Injury, Int. J.

Care Injured 41 (2010) e21–e27

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Review

Functional bracing of humeral shaft fractures. A review of clinical studies

Efthimios Papasoulis *, Georgios I. Drosos, Athanasios N. Ververidis, Dionisios-Alexandros Verettas
Department of Orthopaedic Surgery, Medical School, Democritus University of Thrace, University General Hospital of Alexandroupolis, 68100 Alexandroupolis, Greece

A R T I C L E I N F O A B S T R A C T

Article history: Functional bracing has been widely accepted as the gold standard for treating humeral shaft fractures
Accepted 5 May 2009 conservatively. We conducted a literature review to verify the efficacy of this treatment method. Sixteen
case series and two comparative studies fulfilled the criteria set. Analysis of these clinical studies showed
Keywords: that humeral shaft fractures when treated with functional bracing heal in an average of 10.7 weeks.
Humeral shaft fractures Union rate is high (94.5%). Statistical analysis showed that proximal third fractures and AO type A
Humeral diaphyseal fractures fractures have a higher non-union rate although this is not statistical significant. Residual deformity and
Functional bracing
joint stiffness are considered the main drawbacks of conservative treatment. Angulation – usually varus
Functional treatment
Conservative treatment
– rarely exceeded 108, while full shoulder and elbow motion was achieved in 80% and 85% of the patients,
respectively. Nevertheless, in the few studies that subjective parameters such as functional scores, pain
and quality of life were assessed results were not so promising.
ß 2009 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Functional bracing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Material and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Time to union. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Non-union rate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Delayed union . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e22
Residual deformity/malunion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e23
Functional recovery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e24
Shoulder motion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e24
Elbow motion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e24
Functional scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e24
Residual deformity and function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e24
Radial nerve palsy and complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e25
Special fracture patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e25
Location . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e25
AO type fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e26
Fracture configuration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e26
Long-oblique proximal fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e26
Open . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e26
Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e26
Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e27
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . e27

* Corresponding author. Tel.: +30 2310838437/6974142023; fax: +30 2551031040.

E-mail addresses: siluosapap@yahoo.com, siluosapap@gmail.com (E. Papasoulis).

