However, advancements in surgical techniques and implant technology have progressively shifted clinical preference toward operative interventions, particularly in cases demanding rapid functional recovery.

FUNCTIONAL BRACING VS SURGICAL INTERVENTION

Once considered the gold standard for conservative management, functional bracing demonstrated < 2% nonunion rates in early studies (2000)[2]. This approach leverages humeral positioning under gravity to achieve fracture alignment while permitting shoulder/elbow mobility through brace design (shoulder-to-elbow coverage)[3]. Nevertheless, unlike weight-bearing bones (e.g., femur/tibia), the absence of physiological stress stimulation in the humerus may impede osteogenesis, potentially contributing to delayed union[2].

A 2020 multi-center randomized controlled trial comparing surgery and bracing for closed isolated femoral shaft fractures found superior 6-month Disabilities of the Arm, Shoulder, and Hand (DASH) scores with surgery, though this advantage dissipated by 12 months[4]. Notably, exclusion of complex/multi-segmental fractures and crossover from conservative to surgical groups during follow-up limit the study's generalizability, necessitating cautious interpretation[5].

SURGICAL ADVANCEMENTS

Modern surgical strategies, including open reduction internal fixation (ORIF), intramedullary nailing (IMN), and minimally invasive plate osteosynthesis (MIPO), address the critical limitations of conservative care[6]. Early Rehabilitation: Surgical fixation enables immediate weight-bearing and achieves twice the range of motion vs bracing within 6 months[7].

TECHNIQUE-SPECIFIC TRADE-OFFS

ORIF

Allows anatomical reduction but risks radial nerve injury (3%-11% incidence) and requires extensive soft tissue dissection[4,8].

IMN

Minimally invasive with axial stability, yet associated with rotator cuff injuries (5%-15%)[8].

MIPO

Reduces iatrogenic soft tissue damage and avoids radial nerve exposure[9]. A 2024 meta-analysis highlights surgical superiority, showing 63.9% lower nonunion rates and reduced secondary interventions (8.9% vs 19.9%) vs conservative management[9].

FRACTURE-SPECIFIC OUTCOMES

For AO 12A/B fractures, surgery correlates with better early DASH scores, while conservative care yields lower Visual Analogue Scale pain scores within 6 months[1]. Critically, surgical intervention remains definitive for managing nonunion cases, demonstrating higher union rates (92%-97% vs 70%-82%) and superior functional outcomes[10].

RADIAL NERVE INJURY MANAGEMENT (KEY CONSIDERATIONS)

Spontaneous recovery: > 90% of radial nerve palsies resolve with observation alone[11]; Diagnostic imaging: Ultrasound (89% sensitivity, 95% specificity) effectively detects nerve entrapment between fragments, guiding decisions for surgical exploration[11]; Surgical indications: Immediate decompression is imperative for entrapped nerves with electrophysiological deficits[12].

CONCLUSION

The paradigm shift toward surgical management reflects its advantages in accelerating functional recovery and reducing reoperation risks. However, treatment selection must be personalized. Surgery is preferred for complex fractures, nonunion, or patients requiring rapid upper limb function. Meanwhile, more conservative options retain value in low-demand patients or those with comorbidities contraindicating surgery. Future research should focus on long-term outcomes (≥ 5 years) and cost-effectiveness analyses to refine clinical guidelines.