What is the recommended treatment for a mid shaft simple humerus fracture?

Treatment for Mid Shaft Simple Humerus Fracture

Nonsurgical management with functional bracing is the standard of care for simple mid shaft humeral fractures. 1

Initial Management

• Initial immobilization options:
  • Functional splint (FS) is preferred over coaptation splint (CS)
  • Research shows FS is easier to apply, takes less time, and is better tolerated by patients while providing similar fracture reduction outcomes 2

Definitive Treatment Algorithm

1. First-line treatment: Functional bracing

   • Functional bracing has been the standard approach since the 1970s 1
   • Allows for controlled motion while maintaining fracture alignment
   • Typically worn for 6-8 weeks until clinical and radiographic healing is evident

2. Surgical indications (when to deviate from nonsurgical management):

   • Polytraumatic injuries
   • Open fractures
   • Vascular injury
   • Ipsilateral articular fractures
   • Floating elbow injuries
   • Fractures that fail nonsurgical management 1

Monitoring and Follow-up

• Early detection of potential nonunion:

  • Recent evidence suggests nonunion may be identified as early as 6-8 weeks post-injury 3
  • Regular radiographic follow-up is essential at 2,4,6, and 12 weeks

• Nonunion risk:

  • Traditional literature cites low nonunion rates with functional bracing
  • However, modern studies report nonunion rates may be as high as 33% 3
  • This higher rate suggests the need for vigilant monitoring

Surgical Options (if indicated)

If surgery becomes necessary, options include:

1. Open reduction and internal fixation (ORIF) with compression plating

   • Gold standard for simple (AO/OTA type A) fractures 4
   • Provides excellent stability and high union rates

2. Minimally invasive percutaneous osteosynthesis (MIPO)

   • Less invasive approach preserving periosteal blood supply
   • Allows for indirect bone healing with callus formation 4

3. Intramedullary nailing (antegrade or retrograde)

   • Less soft tissue disruption
   • Improved implant designs have made this a more viable option in recent years 4

4. External fixation

   • Primarily for open fractures or significant soft tissue injury

Complications to Monitor

• Radial nerve injury:

  • A relatively high incidence associated with both the fracture itself and surgical management 1
  • Ultrasound can be used to detect nerve contusion, entrapment, or laceration 4

• Nonunion:

  • If nonunion develops, surgical intervention typically consists of compression plating with or without bone graft 3
  • Specialized techniques such as cortical struts or vascularized fibular grafts may be required in recalcitrant cases

Practice Trends

Recent survey data from the British Elbow and Shoulder Society shows that 90.1% of surgeons prefer nonsurgical management for middle-third humeral shaft fractures, confirming that conservative treatment remains the standard approach 5.

Key Pitfalls to Avoid

1. Failing to recognize surgical indications - While nonsurgical management is standard, certain fracture patterns and patient factors necessitate surgery
2. Inadequate follow-up - Missing early signs of nonunion (at 6-8 weeks) can lead to delayed treatment
3. Poor bracing technique - Improper application of functional bracing can lead to malunion
4. Overlooking radial nerve status - Always document neurological status before and after treatment