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SICOT e-Newsletter

Issue No. 65 - February 2014

Scientific Debate

Humeral shaft fracture fixation. Has the pendulum swung back?

Syah Bahari
KPJ Seremban Specialist Hospital and KPJ Healthcare University College, Malaysia

When discussing the best choice for operative fixation for humeral shaft fracture, one needs to know that historically most humeral shaft fractures are treated by conservative means with satisfactory outcome. The indications for operative fixation for humeral shaft fracture are polytrauma, floating elbow, segmental fracture, pathological fracture, open fracture, non-union, malunion, progressive vascular impairment and inability to maintain reduction with conservative treatment [1].

With this in mind, comparing open reduction and plate fixation and closed reduction and intramedullary nail fixation, the arguments will be on biology and principle of fracture healing, biomechanics, complications and current evidences at the moment.

For a humeral shaft fracture, relative stability at the fracture site is acceptable for fracture union. This can be achieved with the use of an intramedullary nail. With a remote entry point away from the fracture site, the biology of the fracture site will be preserved thus providing an optimum environment for fracture healing [2]. This is clearly not the case with an open reduction and internal fixation technique where extensive soft tissue stripping will likely devascularise the bone and affect fracture healing.

Biomechanically, intramedullary nail is a load-sharing device [3]. Comparative to the plate, the newer interlocking intramedullary nail can also provide compression at the fracture site in simple fracture and is arguably better in bridging of the fracture site in comminuted fracture.

When there is evidence of radial nerve injury, current evidence suggests that this is likely due to a neuropraxia and this is not an absolute indication for surgical intervention [4] unless there is evidence that the nerve is not recovering. However, for humeral shaft fracture without nerve injury, the risk of iatrogenic radial nerve injury is higher with either anterior or posterior approach when compared to intramedullary nailing technique [5]. Infection rate is also noted to be higher with an open approach and plating [5]. Furthermore, there is report on injury to the brachial artery with the open anterior approach that may complicate the open reduction technique [6].

When one looks at the literature on this issue, few randomized controlled trials (RCT) were done in the earlier part of this century. One notable RCT study was by McCormack et al. The endpoints of the study showed similar functional outcome, pain level and time to return to normal activities. The significant differences were between incidence of complication and reoperation rate which were in favour of the plating technique [7]. However, based on the current evidence in the literature, it is very difficult to argue which one is the best choice for operative treatment for humeral shaft fracture fixation. Current meta-analyses [5,8,9] on this issue were unable to draw definite consensus regarding which is the best choice for operative fixation of humeral shaft fracture. Dai et al found in their study that nailing technique has a lower risk of postoperative wound infection rate and lower risk of iatrogenic nerve injury [5]. Ouyang et al noted that the only advantage of plating over nailing technique was the associated shoulder symptom in nailing technique [8]. However, if one looks at the outcome of both techniques in terms of non-union, delayed union, pain level and functional outcome, there is no significant difference in the outcome based on these parameters [9]. Certainly, a large multi-centre randomized control trial is needed to solve this conundrum.

  1. Spiguel AR, Steffner RJ. Humeral shaft fractures. Curr Rev Musculoskelet Med. 2012 Sep;5(3):177-83.
  2. Pfeifer R, Sellei R, Pape HC. The biology of intramedullary reaming. Injury. 2010 Nov;41 Suppl 2:S4-8.
  3. Steriopoulos K, Psarakis SA, Savakis C et al. Architecture of the femoral medullary canal and working length for intramedullary nailing. Biomechanic indications for dynamic nailing. Acta Orthop Scand Suppl. 1997 Oct;275:123-6.
  4. Korompilias AV, Lykissas MG, Kostas-Agnantis IP et al. Approach to radial nerve palsy caused by humerus shaft fracture: Is primary exploration necessary? Injury. 2013 Jan 22
  5. Dai J, Chai Y, Wang C et al. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures: a meta-analysis of RCTs and nonrandomized studies. J Orthop Sci. 2013 Nov 19
  6. Kumar V, Behera P, Aggarwal S et al. Iatrogenic brachial artery injury during anterolateral plating of humeral shaft fracture. Chin J Traumatol. 2013 Dec 1;16(6):371-4
  7. McCormack RG, Brien D, Buckley RE et al. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomized trial. J Bone Joint Surg Br. 2000 Apr;82(3): 336-9
  8. Ouyang H, Xiong J, Xiang P et al. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg. 2013 Mar;22(3):387-95
  9. Liu GD, Zhang QG, Ou S et al. Meta-analysis of the outcomes of intramedullary nailing and plate fixation of humeral shaft fractures. Int J Surg. 2013;11(9):864-8

Surgical management of humeral shaft fractures: Plating is the way forward

Solayar GN, Shannon FJ
University College Hospital Galway, Ireland

Humeral shaft fractures account for 3% of all fractures and 20% of all humeral fractures [1]. The question regarding which fixation type would give the best results remains unanswered. It mostly boils down to the surgeon's own preference. In this article, we convey our argument on why one should perform open fixation via plating rather than intramedullary nailing.

