Humeral shaft fractures account for a small but clinically important proportion of adult fractures. Their epidemiology is typically bimodal: high-energy trauma predominates in younger adults, whereas low-energy falls are increasingly seen in older patients with reduced bone strength.1,2

Many uncomplicated fractures can be managed non-operatively, but surgery is commonly selected for unstable or markedly displaced fractures, open injuries, polytrauma, failure of conservative treatment, and situations in which early mobilisation is important. Operative options include plating and intramedullary nailing; plate fixation remains attractive because it offers reliable control of length, alignment, and rotation.3-5

Conventional open plating allows direct exposure of the fracture, anatomical reduction when required, and protection or exploration of the radial nerve. Its main biological disadvantage is the soft-tissue dissection needed to expose the shaft. Periosteal stripping and disruption of the fracture haematoma may compromise local vascularity, and the approach may also increase the risk of wound problems or iatrogenic radial nerve injury.3,4,6

Anterior bridge plating is a minimally invasive plate osteosynthesis technique in which a long plate is passed through a submuscular tunnel along the anterior humeral surface. Reduction is indirect, the fracture site is not opened, and relative stability encourages callus formation. Cadaveric and clinical studies have shown that the technique is feasible when safe anterior windows and careful protection of the musculocutaneous nerve are used.7-10

Comparative studies and systematic reviews generally report high union rates with both open reduction and minimally invasive plating. Some investigations have found advantages for minimally invasive fixation in blood loss, union time, or radial nerve complications, while others have shown similar functional outcomes. Differences in fracture morphology, surgical technique, outcome definitions, and follow-up periods make a single universal recommendation difficult.6,11-15

The present study compared anterior bridge plating with conventional plating for humeral shaft fractures in a tertiary-care population. The principal outcomes were radiological union, hospital stay, shoulder and elbow function, range of motion, and complications at six months.

AIMS AND OBJECTIVES

The primary aim was to compare the clinical and radiological outcomes of humeral shaft fractures treated by minimally invasive anterior bridge plating and conventional open plating.

The specific objectives were to compare time to radiological union, duration of hospital stay, shoulder and elbow range of motion, UCLA shoulder score, MEPS, and the occurrence of infection, nonunion, nerve palsy, implant-related problems, and other perioperative complications.

Study design and setting

A prospective comparative study was conducted in the Department of Orthopaedics, Navodaya Medical College Hospital and Research Centre, Raichur, Karnataka, India. Recruitment, treatment, follow-up, and data collection were undertaken over 18 months, from April 2024 to October 2025. Institutional Ethics Committee approval was obtained before enrolment, and all participants provided written informed consent. The approval number was not stated in the source dissertation.

Participants

Skeletally mature patients of either sex were eligible when they presented within two weeks of a closed humeral shaft fracture or a Gustilo-Anderson grade I or II open fracture and were willing to complete at least six months of follow-up. Patients with polytrauma could be included. Exclusion criteria were associated vascular injury, Gustilo-Anderson grade III or IV open injury, and medical unfitness for surgery.

Sampling and treatment allocation

Eligible patients were enrolled consecutively until the target sample was reached. The dissertation states that patients were allocated randomly in equal numbers to anterior bridge plating or conventional open plating. The method used to generate the allocation sequence and conceal treatment assignment was not documented in the source material. Group 1 comprised 16 patients treated by anterior bridge plating, and Group 2 comprised 16 patients treated by conventional plating.

Sample size

The final sample comprised 32 patients, with 16 patients in each group. The dissertation described a prevalence-based calculation using an assumed humeral shaft fracture prevalence of 5%, a 95% confidence level, and a 10% allowable error. Because an effect size for a between-group outcome was not specified and the calculation was not reproducible as a conventional comparative power analysis, the present study should be interpreted as an exploratory comparison.

Preoperative assessment

A structured proforma was used to record age, sex, occupation, injury mechanism, affected side, comorbidities, associated injuries, neurovascular status, and AO/OTA fracture classification. Routine clinical and radiographic assessment was completed before surgery. All patients had intact preoperative neurovascular status in the analysed cohort.

Anterior bridge plating technique

Patients were placed supine with the arm abducted approximately 45 degrees, and reduction was performed under fluoroscopic guidance. A proximal window was developed through the deltopectoral or delto-bicipital interval while preserving the cephalic vein. A distal anterior window was made just proximal to the elbow crease. The biceps was retracted, the musculocutaneous nerve and its sensory continuation were protected, and the brachialis was split bluntly. A submuscular tunnel was created and a 9- to 12-hole 4.5-mm narrow plate was passed along the anterior surface of the humerus. Reduction was achieved by traction and indirect manipulation. At least three bicortical screws were inserted on each side of the fracture. The radial nerve was not routinely exposed.

