Original Research

Nonoperative Treatment of Closed Extra-Articular Distal Humeral Shaft Fractures in Adults: A Comparison of Functional Bracing and Above-Elbow Casting

Publish date: May 15, 2018

References

1. McKee MD. Fractures of the shaft of the humerus. In: Bucholz R, Heckman JD, Court-Brown C, eds. Rockwood and Green’s Fractures in Adults. 6th ed. Philadelphia: Lippencott Williams & Wilkins; 2006:1117-1159.

2. Schemitsch E, Bhandari M, Talbot M. Fractures of the humeral shaft. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, Krettek C, eds. Skeletal Trauma. 4th ed. Philadelphia: Saunders-Elsevier Company; 2009:1593-1622.

3. Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: a review. J Shoulder Elbow Surg. 2011;20(5):833-844. doi:10.1016/j.jse.2010.11.030.

4. Balfour GW, Mooney V, Ashby ME. Diaphyseal fractures of the humerus treated with a ready-made fracture brace. J Bone Joint Surg Am. 1982;64(1):11-13. doi:10.2106/00004623-198264010-00002.

5. Jawa A, McCarty P, Doornberg J, Harris M, Ring D. Extra-articular distal-third diaphyseal fractures of the humerus. A comparison of functional bracing and plate fixation. J Bone Joint Surg Am. 2006;88(11):2343-2347. doi:10.2106/JBJS.F.00334.

6. Pehlivan O. Functional treatment of the distal third humeral shaft fractures. Arch Orthop Trauma Surg. 2002;122(7):390-395. doi:10.1007/s00402-002-0403-x.

7. Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace treatment of diaphyseal humerus fractures. J Trauma. 2007;62(5):1157-1158. doi:10.1097/01.ta.0000222719.52619.2c.

8. Sarmiento A, Horowitch A, Aboulafia A, Vangsness CT Jr. Functional bracing for comminuted extra-articular fractures of the distal third of the humerus. J Bone Joint Surg Br. 1990;72(4):283-287.

9. Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977;59(5):596-601.

10. Toivanen JA, Nieminen J, Laine HJ, Honkonen SE, Jarvinen MJ. Functional treatment of closed humeral shaft fractures. Int Orthop. 2005;29(1):10-13. doi:10.1007/s00264-004-0612-8.

11. Wallny T, Westermann K, Sagebiel C, Reimer M, Wagner UA. Functional treatment of humeral shaft fractures: indications and results. J Orthop Trauma. 1997;11(4):283-287.

12. Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium - 2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1-S133.

13. Paris H, Tropiano P, Clouet D'orval B, Chaudet H, Poitout DG. Fractures of the shaft of the humerus: systematic plate fixation. Anatomic and functional results in 156 cases and a review of the literature. Rev Chir Orthop Reparatrice Appar Mot. 2000;86(4):346-359.

In our differing institutions, there are advocates of each type of treatment, providing the opportunity for a comparison. This retrospective study compares brace and cast treatment. The working hypothesis was that there is no difference in elbow motion 6 months or more after fracture. We also compared radiographic alignment after union.

MATERIALS AND METHODS

Between 2003 and 2012, consecutive adult patients treated for a nonpathological fracture of the diaphysis of the distal humerus at the orthopedic trauma service of 3 level 1 academic trauma centers were identified from prospectively collected trauma injury databases. Patients with vascular injury, ipsilateral upper extremity fracture, and periprosthetic fractures were excluded. The attending orthopedic surgeon chose the treatment method and evaluated the range of motion (ROM) of the elbow and radiographic union at the final ambulatory visit. We included patients followed to clinical and radiographic union with a minimum of 6 months of follow-up. We also included patients with <6 months’ follow-up who demonstrated union and had elbow ROM within 10° of the uninjured arm.

We identified 105 consecutive adult patients with a closed nonpathological extra-articular distal humeral shaft fracture (fracture of the distal humeral shaft with an AO/OTA type-12.A, 12.B, or 12.C pattern) treated with an AEC or a brace in our databases.¹² Two patients in the brace group chose surgery to improve alignment within 3 weeks of injury and were excluded from the analysis. Twenty-eight patients had inadequate follow-up.

A total of 75 patients were included in the study. At the first and second institutions, 51 patients were treated with functional bracing with an average follow-up of 7 months. At the third institution, 24 patients were treated with an AEC with an average follow-up of 4 months. Seventeen out of 24 patients in the long arm casting group and 19 out of 51 patients in the bracing group, who were included since they had <6 months of follow-up, demonstrated union and had elbow ROM within 10° of the uninjured arm. Differing methods of closed immobilization were the result of differing treatment algorithms at each institution.

The patients who were treated with a functional brace averaged 34 years of age (range, 18-90 years) and included 27 men and 24 women. The brace was removed at an average of 11.5 weeks (range, 8-18 weeks) after initial injury. Six patients had an injury-associated radial nerve palsy, all of which fully recovered within an average of 4 months (range, 0.5-7 months). Sixteen patients were injured due to a fall from standing height, 2 due to a fall from a greater height than standing, 16 in a motor-vehicle accident, 15 during a sport activity, and 2 were not specifically documented.

Continue to: Four patients had concomitant...