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abstractFull article available online at Healio.com/Orthopedics. Search: 20130724-18

Mid-distal third humeral shaft fractures can be effectively treated with minimally inva-sive plating osteosynthesis and intramedullary nailing (IMN). However, these 2 treat-ments have not been adequately compared. Forty-seven patients (47 fractures) with mid-distal third humeral shaft fractures were randomly allocated to undergo either minimally invasive plating osteosynthesis (n524) or IMN (n523). The 2 groups were similar in terms of fracture patterns, fracture location, age, and associated injuries. Intraoperative measurements included blood loss and operative time. Clinical out-come measurements included fracture healing, radial nerve recovery, and elbow and shoulder discomfort. Radiographic measurements included fracture alignment, time to healing, delayed union, and nonunion. Functional outcome was satisfactory in both groups. Mean American Shoulder and Elbow Surgeons score and Mayo score were both better for the minimally invasive plating osteosynthesis group than for the IMN group (98.2 vs 97.6, respectively, and 93.5 vs 94.1, respectively; P,.001). Operative time was shorter and less intraoperative blood loss occurred in the minimally invasive plating osteosynthesis group than in the IMN group. Average time to union was similar in both groups. Primary union was achieved in 23 of 24 patients in the minimally inva-sive plating osteosynthesis group and in 22 of 23 in the IMN group. Minimally invasive plating osteosynthesis may have outcomes comparable with IMN for the management of mid-distal third humeral shaft fractures. Minimally invasive plating osteosynthesis is more suitable for complex fractures, especially for radial protection and motion recov-ery of adjacent joints, compared with IMN for simple fractures.

The authors are from the Department of Orthopaedic Surgery, The Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People’s Liberation Army, Zhangzhou, China.

The authors have no relevant financial relationships to disclose.Correspondence should be addressed to: Kejian Lian, MD, Department of Orthopaedic Surgery, The

Affiliated Southeast Hospital of Xiamen University, Orthopaedic Center of People’s Liberation Army, No. 269 Zhanghua Rd, Zhangzhou 363000, China (rad1413@126.com).

doi: 10.3928/01477447-20130724-18

Minimally Invasive Plating Osteosynthesis for Mid-distal Third Humeral Shaft FracturesKejian Lian, MD; Lei Wang, MD; Dasheng Lin, MD; ZhiWen Chen, MD

Figure: A 48-year-old man sustained a right humeral shaft fracture (AO-OTA 12 C1) after a car accident and underwent minimally invasive plating osteosyn-thesis with a locking plate under the C-arm guide. One-year postoperative lateral radiograph showing osseous union between all major fragments (A). A 37-year-old woman sustained a right humeral shaft fracture (AO-OTA 12 A1) after a motor vehicle ac-cident and underwent intramedullary nailing under C-arm guidance. One-year postoperative antero-posterior radiograph showing osseous union be-tween all major fragments (B).

A B

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Surgical treatment of humeral shaft fractures, when indicated, is con-troversial. Intramedullary nailing

(IMN)1,2 and minimally invasive plating osteosynthesis,3 which are both types of biological fixation, are safe and effec-tive options for treating mid-distal third humeral shaft fractures. A divergence of opinion exists in the literature between the values of IMN and minimally invasive plating osteosynthesis for the treatment of mid-distal third humeral shaft frac-tures. Modern surgery favors treatment modalities that are minimally invasive, have low morbidity, and provide rapid recovery and prompt return to work and activities of daily living.4 Evidence shows the superiority of biological fixation over a stable mechanical fixation.5 This leads to the development and improvement of biological fixation techniques for frac-tures and the development of stabiliza-tion systems that help achieve biological fixation.6 Both procedures can provide excellent bone healing due to their bio-mechanical advantages.7

To the current authors’ knowledge, these 2 minimally invasive treatments have not been adequately compared. Al-though these 2 procedures are generally considered minimally invasive, differ-ences exist when they are compared. Both methods have inherent advantages and disadvantages that should be considered by the surgeon and patient when select-ing treatment. From the standpoint of biomechanics, the disadvantages between these treatments vary. Encouraging results from recent advances in internal fixation techniques and minimally invasive skills have led to the expansion of surgical indi-cations for such fractures and a dilemma concerning the procedure of choice.

