The results of functional (Sarmiento) bracing of humeral shaft fractures

doi:10.1067/mse.2002.121634

Journal of Shoulder and Elbow Surgery

Volume 11, Issue 2, March–April 2002, Pages 143-150

https://doi.org/10.1067/mse.2002.121634 Get rights and content

Abstract

At the Department of Orthopaedics of the Kantonsspital Fribourg, 67 humeral shaft fractures were treated by Sarmiento bracing in a 15-year period. There were 54 isolated fractures and 13 fractures sustained as a component of polytrauma. Fifty-eight cases (87%) had healed clinically at a mean of 10 weeks; 9 cases failed to heal, so further treatment was carried out operatively. Of the conservatively managed fractures, 95% (55 cases) healed with an excellent or good result. Three patients noted a slight limitation of active range of motion, but all 58 patients returned to full duty at their jobs. Among 9 patients with delayed or nonunion leading to operative intervention, there were 6 cases with transverse fractures. Major reasons for failed conservative management were an incorrect indication, a significant axial deformity, or a hyperextended position of the fracture fragments. In our experience, active repositioning of humeral shaft fractures is not effective in avoiding a delay in fracture healing.The decision to use functional bracing in polytrauma patients should depend on the time of expected bedridden immobilization, on the presence of additional fractures of the ipsilateral upper extremity, and on the patient's need for crutches. The conservative treatment of humeral shaft fractures with the Sarmiento brace remains the treatment of choice, in spite of newer intramedullary operations that are allegedly minimally invasive and technically less complicated. (J Shoulder Elbow Surg 2002;11:143-150)

Introduction

In 1964 Böhler³ stated that fractures of the humeral shaft are the most benign of all diaphyseal fractures of long bones and are almost invariably amenable to conservative treatment. In 1977 Sarmiento et al²² described functional conservative treatment of humeral shaft fractures with a brace that allowed early activity of the affected extremity. They reported excellent results in 51 fractures, which had been immobilized for a mean of 11 days to allow decrease of swelling and were then treated in a functional brace until clinical healing, which was observed at a mean of an additional 7 weeks. Only 9 patients had a mild functional deficit; the others recovered fully. Since then, functional bracing has become the gold standard for the treatment of humeral shaft fractures. Many studies*have been published reporting results of functional bracing in polytrauma patients,6, 10, 13, 14, 18, 24, 29, 30 in pathological fractures,12, 18, 20, 24 in open fractures,14, 26, 30 in fractures with associated primary radial nerve palsy,6, 13, 18, 24, 26, 29, 30 in fractures with associated incomplete plexus palsy,²⁹ and even in fractures with vascular injury.²⁴ The literature suggests that there are only rare and relative contraindications for functional bracing. Radial nerve palsy*dagger;has been considered to be an indication for primary operative treatment by some, and several authors prefer surgical treatment for oblique fractures.6, 16, 27 Treatment remains controversial. It was the purpose of this retrospective study to analyze the results of functionally treated humeral shaft fractures in a time period in which operative treatment of humeral shaft fractures is being recommended more and more aggressively because allegedly more biological or less invasive procedures such as intramedullary nailing have become available.

Section snippets

Materials and methods

Ninety-one humeral shaft fractures were treated in 90 patients in our institution in a 15-year period. Seventeen fractures were operated on acutely on the basis of an individual decision of the attending physician on call. Seventy-four fractures were treated with functional bracing. Six of these patients were initially treated at our institution but subsequently lost to follow-up. One patient died after the beginning of the treatment; thus 67 braced fractures remained for analysis.

The 67 braced

Results

Fracture consolidation was achieved in 48 of the 54 patients (88.9%) in the monotrauma group. The mean time to clinical consolidation was 9.9 weeks (range, 5 to 36 weeks). One union occurred after a delay of 36 weeks in a type B2 fracture of the middle third of the shaft. Treatment was complicated by a secondary radial nerve palsy, pain, and difficulties in the mobilization of the adjacent joints. A residual flexion deficit of the elbow of 40° was noted with axial deformity in the sagittal and

Discussion

In this series, 58 of 67 conservatively treated humeral shaft fractures (87%) healed without operative intervention. Compared with most other studies, a very high proportion of initially treated patients could be reviewed, and this may explain the relatively high rate of failures (13.4%) compared with other series. Of those fractures that healed without intervention, 52% had an excellent result, 43% had a good result, and 5% had a fair result. Of 9 patients in whom conservative treatment

