Ancient Egyptian texts dating back to 1600 BC document the treatment of humeral shaft fractures via immobilization by wrapping in linen until healing.1 Three cases were described in antiquity that were treated with a period of immobilization and went on to clinical healing. It is likely that none of these patients were elderly because the average life expectancy in antiquity is estimated to have been approximately 34 years.1–4 The treatment of humeral shaft fractures with immobilization remained relatively unchanged until the late 1970s AD.5
In 1977, Sarmiento et al2 presented a series of 51 humeral shaft fractures treated with a novel approach. Patients were treated with mobilization of the shoulder and elbow via a prefabricated polypropylene sleeve. They referred to this device as a “functional brace” because movement of the extremity was encouraged. Ninety-eight percent of the humeral shaft fractures healed uneventfully, with the exception of 1 pathologic fracture. The age of the patients in this group was not reported.
In 2000, Sarmiento et al3 followed up with an extensive multicenter study of 922 patients with humeral shaft fractures treated with a functional brace. In the 620 patients followed, 465 (75%) of the fractures were closed and 155 (25%) were open. There was a 2% nonunion rate for closed fractures and 6% nonunion rate for open fractures. The average age of the patients was 36 years (range, 16–38 years) at the time of injury.
Functional bracing remains the treatment of choice for most closed, isolated diaphyseal fractures of the humerus.4 Relative indications for operative fixation include obesity and large breasts because these make brace treatment difficult.5 Surgical fixation has been recommended for patients with vascular injury, open fracture, associated forearm fractures, and polytrauma.5 Concomitant radial nerve injury is generally treated expectantly in closed fractures, followed by electromyography to access nerve recovery.6,7 A recent study comparing minimally invasive bridge plating vs functional bracing concluded that surgical treatment in young adult patients was of uncertain benefit.8
Elderly patients may lose their independence if they have a painful and impaired upper extremity.9 Hence, it is important to understand the union rate of humeral fractures treated with functional bracing in older patients.
Materials and Methods
Radiograph and chart review received institutional research ethical committee approval. The billing department of a single specialty orthopedic trauma group produced a list of patients with a charge code for humeral shaft fractures treated by closed treatment with or without manipulation from April 2007 through April 2017. This group was the basis of this study at a level I trauma center.
The inclusion criteria were (1) humeral shaft fracture treated definitively with a functional brace, (2) age of at least 55 years at the start of treatment, and (3) follow-up of at least 12 weeks. Chart review was undertaken to establish age, smoking history, sex, and medical comorbidities. Patients were excluded from the study if they converted to operative treatment for any reason before 12 weeks.
The initial search for the billing code of humeral shaft fractures at the orthopedic trauma group during a 10-year period yielded 385 fractures in 367 patients. Selecting those who were 55 years or older at the initial injury decreased the number to 55 fractures. There were 40 who were followed for at least 12 weeks. Of these, 9 elected operative treatment. This left 31 fractures that made up this study.
Charts and radiographs of 31 patients were reviewed by a panel of orthopedic surgeons (F.H.P., J.P.M., A.S.). All humeral fractures were classified by anatomic location of the shaft fracture and by AO/OTA classification system. A nonunion of the humerus was defined as no bridging callus or gross motion at the fracture site at 12 weeks, and this was chosen for several reasons. Driesman et al10 recently studied a group of humeral shaft fractures and found that no healing at 6 weeks was highly predictive of no further healing and subsequent non-union. Similarly, the current authors also found no cases that had no healing by 12 weeks that went on to heal by 6 months (Figures 1–2).
Anteroposterior initial (A), preoperative (B), and postoperative (C) radiographs of a 72-year-old woman who had a standing slip and fall injury. She had a closed AO/OTA type 12-B3 right proximal humeral fracture. This patient was a nonsmoker with type 2 diabetes mellitus and hypothyroidism. She was cooperative with the use of a prefabricated polyethylene brace for 6 months. By 6 months, it was evident that a nonunion was present. At 7 months, she underwent repair of the nonunion and had uneventful healing of the humeral fracture.