Conventional plating technique

Conventional fixation was usually performed through a posterior approach with the patient in the lateral decubitus position. A triceps-sparing paratricipital exposure was used, and the radial nerve was identified and protected. The fracture was directly exposed, reduced with clamps, and stabilised with a plate using cortical and locking screws as required. An anterolateral approach was used in selected fractures; in these cases, the brachialis was split longitudinally and the radial nerve was identified in the distal arm.

Follow-up and outcome assessment

Clinical and radiographic data were collected prospectively during follow-up, with final outcome assessment at six months. Radiological outcome was recorded as union within 12 weeks, union after 12 weeks, or nonunion. Functional recovery was assessed by shoulder and elbow range of motion, the UCLA shoulder score, and MEPS. The UCLA score was categorised as excellent (34-35), good (29-33), fair (21-28), or poor (<21). MEPS was categorised as excellent (≥90), good (75-89), fair (60-74), or poor (<60).16,17

Perioperative safety outcomes included intraoperative bleeding or neurovascular injury and postoperative nonunion, infection, radial nerve palsy, compartment syndrome, and bleeding. Duration of hospital stay was also compared.

Statistical analysis

Data were entered in Microsoft Excel and analysed with statistical software. Continuous variables are presented as mean ± standard deviation and range, and categorical variables as frequency and percentage. The Mann-Whitney U test was used for continuous between-group comparisons in the reported analysis. Categorical variables were assessed with the chi-square test or Fisher exact test, as appropriate. All tests were two-sided, and p < 0.05 was considered statistically significant.

Participant and fracture characteristics

All 32 enrolled patients were included in the six-month analysis. The mean age was 37.00 ± 12.00 years in the anterior bridge plating group and 37.50 ± 11.12 years in the conventional plating group (p = 0.8210). Men represented 62.5% of each group. Right-sided fractures and road traffic accidents each accounted for 62.5% of cases in both groups. Fracture-pattern distribution was also similar; AO/OTA type A3 and B1 fractures were the most common. No patient had an associated ipsilateral upper-limb injury or a preoperative neurovascular deficit (Table 1).

Table 1. Baseline demographic and fracture characteristics

Values are n (%) unless otherwise stated. AO/OTA: Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association; SD: standard deviation. The p value for AO/OTA classification represents the overall distribution.

Perioperative course and complications

Regional anaesthesia with a brachial block was used in most patients. No intraoperative complication was recorded after anterior bridge plating; one patient in the conventional group had intraoperative bleeding. Mean hospital stay was 2.06 days shorter in the bridge-plating group and this difference was statistically significant. Postoperative complications occurred in two patients after bridge plating and three after conventional plating. The bridge-plating complications were both classified as nonunion. The conventional group had one nonunion, one infection, and one radial nerve palsy. The difference in overall complication frequency was not significant (Table 2).

Table 2. Perioperative course and complications

*Statistically significant. The reported p value for postoperative complications compares none versus any complication.

Radiological union and range of motion

Fourteen of 16 patients (87.5%) in the bridge-plating group were recorded as united by 12 weeks, compared with 5 of 16 (31.3%) in the conventional group. Ten conventional-plating fractures united after 12 weeks. The reported mean union time was 12.06 ± 4.48 weeks after bridge plating and 14.19 ± 2.32 weeks after conventional plating (p = 0.0014). At six months, full range of motion was present in 14 patients after bridge plating and 13 after conventional plating (p = 1.0000) (Table 3).

Table 3. Radiological union and range of motion

*Statistically significant.

Functional outcomes

Mean shoulder and elbow scores were high in both groups at six months. The mean UCLA score was 32.25 ± 4.12 after bridge plating and 31.81 ± 3.17 after conventional plating (p = 0.1077). Excellent UCLA outcomes were more frequent after bridge plating, but the distribution did not reach statistical significance. Mean MEPS was 91.88 ± 10.39 and 91.44 ± 6.59, respectively (p = 0.1897). Excellent MEPS outcomes were observed in 87.5% and 81.3% of patients (Table 4).

Table 4. Functional outcomes at six months

MEPS: Mayo Elbow Performance Score; UCLA: University of California Los Angeles shoulder score. Category p values represent the overall distribution.

REPRESENTATIVE CLINICAL AND RADIOLOGICAL OUTCOMES

The source dissertation did not contain patient-specific paired preoperative and six-month follow-up radiographs or clinical range-of-motion photographs. The available de-identified image documents the minimally invasive anterior bridge-plating procedure and intraoperative fluoroscopic confirmation of plate placement; it is included below as a representative clinical and radiological illustration of the technique rather than as a final follow-up outcome.

Before journal submission, the authors should verify that Figure 1 is an original study image or obtain the necessary reproduction permission. Matched preoperative and final follow-up anteroposterior/lateral radiographs and clinical shoulder/elbow movement photographs may be added when available, after confirming written consent for publication.

