J Orthop Traumatol (2017) 18:259–263

DOI 10.1007/s10195-017-0459-6

ORIGINAL ARTICLE

Humeral shaft fractures: national trends in management

Bradley S. Schoch1 • Eric M. Padegimas2 • Mitchell Maltenfort3 •

James Krieg3 • Surena Namdari3

Received: 2 November 2016 / Accepted: 14 April 2017 / Published online: 8 May 2017
Ó The Author(s) 2017. This article is an open access publication

Abstract insurance, open fracture, and hospital size, which persisted

Background The incidence of humeral shaft fractures has with multivariate regression analysis. Surprisingly, there
been increasing over time. This represents a growing public was a tendency to shift from a slight increase in ORIF for
health concern in a climate of cost containment. The pur- males with the bivariate case to a slight preference for
pose of this study is to analyze national trends in surgical females in the multivariate case.
management of humeral shaft fractures and determine Conclusion Utilization of ORIF for humeral shaft fractures
factors predictive of surgical intervention. has been steadily increasing with time. Surgical intervention
Materials and methods Humeral shaft fractures were was more common with younger patients, female gender,
identified by the International Classification of Diseases, private insurance, and larger hospital size. The increasing
Ninth Revision, Clinical Modification codes 812.21 and incidence of surgical management for humeral shaft frac-
812.31 in the United States Nationwide Inpatient Sample tures may represent a public health burden given the his-
from 2002 to 2011. Open reduction and internal fixation torical success of non-operative management.
(ORIF) was identified by code 79.31 (ORIF, humerus). Other Level of evidence IV.
case codes analyzed were 79.01 (closed reduction without
internal fixation), 79.11 (closed reduction with internal fix- Keywords Nationwide inpatient sample
NIS
Humerus
ation), and 79.21 (open reduction without internal fixation). fracture
Non-operative
Open reduction internal fixation
Multivariate regression analysis was utilized to determine
predictive factors for utilization of ORIF.
Results 27,908 humeral shaft fractures were identified. Introduction
Utilization of ORIF increased from 47.2% of humeral shaft
fractures in 2002 to 60.3% in 2011. Demographically, Humeral shaft fractures represent 3% of all managed
patients who underwent ORIF were younger (51.5 versus fractures and occur with an incidence of 13 per 100,000 per
59.7 years, p \ 0.001; odds ratio 0.87 per decade of age). year [1, 2]. The incidence of these fractures has been
There were modest increases in ORIF usage with private increasing with the aging population [3]. These injuries
occur in a bimodal age distribution affecting both young
and old patients. Most patients are elderly ([65 years old),
& Surena Namdari representing fragility-type fractures; however, these inju-
[email protected] ries also occur in younger patients (\30 years old) sec-
1
Department of Orthopaedics and Rehabilitation, University
ondary to high-energy trauma [3]. Historically, non-
of Florida, Gainesville, FL, USA operative management has been the preferred method for
2 treating humeral shaft fractures, given the shoulder’s
Department of Orthopedics, Thomas Jefferson University,
Philadelphia, PA, USA ability to compensate for angular and rotational malalign-
3 ment [4, 5]. Sarmiento popularized non-operative man-
Department of Orthopaedic Surgery, Shoulder and Elbow
Surgery, Rothman Institute, Thomas Jefferson University, agement with a functional brace in 1977 after swelling had
925 Chestnut St, 5th Floor, Philadelphia, PA 19107, USA abated following 1–2 weeks in a coaptation splint [6, 7]. In

