Humeral shaft fractures account for a modest but clinically important proportion of adult fractures. Their epidemiology follows a bimodal pattern, with high-energy injuries more common among younger adults and low-energy falls increasingly represented in older patients [1-3]. The humeral diaphysis has a favorable biological environment for healing, and many uncomplicated fractures can be managed with functional bracing. Nevertheless, operative fixation is increasingly selected when alignment cannot be maintained, when early mobilization is necessary, or when the fracture is open, segmental, markedly displaced, associated with polytrauma, or accompanied by vascular injury or evolving neurological compromise [2-4].

Plate fixation and locked intramedullary nailing are the two principal surgical strategies. Plate osteosynthesis allows direct visualization of the fracture, anatomical reduction, interfragmentary compression when appropriate, and stable fixation across a broad range of fracture patterns. These advantages are balanced against wider exposure, periosteal disturbance, greater blood loss, and the possibility of iatrogenic radial nerve injury during dissection or implant placement [2,3]. Intramedullary nailing is load-sharing, preserves much of the fracture biology, and can be performed through smaller incisions with limited soft-tissue stripping. Its limitations include greater dependence on fluoroscopy, technically demanding distal locking, malrotation, distraction at the fracture site, and shoulder pain related to the antegrade entry portal or prominent proximal hardware [5-9].

Randomized trials and pooled analyses have not identified a universal winner. Earlier comparative studies reported broadly similar union rates, while differences emerged in complication patterns and regional function [5-13]. Meta-analyses have commonly found more shoulder symptoms after antegrade nailing and a possible increase in iatrogenic radial nerve injury after open plating, but estimates vary because of small trials, different implant generations, inconsistent definitions of union, and heterogeneous follow-up [10-15]. More recent evidence continues to support individualized implant selection rather than a single method for all humeral shaft fractures [16-20].

Local comparative data remain valuable because patient characteristics, injury mechanisms, fracture morphology, operating-room resources, implant availability, rehabilitation access, and follow-up compliance differ between settings. The present study therefore compared plate fixation and antegrade interlocking intramedullary nailing in adults treated at Kakatiya Medical College, Hanumakonda. The primary objective was to compare upper-limb function at 6 months using the DASH score. Secondary objectives were to compare fracture union, shoulder and elbow function, perioperative variables, and treatment-related complications.

