Braced Humeral-Shaft Fractures May Require Secondary Surgery

NEW YORK (Reuters Health) – Most patients who receive nonoperative care for a closed humeral-shaft fracture will do well, but up to a third may require secondary surgery leading to poorer outcome, according to a secondary analysis of a randomized clinical trial.

“The findings of our study underline the importance of shared decision-making,” Dr. Lasse Ramo of Helsinki University Hospital, in Finland, told Reuters Health by email,

“Patients contemplating the best treatment option for their humeral-shaft fracture should be informed that on average two-thirds of patients heal with good outcomes using non-surgical functional bracing but approximately one-third will end up having secondary surgery due to healing problems.”

In an online paper in JAMA Surgery, Dr. Ramo and colleagues note that the current literature suggests that at one year there are no clinically important differences in patient-reported outcomes between surgery and functional bracing.

To investigate further, the researchers examined data from the Finnish Shaft of the Humerus (FISH) randomized clinical trial to compare the two-year outcomes of patients who required secondary surgery with the outcomes of patients with successful initial treatment.

Initially, 82 patients were randomized to either surgery with plate fixation (38 patients) or to bracing (44 patients). Of the latter group, 30 (68%) healed successfully but 14 (32%) required secondary surgery during the follow-up period.

The researchers used the Disabilities of Arm, Shoulder and Hand score (DASH; range, 0 to 100 points; minimal clinically important difference, 10 points) to compare outcomes at two years. The outcomes where similar following uneventful fracture healing after initial surgery and successful nonoperative functional bracing (6.8 vs. 6.0, respectively), but those who underwent secondary surgery had significantly worse DASH scores, at 17.5.

“Unfortunately,” Dr. Ramo said, “there are no good predictive tools we could use at the time of injury to select those individuals who are most likely to fail non-surgical treatment and possibly would benefit from initial surgical care. Future research should focus on identifying those individuals as early as possible.”

SOURCE: JAMA Surgery, online April 14, 2021.

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