0020–1383/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2009.05.004
e22 E. Papasoulis et al. / Injury, Int. J. Care Injured 41 (2010) e21–e27
Introduction
Fractures of the shaft of the humerus account for 1% to 3% of all
fractures.2,25 Although several absolute and relative indications for
surgical treatment have been proposed,12,25 the general under-
standing and current teaching remains the same as in the past; the
vast majority of humeral shaft fractures can be treated successfully
by conservative methods.5,12,25
The most common conservative methods that have been used
for this purpose are Desault or Velpaue bandages, abduction
splints, U-casts, hanging casts, and functional bracing.12,25 The
later has been so widely accepted as the best conservative method,
that it is considered as the gold standard of humeral shaft fracture
treatment for many authors.
When compared to other conservative methods functional
brace treatment carries many advantages in terms of range of
motion (ROM), patient comfort, and cost reduction.3,14,21,27,29–31
The patient can remove the brace for personal hygiene, the brace is
of limited weight and causes no distraction over the fracture site,
while elbow movements are not restricted and joint stiffness
therefore unlikely to develop.
History
According to Wallny et al.30 the comprehensive Manual of
Functional Treatment for the most frequent bone and joint injuries,
published by Steinmann, was available as early as 1919. In 1967,
Sarmiento20 developed a simple functional brace therapy. Since
then the functional treatment of fractures has gained a new level of
acceptance. Initially developed for tibial fractures,20 it was soon
successfully applied to humeral shaft fractures too.21
Functional bracing
The philosophy of functional bracing is based upon the ‘‘inner
splint’’ caused by circular compression to the muscular compart-
ments. In conjunction with external stabilisation and effect of
gravity, fracture alignment and limb length are controlled. Thus,
immobilisation of adjacent joints is unnecessary.1,14,18,21,22,24,30,31
With early introduction of functional activity to the entire
extremity and active contraction of the muscles around the
fracture, physiologically controlled micromovement takes place,
and blood flow and mineral deposition increase at the fracture site.
These factors appear to stimulate osteogenesis and to provide a
desirable physiological environment conducive to rapid heal-
ing.1,14,21–24,31
Although most of the authors support that the vast majority of
humeral shaft fractures can be treated successfully by conservative
methods, the efficacy of functionally treatment of these fractures
has been questioned.19,23 The excellent results (non-union rate
<3%) of functional brace treatment, reported by some authors,
have not been universally reproduced, with others observing non-
union rates between 6 and 23%.19 Furthermore, because fracture
treatment does not end with bony union,12 the functional
impairment after fracture treatment and the related quality of
life are also important.
The aim of this review was to explore the efficacy of functional
bracing of humeral shaft fractures in terms of union rate,
complications, and functional results.
Material and methods
An electronic literature search was conducted using Medline
database, restricted to English language. The search terms applied
as text words were: humeral shaft fractures, humeral diaphyseal
fractures, functional bracing, functional treatment, conservative
treatment. The identified articles were studied and any additional
articles from theirs references lists were also found.
Inclusion criteria for this review were studies concerning
humeral shaft fractures treated conservatively with functional
bracing, including more that 10 cases.
Table 1 shows the articles that were included in the study.
Fifteen articles1,7,8,10,11,13,16,18,19,21,23,27,29–31 that fulfilled the
criteria set were reviewed. Three more articles9,14,22 that were
restricted to distal third humeral shaft fractures have also been
analysed.
Means and percentiles were used to describe the data and for
categorised variables. In statistical analysis, differences between
the groups were tested using x2 test and a p value of <0.05 was
considered statistically significant.
Results
Patients studied in the included reports were heterogeneous
with regard to age and medical history. The criteria of patient
selection were not always documented; neither was patient
compliance. This might have leaded to positive patient selection.
Even the braces used varied between the different reports. Similar,
mobilisation of the limb was performed with different patterns,
depending on the author. This was also true for almost every issue
concerning application of the brace and after-treatment. Follow-up
varied considerable in the studies and was not always documen-
ted. Results concerning function, pain and residual deformity were
not uniformly presented. Assessing findings against statistical tests
was – for these reasons – not always possible.
Despite this heterogeneity important conclusions were drawn
by the analysis of these reports with regard to non-union rate,
residual deformity, functional outcome and complications of
functional bracing of the humerus. The results of applying
functional bracing on certain patterns of humeral shaft fractures
were also analysed.
Time to union
Time to union is reported to vary between 3 and 40 weeks, but
in most cases it lasts 8–14 weeks. The mean union time is reported
in 13 studies1,8,9,10,11,13,14,18,21–23,30,31 and varies (6.5–22 weeks)
with an average of 10.7 weeks (Table 1). Open fractures are the
ones that heal slower in an average of 13–14 weeks.23,31
Non-union rate
In all but six reports7,8,10,13,19,27 non-union rate was less than 7%
(Table 1). Toivanen et al.27 reported the highest non-union rate
(22.6%); still, their decision to abandon functional bracing if at 6
weeks time there were no radiological or clinical signs of
consolidation, could partially explain this.
The overall non-union rate in 15 reports is 5.5% (79 in 1438
fractures).1,7,8,10,11,13,16,18,19,21,23,27,29–31 This rate is 5.3% (82 in
1550 fractures) if the last 3 studies9,14,22 concerning only distal
third fractures are included.
Delayed union
In our review delayed union is reported in only 5 studies
(Table 1). The rate is 4% (7 cases in 173 fractures). Still, in only one
of these studies14 does the author define what he regards as
delayed union (failure to unite within 4 months but in the presence
of clinical and radiological signs of healing). If the limit of 4 months
is accepted though, the number of delayed unions should certainly
be higher, as in many of the articles there was cases that brace
application lasted for more than 17 weeks (Table 1).
 E. Papasoulis et al. / Injury, Int. J. Care Injured 41 (2010) e21–e27 e23

Table 1
Articles included in the study and their results in terms of union.