Anteroposterior initial (A), preoperative (B), and postoperative (C) radiographs of a 68-year-old man who tripped and fell, sustaining an injury to the left humerus. The radiographs revealed an AO/OTA type 12-A1 midshaft left humeral fracture. He had no history of cigarette use. There was a history of hypertension and atrial fibrillation. At 7 months, the patient had evidence of an established humeral nonunion. He declined surgical fixation. After 3.5 years, he decided to proceed with operative fixation. The patient underwent repair of the left humerus nonunion. He is currently in the early postoperative period.
The study group included 31 patients with a closed humeral shaft fracture. There were 21 (67.7%) females and 10 (32.3%) males with mean age of 72.5 years (range, 55–92 years) (Table 1). There were no significant differences in the demographics or comorbidities between the union and nonunion groups. However, patients with hypothyroidism had a higher occurrence of nonunions (P=.067).
Patient Demographics and Fracture Classification and Distribution
Of the 31 closed humeral shaft fractures, 21 progressed to union status and 10 were classified as nonunions. Additionally, there were differences noted in union rates depending on the fracture location; however, these were not statistically significant. The nonunion rate was 45% in proximal third, 26% in midshaft, and 20% in distal third humeral shaft fractures (P=.488). Furthermore, there was no significant difference in nonunion rate by AO/OTA fracture classification11: type A, 27%; type B, 50%; type C, 20% (P=.436). The overall nonunion rate was 32% for patients 55 years and older. This nonunion rate was significantly higher than the rate seen in historic studies. Interestingly, the authors found a significant correlation between age and union rate in prior studies. As age increased, the union rate decreased (R=−0.9, P=.045) (Figure 3).
Average age by union status of the published cohort studies.
Despite a limited number of published studies of nonsurgical treatment for humeral shaft fractures in older adults, there are several suggestions of impaired healing in this group found in the literature. The authors used the following studies for historical comparison (Table 2). Zagorski et al12 had 170 patients with a nonunion rate of 1.6% at an average age of 36 years. Similarly, Sarmiento et al3 published their largest series with a nonunion rate of 2% at an average age of 36 years. Matsunaga et al8 reported a nonunion rate of 15% at an average age of 40 years. Ali et al13 reported 156 closed humeral shaft fractures with brace treatment; the nonunion rate was 17% at an average age of 54 years. In the current study, the nonunion rate was 32% at a mean age of 74 years. The authors found a clear trend that the older the mean patient age, the lower the union rate (Figure 3).
Summary of Research Studies With Reported Age and Union Status
Ring et al14 retrospectively reviewed humeral shaft fractures that were operatively treated for nonunion during a 10-year period. They identified that midshaft and proximal humeral shaft fractures treated with a fracture brace are more likely to result in nonunion than distal third fractures. Ali et al13 retrospectively reviewed more than 200 humeral shaft fractures that were treated nonoperatively with fracture bracing. They too demonstrated that proximal third humerus fractures are less likely to heal, with a nonunion rate of 24%. These results coincide with the current findings that proximal third fractures treated with fracture bracing tend to have a higher non-union rate.
Large series of humeral fracture studies are often from trauma centers that predominantly treat younger patients. The mechanism of injury in young patients is often different from that in the older group. The literature includes studies of fractures in young patients with often wild injury patterns, including arm wrestling15 and throwing grenades.16,17 Regardless of mechanism, there has been much success with nonoperative treatment in this younger population. Although the mechanism of injury of the current patient population was almost entirely due to falls, studying older patients with this injury is difficult because they often return to their communities and are lost to follow-up.
Many fractures occur in a bimodal age distribution. Younger patients sustain fractures from significant energy dissipated on the skeleton. Older patients sustain fractures with minimal trauma because of balance issues and osteoporosis. The orthopedic treatment is often different in these 2 groups for fractures such as femoral neck or shoulder fractures depending on age. Perhaps age may be a factor to be considered in the care of humeral shaft fractures.
Furthermore, brace treatment of humeral fractures can be difficult to manage in older patients because there are often mobility and cognitive issues. This group is often dependent on ambulation aids such as canes and walkers that make brace use difficult. Idoine et al18 reported that a younger trauma group (average age, 38 years) had a low failure rate with anterior-approach humeral plating with immediate weight bearing. Such treatment or intramedullary rod fixation may help older patients maintain mobility and independence.
