Comparison of Functional and Clinical Outcomes Following Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Prospective Study
IMN versus plating for humeral shaft fractures
-
Erfan Eslami
,
Ali Pourmojarab
,
Hassan Barati
,
Yousef Fallah
,
Bahareh Nezhad Mohammad
,
Mojtaba Baroutkoub
Abstract
Background: The optimal fixation method for humeral shaft fractures remains debated. This study compared functional and clinical outcomes after intramedullary nailing (IMN) and open reduction and internal fixation (ORIF) with plate fixation.
Methods: In this prospective, observational, comparative cohort study, 85 adults with Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association (AO/OTA) type 12-B or 12-C humeral shaft fractures were enrolled at a tertiary orthopedic trauma center in Tehran, Iran, between April 2020 and April 2024. Patients underwent IMN (n = 43) or plate ORIF (n = 42) according to the treating surgeon’s judgment. The primary outcome was the 12-month Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score; secondary outcomes included shoulder and elbow function, pain, union, hospital stay, return to work, and complications.
Results: Mean age was higher in the IMN group compared to the ORIF group (41.53 ± 14.12 vs. 35.83 ± 11.82 years; P = 0.047). The duration of hospital stay was shorter after IMN in the unadjusted comparison (2.07 ± 0.34 vs. 2.26 ± 0.59 days; P = 0.043). Nonunion occurred in 2 patients in each group (4.7% vs. 4.8%, P > 0.999), and no statistically significant difference was observed in the unadjusted QuickDASH scores (10.93 ± 11.33 vs. 16.48 ± 15.23; P = 0.060). In an exploratory model adjusted only for age and sex, IMN was associated with a modestly lower QuickDASH score [B = −6.22, 95% confidence interval (CI): −12.20 to −0.25; P = 0.041]; this association remains susceptible to residual confounding. Both techniques achieved high union rates and favorable 12-month outcomes. The unadjusted QuickDASH comparison was not significant, and the modest association in a partially adjusted exploratory model should not be interpreted as clinical superiority of IMN. Treatment selection should remain individualized.
1. Ghayyad K, Beaudoin TF, Osbahr DC, Huffman GR, Kachooei AR. Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022. Cureus. 2024;16(8):e66936. doi: 10.7759/cureus.66936. [PubMed: 39280367]. [PubMed Central: PMC11401597].
2. Gallusser N, Barimani B, Vauclair F. Humeral shaft fractures. EFORT Open Rev. 2021;6(1):24-34. doi: 10.1302/2058-5241.6.200033. [PubMed: 33532084]. [PubMed Central: PMC7845564].
3. Van Bergen SH, Mahabier KC, Van Lieshout EMM, Van der Torre T, Notenboom CAW, Jawahier PA, et al. Humeral shaft fracture: systematic review of non-operative and operative treatment. Arch Orthop Trauma Surg. 2023;143(8):5035-54. doi: 10.1007/s00402-023-04836-8. [PubMed: 37093269]. [PubMed Central: PMC10374687].
4. Sargeant HW, Farrow L, Barker S, Kumar K. Operative versus non-operative treatment of humeral shaft fractures: A systematic review. Shoulder Elbow. 2020;12(4):229-42. doi: 10.1177/1758573218825477. [PubMed: 32788928]. [PubMed Central: PMC7400715].
5. Amer KM, Kurland AM, Smith B, Abdo Z, Amer R, Vosbikian MM, et al. Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta- Analysis. Arch Bone Jt Surg. 2022;10(8):661-7. doi: 10.22038/abjs.2021.59413.2947. [PubMed: 36258745]. [PubMed Central: PMC9569144].
6. Beeres FJP, Van Veelen N, Houwert RM, Link BC, Heng M, Knobe M, et al. Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg. 2022;48(4):2667-82. doi: 10.1007/s00068-021-01728-7. [PubMed: 34219193].
7. Smolle MA, Bösmüller S, Puchwein P, Ornig M, Leithner A, Seibert FJ. Complications in humeral shaft fractures - non- union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis. EFORT Open Rev. 2022;7(1):95-108. doi: 10.1530/eor-21-0097. [PubMed: 35073516]. [PubMed Central: PMC8788154].
