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.

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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.

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COMPLICATIONS

Two weeks after initiating brace treatment, an obese patient suffered a rash with desquamation that necessitated discontinuation of the brace. However, the skin and fracture ultimately healed with a coaptation splint and sling support without additional complications. In the casting cohort, 2 patients returned to the emergency department after AEC placement because of swelling of the hand and pain in the cast. Both casts were removed and reapplied.

DISCUSSION

Fractures of the distal third of the humeral diaphysis heal without surgery. Fracture angulation and elbow stiffness are the concerns that lead to variations in nonoperative treatment.^1-3 Advocates of casting believe they can get better alignment without losing elbow motion, and advocates of bracing feel that the brace is less cumbersome.^1-3,5-8 We compared these treatments retrospectively and found them comparable.

This study should be considered in light of its limitations. Many patients were lost to follow-up in our urban trauma centers. We do not know if these patients did better, worse, or the same as the patients we were able to evaluate, but our opinion is that patients having problems were more likely to return. The evaluation time was relatively short, but motion can only improve in the longer-term. Two patients that were initially braced chose surgery, probably because either they or their surgeon were nervous about the radiographic appearance of the fracture. In our opinion, continued nonoperative treatment of these patients would not affect the findings.

Cast treatment of distal diaphyseal humerus fractures does not cause permanent elbow stiffness. This is confirmed by our results; as casted patients did not lose final ROM compared to the bracing cohort. These injuries are extra-articular and casted patients are transitioned to bracing once humeri have significant union demonstrated by the arm moving as a unit. To our knowledge, there is no other study that has evaluated casting for these fractures, but it may be that evidence of permanent stiffness with nonoperative treatment of distal metaphyseal fractures of the humerus [AO/OTA type 13] is misapplied to distal humeral shaft fractures [AO/OTA type 12].^3,9,10,12 For brace treatment, Sarmiento and colleagues⁹ showed no significant elbow stiffness in a consecutive cohort of 69 patients, while Jawa and colleagues⁵ showed no increased elbow stiffness compared to plate fixation. Given the accumulated data,^3,5,6,8,13 advocates of operative treatment for distal third diaphyseal humerus fractures¹²can no longer site elbow stiffness as a disadvantage of nonoperative treatment, whether with cast or brace.

As shown in this study, patients that choose nonoperative treatment can expect their fracture to heal with an average of approximately 15° of varus angulation, as well as 2 others evaluating brace treatment.^5,9 Some will heal with as much as 30° of varus angulation.^5,9 The arm may look a little different, particularly in thin patients, but there is no evidence that this angulation affects function. The risks, discomforts, and inconveniences of surgery can be balanced with the ability of surgery to improve alignment and allow elbow motion a few weeks earlier. The aesthetics of the scar after surgery may not be better than the deformity after nonoperative treatment. Patients should be involved in these decisions.

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