This prospective randomized study compared the effectiveness and potential risks of these 2 approaches, which were applied to mid-distal third humeral frac-tures. The authors analyzed the features of each approach and which approach was appropriate in different situations.

Materials and MethodsThis study was performed with the

approval of the authors’ medical ethics committee. Between October 2007 and August 2010, forty-seven consecutive patients with a mid-distal third humeral shaft fracture underwent either mini-mally invasive plating osteosynthesis or IMN. Intramedullary nailing procedures consist of antegrade and retrograde nail-ing. All patients were skeletally mature. Orthopedists selected the patients based on randomized numbers generated by us-ing the sealed-envelope method. Patients were prospectively randomized into 1 of 2 treatment groups using a sealed-envelope method. The IMN group (n523) under-went antegrade and retrograde locked IMN fixation, among which 14 patients underwent retrograde IMN. The second group underwent minimally invasive plat-ing osteosynthesis (n524). All fractures were closed injuries in both groups.

Inclusion criteria were patients with closed displaced unstable middle or dis-tal third humeral shaft fractures or both. Exclusion criteria were undisplaced mid-dle or distal third humeral shaft fracture with associated radial nerve injury, proxi-mal shaft fracture, skeletal immaturity, open fracture, intra-articular fracture, and pathological fracture. All patients were appropriately clinically and radiologically evaluated before surgical intervention was offered. All fractures were classified in order of increasing fracture complexity severity: type A was simple, type B was wedge, and type C was comminuted.

surgical technique Antegrade IMN Approach

A longitudinal skin incision is made over the greater tuberosity. The deltoid muscle is split, and the subdeltoid bursa is incised and retracted. A small longitudi-nal incision is made on the supraspinatus tendon right medial to the greater tuber-osity. While protecting the rotator cuff, a drill bit is used to create a tunnel into the humeral canal. The guide pin is passed

across the fracture site while the fracture is reduced in a closed manner. The entry portal and the medullary canal are lim-ited reamed. For stronger or more curved bone, overreaming of 1 or 2 mm may be necessary. For osteoporotic bone with a wider canal, reaming may be unneces-sary. The extent of over-reaming depends on trial nail insertion. The nail is insert-ed manually along the guide pin until it countersinks in the humeral neck. The nail should pass the fracture site by at least 5 cm. Transfixing screws are inserted from a lateral-to-medial direction. The axillary and radial nerves are protected by blunt dissection of the soft tissue. Two lock-ing screws at either nail end are used for fractures with a wider canal, and 1 screw is used for fractures with a smaller ca-nal. An image intensifier is used intraop-eratively. If a residual fracture gap exists, compression is exerted by either manual compression of the fracture fragments or a backstrike technique before static locking. Finally, the rotator cuff, bursa, and deltoid muscle are repaired.

Retrograde IMN ApproachThe patient is placed in the lateral or su-

pine position, with the injured arm leaning against the chest. A midline longitudinal incision is made over the posterior aspect of the distal humerus directly down to the olecranon fossa by splitting the triceps muscle. The posterior fat pad in the fossa is preserved as much as possible. The entry portal is at the superior edge of the olec-ranon fossa. Multiple drill holes are first created in the medullary canal and then connected with a burr to form a longitu-dinal slot approximately 1.5 to 2 cm long. Passing the guide pin, fracture reduction, medullary canal reaming, and nailing are almost the same as described for antegrade IMN. The locking screws are directed from a posterior-to-anterior or posterolateral-to-anteromedial direction. The number of locking screws used and the intraoperative checkup with the image intensifier are also the same as for antegrade IMN.

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Minimally Invasive Plating OsteosynthesisThe operation is performed with the

patient in a supine position with abduction of the injured arm under image intensifier control. The cephalic vein is preserved if possible, and the proximal humeral shaft is exposed through the deltobicipital inter-val. A distal incision of 4 to 5 cm is made on the anterior side proximal to the elbow crease. The sensory branch of the mus-culocutaneous nerve is usually identified and protected after retracting the biceps muscle. The brachialis muscle is split by blunt dissection. A submuscular tunnel is then developed using the plate and locking sleeve as a handle. Under image intensifier control, reduction is achieved by manual traction, and an additional external fixator is used to maintain the reduction depend-ing on how difficult it is to accomplish the reduction by performing manual traction. A 9- to 12-hole plate is used for fracture stabilization and is fixed on the anterior surface of the humeral shaft. In general, 3 bicortical screws (either locking or corti-cal screws) are inserted on each side of the fracture. However, 2 distal shaft fractures were fixed with 2 screws. No radial nerve exploration is performed.