An advantage offered by conventional plating versus intramedullary nailing is the reduced incidence of shoulder symptoms [2]. The literature suggests increased shoulder stiffness, rotator cuff insufficiencies and chronic shoulder pain associated with nailing. These symptoms are mostly secondary to the antegrade introduction of the nail (via the proximal humerus). In a similar fashion, retrograde humeral nailing has been associated with elbow stiffness, pain, ulna nerve problems and metal prominence. Humeral plating via open reduction avoids these preventable complications and is therefore, in our opinion, a superior option [3].

Next, neurological injury. The risk of radial nerve palsy following humeral shaft fractures is up to 18% with a higher risk noted especially following fractures in the distal third [4]. Though the majority represents neuropraxias, there is still a risk of permanent damage and poor long-term outcomes. Some surgeons prefer visualising, protecting and clearly documenting the nerve’s appearance when dealing with humeral shaft fractures. It appears that nailing is associated with a higher risk of radial nerve injury though the jury is still out with regards to its significance compared with conventional plating [5,6]. An open incision would identify a ruptured/transected nerve well, which might be amenable to early repair again improving chances of nerve recovery. There is evidence of immediate open exploration of the radial nerve following open fractures with radial nerve palsy though expectant treatment (exploration following 16-18 weeks) is advisable following closed fractures treated conservatively [7].
We would also like to point out the significant benefits of plating in terms of basic biomechanics. It offers surgeons the choice between achieving absolute stability through inter-fragmentary compression which leads to direct bone healing and relative stability through bridge plating which allows for indirect bone healing. Intramedullary nailing is not intended for providing compression across simple/oblique fractures which would allow for direct bone healing, but rather allows for relative stability and indirect bone healing. The option of a locking plate construct further expands its appeal as the benefits of this in osteoporotic bone is clear [8].

With respect to both plating and intramedullary nailing, we must address the literature on their respective union rates. The literature seems to show similar union rates for both options and thus, the debate continues [5]. A meta-analysis did show a lower re-operation rate following conventional plating compared to intramedullary nailing [2]. There are many factors that contribute to this discrepancy, among them, the ability to address soft tissue interposition, insults to the soft tissue envelope and achieving good fracture reduction.

In summary, we advocate open reduction and internal fixation with conventional plating. The advantages with regards to shoulder symptoms, improved biomechanics and the ability for direct fracture reduction are clearly attractive options. Large, high quality randomised controlled trials in the future would improve the literature with regards to union rates and complications between plating versus nailing.

  1. Bercik MJ, Tjoumakaris FP, Pepe M, Tucker B, Axelrad A, Ong A, et al. Humerus fractures at a regional trauma center: an epidemiologic study. Orthopedics [Internet]. 2013 Jul [cited 2014 Feb 17];36(7):e891–7. Available from:
  2. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop [Internet]. 2006 Apr [cited 2014 Mar 1];77(2):279–84. Available from:
  3. Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg [Internet]. 2013 Mar [cited 2014 Jan 24];22(3):387–95. Available from:
  4. Venouziou AI, Dailiana ZH, Varitimidis SE, Hantes ME, Gougoulias NE, Malizos KN. Radial nerve palsy associated with humeral shaft fracture. Is the energy of trauma a prognostic factor? Injury [Internet]. 2011 Nov [cited 2014 Feb 17];42(11):1289–93. Available from:
  5. Kurup H, Hossain M, Andrew JG. Dynamic compression plating versus locked intramedullary nailing for humeral shaft fractures in adults. Cochrane database Syst Rev [Internet]. 2011 Jan [cited 2014 Feb 17];(6):CD005959. Available from:
  6. Putti AB, Uppin RB, Putti BB. Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures. J Orthop Surg (Hong Kong) [Internet]. 2009 Aug [cited 2014 Feb 17];17(2):139–41. Available from:
  7. Korompilias A V, Lykissas MG, Kostas-Agnantis IP, Vekris MD, Soucacos PN, Beris AE. Approach to radial nerve palsy caused by humerus shaft fracture: Is primary exploration necessary? Injury [Internet]. Elsevier; 2013 Jan 22 [cited 2014 Mar 1];44(3):323–6. Available from:
  8. Gardner MJ, Griffith MH, Demetrakopoulos D, Brophy RH, Grose A, Helfet DL, et al. Hybrid locked plating of osteoporotic fractures of the humerus. J Bone Joint Surg Am [Internet]. 2006 Sep [cited 2014 Feb 16];88(9):1962–7. Available from: