Humeral shaft fractures: a cost-effectiveness analysis of operative versus nonoperative management

Henry M. Fox, Lauren J. Hsue, Austin R. Thompson, Duncan C. Ramsey, Ryan W. Hadden, Adam J. Mirarchi, Omar F. Nazir

Research output: Contribution to journalReview articlepeer-review


Background: Humeral shaft fractures can be managed operatively or nonoperatively with functional bracing in the absence of neurovascular injury, open fracture, or polytrauma. A consensus on optimal management has not been reached, nor has the cost-effectiveness perspective been investigated. Methods: A decision tree was constructed describing the management of humeral shaft fractures with open reduction–internal fixation (ORIF), intramedullary nailing (IMN), and functional bracing in a non-elderly population. Probabilities were defined using weighted averages determined from systematic review of the literature. Cost-effectiveness was evaluated with incremental cost-effectiveness ratios, measured in cost per quality-adjusted life-year (QALY). Willingness-to-pay thresholds of $50,000/QALY and $100,000/QALY were evaluated. Results: Eighty-six studies were included. Using bracing as the referent in the health care model, we observed that bracing was the preferred strategy at both incremental cost-effectiveness ratio thresholds. ORIF and IMN had higher overall effectiveness (0.917 QALYs and 0.913 QALYs, respectively) compared with bracing (0.877 QALYs). The cost-effectiveness of bracing was driven by a substantially lower overall cost. In the societal model—accounting for both health care and societal costs—the cost difference narrowed between bracing, ORIF, and IMN. Bracing remained the preferred strategy at the $50,000/QALY threshold; ORIF was preferred at the $100,000/QALY threshold. ORIF and IMN were comparable strategies across a range of probability values in sensitivity analyses. Conclusions: Functional bracing, with its low cost and satisfactory clinical outcomes, is often the most cost-effective strategy for humeral shaft fracture management. ORIF becomes preferable at the higher willingness-to-pay threshold when societal burden is considered. QALY values for ORIF and IMN were comparable.

Original languageEnglish (US)
Pages (from-to)1969-1981
Number of pages13
JournalJournal of Shoulder and Elbow Surgery
Issue number9
StatePublished - Sep 2022


  • Economic Analysis
  • Humerus
  • Level III
  • cost-benefit analysis
  • decision making
  • functional bracing
  • intramedullary nail
  • midshaft humerus
  • open reduction–internal fixation
  • quality-adjusted life-years

ASJC Scopus subject areas

  • Surgery
  • Orthopedics and Sports Medicine


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