Postoperative CoursePostoperatively, all patients’ arms

were supported in neck slings for 1 week. Shoulder and elbow range of motion (ROM) were initiated at least 2 weeks preoperatively. Patients were instructed to move their shoulders and elbows and to use their operated limbs to perform activi-ties of daily living (ie, eating and hygiene). Follow-up clinical examinations and an-teroposterior and lateral radiographs were obtained every 5 to 7 weeks until bony union was achieved. Patients with no other problems were discharged 1 week post-operatively; further radiographs were ob-tained at 6- and 12-month follow-up.

Data CollectionOperative time was defined as the

time from skin incision to closure. Union

was defined as the absence of pain and presence of bridging callus on radio-graphs of the humerus. Nonunion was defined as the absence of fracture union 6 months postoperatively and no sign of further fracture healing. Malunion was defined as an angle of 2 parts of the line of the previous fracture seg-ment greater than 15° (range, 15°-90°). Follow-up time was defined as the dura-tion between the operation and the last regular follow-up before this article was written. Shoulder and elbow ROM were measured using a goniometer at the time of union. Postoperatively, operative time, intraoperative blood loss, and time to union were compared. Clinical assess-ment consisted of using the American Shoulder and Elbow Surgeons scoring system for shoulder joints and Mayo per-formance score for elbow joints. Higher

scores in both systems correspond with better joint function. Range of motion and muscle power were rated by com-paring the injured and uninjured arms. Functional recovery at final follow-up was compared between 23 patients who underwent IMN and 24 who underwent minimally invasive plating osteosynthe-sis. Complications, such as nonunion, malunion, infection, nerve injury, and implant failure, were also observed dur-ing follow-up (Table 1). Due to intra-operative radiation exposure, the time of exposure should be collected. Union rates were also compared.

Statistical AnalysisStatistical analysis was performed us-

ing SPSS version 13 software (SPSS, Inc, Chicago, Illinois). The demographic and fracture characteristics of the 2 groups

Table 1

Results

Result MIPO Group (n524) IMN Group (n523) P

Mean operative time, min 95 126 ,.001

Mean radiation exposure, s 197 216 .120

Mean blood loss, mL 147 195 ,.001

Mean time to union, wk 17.1 16.8 .526

Union rate based on AO-OTA classification, No.

Type A 9 8

Type B 9 12

Type C 5 2

Mean functional outcomes

ASES score 98.2 93.5 ,.001

Mayo score 97.6 94.1 ,.001

Complications, No.

Malunion 1 1

Nonunion 1 2

Deep infection 0 0

Postop radial nerve injury 1 3

Ruptured plate or nail 1 1

Abbreviations: ASES, American Shoulder and Elbow Surgeons; IMN, intramedullary nailing; MIPO, minimally invasive plate osteosynthesis; postop, postoperative.

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were compared using chi-square test or Fisher’s exact test for nonparametric cat-egorical variables or by using Student’s t test for parametric variables. Operative time, intraoperative blood loss, union rate, and time to union were compared using Student’s t test, and complications were compared using Fisher’s exact test.

resultsFifty-six patients (56 humeral shaft

fractures) were entered in this study and randomized by a sealed-envelope method after considering the inclusion and ex-clusion criteria. Locked IMNs were used in 4 patients assigned to the IMN group due to 1 surgeon’s (K.L.) preference. Five patients did not undergo the operation be-cause they could not afford it. These 9 pa-tients were excluded from the study. The

remaining 47 pa-tients were included in the study.

No statistically significant differ-ences existed in pa-tient demographics or fracture charac-teristics, including sex, age, and AO-OTA classifica-tion, between the 2 groups (Table 2). Causes of injury were motorcycle accident (n57), fall (n518), motor vehi-cle accident (n516), rolled in a fac-tory machine while working (n53), and crushed by a huge stone (n53). Similar distributions of injury mecha-nisms existed be-tween the 2 groups.

