Conservative Management With Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis

Purpose: This was a network meta-analysis of prospective randomized controlled trials (RCTs) that compared clinical outcomes between treatment methods for extra-articular humeral shaft fractures.

Methods: The interventions compared included nonoperative management with functional bracing (FB) and surgical techniques, such as open reduction and internal fixation (ORIF), minimally invasive plate osteosynthesis (MIPO), and intramedullary nailing through antegrade (aIMN) and retrograde (rIMN) approaches. Outcome measures assessed included time to union, rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences (MDs) and log odds ratios (ORs) with corresponding 95% confidence intervals (95% CIs) were used to analyze continuous and categorical data, respectively.

Results: 21 RCTs were included, reporting the outcomes of 1203 patients treated with either FB (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45). FB had significantly higher odds for nonunion than ORIF (17.4% vs 5.2%, P<0.001), MIPO (0.6%, P<0.001), and aIMN (6.1%, P<0.001), and demonstrated a significantly longer time to achieve union than all surgical techniques (P <0.05). When comparing surgical techniques, MIPO achieved union significantly faster than ORIF (14.5 vs 15.8 weeks, P = 0.008). There were higher odds of malunion with FB than ORIF (3.2% vs 1.2%, P = 0.047). The odds for delayed union were significantly higher with aIMN than ORIF (10.3% vs 3.8%, P = 0.036). The odds for secondary surgical intervention were significantly higher with FB than with ORIF (20.5% vs 5.2%, P = 0.001), MIPO (1.4%, P = 0.007), and aIMN (8.0%, P = 0.004). However, ORIF had higher odds for iatrogenic radial nerve injury than FB (6.3% vs 0.5%, P = 0.019) and MIPO (2.3%, P = 0.002), as well as higher odds for superficial infection than FB (4.2% vs 0%, P = 0.010) and MIPO (0.6%, P = 0.024).

Conclusion: Compared to functional bracing, operative intervention universally demonstrated lower rates of nonunion and reoperation. Minimally invasive plating demonstrated significantly faster time to union when compared to all other surgical techniques.

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