Humeral Shaft Fracture Fixation

Update This article was updated on January 28, 2021, because of previous errors. On page 3, in Table I, the “Total for proximal ext., open” row now includes the footnote “†1 patient received both a plate and a nail, and was included in the ORIF category.” Also in Table I, the “Total for humeral fracture, closed” and “Total for humeral fracture, open” rows have been omitted, and the number of ORIF cases for the “Total for prox. extension” row that had read “81 (3.1%)” now reads “82 (3.1%).” On page 5, in Table V, the values in the “ORIF,” “IMN,” and “P Value” rows for Open Fracture Type and Closed Fracture Type have been recalculated. Additionally, the footnote for Table V that had read “*For both open and closed fractures, the mortality rate was higher after IMN than ORIF and the rate of nerve palsy was higher after ORIF. For open fractures, the infection rate was higher after ORIF.” now reads “*For closed fractures, the mortality rate was higher after IMN and the rate of nerve palsy was higher after ORIF (p < 0.001 for both). For open and closed fractures, the infection rate was higher after ORIF (p = 0.01 and 0.03, respectively).” An erratum has been published: J Bone Joint Surg Am. 2021 Mar 3;103(5):e21. Background: Despite extensive research regarding patient outcomes after operative fixation of humeral shaft fractures by means of open reduction and internal fixation (ORIF) or intramedullary nailing (IMN), no current consensus exists regarding the optimal surgical treatment. The objective of this study was to compare IMN and plate fixation (ORIF) of humeral shaft fractures by using the American Board of Orthopaedic Surgery (ABOS) Part II operative database to analyze incidence rates, changes in management trends over time, early complications, and factors affecting the management choice. Methods: The ABOS database is a collection of surgical cases that are self-reported by orthopaedic candidates approved for admission to the ABOS oral examination. The database was searched for records from 2004 to 2013 for humeral shaft surgical cases as indicated by Current Procedural Terminology (CPT) codes 24515 (open reduction internal fixation) and 24516 (insertion of intramedullary nail) pertaining to humeral shaft fractures. The geographic region and fellowship training of the candidates; the year of surgery, diagnosis code, age, and sex of the patients; and the surgeon-reported complications were analyzed. Results: The search identified 3,430 surgically treated humeral shaft fractures that were reported to the ABOS database from 2004 to 2013. A significant decline in IMN use was seen from 2004 (42.9%) to 2013 (21.2%, p < 0.001). The IMN cohort had lower complication rates pertaining to both infections (1.5% compared with 3.0% for ORIF, p = 0.007) and nerve palsies (3.1% compared with 7.8%, p < 0.001). No significant difference was seen in the rate of nonunion (1.3% for IMN compared with 1.6% for ORIF, p = 0.63), although follow-up may be too short to demonstrate a difference. The IMN cohort did have significantly higher mortality (4.9% compared with 0.7% for ORIF, p < 0.001). Subset analysis demonstrated that the IMN cohort had significantly more pathologic fractures (26.8% compared with 1.5% of the fractures treated with ORIF, p < 0.001). Conclusions: Although the overall incidence of fixation of humeral shaft fractures was unchanged from 2004 to 2013, there was a significant shift from IMN to ORIF using plate fixation during this time period. Possible reasons for this shift in treatment to ORIF include the potential impact of recent publications highlighting complications of IMN and increased surgeon attention to cost containment. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.