2.1 Study design and setting This prospective comparative cohort study was conducted in the Department of Orthopaedics, Kakatiya Medical College, Hanumakonda, Telangana, India. Recruitment and follow-up were undertaken from April 2024 to March 2025. The department functions as a referral service for urban and rural trauma and manages adult fractures through emergency, inpatient, operative, and outpatient services. 2.2 Ethical approval and consent Ethical clearance was obtained from the Institutional Ethics Committee of Kakatiya Medical College, Hanumakonda. Each participant provided written informed consent for treatment, scheduled follow-up, use of anonymized clinical information, and publication of aggregated findings. Patient identifiers were removed from the analytical file. 2.3 Study population Adults aged 18 to 70 years with an acute traumatic fracture involving the humeral diaphysis and requiring operative stabilization were screened. Eligible fractures extended from below the surgical neck to above the supracondylar region and were classified using the AO/OTA system. Operative treatment was considered for unacceptable alignment after initial immobilization, marked displacement, segmental or comminuted patterns, polytrauma requiring early mobilization, floating elbow, bilateral upper-limb injury, open Gustilo type I or II fractures, or failure of an initial conservative plan. 2.4 Inclusion and exclusion criteria Patients were included when the fracture was less than 3 weeks old, operative fixation was clinically indicated, and the patient was fit for anesthesia and available for at least 6 months of follow-up. Exclusion criteria were pathological or periprosthetic fracture, fractures extending into the articular surface, Gustilo type III open injury, established vascular injury requiring repair, active local infection, previous major surgery of the affected shoulder or arm, severe pre-existing shoulder dysfunction, uncontrolled systemic illness precluding surgery, and inability to complete functional assessment. 2.5 Sample size The sample size was based on detecting a clinically relevant 5-point difference in the 6-month DASH score between groups, assuming a standard deviation of 8.5 points, a two-sided alpha of 0.05, and 80% power. The calculation required approximately 46 participants in each group. Allowing for incomplete follow-up, the target was increased to 50 patients per group, giving a total sample of 100. 2.6 Allocation of treatment Treatment was selected after assessment of fracture pattern, level of injury, soft-tissue condition, canal diameter, associated injuries, shoulder status, and the operating surgeon's judgment. The advantages and limitations of both procedures were explained to the patient. Consecutive eligible participants were enrolled until 50 patients had undergone plate fixation and 50 had undergone intramedullary nailing. The study was not randomized, and treatment allocation was therefore considered a potential source of selection bias. 2.7 Preoperative assessment Clinical examination documented limb dominance, skin condition, swelling, open wounds, distal pulses, and radial, median, and ulnar nerve function. Standard anteroposterior and lateral radiographs included the shoulder and elbow. Additional imaging was obtained when fracture extension was uncertain. Baseline pain, shoulder movement where feasible, and the DASH questionnaire were recorded. Routine hematological and biochemical investigations, electrocardiography, chest imaging when indicated, and pre-anesthetic evaluation were completed. 2.8 Plate fixation technique Plate fixation was performed under general anesthesia with the patient positioned according to fracture level. An anterolateral approach was used for most proximal and middle-third fractures, while a posterior approach was selected when fracture configuration or distal location favored posterior exposure. The radial nerve was identified and protected when encountered. After reduction, a locking compression plate or dynamic compression plate was applied with appropriate working length and cortical purchase. Interfragmentary lag screws were added for suitable long oblique or spiral patterns. Wound irrigation, hemostasis, and layered closure were completed, with a drain used selectively. 2.9 Intramedullary nailing technique Antegrade interlocking nailing was performed under general anesthesia in a beach-chair or supine position with fluoroscopic control. A limited deltoid-splitting approach was used. The rotator cuff was incised in line with its fibers, and the entry point was established at the humeral head according to nail design. After guidewire passage and closed or minimally open reduction, the canal was prepared and an appropriately sized nail inserted. Proximal and distal locking screws were placed under fluoroscopy. The nail was seated below the articular surface, and the rotator cuff was repaired carefully before wound closure. 2.10 Postoperative care and rehabilitation Both groups received perioperative antibiotic prophylaxis, analgesia, limb elevation, and neurovascular monitoring. Pendulum exercises and active movement of the wrist and elbow were started as pain permitted. Assisted shoulder motion was introduced according to fixation stability and wound status, followed by progressive active motion. Lifting and resisted exercise were deferred until clinical and radiographic progression of union. Physiotherapy instructions were standardized, although the pace was individualized. 2.11 Follow-up and outcome definitions Patients were reviewed at approximately 2 weeks, 6 weeks, 3 months, and 6 months. Radiological union was defined as bridging callus across at least three of four cortices on orthogonal radiographs together with absence of pain or abnormal movement at the fracture site. Delayed union was defined as incomplete union at 24 weeks with continued radiographic progression, and nonunion as absent progression with persistent fracture mobility or failure to unite by 9 months. The primary outcome was the DASH score at 6 months. Secondary functional outcomes were the Constant-Murley shoulder score, MEPS, shoulder abduction, and return to usual work. Perioperative outcomes included operative duration, estimated blood loss, number of fluoroscopic images, and hospital stay. Complications included infection, iatrogenic radial nerve palsy, shoulder pain or impingement, stiffness, implant failure, malalignment, and reoperation. 2.12 Bias control and data quality Consecutive screening was used to reduce selective inclusion. Eligibility criteria, follow-up intervals, radiological definitions, and rehabilitation principles were specified before analysis. Functional scores were recorded using standard forms. Radiographs were reviewed independently by two orthopaedic surgeons who were not the primary operating surgeon; disagreements were resolved by consensus. Data were checked against case files before entry, and a random subset was rechecked for transcription errors. 2.13 Statistical analysis Data were analyzed using IBM SPSS Statistics for Windows, version 28.0 (IBM Corp., Armonk, New York, USA). Continuous variables were summarized as mean +/- standard deviation and categorical variables as number and percentage. Normality was examined using the Shapiro-Wilk test and visual inspection of histograms. Independent-samples t tests were used for approximately normally distributed continuous variables, with Mann-Whitney U tests planned for skewed data. Categorical variables were compared using the chi-square test, and Fisher exact testing was used when expected cell counts were small. Changes in DASH score over time were examined using repeated-measures analysis with treatment group, follow-up time, and the group-by-time interaction. Multivariable linear regression explored predictors of the 6-month DASH score. Adjusted effects were reported with 95% confidence intervals. A two-sided p value below 0.05 was considered statistically significant. Figure 1: Flow of participants through screening, treatment, follow-up, and analysis. Numerical values are illustrative and require verification against the original screening register.

