Humeral shaft fractures represent 1–3% of all the fractures coming in our OPD [1]. Currently, there are no defined gold standards for the treatment of humeral shaft fractures [2,3]. Most of these fractures are mostly treated conservatively. Although nonoperative treatment has a long and successful history in certain cases [4]. It requires good patient compliance for a successful outcome. Therefore, new surgical treatment methods have been developed to reduce soft tissue damage, improve early training and prevent long uncomfortable periods of immobilization, which can be associated with nonoperative treatment [3,5,8].

Internal fixation may be indicated in open fractures with nerve injury, fractures associated with vascular injury, fractures extending into neighbouring joints, bilateral fractures and inpatient with multiple injuries. [9, 10]. The internal fixation methods for humerus shaft fractures can be broadly grouped into plating or intramedullary techniques. Plate osteosynthesis remains the gold standard of fixation of humeral shaft fractures compared to other methods [11]. In our centre we mainly used plate fixation for treating humerus fractures, mainly two-part fractures [12]. Nailing was rarely used when plating was not possible due to fracture pattern.

Although plate fixation has the advantage of lesser rates of malunion and non-union, it causes soft tissue disruption, more blood loss and there are higher chances of infection and radial nerve damage with an open plating procedure [13,14]. Union was defined as a radiologically detectable callus bridge or at least three visible cortices on the radiographs [15]. Depending on the type of callus formation, fracture healing was denoted as direct fracture healing (absolute stability: no callus formation) or indirect fracture healing (relative stability: callus formation) [16].

Nonunion was defined as failed fracture healing six months after the initial trauma. It was assessed clinically by the presence of pain and radiographically by the absence of a callus bridge or the persistence of visible fracture lines. Infection was defined by positive clinical signs of an infection, such as local pain, erythema, warmth, swelling and draining wounds in the affected limb leading to revision surgery [17]. Our study aimed to evaluate the results of plate fixation in our hospital that employs plate fixation as the golden standard.

6 months (4^th check x-ray). Clinical evaluation in form of a range of movement of shoulder and elbow joint was also done in every follow-up. In each follow up under the supervision of the operating surgeon and physiotherapist, early non-weight- bearing range of motion exercises was taught to the patient to do at home. Superficial surgical site infections were classified as either superficial or deep according to the definition of the Centres for Disease Control and Prevention [20]. Non-union was defined as the absence of bone healing after 6 months. Patients with impairment of shoulder and elbow function were classified as having either no impairment of range of motion (full recovery) or suffering from impairment in a range of motion regardless of severity (shoulder/elbow impairment).

The median hospital stay was 6 days (range 2–18). Patients were followed up for 6 months. Patients with follow up less than 6 months were not included in the study

Plate fixation (4.5mm Locking Compression Plate, LCP) was performed in 40 patients with a humeral shaft fracture (Fig 2 & 4). The mean age was 50 (SD 20) years with 60 % (n = 24) being male. There were 55 % (n = 22) fractures in the right and 45 % (n = 18) fractures in the left. Out of 40 patients, 21 patients (52.5%) had an AO/OTA type-A fracture, 13 patients (32.5%) had type-B and 6 patients (15 %) had type-C fracture. Anterolateral approach (in supine position) was done in 24 patients (60 %) of cases and posterior approach (in lateral position) was done in the remaining 16 (40%) cases. All fractures were fixed by a 4.5 mm narrow LCP plate (Fig 2 & 4). None of the patients develops superficial surgical site infection. Complications like radial nerve palsy, deep surgical site infections and non-union occurred in 2.5 % (n = 1), 2.5 % (n = 1) and 5 % (n = 2) of patients respectively.

In one patient who developed radial nerve palsy postoperatively, the palsy recovered spontaneously in 4 months. In our study, we found no radial nerve palsy before surgery. In one case of deep surgical infection, culture sensitivity of wound was done and accordingly intra-venous antibiotic injections were given for 5 days postoperatively followed by oral antibiotics for next 9 days and the patient stayed in the hospital during this period for dressings. The patient was discharged when the wound healed and stitch removal was done.

Fig 1:Pre-op X-ray

Fig 2: Post-op X-ray

Case 2:

Fig 3: Pre-op X-ray

Fig 4:  Post-op X-ray

Most of the humerus fractures are treated conservatively. Non-operative treatment requires good patient compliance for a successful outcome. It is generally accepted that conservative management is best for isolated closed fractures of the shaft of the humerus [9,21-24].

The best treatment for humeral shaft fractures complicated with radial nerve injury is highly controversial [38,39]. While concomitant nerve injury has been used as an argument for the immediate surgical treatment of fractures in the past (using a posterior approach and visualizing the radial nerve) (40), recent investigations have shown no significant difference in radial nerve palsy recovery between initial operative and nonoperative management strategies [36,41].

Most radial nerve injuries in cases of humeral shaft fracture are caused by traction or compression of the nerve, which is known as neuropraxia. Much fewer nerve injuries are identified as discontinuity of the nerve (axonotmesis or neurotmesis) [42]. Neuropraxia is a reversible injury, resulting in spontaneous reversibility in a large portion of traumatic radial nerve palsy cases (36). Plate fixation is the golden standard in our hospital.

Our study included only those cases of humerus fractures that were managed surgically by plate fixation It is a well-known fact that a higher level of training generally yields better results [43,44)]. This greater expertise is likely reflected in the results of this study. With greater experience, complication rates can be minimized in patients undergoing plate fixation for humeral shaft fractures. The objections which have been made to humeral shaft plating are that it may lead to non-union [45]. or to radial nerve injury [21,46]. or to infection, or that the fixation may fail with refracture through the screw holes (9).

Although no long-term complications occurred in our study, one limitation is the lesser duration of follow-up time (six months). Due to limited sample size and lesser duration of follow-up and therefore studies with big sample size and longer duration of follow up will be required to prove the advantage of plating in humerus fractures We only calculated the proportion of patients with full recovery of the shoulder in 34 cases (85%) and elbow function in 36 cases (90%) following surgery.

These proportions are comparable to those found in similar studies [47,48,49]. Nevertheless, functional results are equally important to take into consideration when determining the optimal treatment for patients with humeral shaft fractures. There were several limitations in our study that should be considered when interpreting the results. It was a retrospective study and will have certain amounts of selection bias.