Treatment outcomes in humeral fractures of different location (review)

The choice of treatment (open reduction and internal fixation) for a humeral fracture with a plate versus an intramedullary nail is highly debated. We compared outcomes (fracture union, reoperation, and adverse events) of intramedullary nailing and plate fixation in patients with proximal humeral, humeral shaft, and distal humeral fractures. No significant differences were found between intramedullary nailing and plate fixation for fracture union, reoperation, or adverse events in patients with proximal humeral or humeral shaft fractures. There is a scarcity of evidence comparing intramedullary nailing and plating for distal humeral fractures. No recommendations can be given from current evidence. Surgeons may have to continue to use discretion based on their personal preference, experience as well as patient’s characteristics and fracture features before more high-quality evidence is available.


Introduction
According to Y. Akalin et al., fractures of the humerus, a common injury presenting to orthopedic surgeons, account for 1 to 3 % of all fractures in the elderly and 4 to 6 % in young patients [1].
The choice of open reduction and internal fixation for a humeral fracture with a plate versus an intramedullary nail is highly debated. Each treatment option has advantages. J.-G. Zhao et al. think that fixation using a plate allows direct visualization of the fracture site and facilitates the identification and protection of the radial nerve, whereas using intramedullary nail to fix humeral fracture preserves the periosteal blood supply and minimizes the disruption of the biology of the fracture healing [2].
The aim of the present work was to determine whether the location of humeral fracture (proximal humeral, humeral shaft, and distal humeral fractures) needs to be taken into consideration when choosing between intramedullary nailing and plate fixation as the treatment option. Specifically, by searching the PubMed database, we examined the following outcomes from randomized controlled trials (RCTs) -fracture union, reoperation, and adverse events.

Humeral shaft fractures
Outcomes of the union as well as the reoperation and adverse events in humeral shaft fractures are presented in Tables 3 and 4, respectively. We found no significant differences between intramedullary nailing and plate fixation for fracture union, reoperation, or adverse events.

Distal humeral fractures
No RCT evidence comparing plating and intramedullary nailing for distal humeral fractures was identified in the PubMed database. This is probably due to the fact that distal humeral fractures are mostly unstable, and not conducive to intramedullary nailing, so rigid plate fixation is preferred.

Conclusions
In this publication, we compared outcomes (fracture union, reoperation, and adverse events) of intramedullary nailing and plate fixation in patients with proxi-mal humeral, humeral shaft, and distal humeral fractures.
Generally, our quantitative analysis using RCT evidence found that there were no significant differences between intramedullary nailing and plate fixation in terms of the fracture union, reoperation, or adverse events in patients with proximal humeral fractures or those with humeral shaft fractures (Tables 1-4). There is a scarcity of evidence comparing intramedullary nailing and plating for distal humeral fractures.
Some of our findings based on RCTs, such as the adverse events in proximal humeral fractures, were not consistent with findings from other meta-analyses synthesizing both RCTs and non-randomized studies of interventions. For example, a meta-analysis conducted by Shi et al. (2019) reported the adverse events of intramedullary nailing and locking plate used in the treatment of proximal humeral fracture by summarizing 29 individual studies, which consisted of 2 RCTs and 27 retrospective observational studies [19]. The results of the meta-analysis, which differed from our results (relative risk 1.06, 95% confidence interval 0.40 to 2.80), showed that patients who underwent intramedullary nail fixation for proximal humeral fractures were less Heterogeneity: Tau z = 0.14; Chi z = 12.84, df = 8 (P = 0.12); I z = 38 % Test for overall effect: Z = 1.50 (P = 0.13)

Еnd of table 4
likely to have complications than those who underwent plate fixation (odds ratio 0.75; 95% CI 0.57 to 0.97). The RCTs may be limited in terms of providing data on adverse events due to their relatively small sample size, restricted eligibility for participants, and/or limited duration of follow-up. In addition, despite our results on fracture union, reoperation, or adverse events suggesting no differences, some meta-analyses synthesizing both RCT and non-randomized studies demonstrated the superiority of intramedullary nail over plate in treating either proximal humeral fractures (Shi et al., 2019) [19]  Altogether, no strong conclusions can be drawn from current evidence. Surgeons may have to discretion based on their personal preference, experience as well as patient's and fracture features before more high-quality evidence is available.