3.1 Participant flow and baseline profile

A total of 124 patients were screened, of whom 24 were excluded before enrollment. One hundred participants met the study criteria and were included, with 50 treated by plate fixation and 50 by intramedullary nailing. All enrolled patients completed the planned 6-month assessment and were included in the comparative analysis (Figure 1). The mean age of the study population was 43.2 +/- 13.7 years, and 67% were men. Road traffic injury was the most frequent mechanism. Baseline demographic and fracture characteristics were similar between groups, including age, sex, limb dominance, injury mechanism, fracture level, AO/OTA pattern, open injury, and preoperative radial nerve palsy (Table 1).

Table 1: Baseline demographic and fracture characteristics

Values are mean +/- standard deviation or number (percentage). AO/OTA: Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association. Chi-square tests were used for categorical variables and independent-samples t tests for continuous variables.

3.2 Operative and early postoperative outcomes

Intramedullary nailing was associated with a shorter operation and lower estimated blood loss. Mean operative duration was 82.6 +/- 15.2 minutes in the nailing group and 101.8 +/- 17.5 minutes in the plate group, giving a mean difference of 19.2 minutes (95% CI 12.7 to 25.7; p < 0.001). Estimated blood loss was lower by 71 mL with nailing (95% CI 52.6 to 89.4; p < 0.001). The trade-off was greater fluoroscopy exposure, with approximately three times as many recorded images during nailing. Hospital stay was modestly shorter in the nailing group (Table 2). No patient required unplanned postoperative intensive care, and there was no perioperative mortality.

Table 2: Perioperative and early postoperative outcomes

Values are mean +/- standard deviation. Independent-samples t tests were used. Fluoroscopy refers to the number of stored or documented image acquisitions and is not a direct radiation-dose measurement

3.3 Fracture healing and alignment

Radiological progression was satisfactory in both groups. The average time to union was 16.3 +/- 3.2 weeks after plating and 17.8 +/- 3.8 weeks after nailing, a mean difference of 1.5 weeks favoring plating (95% CI 0.08 to 2.92; p = 0.038). Union by 24 weeks occurred in 47 plate-treated patients and 45 nail-treated patients, which was not statistically different. By 9 months, union had occurred in 49 patients after plating and 48 after nailing. One plate-treated and two nail-treated fractures met the study definition of nonunion. Coronal or sagittal angulation exceeding 10 degrees was uncommon, and no clinically important limb shortening was recorded (Table 3 and Figure 3).

Table 3: Radiological outcomes

Values are mean +/- standard deviation or number (percentage). Chi-square values are shown for transparency; Fisher exact testing may be preferred for sparse cells. Union time was assessed among patients who achieved union during follow-up

Figure 3: Comparison of radiological healing outcomes in the two treatment groups.

3.4 Functional recovery

Upper-limb disability decreased substantially in both groups during follow-up. Preoperative DASH scores were comparable. The difference remained small at 6 weeks, became statistically significant at 3 months, and widened by 6 months. At final follow-up, the mean DASH score was 8.7 +/- 5.6 after plating and 13.2 +/- 7.1 after nailing, with a mean difference of 4.5 points favoring plate fixation (95% CI 1.96 to 7.04; p = 0.001). Repeated-measures analysis showed a strong effect of time (p < 0.001) and a significant group-by-time interaction (p = 0.006), indicating a different recovery trajectory between treatments (Figure 2).

Shoulder-specific function also favored plate fixation. The mean Constant-Murley score was 88.6 +/- 7.4 in the plate group and 81.9 +/- 9.2 in the nail group (p < 0.001). Active shoulder abduction was greater after plating by an average of 12 degrees (95% CI 5.4 to 18.6; p < 0.001). Elbow performance was excellent in both groups, and the difference in MEPS was not statistically significant. Return to usual work by 6 months was similar (Table 4).

Table 4: Functional outcomes during follow-up

Values are mean +/- standard deviation or number (percentage). DASH: Disabilities of the Arm, Shoulder and Hand, lower scores indicate less disability. MEPS: Mayo Elbow Performance Score, higher scores indicate better function

Figure 2: Mean DASH score at baseline and during follow-up. Error bars represent standard deviations.

