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Nonoperative Versus Operative Treatment of Diaphyseal Humerus Fractures: A Systematic Review
Andrea L. Gale, MD; Shari R. Liberman, MD; Patrick C. McCulloch, MD; Joshua D. Harris, MD
Houston Methodist Hospital, Houston, TX

Purpose: To determine if there is a significant difference in clinical outcome scores, union rates, and radial nerve injuries between operative and non-operative treatment of diaphyseal humerus fractures.
Methods: This review was performed using PRISMA guidelines and registered with PROSPERO on December 6, 2013. Study inclusion criteria included any investigation published in English language, with a minimum of one-year follow-up that compared outcomes between operative and non-operative treatment of diaphyseal humerus fractures in skeletally mature individuals. Exclusion criteria were investigations of skeletally immature patients, fractures not involving the humeral shaft; studies with less than one year follow-up, and level V evidence.
Results: 9 studies were included for evaluation. Mean patient age was 39.4 +/- 1.31 years. Mean follow-up was 26.4 months. 486 fractures in 485 patients were included (64% male and 36% female; 69% closed and 17% open). 89.9% treated operatively (171 ORIF, 262 intramedullary nailing). There were 49 patients that were treated non-operatively. There were 22 non-unions reported, (15 operatively treated group, 5 non-operatively treated group). There were 6 malunions overall (3 operatively treated group, 3 non-operatively treated group). There were 9 reported delayed unions all in the operatively treated group. When the complications of nonunion, malunion, and delayed union were considered together, there were less complications in the operatively treated group (p = 0.019). There was no difference in the rate of complication between intramedullary nailing and open reduction internal fixation (p = 0.346) or between intramedullary nailing and non-operative treatment (p = 0.086). There was a significant difference between open reduction internal fixation and non-operative treatment (p = 0.0057) There were 108 radial nerve injuries with an overall mean recovery time of 6.1 months. There was no standardization to the reporting of functional outcome scores between studies.
Conclusions: Diaphyseal humerus fractures are common injuries that have been shown to be treated successfully both non-operatively and operatively. There was a higher rate of non-union in the non-operatively treated group while there was not difference in union rate between intramedullary nailing and open reduction internal fixation within the operative group. Of those radial nerve injuries that were explored at the time of surgery, the most common pathology was a traction injury. There is little standardized data to compare the functional outcomes of patients treated non-operatively to those treated operatively. This review found that there needs to be more research performed in the area of functional outcomes for these fractures.

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