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contrast, both compression plating and intramedullary and R [R Development Core Team (2008) R: a language
nailing were developed in an attempt to improve functional and environment for statistical computing. R Foundation
outcomes. for Statistical Computing, Vienna, Austria] was used for all
Recently, open reduction and internal fixation (ORIF) statistical calculations. Statistical significance was consid-
has become more prevalent, with analysis from Finland ered for a p value less than 0.05.
finding a two-fold increase in operative management
between 1987 and 2009 [8]. However, in the United States,
it is unclear how the incidence of ORIF has changed over Results
time. Analysis of national trends may provide insight into
changing surgeon and patient expectations. Additionally, Between 2002 and 2011, 27,908 humeral shaft fractures
understanding the national trends in management of hum- were identified through the NIS database. Using the
eral shaft fractures may clarify the public health burden assumption that the NIS database represents 20% of inpa-
that these injuries might represent. The purpose of this tient hospitalization discharges, Healthcare Cost and
study is to analyze national trends in surgical management Utilization Project (HCUP) statistical corrections were
of humeral shaft fractures and determine any factors pre- used to estimate a national burden of 149,300 humeral
dictive of surgical intervention. shaft fractures over that time period [10, 11]. Of the 27,908
unique fractures identified in the sample, there were 15,142
(49.6%) who underwent ORIF, 4036 (14.5%) who under-
Materials and methods went a surgical procedure other than ORIF (closed reduc-
tion without internal fixation, closed reduction with internal
This study was conducted in the United States using the fixation, or open reduction without internal fixation), and
Nationwide Inpatient Sample (NIS). All humeral shaft 8730 (31.3%) who did not undergo surgical treatment.
fractures treated between 2002 and 2011 were identified There were 2672 (9.6%) open fractures compared to 25,236
using International Classification of Diseases, Ninth Revi- (90.4%) closed. In 2002, there were 2486 (8.9% of total)
sion, Clinical Modification (ICD-9-CM) codes. Patients with 1174 (47.2%) treated by ORIF, 308 (12.4%) treated
were included if they received a diagnosis of 812.21 with a different surgical procedure, and 1004 (40.4%)
(closed fracture of humeral shaft) or 812.31 (open fracture treated non-operatively. By 2011, there were 3033 (10.9%)
of humeral shaft). The group was then subdivided into with 1828 (60.3%) treated by ORIF, 246 (8.1%) treated
those treated non-operatively and those treated operatively. with a different surgical procedure, and 959 (31.6%) trea-
Fractures treated operatively were identified by ICD-9-CM ted non-operatively. Logistic regression estimated that the
code 79.01 (closed reduction without internal fixation), probability for a humeral fracture patient receiving ORIF
79.11 (closed reduction with internal fixation), 79.21 (open increased annually with an odds ratio (OR) of 1.07 per year
reduction without internal fixation), or 79.31 (ORIF). [95% confidence interval (CI) 1.06–1.08], and that the odds
Patients under the age of 18 were excluded, given the for an operatively treated patient receiving ORIF increased
possible presence of open physes. with an OR of 1.10 per year (95% CI 1.08–1.11). The
The NIS is currently the largest national payer database yearly trend for this is shown in Figs. 1 and 2.
with the ability to follow inpatient hospitalizations. Infor-
mation is captured from *8 million patients and encom-
passes over 1000 hospitals, with results added on a yearly
basis. Both federal and private hospitals are available for
analysis, including smaller specialty hospitals. The annual
survey has been estimated to represent 20% of all hospital
discharges within the United States [9]. The Healthcare
Cost and Utilization Project produces yearly statistical
analyses to adjust for yearly variation in the NIS sampling
[10, 11]. From this sample, demographic factors of age,
gender, and ethnicity were recorded for each patient.
Insurance variables and hospital size were also
characterized.
Trends in utilization of ORIF over time were analyzed
by Pearson’s correlation analysis. Multivariate analysis
was utilized to determine predictive factors for utilization Fig. 1 Annual trend of utilization of all treatment modalities for
of ORIF. Microsoft Excel (2013; Redmond, WA, USA) humeral shaft fractures

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p \ 0.0001). ORIF use also increased with the size of the

hospital: 44.6% for small hospitals, 50.4% for medium, and
52.7% for large (p \ 0.0001).

Discussion

Union rates with non-operatively treated humeral shaft

fracture have been reported between 67 and 98% [12–14].
Despite these rates, some patients are unable or unwilling
to undergo non-operative management. Clinical union and
removal of brace takes an average of 11.5 weeks with a
range of 4–22 weeks with functional bracing compared
Fig. 2 Annual trend of operative and non-operative management of with 6.3–9.8 weeks for intramedullary nailing and
humeral shaft fractures 8.9–10.4 weeks for compression plating [14–16]. Return to
weight-bearing remains a function of bone quality and
Analyzing the entire study population of fracture, surgical fixation. Weight-bearing restrictions may be dev-
patients who underwent ORIF were younger (Fig. 3; 53.2 astating to the elderly, who often require their arm to
versus 61.2 years, p \ 0.001), as seen in the trend in transfer or even weight-bear. In the younger patient, non-
Fig. 3. Multivariate analysis adjusting for other factors operative management may also delay their ability to return
showed odds of ORIF decreased with an OR of 0.87 (95% to work. In addition to functional limitations, functional
CI 0.85–0.88) per decade of age. When gender was ana- bracing also carries a 1–9.5% risk of skin and soft tissue
lyzed in this multivariate regression analysis, males were complications [17–19].
slightly more likely to receive ORIF: 54.0% of males We demonstrate that surgical treatment of humeral shaft
received ORIF versus 49.4% of females (p \ 0.001). fractures in the United States has been increasing over
However, the multivariate analysis showed a slight pref- time. The reason for this rise remains unclear, as numerous
erence for females getting ORIF (OR of 1.07, 95% CI studies have reported satisfactory treatment with non-op-
1.01–1.13, p = 0.026). With respect to insurance type, erative management. Complications following ORIF also
42.2% of national government insurance for patients occur at a similar rate to bracing, albeit with a different
[65 years old (Medicare) and 55.0% of state government profile. Nerve palsy is the most common complication,
insurance for low-income patients (Medicaid) underwent reported in up to 7% of patients. Infection is also a com-
ORIF compared to 59.4% of patients with private insur- mon complication, affecting up to 3% of patients [20].
ance. Comparing between insurance groups and correcting Possible reasons for increased ORIF utilization include a
for multiple comparisons with the Holm–Bonferroni perceived quicker return to work, earlier initiation of
adjustment, Medicare had lower rates of ORIF than any shoulder and elbow rehabilitation, and avoidance of brace
other insurance group (p \ 0.001), while private insurance wear during the recovery period. While fixed-angle locked
had higher rates of ORIF than for self-pay (54.7%). Open plating was introduced in 2005 and has been described for
fractures had higher rates of ORIF than closed fractures comminuted humeral shaft fractures and osteoporotic bone,
(65.1 vs 49.9%; adjusted OR 1.47, 95% CI 1.35–2.61, the mainstay of treatment remains non-locked plating