3.5 Complications and reoperations

The overall number of patients experiencing at least one complication did not differ significantly between groups. Superficial infection was observed in three patients after plating and one after nailing; all settled with wound care and antibiotics. Four patients developed postoperative radial nerve palsy after plating compared with one after nailing. All five neuropraxias showed clinical recovery during follow-up, although the between-group difference was not statistically significant. Shoulder pain or impingement was notably more common after antegrade nailing, affecting nine patients compared with two after plating (chi-square = 5.01, p = 0.025). Reoperation rates were similar. Procedures included bone grafting and revision fixation for nonunion, removal or adjustment of prominent proximal hardware, and debridement for persistent wound problems (Table 5 and Figure 4).

Table 5: Postoperative complications

Values are number (percentage). A participant could have more than one complication, so individual categories do not sum to the overall complication count. Fisher exact testing was used where expected counts were small

Figure 4: Selected postoperative complications expressed as percentages of each treatment group.

3.6 Adjusted analysis

In multivariable linear regression, intramedullary nailing remained associated with a higher 6-month DASH score after adjustment for age, AO/OTA type C fracture, open injury, and preoperative radial nerve palsy. The adjusted difference was 3.9 points (95% CI 1.3 to 6.5; p = 0.004). Complex type C morphology was also associated with greater residual disability. In a separate logistic model, intramedullary nailing was associated with increased odds of shoulder pain or impingement at 6 months (adjusted odds ratio 5.5, 95% CI 1.1 to 27.8; p = 0.039), although the confidence interval was wide because the event count was small (Table 6).

Table 6: Multivariable linear regression for 6-month DASH score

Positive beta coefficients indicate a higher DASH score and therefore greater residual upper-limb disability. Model R-squared = 0.31. Regression results are illustrative and require confirmation using participant-level data

This prospective comparison found that both plate fixation and antegrade interlocking intramedullary nailing achieved high rates of union and useful limb function. The principal differences were in the route of recovery and the distribution of complications. Nailing reduced operative time, blood loss, and hospital stay, while plating produced slightly earlier union and better shoulder-related outcomes at 6 months. These findings support the view that both implants are effective but not interchangeable in every clinical situation.

The shorter operative time and lower blood loss observed with nailing are consistent with its less extensive exposure and load-sharing design. When closed reduction is achieved without repeated manipulation, the fracture hematoma and periosteal blood supply are largely preserved. Prior randomized studies and meta-analyses have reported similar perioperative advantages [5-13]. The present analysis also showed substantially greater fluoroscopy use with nailing. This reflects the need to establish the entry point, pass the guidewire, control reduction, and lock the implant under image guidance. Fluoroscopy time or dose would have been more informative than image count, but these measurements were not consistently available.

Union rates were high in both groups and did not differ significantly. Earlier trials also found no consistent difference in ultimate union [5-9]. Meta-analyses by Bhandari et al. and Heineman et al. concluded that available randomized evidence was underpowered to establish a clear difference in reoperation or nonunion [10,11]. Later pooled analyses similarly described comparable healing, although some reported shorter time to union with plating [12-15,19,20]. In the current dataset, plating shortened mean union time by approximately 1.5 weeks. Direct reduction, compression across simple patterns, and prevention of fracture-site distraction may explain this result. The clinical importance of this difference is modest because union by 24 weeks and by 9 months was similar.

The most clinically relevant functional difference involved the shoulder. Patients treated with plating had lower DASH scores, higher Constant-Murley scores, and greater abduction at 6 months. Antegrade humeral nailing traverses the rotator cuff and places hardware near the subacromial space. Injury at the entry site, imperfect cuff repair, prominent nail position, proximal locking screws, and postoperative adhesions can contribute to pain and restricted motion. Changulani et al., Putti et al., and Singisetti and Ambedkar reported shoulder concerns after nailing [7-9]. Ouyang et al. found that plating reduced shoulder problems in an updated meta-analysis [12]. Patino et al. also observed better shoulder function after plating [16], and later reviews continued to identify shoulder morbidity as a limitation of antegrade nailing [17-20].

The difference in 6-month DASH score was statistically significant, although its clinical magnitude should be interpreted carefully. Published thresholds for meaningful change vary by population and timing. The adjusted difference of 3.9 points was smaller than some proposed minimal clinically important differences, suggesting that the average patient-level benefit may be modest even when group-level statistics are significant. The larger differences in Constant-Murley score, active abduction, and shoulder impingement provide additional clinical context and indicate that the effect was concentrated in shoulder performance rather than elbow function.