Mean follow-up for all patients was 14.5 months

(range, 7-20 months), 15 months (range, 10-16 months) for the IMN group, and 14 months (range, 7-20) for the minimally invasive plating osteosynthesis group. Mean operative time for the minimally invasive plating osteosynthesis group (95 minutes; 95% confidence interval [CI], 90.30-99.70 minutes) was shorter than for the IMN group (126 minutes; 95% CI, 121.04-130.96 minutes; P,.001). Primary union was achieved in 23 (95.8%) of 24 patients in the minimally invasive plating osteosynthesis group (Figure 1) and 22 (95.7%) of 23 in the IMN group (Figure 2). Mean healing time was 17.1 weeks (95% CI, 16.30-17.90 weeks) for the minimally invasive plating osteosyn-thesis group and 16.8 weeks (95% CI, 16.25-17.35 weeks) for the IMN group. Mean American Shoulder and Elbow

Surgeons and Mayo scores were 98.2 and 97.6, respectively, for the minimally inva-sive plating osteosynthesis group and 93.5 and 94.1, respectively, for the IMN group. Intraoperative radiation exposure time was 197 seconds (95% CI, 172.18-221.82 seconds) in the IMN group and 216 sec-onds (95% CI, 197.01-235.00 seconds) in the minimally invasive plating osteo-synthesis group. No significant difference existed between the radiation exposure time of the 2 groups (P5.120). Average time to union was similar in both groups (P5.526). Operative time and intraopera-tive blood loss were significantly lower in patients who underwent minimally inva-sive plating osteosynthesis compared with those who underwent IMN (P,.001 for both). Patient results are shown in Table 1.

All patients in both groups were able to return to their previous jobs within 6 months postoperatively. Due to nail im-pingement in the IMN group, the fractures healed with simultaneous shoulder abduc-tion and elbow flexion restrictions (n51), shoulder abduction restrictions (n53), and elbow flexion restrictions (n52). These patients had decreased shoulder or elbow joint ROM (abduction, forward flexion, or stretch) greater than approximately 25° to 45° compared with the uninjured side. They underwent nail extraction once frac-ture union occurred. One nonunion and 1 malunion occurred in the minimally inva-sive plating osteosynthesis group, and 2 nonunions and 1 malunion occurred in the IMN group. To treat nonunion, the authors extracted the nail or the plating and per-formed open reduction and internal fixa-tion combined with a graft technique. All nonunions were commuted fractures of distal shaft after minimally invasive plat-ing osteosynthesis and IMN, probably due to inappropriate fixation and poor stabil-ity. Postoperatively, 3 radial nerve injuries occurred in IMN group and 1 occurred in the minimally invasive plating osteosyn-thesis group. All 4 nerve deficits resolved completely within 3 months. No patients sustained deep infection, intraoperative

Table 2

Patient Dataa

DemographicMIPO Group

(n524)IMN Group

(n523) P

Sex, No. .609

Male 15 16

Female 9 7

Mean age (range), y 38.8 (17-76) 37.6 (17-77) .776

AO-OTA classification, No. .480

Type A 9 8

Type B 9 12

Type C 6 3

Mechanism of injury, No. .868

Fall 8 10

Motorcycle accident 4 3

Motor vehicle accident 9 7

Rolled in machine 1 2

Crushed by huge stone 2 1

Abbreviations: IMN, intramedullary nailing; MIPO, minimally invasive plating osteosynthesis. aAge of the 2 groups was compared using the independent-sample Student’s t test for parametric variables. Other demographic and fracture characteristics of the 2 groups were compared using the chi-square test or Fisher’s exact test for nonparametric categorical variables. Patient demographics and clinical characteristics were similar in the 2 groups (P..05).

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or postoperative fracture, heterotopic os-sification, or neurological complication. Their nails or plates were removed exclu-sively at their request.

discussionThe optimal treatment of mid-distal

humeral shaft fractures has not been clearly defined.8,9 Intramedullary nailing and minimally invasive plating osteosyn-thesis have been the treatments of choice for mid-distal shaft fractures when opera-tive treatment is needed.3,7,10 The current authors found that both IMN and mini-mally invasive plating osteosynthesis can achieve similar good outcomes for mid-distal humeral shaft fractures with some slight variances between them. Patients who underwent IMN required a longer time for shoulder and elbow functional recovery than those who underwent mini-mally invasive plating osteosynthesis. The minimally invasive plating osteosynthesis approach required shorter a operative time but was more technically demanding.