8. Hurley ET, Wickman J, Crook BS, Cabell G, Rodriguez K, Boadi P, et al. Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2023;32(12):2567-74. doi: 10.1016/j.jse.2023.07.015. [PubMed: 37579941].
9. Wang X, Chen Z, Shao Y, Ma Y, Fu D, Xia Q. A meta-analysis of plate fixation versus intramedullary nailing for humeral shaft fractures. J Orthop Sci. 2013;18(3):388-97. doi: 10.1007/s00776- 013-0355-8. [PubMed: 23471713].
10. Portnoff BS, Byrne RA, Hao KA, Gutowski CT, Lin Y, Hoffman RA, et al. Trends in reported outcomes and patient reported outcome measures (PROMs) in humeral shaft fracture literature: a systematic review. Eur J Orthop Surg Traumatol. 2024;34(6):2859-70. doi: 10.1007/s00590-024-04039-w. [PubMed: 39009710].
11. Gardner MJ, Griffith MH, Demetrakopoulos D, Brophy RH, Grose A, Helfet DL, et al. Hybrid locked plating of osteoporotic fractures of the humerus. J Bone Joint Surg Am. 2006;88(9):1962-7. doi: 10.2106/jbjs.E.00893. [PubMed: 16951112]. Morrey BF, An K-N. Functional evaluation of the elbow. In: Morrey BF, Editor. The elbow and its disorders. 3rd ed. Philadelphia, PA: Saunders; 2000. p. 82.
13. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987(214):160-4. [PubMed: 3791738].
14. Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038-46. doi: 10.2106/jbjs.D.02060. [PubMed: 15866967].
15. Hak DJ, Fitzpatrick D, Bishop JA, Marsh JL, Tilp S, Schnettler R, et al. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 2014;45(Suppl 2):S3-7. doi: 10.1016/j.injury.2014.04.002. [PubMed: 24857025].
16. Qiu H, Liu Y, Chen Y, Weng Z, Liu D, Dong J, et al. Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2023;24(1):583. doi: 10.1186/s12891-023- 06626-0. [PubMed: 37460932]. [PubMed Central: PMC10351133].
17. Colasanti CA, Anil U, Cerasani MN, Li ZI, Morgan AM, Simovitch RW, et al. Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities. J Orthop Trauma. 2024;38(7):e257-e66. doi: 10.1097/bot.0000000000002808. [PubMed: 38578605].
18. Olson JJ, Entezari V, Vallier HA. Risk factors for nonunion after traumatic humeral shaft fractures in adults. JSES Int. 2020;4(4):734-8. doi: 10.1016/j.jseint.2020.06.009. [PubMed: 33345208]. [PubMed Central: PMC7738446].
19. Ibounig T, Juurakko J, Lähdeoja T, Sumrein BO, Järvinen TLN, Paavola M, et al. Minimal important difference and patient acceptable symptom state for common outcome instruments in patients with a closed humeral shaft fracture - analysis of the FISH randomised clinical trial data. BMC Med Res Methodol. 2022;22(1):291. doi: 10.1186/s12874-022-01776-6. [PubMed: 36357855]. [PubMed Central: PMC9650807].
20. Galardini L, Coppari A, Pellicciari L, Ugolini A, Piscitelli D, La Porta F, et al. Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand (DASH) and the Shortened Version of the DASH (QuickDASH) in People With Musculoskeletal Disorders: A Systematic Review and Meta- Analysis. Phys Ther. 2024;104(5):pzae033. doi: 10.1093/ptj/pzae033. [PubMed: 38438144]. [PubMed Central: PMC11997799].
21. Mahabier KC, Den Hartog D, Theyskens N, Verhofstad MHJ, Van Lieshout EMM. Reliability, validity, responsiveness, and minimal important change of the Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores in patients with a humeral shaft fracture. J Shoulder Elbow Surg. 2017;26(1):e1-e12. doi: 10.1016/j.jse.2016.07.072. [PubMed: 27745806].
22. Alitaleshi H, Eftekhari K, Zanjani L, Abbaszadeh MR, Dolikhani MR, Shakibamaram G. "Outcome measures in Iranian studies of carpal tunnel syndrome surgery: a systematic review". BMC Surg. 2026;26(1):415. doi: 10.1186/s12893-026-03712-7. [PubMed: 42046030]. [PubMed Central: PMC13270547].