Study Study design Fractures n Follow-up Union n Non- Delayed Time of brace Follow-up time mean (range)
n (%) (%) union (%) union n (%) application in
weeks (range)

Sarmiento et al.21 Retrospective 51 51 (100) 50 (98) 2 8.5 (3–22.5) – (2–30 months after removal)
Balfour et al.1 Prospective 74 42 (57) 41 (97.6) 2.4 1 (2.4) 7.5 (4–15) – (6 weeks–3 years, stop
when full motion)
Ricciardi-Pollini Retrospective 14 14 (100) 14 (100) 0 1 (7.1) – (8–13) Not specified
and Falez16
Naver and Aalberg13 Prospective 20 20 (100) 18 (90) 10 6.5 (4–24) 13.2 months (6–25 months)
Zagorski et al.31 Retrospective 233 170 (73) 167 (98.2) 1.8 10.6 (5–20) 28 weeks (5 weeks–4 years)
Leung et al.11 Retrospective 29 29 (100) 29 (100) 0 1 (3.4) 7 (4–18) – (at least 9 months)
Wallny et al.30 Retrospective 79 79 (100) 74 (93.7) 6.3 8.7 (4–17) 2.5 years (2–6 years)
Wallny et al.29 Comparative/ 44 44 (100) 42 (95.5) 4.5 – (7–10) 27 months (12–48 months)
retrospective
Sarmiento et al.23 Retrospective 922 620 (67) 604 (97.4) 2.6 11.5 (5–22) Until union
Fjalestad et al.8 Retrospective 67 67 (100) 61 (91.1) 8.9 12 (6–25) 30 weeks (10–152 weeks)
Koch et al.10 Retrospective 74 67 (91) 58 (86.6) 13.4 1 (1.4) 10 (5–36) 1 year
Toivanen et al.27 Retrospective 93 93 (100) 72 (77.4) 22.6 Not specified Until union
Rosenberg et al.18 Prospective 15 15 (100) 15 (100) 0 22 (10–40) 30 months (12–57 months)
Ekholm et al.7 Retrospective/ 78 78/50a (100/64)a 70 (89.7) 10.3 Not specified 26.4 months
prospectivea
Rutgers et al.19 Retrospective 52 49 (94) 44 (89.8) 10.2 Not specified 14 months (2–50 months)

Distal third
Sarmiento et al.22 Retrospective 85 72 (85) 69 (95.8) 4.2 10 Not specified
Pehlivan14 Prospective 25 21 (84) 21 (100) 0 3 (14.3) 11.8 (8–30) 39 weeks (29–70 weeks)
Jawa et al.9 Comparative/ 21 19 (90) 19 (100) 0 9.7 (8–12) 21 months (2–45 months)
retrospective
a
Retrospective study on union (78 fractures)–prospective on function and quality of life (50 patients).

Residual deformity/malunion cles1,9,10,13,14,19,21,22,27), while the average angulation was 5.98

One of the disadvantages of functional bracing in comparison
with surgical treatment is the possible residual deformity of the
arm, particularly in patients with short or obese arms.29–31
It is generally accepted that the most common deformity is
varus angulation.1,8,10,14,19,21,31 In most reports angulation of less
than 108 was found in more than 85% of the patients,13,14,16,21,29–31
while the deformity in rare occasions exceeded 208 (Table 2).
Frontal plane angulation exceeded 108 in 23.3% of the patients
(sufficient data in 844 fractures from 7 articles10,13,14,22,23,29,30),
208 in 4.4% of the patients (383 fractures from 9 arti-
(383 fractures from 8 articles1,9,10,13,14,18,21,31).
In the saggital plane results are equally satisfying – if not
better1,9,10,13,14,16,18,19,21–23,27,29,31 (Table 2). Angulation exceeded
108 in 13.9% of the patients (sufficient data in 760 fractures from 7
articles10,13,14,16,22,23,29), 208 in 2% of the patients (293 fractures
from 7 articles9,13,14,19,21,22,27), and the average angulation was 3.78
(452 fractures from 9 articles1,9,10,13,14,18,21,22,31).
Rotational deformity is difficult to identify in plain radio-
graphs and its incidence is seldom reported. In three
reports14,21,31 no clinically or radiologically significant rotational
deformity was observed. Fjalestad et al.8 were the only ones to