According to the recent modern biological-fixation theory, minimally in-vasive plating osteosynthesis and IMN have emerged as typical surgical biologic fixation procedures.10,11

Neither the fracture sites nor the ra-dial nerves need to be dissected when performing minimally invasive plating osteosynthesis using an anteriorly placed plate to treat humeral shaft fractures.12 However, during IMN, the nail needs to be inserted into the bone marrow cavity, including the fracture segment.7 For intra-operative clinical application, the danger zone for the radial nerve is approximately three- (37.5%) to five-eighths (62.5%) of the humeral length measured from the tip of the acromion process to the lateral epicondyle when the humeral length is divided into 8 parts. The zone that had radial nerve injuries averaged from 10.8 to 17.59 cm (36.35% to 59.20%) of the humeral length, and the most dangerous screws that penetrated or were closest to the radial nerve were the sixth and sev-

enth holes, which lie in 12.67 to 15.8 cm (47.22% to 53.21%) of the humeral length from the lateral epicondyle.

The plate should be long enough to bridge the fracture over the danger zone of the radial nerve.13 Anterior interven-tion to the humerus, which is suitable for mid-distal third humeral shaft fractures in many minimally invasive plating os-teosynthesis applications, is preferred be-

cause the radial nerve does not need to be exposed. This is partly because the coro-noid fossa is in the distal part of the hu-merus; in fractures with small distal frag-ments, theoretical fixation on the anterior face of the humerus is impossible.14 The radial nerve is not at risk as long as the forearm is kept in supination intraopera-tively when the anterior approach is used. No screws are inserted into the part of

1B1A

1CFigure 1: Anteroposterior (A) and lateral (B) radiographs of a 37-year-old woman who sustained a right humeral shaft fracture (AO-OTA 12 A1) after a motor vehicle accident. She underwent intramedullary nail-ing under C-arm guidance. Postoperative anteroposterior (C) and lateral (D) radiographs showing accept-able alignment, although trivial room between the proximal and the distal fragment of the humeral shaft existed. One-year postoperative lateral (E) and anteroposterior (F) radiographs showing osseous union between all major fragments. The patient had a complete functional recovery.

1E1D 1F

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the humeral shaft where the radial nerve runs along the spiral groove, which is a merit in preserving the radial nerve when the anterior approach is used.3 Surgeons have cautioned regarding the risk of radial nerve injury when either IMN or minimal-ly invasive plating osteosynthesis are per-formed to treat mid-distal humeral shaft fractures. It is not uncommon to see radial nerve damage in IMN even if the nail does not touch the nerve, with the exception of preoperative radial nerve injury. Anterior dissection and posterior retraction of the

radial nerve during the lateral approach may preserve its blood supply and reduce the risk of iatrogenic injury.15 Transient or permanent radial injury or both following distal humerus fractures may occur iatro-genically intraoperatively,16,17 and the re-ported incidence of radial nerve injury fol-lowing surgical intervention ranges from 2% to 5%.16,18 The rate in the current study was within the range of 2% to 5%. As a general rule, no risk of axillary nerve inju-ry exists when minimally invasive plating osteosynthesis is performed. Furthermore,

the radial nerve is not at risk if the forearm is kept in supination intraoperatively and no screws are inserted into the humeral shaft where the radial nerve runs along the spiral groove.14 Consequently, physi-cians must take the dangerous zone of ra-dial injury into consideration and must be acquainted with the anatomical position when performing minimally invasive plat-ing osteosynthesis.

As for the humerus, it is important to distinguish rotational stress from ax-ial stress, bending stresses, and shearing stress.19 With the formation of callus, plates have played an increasingly sig-nificant role in sharing the load. Double-plate fixation can sometimes improve the stability of the fixation.20 Moreover, if the plate is locked, the stability will move a single step forward, especially for pa-tients with osteoporosis.6 Nevertheless, with the improved design and surgical technique, interlocking intramedullary nails stabilize the fracture fragment and hold the intramedullary nails back from slipping off.21 Compared with plates, intramedullary nails belong to axis fixa-tions bearing smaller bending stress, which can deliver load and restore align-ment and have a low stress-shielding rate. Interlocked IMNs have a stronger capacity to assist rotation than noninter-locked IMNs. Locked nailing provides a rationally stable fixation and avoids the tendency of various unlocked nails to back out.22 From a biomechanical stand-point, the intramedullary positioning of these devices places them in line with the mechanical axis of the humeral diaphy-sis, thereby subjecting the implant to lower bending loads. By being centrally positioned, the nail functions in a load-sharing capacity and mitigates the poten-tial effects that stress shielding may play compared with compression plating.23