23. Fox HM, Hsue LJ, Thompson AR, Ramsey DC, Hadden RW, Mirarchi AJ, et al. Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management. J Shoulder Elbow Surg. 2022;31(9):1969-81. doi: 10.1016/j.jse.2022.02.033. [PubMed: 35398163].
24. Stephens AR, Presson AP, Zhang C, Orleans B, Martin M, Tyser AR, et al. Comparison of direct surgical cost for humeral shaft fracture fixation: open reduction internal fixation versus intramedullary nailing. JSES Int. 2021;5(4):734-8. doi: 10.1016/j.jseint.2021.04.005. [PubMed: 34223423]. [PubMed Central: PMC8245982].
25. Hendrickx LAM, Hilgersom NFJ, Alkaduhimi H, Doornberg JN, van den Bekerom MPJ. Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients. Arch Orthop Trauma Surg. 2021;141(4):561-8. doi: 10.1007/s00402-020-03446-y. [PubMed: 32285189]. [PubMed Central: PMC7966639].
26. Whitaker S, Cole S, O'Neill C, Satalich J, Schmidt RC, Vanderbeck J. Short-term complication rates of open reduction and plate fixation and intramedullary nailing in the treatment of humeral shaft fractures: a propensity score matched analysis. Arch Orthop Trauma Surg. 2024;144(8): 3361-8. doi: 10.1007/s00402-024-05491-3. [PubMed: 39123065]. [PubMed Central: PMC11417072].
27. Zhang Z, Lin Z, Qiu Q, Xiao X, Su S, Wen X, et al. Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury. Eur J Med Res. 2024;29(1):385. doi: 10.1186/s40001-024-01981-7. [PubMed: 39054555]. [PubMed Central: PMC11270843].
28. Derbas J, Moghamis I, Alzobi O, Elshoeibi A, Murshid A, Ahmed G. Outcomes of intramedullary nailing versus plate fixation for humeral shaft fractures: a retrospective cohort study. Eur J Orthop Surg Traumatol. 2025;35(1):63. doi: 10.1007/s00590-025- 04181-z. [PubMed: 39915345]. [PubMed Central: PMC11802612].
29. Ebrahimpour A, Dolikhani M, Shakibamaram G. Artificial Intelligence (AI) as a Catalyst for Orthopedic Residency Training. Arch Bone Jt Surg. 2025;13(12):773-5. doi: 10.22038/abjs.2025.91837.4159. [PubMed: 41509057]. [PubMed Central: PMC12777714].
2. Gallusser N, Barimani B, Vauclair F. Humeral shaft fractures. EFORT Open Rev. 2021;6(1):24-34. doi: 10.1302/2058-5241.6.200033. [PubMed: 33532084]. [PubMed Central: PMC7845564].
3. Van Bergen SH, Mahabier KC, Van Lieshout EMM, Van der Torre T, Notenboom CAW, Jawahier PA, et al. Humeral shaft fracture: systematic review of non-operative and operative treatment. Arch Orthop Trauma Surg. 2023;143(8):5035-54. doi: 10.1007/s00402-023-04836-8. [PubMed: 37093269]. [PubMed Central: PMC10374687].
4. Sargeant HW, Farrow L, Barker S, Kumar K. Operative versus non-operative treatment of humeral shaft fractures: A systematic review. Shoulder Elbow. 2020;12(4):229-42. doi: 10.1177/1758573218825477. [PubMed: 32788928]. [PubMed Central: PMC7400715].
5. Amer KM, Kurland AM, Smith B, Abdo Z, Amer R, Vosbikian MM, et al. Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Systematic Review and Meta- Analysis. Arch Bone Jt Surg. 2022;10(8):661-7. doi: 10.22038/abjs.2021.59413.2947. [PubMed: 36258745]. [PubMed Central: PMC9569144].
6. Beeres FJP, Van Veelen N, Houwert RM, Link BC, Heng M, Knobe M, et al. Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg. 2022;48(4):2667-82. doi: 10.1007/s00068-021-01728-7. [PubMed: 34219193].