Table 2
Residual deformity in the reports with sufficient data.

Study Patients Varus–valgus deformity Anterior–posterior deformity Shortening

Number of patients Limit in Malunion Average >208 Limit in Malunion Average >208 Average
evaluated for degrees (%) deformity deformity degrees (%) deformity deformity (maximum)
malunion in degrees (%) in degrees (%) in mm

21 50 >5 16 4 0 >5 16 4 0
1 42 9 11.9 6.2
16 14 >5 7.1 >5 0
13 18 >10 11.1 3.3 5.6 >10 11.1 4.2 0 0 (0)
31 170 >8 18.5 5 >8 11 3 4 (15)
30 79 >10 12.6
29 44 >10 13.6 >10 13.6
23 565/546a >10 25 >10 13.9
8 47/61b >15 14.9 >15 36.1 – (20)
10 48 >10 18.8 6 0 >10 6.3 4.1
27 72 0 0
18 15 13 9
19 44 6.8 0

Distal third
22 69 >10 42 8.7 >10 27.5 3.2 5.8 1.8 (15)
14 21 >10 0 3 0 >5 0 0.5 0 1.9 (20)
9 19 12 10.5 3 10.5
a
Frontal plane 565 patients evaluated, saggital plane 546 patients.
b
Frontal plane 47 patients evaluated, saggital plane 61 patients.
e24 E. Papasoulis et al. / Injury, Int. J. Care Injured 41 (2010) e21–e27