Minimally invasive plating osteosyn-thesis, which is characterized by mini-mally invasive stabilized fixation and pro-tecting the fracture fragment as much as possible, is an emerging procedure for the

2B2A 2C

Figure 2: Lateral (A) and anteroposterior (B) radiographs of a 48-year-old man who sustained a right hu-meral shaft fracture (AO-OTA 12 C1) after a motor vehicle accident. He underwent minimally invasive plating osteosynthesis with a locking plate under C-arm guidance. Postoperative lateral (C) and anteroposterior (D) radiographs showing acceptable alignment and a spiral wedge fragment of the humeral shaft that was not reduced. One-year postoperative lateral (E) and anteroposterior (F) radiographs showing osseous union between all major fragments. The patient had complete functional recovery.

2E2D 2F

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treatment of humeral shaft fractures and has a wide application.10,24 Apivatthakakul et al3 anatomically evaluated the feasibil-ity of minimally invasive anterior plating and confirmed that it is clinically safe as long as plating occurred with the arm maximally supinated to avert injury to the radial nerve. Minimally invasive plating osteosynthesis prevents the need for bone grafts because of the high union rate.25 As with the IMN procedure, fluoroscopic control must be used for a long time for minimally invasive plating osteosynthesis to have a satisfactory alignment. In the current study, no significant difference ex-isted in intraoperative radiation exposure time. To the authors’ knowledge, few re-ports have investigated the effects of ra-diation exposure on bone healing.

Problems can occur with shoulder func-tion when nails are inserted in an antegrade fashion, although IMN is generally con-sidered a minimally invasive procedure.26 It has proven to be technically demanding and can be associated with iatrogenic frac-tures, although retrograde nail insertion was introduced to avoid shoulder dysfunc-tion.27 However, recent reports of mini-mally invasive plating osteosynthesis for humeral shaft fractures have shown good ROM of adjacent joints.10,12,28 The IMN of-ten contacts the adjacent joints, which may render the ROM of some joints abnormal. Nevertheless, Kobayashi et al29 reported that minimally invasive plating osteosyn-thesis is a promising option for humeral shaft fractures because of early ROM re-covery in the adjacent joints. To avoid plate impingement, the distance between the dis-tal fracture line and the upper edge of the coronoid fossa should be more than 6 cm to accept 3 screws in the distal fragment. It is preferable to insert 3 bicortical screws in the distal fragment to permit early use of the operated limb for activities of daily liv-ing.29 In regard to mid-distal humeral shaft fractures, sufficient space exists to contain 3 screws fixed in the distance between the proximal fracture fragment and the rota-tor cuff, which has a significant function

in shoulder ROM. Anterior fixation of minimally invasive plating osteosynthe-sis avoids impingement of the elbow and shoulder joints to the plating, which makes early full shoulder and elbow ROM obtain quick functional recovery. However, stimu-lation of the interlocking nail to the shoul-der or elbow often poses oppression on the round soft tissue, which causes shoulder or elbow pain.

The current study has limitations. First, a prospective study with a larger number of patients would help confirm the advan-tages of minimally invasive plating osteo-synthesis for the treatment of mid-distal humeral shaft fractures. The trivial sample may have a certain role in the clinical ap-plications for orthopedic surgeons to make decisions. Second, whether the exposure radiation factors that must be involved lead to some microcosmic bone transfor-mation is a problematic facet and will be a tough question to answer. Third, other dis-eases associated with humeral fractures may pose general reactions that affect the time to union. Both methods have inher-ent advantages and disadvantages that should be considered by the surgeon and patient when selecting treatment. Patients can express their preferences after being informed of the advantage, disadvantages, and risks of both approaches.

conclusionMid-distal third humeral shaft frac-

tures can be effectively treated with mini-mally invasive plating osteosynthesis and IMN; minimally invasive plating osteo-synthesis is a good option for complex fractures and IMN is a good option for relatively simple fractures. However, min-imally invasive plating osteosynthesis may have the advantages of shorter time to fracture union, lower incidence of iatro-genic radial nerve palsy, and better func-tional outcomes compared with IMN.

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