A comparison of compression plates and locked nails for surgically fixing fractures of the upper arm bone (humerus) in adults

Fractures (breaks) of the humerus are commonly treated without an operation. The indications for surgery are not completely clear, but often include open fractures (fractures exposed to contamination through the skin) or unstable fractures such as segmental fractures (where there are two or more fractures in the same bone with a free fragment in between).

When an operation is needed the choice is usually between a plate or an intramedullary nail. Plating is achieved by exposing the fracture site, fixing a plate to the bone and securing it with screws. Intramedullary nailing is performed through small cuts in the skin. The nail is inserted to lie within the central cavity of the bone through a carefully prepared hole, usually at the top end of the humerus. Locking screws in both ends may be used to further stabilize the nail.

Five poor quality trials were included in this review. These involved a total of 260 participants who were randomly assigned to having their humerus fractures fixed with either a plate or a nail. Both nailing and plating had similar fracture union rates. Compared with plating, nailing was associated with an increased risk of shoulder impingement involving shoulder pain and restrictions in shoulder range of movement. Usually because of impingement, nails had to be removed more frequently than plates. The limited available evidence did not show important differences between the two surgical methods in the other outcomes reported by one or more trials. These outcomes included nerve injury, infection, healing time, operating time, blood loss and return to pre-injury occupation.

Authors' conclusions: 

The available evidence shows that intramedullary nailing is associated with an increased risk of shoulder impingement, with a related increase in restriction of shoulder movement and need for removal of metalwork. There was insufficient evidence to determine if there were any other important differences, including in functional outcome, between dynamic compression plating and locked intramedullary nailing for humeral shaft fractures.

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Background: 

Surgical fixation of fractures of the shaft of the humerus generally involves plating or nailing. It is unclear whether one method is more effective than the other.

Objectives: 

To compare compression plating and locked intramedullary nailing for primary surgical fixation (surgical fixation of an acute fracture or early fixation following failure of conservative treatment) of humeral shaft fractures in adults.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (February 2011), The Cochrane Library 2011, Issue 1, MEDLINE and EMBASE (both to February 2011) and trial registries for ongoing trials.

Selection criteria: 

Randomised and quasi-randomised controlled trials comparing compression plates and locked intramedullary nail fixation for humeral shaft fractures in adults.

Data collection and analysis: 

Two authors independently assessed trial methodology and extracted data. Disagreement was resolved by discussion, or third party adjudication. Treatment effects were assessed using risk ratios for dichotomous data and mean differences for continuous data, together with 95% confidence intervals. Where appropriate, data were pooled using a fixed-effect model.

Main results: 

Five small trials comparing dynamic compression plates with locked intramedullary nailing were included in this review. These involved a total of 260 participants undergoing surgery for either acute fractures or after early failure of conservative treatment. All five trials had methodological flaws, such as the lack of assessor blinding, that could have influenced their findings. There was no significant difference in fracture union between plating and nailing (five trials, RR 1.05; 95% CI 0.97 to 1.13). There was a statistically significant increase in shoulder impingement following nailing when compared with plating (five trials, RR 0.12; 95% CI 0.04 to 0.38). Intramedullary nails were removed significantly more frequently than plates (three trials, RR 0.17; 95% CI 0.04 to 0.76). There was no statistically significant difference between plating and nailing in operating time, blood loss during surgery, iatrogenic radial nerve injury, return to pre-injury occupation by six months or American Shoulder and Elbow Surgeons (ASES) scores.

Two further small trials are awaiting classification.

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