This study had some limitations. By the nature of the retrospective review, the data may have been skewed from bias. Surgeon bias may have existed to treat fractures operatively vs nonoperatively because no set protocol was in place and treatment was at the discretion of the attending orthopedic trauma surgeon. Selection bias may have also influenced treatment decisions. Certain fracture patterns may have been treated nonoperatively initially and then the treatment plan changed to operative fixation secondary to surgeon preference or patient request.
Furthermore, the current study has relatively low numbers. These patients are difficult to follow because they may have changes in their community status and location. A larger data set may demonstrate risk factors such as fracture location, fracture type, and other comorbidities that have a larger significance in the development of nonunion.
The incidence of nonunion in patients older than 55 years was found to be significantly higher than that reported in historical orthopedic literature. Furthermore, there was a significant correlation between increasing age and nonunion of humeral shaft fractures. This information can help inform clinicians about the potential advantages of early operative fixation of humeral shaft fractures in older patients. Future studies may help identify risk factors for humeral fracture nonunion in the elderly. This is a difficult group of patients to follow. With a mean age of 72.5 years, many of these patients had multiple orthopedic and medical comorbidities. A multicenter study to confirm these results would be helpful.
To the authors' knowledge, this is the first study demonstrating that age-dependent treatment of humeral shaft fractures may be advisable. Because it appears that older patients are more likely to have a nonunion of their diaphyseal fracture when treated with a functional brace, early operative stabilization may be warranted. Future multicenter, prospective, randomized studies comparing operative vs nonoperative treatment of humeral shaft fractures are recommended.
- Brorson S. Management of fractures of the humerus in Ancient Egypt, Greece, and Rome: an historical review. Clin Orthop Relat Res. 2009;467(7):1907–1914. doi:10.1007/s11999-008-0612-x [CrossRef] PMID:19002538
- Sarmiento A, Kinman PB, Galvin EG, Schmitt RH, Phillips JG. Functional bracing of fractures of the shaft of the humerus. J Bone Joint Surg Am. 1977;59(5):596–601. doi:10.2106/00004623-197759050-00004 [CrossRef] PMID:873955
- Sarmiento A, Zagorski JB, Zych GA, Latta LL, Capps CA. Functional bracing for the treatment of fractures of the humeral diaphysis. J Bone Joint Surg Am. 2000;82(4):478–486. doi:10.2106/00004623-200004000-00003 [CrossRef] PMID:10761938
- Ring D, Chin K, Taghinia AH, Jupiter JB. Nonunion after functional brace treatment of diaphyseal humerus fractures. J Trauma. 2007;62(5):1157–1158. doi:10.1097/01.ta.0000222719.52619.2c [CrossRef] PMID:17495717
- McKee MD, Larsson S. Humeral shaft fractures. In: Court-Brown C, Heckman JD, McKee M, McQueen MM, Ricci W, Tornetta P, eds. Rockwood and Green's Fractures in Adults. 7th ed. Philadelphia, PA: Wolters Kluwer Health; 1013–1015.
- Pollock FH, Drake D, Bovill EG, Day L, Trafton PG. Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am. 1981;63(2):239–243. doi:10.2106/00004623-198163020-00009 [CrossRef] PMID:7462281
- Foster RJ, Swiontkowski MF, Bach AW, Sack JT. Radial nerve palsy caused by open humeral shaft fractures. J Hand Surg Am. 1993;18(1):121–124. doi:10.1016/0363-5023(93)90255-2 [CrossRef] PMID:8423295
- Matsunaga F, Tamaoki MJ, Matsumoto M, et al. Minimally invasive osteosynthesis with a bridge plate versus a functional brace for humeral shaft fractures. J Bone Joint Surg Am. 2017;99:583–592. doi:10.2106/JBJS.16.00628 [CrossRef]
- Sonn U. Longitudinal studies of dependence in daily life activities among elderly persons. Scand J Rehabil Med Suppl. 1996;34:1–35. PMID: 8701230
- Driesman AS, Fisher N, Karia R, Konda S, Egol KA. Fracture site mobility at 6 weeks after humeral shaft fracture predicts non-union without surgery. J Orthop Trauma. 2017;31(12):657–662. doi:10.1097/BOT.0000000000000960 [CrossRef] PMID:28708781
- Mahabier KC, Van Lieshout EM, Van Der Schaaf BC, et al. Reliability and reproducibility of the OTA/AO classification for humeral shaft fractures. J Orthop Trauma. 2017;31(3):e75–e80. doi:10.1097/BOT.0000000000000738 [CrossRef] PMID:27755334
- Zagorski JB, Latta LL, Zych GA, Finnieston AR. Diaphyseal fractures of the humerus: treatment with prefabricated braces. J Bone Joint Surg Am. 1988;70(4):606–610.
