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Volume:4 Issue:11 Number:1 ISSN#:2563-559X
OE Original

Intramedullary Nail- Versus Plate- Fixation for Humeral Fractures: A Review of Outcomes by Fracture Location

Authored By: OrthoEvidence

November 1, 2021

How to Cite

OrthoEvidence. Intramedullary Nail- Versus Plate- Fixation for Humeral Fractures: A Review of Outcomes by Fracture Location. OE Original. 2021;4(11):1. Available from: https://myorthoevidence.com/Blog/Show/155

Highlights


- The choice of open reduction and internal fixation of a humeral fracture with a plate versus an intramedullary nail is highly debated. We compared outcomes (i.e., fracture union, reoperation, and adverse events) between intramedullary nail fixation and plate fixation for patients with proximal humeral fractures, humeral shaft fractures, and distal humeral fractures, respectively.


  • - No significant differences were identified between intramedullary nail and plate fixation in fracture union, reoperation, or adverse events in patients who had proximal humeral fractures or humeral shaft fractures. There is a scarcity of evidence comparing intramedullary nails to plating for distal humeral fractures.


  • - No recommendations can be given from current evidence. Surgeons may have to continue to use discretion based on their personal preference, experience as well as patient and specific fracture characteristics before more high-quality evidence is available.









Fractures of the humerus, a common injury presenting to orthopedic surgeons, account for 1% to 3% of all fractures in elderly patients and 4% to 6% in young patients (Attum et al., 2021).


The choice of open reduction and internal fixation of a humeral fracture with a plate versus an intramedullary nail is highly debated. Each treatment option has respective advantages. For instance, fixation using a plate allows direct visualization of the fracture site and facilitates the identification and protection of the radial nerve, whereas using intramedullary nail to fix humeral fracture preserves the periosteal blood supply and minimizes the disruption of the biology of the fracture healing (Zhao et al., 2015).


The aim of the present OE Original was to determine whether the location of humeral fracture (i.e., proximal humeral fractures, humeral shaft fractures, and distal humeral fractures) needs to be taken into consideration when choosing between intramedullary nail- and plate- fixation as the treatment option for humeral fracture. Specifically, by searching the OE MIND database, we examined the following outcomes -- fracture union, reoperation, and adverse events, from randomized controlled trials (RCTs).



1. Proximal Humeral Fractures


Three RCTs, reporting fracture union, reoperation, and/or adverse events between intramedullary nail- and plate- fixation in proximal humeral fractures, were identified from the OE MIND database (Gracitelli et al., 2016; Plath et al., 2019; Zhu et al., 2011).


Results of the union outcomes as well as the reoperation and adverse events outcomes for proximal humeral fractures are presented in Figure 1 and Figure 2, respectively. No significant differences were identified between intramedullary nail- and plate- fixation in fracture union, reoperation, or adverse events in patients who had proximal humeral fractures.















2. Humeral Shaft Fractures


Several meta-analyses, comparing fracture union, reoperation, and/or adverse events between intramedullary nail- and plate- fixation in humeral shaft fractures were identified (e.g., Beeres et al., 2021; Bhandari et al., 2006; Heineman et al., 2010; Wen et al., 2019; Zhao et al., 2015). Most of them conducted meta-analyses using both RCTs and non-randomized studies of intervention (NRSIs).


We identified 13 eligible RCTs from these meta-analyses and conducted a quantitative synthesis on fracture union, reoperation, and adverse events ((Akalin et al., 2020; Benegas E et al., 2007; Benegas et al., 2014; Bolano et al., 1995; Changulani et al., 2007; Chapman et al., 2000; Fan et al., 2015; D. Li et al., 2011; Y. Li et al., 2011; McCormack et al., 2000; Putti et al., 2009; Wali et al., 2014; Zhang et al., 2015).


Results of the union outcomes as well as the reoperation and adverse events outcomes for humeral shaft fractures are presented in Figure 3 and Figure 4, respectively. We found no significant differences between intramedullary nail- and plate- fixation in fracture union, reoperation, or adverse events in patients who had humeral shaft fractures.