Fig. 3 Utilization of operative

intervention for humeral shaft
fractures by age

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[21, 22]. Additionally, the increase in ORIF seen over time coaptation splint, discharged for outpatient follow-up, and
predated the introduction of locked plating, with no upward treated non-operatively would be missed. Similarly, any
inflexion point seen over time. As a result, we do not patient discharged for outpatient follow-up treated opera-
believe that advancements in plate technology are tively, but in an outpatient surgical setting in which they
responsible for the increased ORIF utilization described in were not admitted, would be missed. This study also does
this study. However, the development of intramedullary not explore the relationship between surgical fixation and
nailing for humeral shaft fractures does coincide with the discharge disposition, a relationship described by Matus-
timing of the increase in operative intervention [23, 24]. zewski et al. [28]. Lastly, the NIS does not capture fracture
The increasing utilization of this technique may correlate classification or fixation type (plate size, locking/nonlock-
with the observed trend. ing), making analysis based on these variables impossible.
Multiple predictive factors for operative intervention Further outcomes-based studies are needed to identify the
were identified. The first was younger age. We are unable effect of increased operative fixation on patient outcomes
to analyze other potential confounding factors which would in these groups.
make fixation more common in younger patients. However, In conclusion, humeral shaft fractures have continued to
older patients with osteoporotic bone and more medical increase along with an aging population. Independent of
comorbidities may be less willing to undertake or less this increased prevalence of humeral shaft fractures, the
likely to be recommended for surgery. Younger patients are utilization of ORIF in the United States has also trended
also more likely to be involve in high energy poly-trauma upwards in a similar manner. Predictive factors for oper-
[25], which is a relative indication for fixation of a humeral ative ultization were identified as younger age, open frac-
shaft fracture [26, 27]. Younger patients also have more ture, and private insurance.
demands to return to work and may not accept a longer
duration of functional limitations. This result is in contrast Compliance with ethical standards
with that of Matuszeqski et al. who showed that patients Conflict of interest Bradley Schoch is a paid speaker for DJO. James
undergoing surgical fixation of humeral shaft fractures in Krieg is a paid consultant for Conventus, Merck, and Synthes. James
the United States National Trauma Database were Krieg owns stock in Conventus, Domain Surgical, MDLive, and Trice
3.5 years older than those treated non-operatively [28]. Medical. James Krieg receives royalties from Synthes and SAM
Medical. Surena Namdari receives divisional research funding from
Open fractures were highly associated with fixation, Depuy, Zimmer, Integra Life Sciences, and Arthrex. Surena Namdari
which is a well-established indication for surgical inter- is a paid consultant for DJO Surgical, Integra Life Sciences, and
vention [23]. Patients with private insurance were also Miami Device Solutions. Surena Namdari receives royalty payments
more likely to undergo operative intervention. This was an from DJO Surgical, Miami Device Solutions, and Elsevier. The
authors declare that they have no conflict of interest in relation to this
independent association on multivariate regression analysis manuscript.
and therefore not simply driven by Medicare patients being
statistically older than privately insured patients. This Patient consent Unnecessary, since data is obtained from a public
finding is similar to a previous analysis that identified an data base of anonymized patients.
association between surgery for upper extremity fracture
Ethical approval Unnecessary, since data is obtained from a public
and private insurance [29]. Additionally, previous analysis data base of anonymized patients.
of supracondylar humerus fractures treated as outpatients
in the pediatric population found that privately insured Funding No external funding was received for this study.
patients were nearly two and a half times as likely to return
for surgical intervention than those with public or no Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea
insurance [30]. This independent association between tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
lower surgical intervention rates and non-private insurance distribution, and reproduction in any medium, provided you give
may be a barrier to care that pushes the treating surgeon to appropriate credit to the original author(s) and the source, provide a
admit these patients rather than discharge for outpatient link to the Creative Commons license, and indicate if changes were
made.
follow-up.
This study has multiple limitations. While the NIS
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