Bracing Versus Surgery for Humeral Shaft Fractures — All Is Not As It Appears

It's worth taking a close look at a well-designed but misinterpreted network meta-analysis

Bracing Versus Surgery for Humeral Shaft Fractures — All Is Not As It Appears
Editor’s Note: Sometimes at CORRelations, we’ll cover an article we think may cross your desk because we have reservations about the message. This study is from last year, but the controversy continues unabated, so we’re covering it now. — SSL

What’s the Claim?

A network meta-analysis of RCTs compared functional bracing to several surgical techniques (ORIF, minimally invasive plate osteosynthesis [MIPO], and IM nailing), and claimed:

  • Higher odds of nonunion with bracing than with any of the surgical approaches, and longer time to union (the latter is a finding that has soft spots)
  • Higher odds of unplanned operation or reoperation with bracing than with ORIF, MIPO, or antegrade IM nailing
  • Higher odds of radial nerve injury with ORIF than with MIPO

The main reason we’re covering this study is that we’d emphasize the findings differently from how they were presented (and how they’re commonly discussed):

  • By focusing on conversion to surgery of a small number of patients initially treated with bracing (their first operation), one misses the fact that all the patients in the other groups already had a first operation and some of them had a second one, and the risk of nerve injury was higher with ORIF than with bracing.

We’re not saying bracing is better, but it’s important to look at these comparisons sensibly, so as to be able to counsel patients fairly.

How’s It Stack Up?