examine the degree of malrotation with a CT scan and they
correlated it with loss of external rotation of the shoulder. They
believe that early fracture stabilisation by a functional brace may
reduce this malrotation and that the sling should be discarded
soon in order not to inhibit the fracture during muscle activity.
This allows for early active contraction of the flexors and
extensors of the elbow together with the effect of gravity to
correct malrotation both functionally and aesthetically in an
acceptable degree.14,23
Shortening can also occur. In no case, though, did it exceed
2 cm.8,13,14,22,31
Functional recovery
Almost as important as union and deformity in estimating the
efficacy of functional bracing as treatment method is residual joint
stiffness (Table 3). An important factor affecting the final
functional outcome is age. Koch et al.10 found that patients older
than 40 years are at a greater risk to have joint motion loss
developed compared with younger patients.
Moreover, the fact that motion range may improve with use22
should always be kept in mind, when estimating the functional
recovery after functional bracing, since most of these findings were
true at the time of union and brace removal.
Shoulder motion
Full range of motion has been reported to be present in 40–93%
of patients after functional bracing. In a total of 535 patients – from
9 articles1,8,10,11,16,21,29–31 with sufficient data – full range of
motion has been achieved in 424 of them (79.3%).
External rotation is more often affected8,9,10,14,19,21–23,29,30;
abduction1,8,9,10,14,19,21–23,29,30 and forward flexion8,9,22,23,29,31
follow. Limitation of other movements (internal rotation, exten-
sion) is seldom reported.8,10,19 A deficit of more than 108 has been
found in 12.7% of 245 patients for external rotation,8,9,10,14,19,22 and
in 5.9% of 305 patients for abduction.1,9,10,14,19,22,30
The use of a custom-made brace with a lateral extension on the
shoulder may explain the difference in the functional outcome
concerning shoulder motion in some studies.8,31 Another impor-
tant factor is the duration of brace application. Rosenberg18
reported bad functional results in patients who discarded the brace
after 22 weeks, while the time recommended in most studies
varies between 8 and 14 weeks.
The results indicate that a certain degree of shoulder impair-
ment is anticipated. Most authors consider that the degree of this
impairment can be accepted9,10,14,21,22; others are more skepti-
cal.8,18
Elbow motion
Restriction of elbow motion is reported to be less often than in
shoulder (Table 3). In most articles full range of elbow movement
was achieved by more than 85% of the patients.1,8,10,14,16,21,29–31 In
a total of 857 patients – from 11 articles1,8,10,11,14,16,21,23,29–31 with
sufficient data – full range of motion was achieved in 727 of them
(84.8%). A deficit greater than 108 was present in 1.8% of 278
patients from 7 articles1,8,9,10,14,19,21 concerning elbow flexion and
in 0.8% of 527 patients from 9 articles1,8,9,10,14,19,21,30,31 concerning
elbow extension.
Functional scores
Evaluation of function results has been performed in some of
these articles with the use of various scoring systems. Neither
these nor other parameters, such as pain, satisfaction by treatment,
or time off work were uniformly presented (Table 4).
In most of these studies excellent and good results were found
in more than 80% of the patients. On the other hand, in many
reports excellent results alone were around only 50%.7,8,10,30
Similarly, results were far from excellent, when parameters such as
shoulder function scores,18 pain8,10,18,29,30 and quality of life7 were
evaluated.
Residual deformity and function
Fjalestad et al.8 reported the worst results on malunion,
which could perhaps explain the disappointing shoulder
functional results that came along. They agree, however, with
most of the authors that angulatory deformities of the humeral
shaft of up to 20–258 can be tolerated both functionally and
cosmetically because of the large soft-tissue mass around the
humerus and the large range of movement of the adjacent

Table 3
Range of motion following functional bracing in the reports with sufficient data.

Study Follow up Shoulder Elbow

Number of patients Full Loss of abduction Loss of external Loss of forward Full Loss of flexion Loss of extension
followed up with motion rotation flexion motion
regard to motion (%) (%)
Limit in (%) Limit in (%) Limit in (%) Limit in (%) Limit in (%)
degrees degrees degrees degrees degrees

21 50 82 >15 0 >15 0 100 Any 0 Any 0

1 41 90 >10 4.9 90 >10 2.4
16 14 86 86
31 170 93 >15 0 93 >5 0
11 29 55 55
30 74 86 >10 6.8 86 >10 0
29 44 86 Any 6.8 Any 4.5 Any 4.5 91
23 NS/301a 60 76
8 55 40 Any 30.9 >10 27.3 Any 27.3 91 >10 1.8 >10 1.8
10 58/48b 62 >10 2.1 >10 12.5 86 >10 4.2 >10 0
19 44 >10 2.3 >10 0 >10 2.3 >10 2.3 >10 0

Distal third
22 58 >10 15.5 >10 17.2 >5 13.8 >5 25.9 >5 24.1
14 21 >10 0 >10 0 100 Any 0 Any 0
9 19 >10 0 >10 0 >10 0 >10 5.2 >10 10.5
a
Not specified number for shoulder motion, 301 for elbow.
b
Full motion was evaluated on 58 patients, different movements on 48 patients of the monotrauma group.
 E. Papasoulis et al. / Injury, Int. J. Care Injured 41 (2010) e21–e27 e25

Table 4
Evaluation of final outcome.