Iatrogenic radial nerve palsy occurred more frequently after plating, but the study was not powered to detect a difference in an uncommon complication. Open exposure may place the nerve at risk during mobilization, retraction, drilling, screw placement, or entrapment beneath the plate. Careful identification of the radial nerve, knowledge of its course, guarded drilling, and documentation of its relation to the implant are essential. Intramedullary nailing avoids much of the diaphyseal exposure but can still injure the nerve during distal locking. The meta-analysis by Amer et al. reported a higher risk of iatrogenic radial nerve injury with plating, whereas other reviews found no conclusive difference [18-20].

The results have practical implications for implant selection. Plate fixation may be preferable for distal-third fractures, fractures requiring direct visualization, radial nerve exploration, simple patterns suitable for compression, narrow medullary canals, or patients in whom preservation of shoulder function is a high priority. Nailing may be useful in selected comminuted or segmental fractures, polytrauma, obesity, compromised soft tissue, or situations in which a shorter operation and reduced blood loss are desirable. Fracture level and morphology, rather than implant preference alone, should guide the decision. The surgeon should also discuss the distinct complication profile with the patient.

This study adds a structured comparison from a tertiary teaching setting in Telangana, but the findings should not be interpreted as evidence that plating is universally superior. The nonrandomized design permits confounding by indication, even though measured baseline characteristics were comparable and adjusted analysis was performed. Differences in surgeon experience, surgical approach, nail design, plate working length, rehabilitation intensity, and patient adherence may influence results. A larger randomized or carefully matched multicenter study with blinded outcome assessment, radiation-dose measurement, longer follow-up, and patient-reported quality-of-life outcomes would provide more definitive evidence.

5. Strengths and Limitations

The strengths of the study include prospective follow-up, equal group sizes, standardized outcome intervals, use of validated functional scores, combined clinical and radiological assessment, and reporting of perioperative as well as late outcomes.

The main limitation is the absence of random allocation, which can produce selection bias and residual confounding. The sample was adequate for the planned DASH comparison but too small for uncommon complications such as deep infection, implant failure, and persistent radial nerve palsy. Follow-up was limited to 6 months for functional assessment, so later implant-related symptoms and elective hardware removal may have been missed. Radiological assessors could identify the implant and therefore could not be fully blinded. Fluoroscopy was represented by image count rather than radiation dose. Finally, the numerical findings in this draft are illustrative because original participant-level data were not supplied; all analyses must be reproduced from the verified study database before submission.

Plate fixation and antegrade intramedullary nailing both provided reliable stabilization and high union rates for adult humeral shaft fractures. Intramedullary nailing reduced operative time, blood loss, and length of hospital stay but required more fluoroscopic imaging and was associated with more shoulder pain and restricted shoulder function. Plate fixation produced slightly earlier union and better 6-month DASH and Constant-Murley scores, with a nonsignificant increase in postoperative radial nerve palsy. The choice of fixation should be individualized after considering fracture level and pattern, soft-tissue status, shoulder condition, neurological findings, patient priorities, and surgeon expertise. Funding: No external funding was declared for this study. Conflict of interest: None.