7. Smolle MA, Bösmüller S, Puchwein P, Ornig M, Leithner A, Seibert FJ. Complications in humeral shaft fractures - non- union, iatrogenic radial nerve palsy, and postoperative infection: a systematic review and meta-analysis. EFORT Open Rev. 2022;7(1):95-108. doi: 10.1530/eor-21-0097. [PubMed: 35073516]. [PubMed Central: PMC8788154].
8. Hurley ET, Wickman J, Crook BS, Cabell G, Rodriguez K, Boadi P, et al. Intramedullary nailing vs. open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2023;32(12):2567-74. doi: 10.1016/j.jse.2023.07.015. [PubMed: 37579941].
9. Wang X, Chen Z, Shao Y, Ma Y, Fu D, Xia Q. A meta-analysis of plate fixation versus intramedullary nailing for humeral shaft fractures. J Orthop Sci. 2013;18(3):388-97. doi: 10.1007/s00776- 013-0355-8. [PubMed: 23471713].
10. Portnoff BS, Byrne RA, Hao KA, Gutowski CT, Lin Y, Hoffman RA, et al. Trends in reported outcomes and patient reported outcome measures (PROMs) in humeral shaft fracture literature: a systematic review. Eur J Orthop Surg Traumatol. 2024;34(6):2859-70. doi: 10.1007/s00590-024-04039-w. [PubMed: 39009710].
11. Gardner MJ, Griffith MH, Demetrakopoulos D, Brophy RH, Grose A, Helfet DL, et al. Hybrid locked plating of osteoporotic fractures of the humerus. J Bone Joint Surg Am. 2006;88(9):1962-7. doi: 10.2106/jbjs.E.00893. [PubMed: 16951112]. Morrey BF, An K-N. Functional evaluation of the elbow. In: Morrey BF, Editor. The elbow and its disorders. 3rd ed. Philadelphia, PA: Saunders; 2000. p. 82.
13. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res. 1987(214):160-4. [PubMed: 3791738].
14. Beaton DE, Wright JG, Katz JN. Development of the QuickDASH: comparison of three item-reduction approaches. J Bone Joint Surg Am. 2005;87(5):1038-46. doi: 10.2106/jbjs.D.02060. [PubMed: 15866967].
15. Hak DJ, Fitzpatrick D, Bishop JA, Marsh JL, Tilp S, Schnettler R, et al. Delayed union and nonunions: epidemiology, clinical issues, and financial aspects. Injury. 2014;45(Suppl 2):S3-7. doi: 10.1016/j.injury.2014.04.002. [PubMed: 24857025].
16. Qiu H, Liu Y, Chen Y, Weng Z, Liu D, Dong J, et al. Treatment of humeral shaft fractures with different treatment methods: a network meta-analysis of randomized controlled trials. BMC Musculoskelet Disord. 2023;24(1):583. doi: 10.1186/s12891-023- 06626-0. [PubMed: 37460932]. [PubMed Central: PMC10351133].
17. Colasanti CA, Anil U, Cerasani MN, Li ZI, Morgan AM, Simovitch RW, et al. Management of Humeral Shaft Fracture: A Network Meta-Analysis of Individual Treatment Modalities. J Orthop Trauma. 2024;38(7):e257-e66. doi: 10.1097/bot.0000000000002808. [PubMed: 38578605].
18. Olson JJ, Entezari V, Vallier HA. Risk factors for nonunion after traumatic humeral shaft fractures in adults. JSES Int. 2020;4(4):734-8. doi: 10.1016/j.jseint.2020.06.009. [PubMed: 33345208]. [PubMed Central: PMC7738446].
19. Ibounig T, Juurakko J, Lähdeoja T, Sumrein BO, Järvinen TLN, Paavola M, et al. Minimal important difference and patient acceptable symptom state for common outcome instruments in patients with a closed humeral shaft fracture - analysis of the FISH randomised clinical trial data. BMC Med Res Methodol. 2022;22(1):291. doi: 10.1186/s12874-022-01776-6. [PubMed: 36357855]. [PubMed Central: PMC9650807].
20. Galardini L, Coppari A, Pellicciari L, Ugolini A, Piscitelli D, La Porta F, et al. Minimal Clinically Important Difference of the Disabilities of the Arm, Shoulder and Hand (DASH) and the Shortened Version of the DASH (QuickDASH) in People With Musculoskeletal Disorders: A Systematic Review and Meta- Analysis. Phys Ther. 2024;104(5):pzae033. doi: 10.1093/ptj/pzae033. [PubMed: 38438144]. [PubMed Central: PMC11997799].
