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Nonoperative Treatment of Closed Extra-Articular Distal Humeral Shaft Fractures in Adults: A Comparison of Functional Bracing and Above-Elbow Casting

May 15, 2018|Surgery
H.J. Christiaan Swellengrebel, MS;David Saper, MD;Paul Yi, MD;Alexander A. Weening, MD;David Ring, MD;Andrew Jawa, MD
Author and Disclosure Information

Authors’ Disclosure Statement: Dr. Ring reports that he is a board or committee member of the American Academy of Orthopaedic Surgeons and the Orthopaedic Trauma Association; is on the editorial or governing board of Clinical Orthopaedics and Related Research and Journal of Orthopaedic Trauma; and receives intellectual property royalties from Skeletal Dynamics and Wright Medical Technology, Inc. The other authors report no actual or potential conflict of interest in relation to this article.

Dr. Swellengrebel is an Attending Surgeon, Haaglanden Medical Centre (HMC), The Hague, The Netherlands. Dr. Saper is an Attending Surgeon, Orthopaedic and Rehabilitation Centers, Chicago, Illinois. Dr. Yi is a Radiology Resident, Johns Hopkins University School of Medicine, Baltimore, Maryland. Dr. Weening is an Attending Surgeon, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands. Dr. Ring is Associate Dean for Comprehensive Care and Professor of Surgery, Dell Medical School, The University of Texas at Austin, Austin, Texas. Dr. Jawa is an Attending Surgeon, New England Baptist Hospital, Boston, Massachusetts.

Address correspondence to: David Saper, MD, 850 Harrison Ave., Dowling 2 North, Boston MA, 02118 (tel, 617-638-8934; fax, 888-267-7761; email, Dave.saper@gmail.com).

Am J Orthop. 2018;47(5). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

H.J. Christiaan Swellengrebel, MS David Saper, MD Paul Yi, MD Alexander A. Weening, MD David Ring, MD Andrew Jawa, MD . Nonoperative Treatment of Closed Extra-Articular Distal Humeral Shaft Fractures in Adults: A Comparison of Functional Bracing and Above-Elbow Casting. Am J Orthop.

May 15, 2018

TAKE-HOME POINTS

  • Closed extra-articular distal diaphyseal humerus fractures heal predictably with both bracing and casting.
  • There are no differences in average elbow motion between bracing and casting of these fractures.
  • There are no differences in radiographic alignment between bracing and casting of these fractures.
  • The distal diaphyseal humerus has a natural anatomic and biologic propensity to heal with closed immobilization.
  • Patients preferring nonoperative treatment can choose between a cast or a brace with confidence of the efficacy of either treatment.

ABSTRACT

Diaphyseal fractures of the distal humerus have a high rate of union when treated with a functional brace or an above-elbow cast (AEC). This study compares alignment of the humerus and motion of the elbow after functional brace or AEC treatment.

One-hundred and five consecutive patients with a closed, extra-articular fracture of the distal humeral diaphysis were identified in the orthopedic trauma databases of 3 hospitals between 2003 and 2012. Seventy-five patients with a follow-up of at least 6 months or with radiographic and clinical evidence of fracture union were included (51 treated with functional bracing and 24 treated with an AEC).

All of the fractures healed. The average arc of elbow flexion was 130° ± 9° in braced patients vs 127° ± 12° in casted patients. Four patients (8%) in the bracing group and 4 (17%) in the casting group lost >20° of elbow motion. The average varus angulation on radiographs was 17° ± 8° in braced and 13° ± 8° in casted patients, while the average posterior angulation was 9° ± 6° vs 7° ± 7°, respectively.

Closed extra-articular distal diaphyseal humerus fractures heal with both bracing and casting and there are no differences in average elbow motion or radiographic alignment.

Nonoperative treatment of closed fractures of the humeral shaft (AO/OTA [Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association] type 12) with a functional brace or above-elbow cast (AEC) is associated with a high union rate, good motion, and good function. Advocates of casting believe that a brace cannot control fracture alignment as well as a cast that allows for immobilization and molding. Advocates of brace treatment are concerned that immobilization in a cast will cause elbow stiffness.1-11

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