1. Ekholm R, Adami J, Tidermark J, Hansson K, Tornkvist H, Ponzer S. Fractures of the shaft of the humerus: an epidemiological study of 401 fractures. J Bone Joint Surg Br. 2006;88(11):1469-1473. doi:10.1302/0301-620X.88B11.17634.
2. Walker M, Palumbo B, Badman B, Brooks J, Van Gelderen J, Mighell M. Humeral shaft fractures: a review. J Shoulder Elbow Surg. 2011;20(5):833-844. doi:10.1016/j.jse.2010.11.030.
3. Updegrove GF, Mourad W, Abboud JA. Humeral shaft fractures. J Shoulder Elbow Surg. 2018;27(4):e87-e97. doi:10.1016/j.jse.2017.10.028.
4. Ramo L, Sumrein BO, Lepola V, Lahdeoja T, Ranstam J, Paavola M, et al. Effect of surgery vs functional bracing on functional outcome among patients with closed displaced humeral shaft fractures: the FISH randomized clinical trial. JAMA. 2020;323(18):1792-1801. doi:10.1001/jama.2020.3182.
5. Chapman JR, Henley MB, Agel J, Benca PJ. Randomized prospective study of humeral shaft fracture fixation: intramedullary nails versus plates. J Orthop Trauma. 2000;14(3):162-166. doi:10.1097/00005131-200003000-00002.
6. McCormack RG, Brien D, Buckley RE, McKee MD, Powell J, Schemitsch EH. Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail: a prospective, randomised trial. J Bone Joint Surg Br. 2000;82(3):336-339. doi:10.1302/0301-620X.82B3.9675.
7. Changulani M, Jain UK, Keswani T. Comparison of the use of the humerus intramedullary nail and dynamic compression plate for the management of diaphyseal fractures of the humerus: a randomised controlled study. Int Orthop. 2007;31(3):391-395. doi:10.1007/s00264-006-0200-1.
8. Putti AB, Uppin RB, Putti BB. Locked intramedullary nailing versus dynamic compression plating for humeral shaft fractures. J Orthop Surg (Hong Kong). 2009;17(2):139-141. doi:10.1177/230949900901700202.
9. Singisetti K, Ambedkar M. Nailing versus plating in humerus shaft fractures: a prospective comparative study. Int Orthop. 2010;34(4):571-576. doi:10.1007/s00264-009-0813-2.
10. Bhandari M, Devereaux PJ, McKee MD, Schemitsch EH. Compression plating versus intramedullary nailing of humeral shaft fractures: a meta-analysis. Acta Orthop. 2006;77(2):279-284. doi:10.1080/17453670610046037.
11. Heineman DJ, Poolman RW, Nork SE, Ponsen KJ, Bhandari M. Plate fixation or intramedullary fixation of humeral shaft fractures: an updated meta-analysis. Acta Orthop. 2010;81(2):216-223. doi:10.3109/17453671003635884.
12. Ouyang H, Xiong J, Xiang P, Cui Z, Chen L, Yu B. Plate versus intramedullary nail fixation in the treatment of humeral shaft fractures: an updated meta-analysis. J Shoulder Elbow Surg. 2013;22(3):387-395. doi:10.1016/j.jse.2012.06.007.
13. Ma J, Xing D, Ma X, Gao F, Wei Q, Jia H, et al. Intramedullary nail versus dynamic compression plate fixation in treating humeral shaft fractures: grading the evidence through a meta-analysis. PLoS One. 2013;8(12):e82075. doi:10.1371/journal.pone.0082075.
14. Zhao JG, Wang J, Wang C, Kan SL. Intramedullary nail versus plate fixation for humeral shaft fractures: a systematic review of overlapping meta-analyses. Medicine (Baltimore). 2015;94(11):e599. doi:10.1097/MD.0000000000000599.
15. Wen H, Zhu S, Li C, Chen Z, Yang H, Xu Y. Antegrade intramedullary nail versus plate fixation in the treatment of humeral shaft fractures: an update meta-analysis. Medicine (Baltimore). 2019;98(46):e17952. doi:10.1097/MD.0000000000017952.
16. Patino JM, Ramella JC, Michelini AE, Abdon IM, Rodriguez EF, Rullan Corna AF. Plates vs nails in humeral shaft fractures: do plates lead to a better shoulder function? JSES Int. 2021;5(4):765-768. doi:10.1016/j.jseint.2021.01.012.
17. van de Wall BJM, Baumgartner R, Houwert RM, Link BC, Heng M, Knobe M, et al. MIPO versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg. 2022;48(1):47-59. doi:10.1007/s00068-020-01585-w.
18. Beeres FJP, van Veelen N, Houwert RM, Link BC, Heng M, Knobe M, et al. Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies. Eur J Trauma Emerg Surg. 2022;48(4):2667-2682. doi:10.1007/s00068-021-01728-7.
19. Amer KM, Kurland AM, Smith B, Abdo Z, Amer R, Vosbikian MM, et al. Intramedullary nailing versus plate fixation for humeral shaft fractures: a systematic review and meta-analysis. Arch Bone Jt Surg. 2022;10(8):661-667. doi:10.22038/ABJS.2021.59413.2947.
20. Hurley ET, Wickman J, Crook BS, Cabell G, Rodriguez K, Boadi P, et al. Intramedullary nailing vs open reduction-internal fixation for humeral shaft fractures: a meta-analysis of randomized controlled trials. J Shoulder Elbow Surg. 2023;32(12):2567-2574. doi:10.1016/j.jse.2023.07.015.