Functional and clinical outcome after operative versus nonoperative treatment of a humeral shaft fracture (HUMMER): results of a multicenter prospective cohort study
Authors: Den Hartog Dennis , Van Bergen Saskia H. , Mahabier Kiran C. , Verhofstad Michael H. J. , Van Lieshout Esther M. M. ,   the HUMMER Investigators, Beetz Ivo , Bolhuis Hugo W. , Bos P. Koen , Bronkhorst Maarten W. G. A. , Bruijninckx Milko M. M. , De Haan Jeroen , Deenik Axel R. , Den Hoed P. Ted , Eversdijk Martin G. , Goslings J. Carel , Haverlag Robert , Heetveld Martin J. , Kerver Albertus J. H. , Kolkman Karel A. , Leenhouts Peter A. , Meylaerts Sven A. G. , Onstenk Ron , Poeze Martijn , Poolman Rudolf W. , Punt Bas J. , Ritchie Ewan D. , Roerdink W. Herbert , Roukema Gert R. , Sintenie Jan Bernard , Soesman Nicolaj M. R. , Holder Edgar J. T. Ten , Tuinebreijer Wim E. , Van der Elst Maarten , Van der Heijden Frank H. W. M. , Van der Linden Frits M. , Van der Zwaal Peer , Van Dijk Jan P. , Van Jonbergen Hans-Peter W. , Verleisdonk Egbert J. M. M. , Vroemen Jos P. A. M. , Waleboer Marco , Wittich Philippe , Zuidema Wietse P. , Al Khanim Ahmed , Bousema Jelle E. , Cheng Kevin , Claes Yordy , Cnossen J. Daniël , Dekker Emmelie N. , De Zwart Aron J. M. , Jawahier Priscilla A. , Joling Boudijn S. H. , Notenboom Cornelia A. W. , Schulte Jaap B. , Theyskens Nina , Van Aert Gijs J. J. , Van der Schaaf Boyd C. P. , Van der Torre Tim , Van Veldhuizen Joyce , Verhagen Lois M. M. , Verwer Maarten , Vollbrandt Joris 
Published: February 2022

Abstract
Purpose
The best treatment of humeral shaft fractures in adults is still under debate. This study aimed to compare functional and clinical outcome of operative versus nonoperative treatment in adult patients with a humeral shaft fracture. We hypothesized that operative treatment would result in earlier functional recovery.

Methods
From October 23, 2012 to October 03, 2018, adults with a humeral shaft fracture AO type 12A or 12B were enrolled in a prospective cohort study in 29 hospitals. Patients were treated operatively or nonoperatively. Outcome measures were the Disabilities of the Arm, Shoulder, and Hand score (DASH; primary outcome), Constant–Murley score, pain (Visual Analog Score, VAS), health-related quality of life (Short Form-36 (SF-36) and EuroQoL-5D-3L (EQ-5D)), activity resumption (Numeric Rating Scale, NRS), range of motion (ROM) of the shoulder and elbow joint, radiologic healing, and complications. Patients were followed for one year. Repeated measure analysis was done with correction for age, gender, and fracture type.

Results
Of the 390 included patients, 245 underwent osteosynthesis and 145 were primarily treated nonoperatively. Patients in the operative group were younger (median 53 versus 62 years; p < 0.001) and less frequently female (54.3% versus 64.8%; p = 0.044). Superior results in favor of the operative group were noted until six months follow-up for the DASH, Constant–Murley, abduction, anteflexion, and external rotation of the shoulder, and flexion and extension of the elbow. The EQ-US, and pronation and supination showed superior results for the operative group until six weeks follow-up. Malalignment occurred only in the nonoperative group (N = 14; 9.7%). In 19 patients with implant-related complications (N = 26; 10.6%) the implant was exchanged or removed. Nonunion occurred more often in the nonoperative group (26.3% versus 10.10% in the operative group; p < 0.001).

Conclusion
Primary osteosynthesis of a humeral shaft fracture (AO type 12A and 12B) in adults is safe and superior to nonoperative treatment, and should therefore be the treatment of choice. It is associated with a more than twofold reduced risk of nonunion, earlier functional recovery and a better range of motion of the shoulder and elbow joint than nonoperative treatment. Even after including the implant-related complications, the overall rate of complications as well as secondary surgical interventions was highest in the nonoperative group.

Trial registration
NTR3617 (registration date 18-SEP-2012).