title: Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients.
abstract: BACKGROUND
  Although the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear.
  
  
  OBJECTIVE
  To compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients.
  
  
  METHODS
  A multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher's exact tests, Mann-Whitney U-tests and adjusted analysis of variance (ANOVA).
  
  
  RESULTS
  Forty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17-86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up.
  
  
  CONCLUSIONS
  Our findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.
authors.forename: J J
authors.initials: JJ
authors.lastname: van Middendorp
authors.forename: F
authors.initials: F
authors.lastname: Kazacsay
authors.forename: P
authors.initials: P
authors.lastname: Lichtenhahn
authors.forename: N
authors.initials: N
authors.lastname: Renner
authors.forename: R
authors.initials: R
authors.lastname: Babst
authors.forename: G
authors.initials: G
authors.lastname: Melcher