Study Patients n Score used Excellent % Good % Moderate % Poor % Other parameters—scores

16 14 Their own criteria 85.7

13 20 Hunter 80 10 5 5 80% no restriction of activity (Grade V)
30 74 Hannover Shoulder Score 63 17.7 15.2 3.8 95% content with treatment, 65% no pain
29 44 95.5% content with treatment, 50% no pain,
45.5% pain with exercise, 4.5% rest pain, score
described by Wulker et al.: 90.8 points
8 54/61a Modified Wasmer score 45 24 20 69% no pain, 8% rest pain
10 58/48b Their own criteria 51.7 43.1 5.2 0 11.8 weeks pain, 11.3 weeks off work, 17.2% chronic pain
18 15 Oxford Shoulder score: 34 (12–60, 12 = normal),
Constant score: significant lower than normal limb,
VAS score on pain: 5 (0–10, 0 = no pain)
7 43 Reported by the patients 49 SMFA (Short Musculoskeletal Functional Assessment):
as full recovery Dysfunction index 21.0, Bother index 18.8—SF-36 score
on quality of life lower than general population
14 21 Modified Hannover 86 14
Shoulder Score
a
Fifty-four patients evaluated with Wasmer score, 61 for pain.
b
Fifty-eight patients evaluated with the scoring system, 48 of the monotrauma group evaluated for pain.

joints.1,8,10,13,14,19,21–23,27,29–31 Equally important, in none of the
reported studies malalignment of humeral shaft fractures was
correlated to secondary osteoarthritis.
However, the general impression that radiological features of a
certain degree of malalignment is not correlated with the
functional result and therefore does not affect the clinical outcome
is only an observation, once none of the authors has actually
estimated the functional result with regard to the degree of
residual deformity.
Radial nerve palsy and complications
The rate of primary radial nerve damage in humeral shaft
fractures has been reported to vary between 4% and 22%,14 with an
average of 11–12%.15,26 In 14 articles of this review with sufficient
data1,7–10,14,19,21–23,27,29–31 the radial nerve palsy rate ranged
between 0% and 16.7%, with a total of 136 incidences in 1472
fractures and an average of 9.2% (Table 5). Most of the authors
treating humeral shaft fractures with functional bracing agree that
the majority of primary radial nerve injuries resolves sponta-
neously1,7,8,9,10,14,19,21–23,29–31 (86.2% of 130 fractures from 13
articles). Therefore, it seems that early nerve exploration for nerve
injury is not justified.8,22,23,29–31 In these cases splinting of the
wrist may be performed in conjunction with bracing.31 Good
results though, can also be obtained with no special treatment,
except adding passive exercises for the wrist and fingers to the
shoulder and elbow exercises.22,23 If resolution does not occur and
there is residual motor deficiency by the time of union of the
fracture, surgical intervention may then be considered.31 There is
only one report of secondary radial nerve palsy developed during
functional treatment.10 In a total of 54 monotrauma patients
treated by Koch et al.10 there were two such cases; both recovered
with observation.
Other complications of the use of braces are usually minor
such as skin problems – treated without interrupting the
treatment, by skin care and dermatologic ointments,14,31
swelling of the arm, which requires loosening of the straps,
and inferior glenohumeral subluxation, which is seldom
reported19,23,31 and rapidly restored by early voluntary contrac-
tions of the biceps and triceps muscles.
Special fracture patterns
There are certain types or locations of humeral shaft fractures
that have been associated with an increased rate of non-union.
Further analysis of the efficacy of functional bracing depending on
the location or type of fracture has been performed (Table 6). Only
the studies that supply sufficient data on the number of non-
unions confronted with regard to specific fracture pattern have
been used.
Location
In 8 articles7,8,11,16,18,19,23,27 with sufficient data concerning
non-union with regard to fracture location the non-union rate
was 8.2% for proximal third, 6.1% for middle third and 4.2% for

Table 5
Radial nerve palsies (RNP) confronted in the articles of the review.