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Cited by (124)

Intramedullary nailing for humeral shaft fractures: Is distal locking necessary?
2023, Revue de Chirurgie Orthopedique et Traumatologique
L’enclouage centromédullaire (ECM) des fractures de diaphyse humérale est un moyen fiable d’obtenir la consolidation osseuse et permet une mobilisation précoce. Notre hypothèse principale était qu’une stabilité primaire du clou impacté dans la partie distale tronconique du fût médullaire permettait de s’affranchir du verrouillage distal. L’objectif principal était de confirmer le succès de la procédure sans verrouillage distal en identifiant les critères d’échec. Les objectifs secondaires étaient de comparer les résultats des ECM avec ou sans verrouillage distal.
Cette étude rétrospective monocentrique non randomisée, réalisée de 2012 à 2020, inclut 128 patients ayant eu une fracture de diaphyse ostéosynthésée par clou centromédullaire long. Le verrouillage proximal était systématique. Nous testions ensuite la stabilité rotatoire du clou. Les clous stables n’étaient pas verrouillés en distal (groupe A), sinon le verrouillage s’effectuait par un abord antérieur (groupe B). Tous les patients étaient évalués avec 12 mois de recul minimum.
Le verrouillage distal a été réalisé chez 30 patients de 63 ans (17–91) d’âge moyen. Quatre-vingt dix-huit patients de 65 ans (20–93) d’âge moyen n’ont pas eu de verrouillage distal. Le délai moyen de consolidation était de 4 mois (2–6). En moyenne la durée opératoire dans le groupe B était de 87 minutes (35–185) avec 90 secondes de fluoroscopie (33–158) contre 52 minutes (20–127) et 44 secondes (12–143) dans le groupe A (p < 0,05). Dans le groupe B, 4 patients ont présenté une paralysie radiale postopératoire et deux autres une fracture itérative au niveau de la vis de verrouillage distal. Le taux de consolidation n’était pas différent entre le groupe A : 94,6 % et le groupe B : 86,2 % (p = 0,217), ainsi que la récupération fonctionnelle : subjective shoulder value à 79,5 (10–100) dans le groupe A contre 76 (40–100) dans le groupe B (p = 0,271) et les amplitudes dans les deux groupes (p > 0,05). Nous n’avons pas observé de troubles rotatoires.
Lorsque le clou s’impacte dans la cavité médullaire en dehors de certaines fractures du tiers distal (p = 0,001), il n’est pas indispensable de le verrouiller en distal pour obtenir la consolidation osseuse et ceci diminue la durée opératoire, la fluoroscopie et le risque de lésion neurologique (p = 0,001).
IV.
Intramedullary nailing for humeral shaft fractures: Is distal locking necessary?
2023, Orthopaedics and Traumatology: Surgery and Research
Intramedullary (IM) nailing of humeral shaft fractures is a reliable means to achieve bone union while allowing early motion. The hypothesis was that distal locking is unnecessary due to good primary stability of the impacted nail in the distal, truncated cone portion of the medullary canal. The primary objective of this study was to confirm the success of the procedure without distal locking by identifying failure criteria. The secondary objectives were to compare the outcomes of IM nailing with and without distal locking.
This was a retrospective, single-center, non-randomized study of 128 patients with a humeral shaft fracture between 2012 and 2020 treated surgically with a long IM nail. Proximal locking was done in every case, then the rotational stability of the nail was tested. Stable nails were not locked distally (group A), while unstable nails were locked distally through an anterior approach (group B). All patients were reviewed with at least 12 months’ follow-up.
Distal locking was performed in 30 patients (mean age 63, 17–91) while the fracture in 98 patients (mean age 65, 20–93) did not require distal locking. The average time to union was 4 months (2–6). The average operative time in group B was 87 min (35–185) with 90 s fluoroscopy time (33–158) versus 52 min (20–127) with 44 s fluoroscopy time (12–143) in group A (p < 0.05). Four patients in group B suffered postoperative radial nerve palsy and two others had another fracture at the level of the distal locking screws. The union rate did not differ between groups (Group A 94.6%, group B 86.2%, p = 0.217) nor did the functional recovery – SSV of 79.5 (10–100) in group A versus 76 (40–100) in group B (p = 0.271) – or the range of motion (p > 0.05). There were no instances of rotational malunion.
Except for certain distal third fractures, distal locking is not necessary to achieve bone union when the nail is impacted into the medullary canal. This reduces the operative time, fluoroscopy time and risk of neurological damage.
IV.
Locking compression plate fixation in humeral shaft fractures: A comparative study to literature conservative treatment
2023, Injury
Humeral shaft fractures represent about 3% of all fractures. While there are several treatment options for this type of fractures, there is no evidence in literature showing which is the best one. This study aims at analysing the outcomes for patients with humeral shaft fractures treated with Locking Compression Plate (LCP) fixation in our hospital and comparing them with the outcome for patients conservatively treated (according to data from Pubmed), in order to determine the best treatment option.
We treated surgically 220 humeral shaft fractures in our department from February 2005 to March 2012. Seventy-three of them met all the inclusion criteria for this study. All fractures were then classified according to the AO classification. The follow-up considered the radiographic healing of the fracture. All patients were treated with plate fixation (LCP - DePuySynthes Co). At the end of the four-year follow-up, the function was evaluated by means of the DASH score.
A systematic review of the literature of the last 20 years was performed on MEDLINE (PubMed).
We had 2 infections and 8 patients had postoperative nerve palsy which recovered in average time of 6.7 months. In addition, 4 fractures (5.48%) didn't heal within 6 months and they were considered as nonunions and healed after a second surgery. One of these 4 nonunions was infected. The mean DASH score was 18.24±19.18. No malunions were found. We identified 13 studies that were eligible for our systematic review. The mean non-union rate found was 17% in 2517 fractures with a follow-up that ranging from 67% to 100% of patients and a primary radial nerve palsy ranging from 0 to 115 patients. Malalignment rate ranged from 12.7 to 42%.
