Plating/Internal Fixation, Intramedullary Fixation, and/or Photodynamic Polymer

Three lower quality studies were included and examined for this portion of the clinical practice guideline. These studies were retrospective and included low numbers of patients. Further, these studies included varied outcomes measured in terms of surgical complications and clinical function.  

When treating pathologic diaphyseal humerus fractures in the setting of metastatic disease, the available evidence does not appear to show a significant difference in clinical outcomes (pain relief, upper extremity function, complication rates) between these constructs.  However, with the low numbers available there was noted an increased failure rate with photodynamic polymer fixation compared to intramedullary nail fixation.  Despite this potential difference, there does not appear to be a significant difference in reoperation rate between plating/internal fixation, intramedullary fixation, and photodynamic polymer.

Based on the low-level evidence of the articles analyzed, any of the constructs, including intramedullary nailing, photodynamic polymer, or plating/internal fixation, constitutes a reasonable and safe option when treating realized or impending pathologic diaphyseal humerus fractures. However, caution is advised regarding the use of photodynamic polymer fixation until further evidence is available due to the potential higher failure rates with this construct. 

Further research is needed to better elucidate any potentially undetected outcome difference among the various constructs. The best study design to help determine this would be a collaborative, multicenter, randomized controlled trial.