Study Fractures n RNP n RNP % Spontaneously recovered n Residual dysfunction n Operated n Secondary RNP n

21 51 6 11.8 6 0 0
1 42 4 9.5 3 1 0
31 170 7 4.1 7 0 0 0
30 79 6 7.6 2 4
29 44 6 13.6 2 4 0
23 620 67 10.8 66 1 0
8 67 8 11.9 5 3 0
10 67 4 6.0 4 0 0 2
27 93 6 6.5 – – –
7 78 5 6.4 3 2 0
19 49 3 6.1 3 0 0
22 72 12 16.7 9 3 0
14 21 0 0 – – – 0
9 19 2 10.5 2 0 0 0

Total 1472 136 9.2 112 (86.2%) 10 (7.7%) 8 2

e26 E. Papasoulis et al. / Injury, Int. J. Care Injured 41 (2010) e21–e27
Table 6
Statistics of non-unions with regard to fracture pattern.
Fracture subtype (number of articles with sufficient data) Fractures (n)
Location (8 articles)
Proximal 170
Middle 496
Distal 289
Total 955
AO type (5 articles)
A 182
B 73
C 19
Total 274
Fracture configuration (6 articles)
Spiral 94
Oblique 57
Transverse 101
Comminuted + segmental 66
Total 318
distal third fractures, while the overall non-union rate was 5.9%
(Table 6). These differences were not statistically significant
(p > 0.05).
AO type fracture
In 5 articles7,8,14,18,27 that sufficiently analysed non-union with
regard to AO type fracture there were 35 non-unions in 274
fractures and an overall non-union rate of 12.8% (Table 6). Type A
fractures were found to have the worst rate with 15.4%, while type
B had 9.6% and type C 0%.
These differences in the non-union rate, however, were not
found to be statistically significant (p > 0.05).
Fracture configuration
In only 7 of the articles8,14,16,23,27,29,30 did the authors classified
non-unions according to fracture configuration. Non-union rate
was 12.8% for spiral, 4.9% for oblique, 8.9% for transverse and 2.2%
for comminuted and segmental fractures. According to these
results spiral fractures should have the highest non-union rate.
This, however, is not supported by any report.
Excluding the series of Sarmiento et al.23 the non-union rates
are 12.8% for spiral, 17.5% for oblique, 8.9% for transverse and 4.5%
for comminuted and segmental fractures and a total rate of 10.7%
(34 non-unions in 318 cases – Table 6). These differences are not
statistically significant (p < 0.05).
This exclusion is based on the fact that Sarmiento et al.23
reported no spiral fracture in a total of 620 fractures, when in the
remaining six studies there are 29.6% spiral fractures (94 in 318
fractures), and the reported rate of spiral fractures in the humerus
in epidemiological studies is 37.7% according to Ekholm et al.,6 and
29.2% according to Tytherleigh-Strong et al.28 Perhaps Sarmiento
et al.23 reported spiral and oblique fractures together as oblique,
since the rate of oblique fractures they reported (24%, 149 in 620) is
higher than in the other six studies (17.9%) or in the epidemio-
logical studies (8.6%6 and 10.8%28).
Long-oblique proximal fractures
Recently two retrospective studies4,17 of humeral non-unions
observed that a significant proportion of non-united fractures in
their series were long-oblique fractures in the junction of
proximal to middle third of the diaphysis of the humerus. Ring
et al.17 concluded that oblique fractures of the mid- to proximal
third of the diaphysis are more susceptible to non-union with
Non-unions (n) Non-union rate (%) p
14 8.2
30 6.1
12 4.2
56 5.9 >0.05
28 15.4
7 9.6
0 0
35 12.8 >0.05
12 12.8
10 17.5
9 8.9
3 4.5
34 10.7 >0.05
functional brace treatment (27 out of 32 non-unions). Only two
articles included in our review reported similar findings, with 2
out of 6 non-unions8 and 4 out of 519 in long oblique fractures. In
the rest of the studies such findings are not mentioned. It is
unclear why some surgeons observe high union rates in long-
oblique fractures in the junction of proximal to middle third of the
diaphysis of the humerus and others do not. Additional research is
needed.
Open
Open humeral fractures are usually regarded as an indication
for operative treatment.9,11,14,19,27,29 Still, functional bracing has
been used in the treatment of open humeral shaft fractures. The
type (severity) of the open fracture is not always stated and in
many studies the non-union rate for open fractures is not
specified.1,8,10,30 In five studies7,21–23,31 the overall non-union rate
was 4.9% (11 non-unions in 224 fractures). In these 5 articles there
were a total of 991 fractures, both closed and open, and 31 non-
unions with an overall non-union rate of 3.1%. The difference was