After taking into account both the conservative and the surgical treatment, for humeral shaft fractures we suggest the operative treatment, because the patient's function of the upper limb recovers quickly in the immediate postoperative period and the incidence of malunions may be avoided.
Fixation of humerus shaft fractures in polytrauma patients does not improve short-term outcomes
2023, Injury
Surgical fixation of humeral shaft fractures is widely considered a relative indication for polytraumatized patients to improve mobility and expedite care. This study aimed to determine whether operative treatment of humeral shaft fractures improves short term outcomes in polytrauma (PT] patients.
Using the National Trauma Data Bank, PT patients with humeral shaft fractures were identified from 2010-2015. Three PT groups were analyzed: Group 1 – PT with nonoperative humeral shaft fracture, Group 2 – PT with humeral fixation on Day 1, and Group 3 – PT with humeral fixation on Day 2+. Cox proportional hazards regression models were used to compare discharge timing and days on ventilator and in ICU between the three groups.
There were 395 patients in Group 1, 1,346 in Group 2, and 1,318 in Group 3. There were no differences between the three groups when comparing Glasgow Coma Scale (p=0.3]; however, Injury Severity Score and Abbreviated Injury Scale were statistically different (p<0.001]. No differences were found in ICU or ventilator days between the three groups (p=0.2, p=0.5]. For Length of Stay, no difference was observed in Group 1 vs. Group 2 and Group 2 vs. Group 3. However, non-surgical patients were discharged 20% faster than those with Day 1 surgery (p=0.005]. Open fractures were treated one day earlier than closed fractures but discharged one day later (p<0.001].
This NTDB study demonstrates no differences in length of stay, days in the ICU or on the ventilator in patients with humeral shaft fractures treated non-operatively versus operative fixation. Overall, 44%-58% in all 3 groups had an ISS ≥ 14. Based on these results, we assert that fixation of the humeral shaft provides no short-term benefits in the multiply injured patient.
The devastating effects of humeral nonunion on health-related quality of life
2022, Journal of Shoulder and Elbow Surgery
Humeral nonunion is estimated to occur at a rate of 1.1%-25% depending on the fracture location and pattern, mechanism of injury, patient compliance with the immobilization protocol and patient's nutritional status and medical comorbidities. Fracture nonunion can cause chronic pain and limited range of motion and may hinder normal function. There is very little data from the patients' perspective regarding their experience with a humeral nonunion. The aim of this study was to establish health-related quality of life (HRQoL) norms for patients diagnosed with a humeral nonunion.
We reviewed a prospectively collected database of 185 humeral nonunions seen and treated at our quaternary referral center. We recorded patient characteristics including sex, age, history of infection, previous surgery, associated nerve palsy, handedness, and the anatomic location of the nonunion. At initial clinical evaluation, all patients were asked to complete the 12-Item Short Form Health Survey (SF-12), Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, Brief Pain Inventory (BPI), and a time trade-off questionnaire. These scores were compared to other well-known chronic medical conditions' HRQoL scores.
The cohort reported an average utility score of 0.55 ± 0.35, average SF-12 Physical Component Summary score of 30.2 ± 7.6, average SF-12 Mental Component Summary score of 42.5 ± 6.1, and average raw DASH score of 69 ± 21, which was worse than the general US population, patients with asthma, hypertension, stroke, type 2 diabetes, and AIDS. Patients with humeral nonunion are willing to trade 45% of their remaining life to obtain perfect health, and when stratified by handedness, we found that patients with a humeral nonunion of their dominant arm were willing to trade 49.7% compared with 39.7% in patients with a humeral nonunion of their nondominant arm (P = .04).
The results of our study show that humeral nonunion is a chronic medical condition that has a debilitating effect on patients, both physically and mentally. It is important for orthopedic surgeons to acknowledge these conditions as physically and mentally debilitating to their patients. Our study highlights these physical and mental burdens and helps to quantify humeral nonunion in relation to more well-known chronic conditions, such as asthma, diabetes, AIDS, and stroke.
Humeral nonunions have a devastating effect on a patient's physical and mental health with HRQoL measures lower than patients with other chronic conditions, such as asthma, diabetes, AIDS, and stroke. We found that our patients, on average, would trade approximately 45% of their remaining life span for perfect health.
Humeral Shaft Fractures
2022, Skeletal Trauma of the Upper Extremity
Fractures of the humeral shaft represent 1% to 3% of all fractures and have an annual incidence of 4.5 per 100,000 patients. The distribution of fractures follows a bimodal distribution with peaks occurring in the seventh and third decades of life commonly due to ground-level falls in elderly females and high-energy trauma in young males, respectively. The nonoperative management of humeral shaft fractures has historically resulted in very high union rates and a high degree of patient satisfaction, with deformity of the humerus well accommodated by the large arc of motion at the shoulder and elbow. Wider indications for fixation and lower union rates with nonoperative management described in recent literature have expanded the role of operative management for humeral shaft fractures in recent years. Operative techniques include open reduction and plate fixation, minimally invasive plate osteosynthesis (MIPO), intramedullary nailing, and external fixation.