- Ali E, Griffiths D, Obi N, Tytherleigh-Strong G, Van Rensburg L. Nonoperative treatment of humeral shaft fractures revisited. J Shoulder Elbow Surg. 2015;24(2):210–214. doi:10.1016/j.jse.2014.05.009 [CrossRef] PMID:25088479
- Ring D, Perey BH, Jupiter JB. The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients. J Bone Joint Surg Am. 1999;81(2):177–190. doi:10.2106/00004623-199902000-00005 [CrossRef] PMID:10073581
- Mayfield CK, Egol KA. Humeral fractures sustained during arm wrestling: a retrospective cohort analysis and review of the literature. Orthopedics. 2018;41(2):e207–e210. doi:10.3928/01477447-20180102-05 [CrossRef] PMID:29309719
- Chao SL, Miller M, Teng SW. A mechanism of spiral fracture of the humerus: a report of 129 cases following the throwing of hand grenades. J Trauma. 1971;11(7):602–605. doi:10.1097/00005373-197107000-00012 [CrossRef] PMID:5555684
- Aydin BK, Akmese R, Agar M. Humeral shaft fractures secondary to hand grenade throwing. ISRN Orthopedics. doi:10.1155/2013/962609 [CrossRef];
- Idoine JD III, French BG, Opalek JM, De-Mott L. Plating of acute humeral diaphy-seal fractures through an anterior approach in multiple trauma patients. J Orthop Trauma. 2012;26(1):9–18. doi:10.1097/BOT.0b013e318214ebd5 [CrossRef] PMID:21577147
Patient Demographics and Fracture Classification and Distribution
|Nonunion (N=10)||Union (N=21)|
|Female||6 (60.0)||15 (71.4)||.685|
|Diabetes mellitus||4 (40.0)||6 (28.6)||.685|
|Hypertension||2 (20.0)||9 (42.9)||.262|
|Congestive heart failure||1 (10.0)||4 (19.0)||1.000|
|Anemia||1 (10.0)||4 (19.0)||1.000|
|Hypothyroidism||4 (40.0)||2 (9.5)||.067|
|Renal failure||0 (0.0)||5 (23.8)||.147|
|Coronary artery disease||3 (30.0)||5 (23.8)||1.000|
|Age <67 y||2 (20.0)||7 (33.3)||.677|
|Smoker||2 (20.0)||4 (19.0)||1.000|
|Married||8 (80.0)||13 (61.9)||.428|
| A||5 (50.0)||13 (61.9)|
| B||4 (40.0)||4 (19.0)|
| C||1 (10.0)||4 (19.0)||.436|
| Distal third||1 (10.0)||4 (19.0)|
| Midshaft||4 (40.0)||11 (52.4)|
| Proximal third||5 (50.0)||6 (28.6)||.488|
Summary of Research Studies With Reported Age and Union Status
|Study (Year)||Average Age, y||SD||No. of Patients||No. of Unions||No. of Nonunions||% Union|
|Zagorski et al12 (1988)||36||170||167||3||98.2|
|Sarmiento et al3 (2000)||36||620||601||19||96.9|
|Matsunaga et al8 (2017)||40.3||17.2||46||39||7||84.8|
|Ali et al13 (2015)||54||138||114||24||82.6|