not statistically significant (p > 0.05). These authors agree that
open fractures without nerve or vascular injury may be success-
fully treated with operative debridement and irrigation, intrave-
nous antibiotic therapy, and immobilisation using a plaster
(coaptation) splint. Bracing begins at the time of the first change
of dressing (at 2 to 3 days), and the wound is left open to heal by
secondary intention.
Most surgeons would be reluctant to treat open humeral
shaft fractures conservatively. The above findings however,
show that these fractures can be treated successfully with
functional bracing under certain conditions. These conditions
are yet to be clarified.
Limitations
There are a number of limitations in this literature review.
Exclusion of studies published in languages other than English is
one of them. Only case series and two comparative studies were
available for analysis. These have a low evidence level. Conclusions
about the effectiveness of a specific therapeutic intervention are
best provided by well-conducted randomised controlled trials or
meta-analyses, but none of these exist. Therefore only a systematic
review of non-randomised trials could be performed. Moreover –
as previously stated – the heterogeneity of the demographics and
of the way the results are presented in the studies analysed make
statistical analysis difficult.
 E. Papasoulis et al. / Injury, Int. J. Care Injured 41 (2010) e21–e27
Conclusions
The aim of this review was to investigate the efficacy of
functional bracing in the treatment of humeral shaft fractures.
According to the results the union rate is about 95%, with an
average time to union of 10–11 weeks. Analysis of the non-union
rate with regard to location or AO type of the fracture has shown
that proximal third fractures and AO type A fractures have a higher
non-union rate. Still, no statistical significant difference exists.
Analysis with regard to fracture configuration was more trouble-
some. Spiral fractures were found to have a significantly higher
non-union rate, but we have reasons to doubt the credibility of this
finding. Therefore it could not be proved that a certain fracture
pattern of the humeral shaft is unsuitable for functional bracing.
Residual deformity – especially varus angulation – is one of the
commonest complications of this method, but for most authors a
malunion up to 208 can be accepted both functionally and
cosmetically. Nevertheless, there is no study that has actually
correlated the degree of malalignment with limitation of motion or
other functional parameters.
Despite early mobilisation of adjacent joints a certain degree of
shoulder and – less often – elbow impairment is to be expected.
Full shoulder and elbow motion is usually present in as much as
80% of the patients. External rotation and abduction of the shoulder
and extension of the elbow are more commonly affected, but the
deficit of movement rarely exceeds 108. However, when assessing
the functional outcome using subjective criteria the results are not
always as good as the overall impression that most authors carry
concerning this method of treatment. The heterogeneity of these
results makes it difficult for final conclusions to be conducted.
Future studies should perhaps pay more attention in the method of
functional evaluation after functional bracing of humeral shaft
fractures, using commonly accepted methods of assessing the
shoulder and arm function, such as the Constant score or the DASH
questionnaire.
For most authors functional bracing remains the gold standard
and the first treatment of choice for humeral shaft fractures. It
offers high rate of union, good functional results, patient comfort,
and cost reduction, while avoiding the possible complications of an
operative treatment. Nevertheless there are certain parameters,
such as the functional outcome after brace treatment, indications
of bracing open fractures, and correlation between residual
deformity and loss of joint motion, that remain unclear, and
further research is required to elucidate them.
Conflict of interest statement
None of the authors of this article has been related financially or
personally with other people or organisations that could inappro-
priately influence the writing of this article; thus there is no
conflict of interest concerning any of the authors.
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