21. Mahabier KC, Den Hartog D, Theyskens N, Verhofstad MHJ, Van Lieshout EMM. Reliability, validity, responsiveness, and minimal important change of the Disabilities of the Arm, Shoulder and Hand and Constant-Murley scores in patients with a humeral shaft fracture. J Shoulder Elbow Surg. 2017;26(1):e1-e12. doi: 10.1016/j.jse.2016.07.072. [PubMed: 27745806].
22. Alitaleshi H, Eftekhari K, Zanjani L, Abbaszadeh MR, Dolikhani MR, Shakibamaram G. "Outcome measures in Iranian studies of carpal tunnel syndrome surgery: a systematic review". BMC Surg. 2026;26(1):415. doi: 10.1186/s12893-026-03712-7. [PubMed: 42046030]. [PubMed Central: PMC13270547].
23. Fox HM, Hsue LJ, Thompson AR, Ramsey DC, Hadden RW, Mirarchi AJ, et al. Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management. J Shoulder Elbow Surg. 2022;31(9):1969-81. doi: 10.1016/j.jse.2022.02.033. [PubMed: 35398163].
24. Stephens AR, Presson AP, Zhang C, Orleans B, Martin M, Tyser AR, et al. Comparison of direct surgical cost for humeral shaft fracture fixation: open reduction internal fixation versus intramedullary nailing. JSES Int. 2021;5(4):734-8. doi: 10.1016/j.jseint.2021.04.005. [PubMed: 34223423]. [PubMed Central: PMC8245982].
25. Hendrickx LAM, Hilgersom NFJ, Alkaduhimi H, Doornberg JN, van den Bekerom MPJ. Radial nerve palsy associated with closed humeral shaft fractures: a systematic review of 1758 patients. Arch Orthop Trauma Surg. 2021;141(4):561-8. doi: 10.1007/s00402-020-03446-y. [PubMed: 32285189]. [PubMed Central: PMC7966639].
26. Whitaker S, Cole S, O'Neill C, Satalich J, Schmidt RC, Vanderbeck J. Short-term complication rates of open reduction and plate fixation and intramedullary nailing in the treatment of humeral shaft fractures: a propensity score matched analysis. Arch Orthop Trauma Surg. 2024;144(8): 3361-8. doi: 10.1007/s00402-024-05491-3. [PubMed: 39123065]. [PubMed Central: PMC11417072].
27. Zhang Z, Lin Z, Qiu Q, Xiao X, Su S, Wen X, et al. Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury. Eur J Med Res. 2024;29(1):385. doi: 10.1186/s40001-024-01981-7. [PubMed: 39054555]. [PubMed Central: PMC11270843].
28. Derbas J, Moghamis I, Alzobi O, Elshoeibi A, Murshid A, Ahmed G. Outcomes of intramedullary nailing versus plate fixation for humeral shaft fractures: a retrospective cohort study. Eur J Orthop Surg Traumatol. 2025;35(1):63. doi: 10.1007/s00590-025- 04181-z. [PubMed: 39915345]. [PubMed Central: PMC11802612].
29. Ebrahimpour A, Dolikhani M, Shakibamaram G. Artificial Intelligence (AI) as a Catalyst for Orthopedic Residency Training. Arch Bone Jt Surg. 2025;13(12):773-5. doi: 10.22038/abjs.2025.91837.4159. [PubMed: 41509057]. [PubMed Central: PMC12777714].
| Files | ||
| Issue | Vol 12 No 4 (2026) | |
| Section | Research Articles | |
| Keywords | ||
| Humeral shaft fracture Intramedullary Nailing Bone Plates Fracture Fixation Recovery of Function Disability Evaluation | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Eslami E, Pourmojarab A, Barati H, Fallah Y, Nezhad Mohammad B, Baroutkoub M. Comparison of Functional and Clinical Outcomes Following Intramedullary Nailing Versus Plate Fixation for Humeral Shaft Fractures: A Prospective Study. J Orthop Spine Trauma. 2026;12(4):197-203.
