Indications for ORIF of Humeral Fractures
The decision to perform ORIF on a humeral fracture depends primarily on fracture location, displacement, neurovascular status, and whether closed reduction is achievable—with displaced pediatric supracondylar fractures requiring closed reduction with pinning (or open reduction if closed fails), while adult proximal humerus fractures have less clear surgical indications.
Pediatric Supracondylar Humerus Fractures
Absolute Indications for Surgical Intervention
- Displaced fractures (Gartland types II and III) require closed reduction with percutaneous pin fixation rather than ORIF 1
- Emergent closed reduction is indicated for patients with decreased hand perfusion, with open reduction reserved only if closed technique fails 1
- Open reduction becomes necessary when closed reduction cannot be achieved due to fracture pattern, soft-tissue interposition, or technical factors 1
Vascular Compromise Algorithm
The AAOS guidelines provide a structured approach based on perfusion status 1:
- Absent pulses with cold, pale hand after reduction and pinning: Open exploration of antecubital fossa is indicated to prevent limb loss 1
- Absent pulses but perfused hand after reduction: Evidence is inconclusive, requiring clinical judgment 1
- Decreased perfusion pre-reduction: Emergent closed reduction should be attempted first 1
Key Clinical Pitfall
While the evidence for open reduction in pediatric supracondylar fractures without neurovascular injury is inconclusive, several factors mandate consideration 1:
- Fracture pattern complexity
- Soft-tissue interposition preventing closed reduction
- Surgeon experience and available resources
- Time from injury (mixed evidence suggests surgery within 12 hours may reduce need for open reduction) 1
Important caveat: Open reduction in pediatric cases is associated with greater elbow stiffness compared to closed reduction with pinning, though it shows lower rates of loss of reduction 1
Adult Proximal Humerus Fractures
Indications for ORIF
The evidence for adult proximal humerus fractures is less definitive than pediatric guidelines. ORIF may be considered for 2, 3:
- 3-part and 4-part fractures where functional restoration is the goal, though comparative evidence with non-operative management remains controversial 2, 4
- Fractures with significant displacement that cannot maintain acceptable alignment non-operatively 2
Evidence Limitations
Recent research shows 4:
- Three previous randomized controlled trials found no difference in patient-centered outcomes between non-operative treatment and ORIF for displaced 3- and 4-part proximal humerus fractures
- Management remains controversial due to methodological concerns in existing studies
Outcomes Consideration
When ORIF is performed for 3- and 4-part proximal humerus fractures 2, 3:
- 87% achieve good or excellent results at 10-year follow-up 2
- Avascular necrosis develops in 37% of cases, but 77% of these patients still achieve good or excellent outcomes 2
- Augmentation with bone grafting shows 82% radiographic healing rates 3
Humeral Shaft Fractures
Surgical Indications
ORIF for humeral shaft fractures is indicated when 5, 6:
- Open fractures requiring debridement and stabilization 6
- Multiple injuries necessitating early mobilization 6
- Failed non-operative treatment to maintain acceptable reduction 6
- Neurovascular injury requiring exploration
Technical Considerations
When surgery is indicated 5, 6:
- Both MIPO and conventional ORIF show comparable functional outcomes 5
- MIPO demonstrates shorter union time (4 vs 5 months median) 5
- Proper AO plating technique yields 97% union rates with minimal complications 6
Common Pitfall
The primary risk with humeral shaft ORIF is iatrogenic radial nerve injury, though this occurs at low rates (transient palsy in isolated cases) when proper technique is followed 5, 6