View all citing articles on Scopus

^*: Reprint requests: Christian Gerber, MD, Department of Orthopaedics, University of Zürich, Balgrist, Forchstrasse 340, CH–8008 Zürich, Switzerland.

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Original articleThe results of functional (Sarmiento) bracing of humeral shaft fractures*

Abstract

Introduction

Section snippets

Materials and methods

Results

Discussion

Injury

Injury

Traumatic lesions of the radial nerve of the arm [in French]

Rev Chir Orthop Reparatrice Appar Mot

Treatment of humeral shaft fractures related to associated injuries

Acta Orthop Scand

Gegen die operative Behandlung von frischen Oberarmschaftbrüchen

Langenbecks Arch Klein Chir

Randomised prospective study of humeral shaft fracture fixation. intramedullary nails versus plates

J Orthop Trauma

Functional treatment of recent fractures of the humeral shaft using the Sarmiento method [in French]

Rev Chir Orthop Reparatrice Appar Mot

Prevention of infection in the treatment of one thousand and twenty-five open fractures. retrospective and prospective analyses

J Bone Joint Surg Am

Problems in the management of type III (severe) open fracturesa new classification of type III open fractures

J Trauma

Fractures of the humerus with radial nerve paralysis

J Bone Joint Surg Am

Functional treatment of fractures of the humerus using the method of Sarmiento. Results after 3 years' experience [in German]

Unfallchirurg

Conservative fracture treatment by Sarmiento's brace

Zentralbl Chir

Clinical experiences in the treatment of humeral shaft fractures with the Sarmiento brace [in German]

Unfallchirurg

Humerus shaft fractures-results and experience from functional treatment according to Sarmiento [in German]

Zentralbl Chir

Functional treatment of humerus fractures by Sarmiento's method [in German]

Helv Chir Acta

Original article
The results of functional (Sarmiento) bracing of humeral shaft fractures*