3. Distal Humeral Fractures


No RCT evidence comparing plating to intramedullary nails for distal humeral fractures was identified in the OE MIND database. This is likely because distal humeral fractures are generally unstable fracture patterns, and not conducive to intramedullary nailing and rigid plate fixation is preferred.





Summary


In this OE Original, we compared outcomes (i.e., fracture union, reoperation, and adverse events) between intramedullary nail fixation and plate fixation for patients with proximal humeral fractures, humeral shaft fractures, and distal humeral fractures, respectively.


Overall, our quantitative synthesis using RCT evidence found that there were no significant differences between intramedullary nail- and plate- fixation in fracture union, reoperation, or adverse events in patients with proximal humeral fractures or patients with humeral shaft fractures (Figures 1-4). There is a scarcity of evidence comparing intramedullary nails to plating for distal humeral fractures.


Some of our findings based on RCTs, such as the adverse events in proximal humeral fractures, were not consistent with findings from other meta-analyses synthesizing both RCTs and non-randomized studies of interventions. For example, a meta-analysis conducted by Shi et al. (2019) reported the adverse events of intramedullary nail and locking plate in the treatment of proximal humerus fracture by summarizing 29 individual studies, which consisted of 2 RCTs (i.e., Gracitelli et al., 2016; Zhu et al., 2011) and 27 retrospective observational studies (Shi et al., 2019). The results of the meta-analysis, which differed from our results [relative risk (RR): 1.06, 95% confidence interval (CI): 0.40 to 2.80], showed that patients who had received intramedullary nail fixation for proximal humeral fractures was less likely to have complications than those who had received plate fixation [odds ratio (OR): ?0.75; 95% CI: 0.57 to 0.97]. The RCTs mayt be limited in terms of providing data on adverse events due to their relatively small sample size, restricted eligibility for participants, and/or limited duration of follow-up (Higgins et al., 2021). Non-randomized studies, such as cohort and case-control studies, may be needed to address adverse events (Higgins et al., 2021).


In addition, although our results on fracture union, reoperation, or adverse events suggest no differences, some meta-analyses synthesizing both RCT and non-randomized studies suggest the superiority of intramedullary nail over plate in treating either proximal humeral fractures (Shi et al., 2019) or humeral shaft fractures (Beeres et al., 2021; Wen et al., 2019) based on outcomes such as intraoperative blood loss, operative time, postoperative fracture healing time, and postoperative infections. With non-randomized studies included in these meta-analyses, the precision of summary effect estimates was narrowed, however, at the cost of a greater risk of bias (Higgins et al., 2021).


Altogether, no strong conclusions can be drawn from current evidence. Surgeons may have to use discretion based on their personal preference, experience as well as patient and specific fracture characteristics before more high-quality evidence is available.




References


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Attum B, Thompson JH. Humerus Fractures Overview. [Updated 2021 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482281/

Beeres, F. J. P., et al. (2021). Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. European Journal of Trauma and Emergency Surgery. doi:10.1007/s00068-021-01728-7

Benegas E, et al. (2007). Estudo comparativo prospectivo e randomizado entre o tratamento cirúrgico das fraturas diafisárias do úmero com placa em ponte e haste intramedular bloqueada. Acta Ortopédica Brasileira, 15, 87-92.

Benegas, E., et al. (2014). Shoulder function after surgical treatment of displaced fractures of the humeral shaft: a randomized trial comparing antegrade intramedullary nailing with minimally invasive plate osteosynthesis. J Shoulder Elbow Surg, 23(6), 767-774. doi:10.1016/j.jse.2014.02.010

Bhandari, M., et al. (2006). Compression plating versus intramedullary nailing of humeral shaft fractures--a meta-analysis. Acta Orthop, 77(2), 279-284. doi:10.1080/17453670610046037

Bolano, L. I., et al. (1995). Operative treatment of humerus shaft fractures: A prospective randomized study comparing intramedullary nailing with dynamic compression plating. Paper presented at the Annual Meeting of the American Academy of Orthopaedic Surgeons.

Changulani, M., et al. (2007). Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus. A randomised controlled study. Int Orthop, 31(3), 391-395. doi:10.1007/s00264-006-0200-1

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