The main finding of this study was that anterior bridge plating and conventional plating produced similar six-month shoulder and elbow function, while the bridge-plating group had a shorter hospital stay and an earlier recorded time to union. Baseline characteristics, fracture morphology, and injury mechanisms were closely balanced, which supports a direct comparison within this cohort. The overall complication frequencies were low and did not differ statistically.

The younger mean age and male predominance in the present series reflect the large contribution of road traffic trauma in the local population. Comparable age and sex patterns have been reported in Indian studies of anterior bridge plating and in comparative cohorts of humeral shaft fixation.12-15

The biological rationale for anterior bridge plating is preservation of the fracture haematoma and periosteal circulation while providing relative stability. Experimental work has shown that fixation strategy and local mechanics influence callus formation, and minimally invasive approaches were developed to exploit this principle.8-10,18

In the present study, the recorded mean union time was approximately two weeks shorter after bridge plating. Oh et al. reported comparable union with minimally invasive and conventional plating, while other observational series have described union within approximately 10-16 weeks after anterior bridge plating. A systematic review comparing open reduction and MIPO concluded that both methods achieve high union rates and suggested possible benefits of MIPO for certain complications, although study heterogeneity remained substantial.6,11-15

The union-time result in this cohort requires careful interpretation. Three patients were classified as having nonunion, yet the raw dataset retained numerical follow-up times of 20-24 weeks for those cases and included them in the reported continuous comparison. This may affect the clinical meaning of the mean union-time difference. The categorical findings—14 early unions after bridge plating versus 5 after conventional plating—are therefore useful, but confirmation in a larger study with a clearly prespecified definition and time-to-event analysis is needed.

The shorter hospital stay after bridge plating is clinically plausible because the technique uses smaller incisions and avoids direct fracture exposure. Reduced soft-tissue trauma may facilitate wound recovery and mobilisation. However, length of stay can also be influenced by institutional discharge practices, social factors, comorbidity, and rehabilitation access; these potential confounders were not separately analysed.

Shoulder and elbow function were satisfactory in both groups. Mean UCLA scores exceeded 31 and mean MEPS exceeded 91 at six months. These findings are consistent with previous series in which most patients achieved good or excellent function following either minimally invasive or conventional plating. The lack of a statistically significant difference suggests that, once union and alignment are achieved, both constructs can permit useful functional recovery.11-17

The bridge-plating group had no infection or radial nerve palsy, whereas one of each occurred after conventional plating. Although this pattern is compatible with the proposed benefit of reduced exposure, the numbers were too small for a reliable difference. A single event changes the percentage by more than six points in a group of 16, and the study was not powered for uncommon complications. The finding should therefore be regarded as descriptive rather than proof of superior safety.

From a practical perspective, anterior bridge plating may be particularly attractive for suitable diaphyseal fractures when the surgeon is familiar with the safe anterior corridor and indirect reduction. Conventional plating remains valuable when direct visualisation, precise reduction, or radial nerve exploration is required. Treatment choice should account for fracture location and pattern, soft-tissue condition, bone quality, patient factors, imaging resources, and surgeon experience.

Strengths and limitations

The prospective design, equal group sizes, consistent single-centre care, use of validated shoulder and elbow scores, and availability of patient-level data are strengths. The principal limitations are the small sample, six-month follow-up, single-centre setting, absence of a reproducible comparative sample-size calculation, and incomplete documentation of random-sequence generation and allocation concealment. Operative time, blood loss, pain, quality of reduction, return to work, and patient-reported quality of life were not available as analysable outcomes. Outcome assessment was not described as blinded. In addition, the handling of nonunion cases in the continuous union-time variable introduces uncertainty. These limitations restrict causal and generalisable conclusions.

Anterior bridge plating and conventional plating both provided satisfactory short-term functional outcomes for humeral shaft fractures. In this cohort, bridge plating was associated with a significantly shorter hospital stay and earlier recorded radiological union, whereas range of motion, UCLA shoulder score, MEPS, and overall complication rates were statistically comparable. The results support anterior bridge plating as a useful minimally invasive option rather than establishing universal superiority. A larger, adequately powered multicentre study with concealed allocation, standardised union definitions, blinded outcome assessment, and longer follow-up is warranted.

1. Updegrove GF, Mourad W, Abboud JA. Humeral shaft fractures. J Shoulder Elbow Surg. 2018;27(4):e87-e97.
2. Mattila H, Keskitalo T, Simons T, Ibounig T, Rämö L. Epidemiology of 936 humeral shaft fractures in a large Finnish trauma center. J Shoulder Elbow Surg. 2023;32(5):e206-e215.
3. Carroll EA, Schweppe M, Langfitt M, Miller AN, Halvorson JJ. Management of humeral shaft fractures. J Am Acad Orthop Surg. 2012;20(7):423-433.
4. Pidhorz L. Acute and chronic humeral shaft fractures in adults. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S41-S49.
5. Orapiriyakul W, Apivatthakakul V, Theppariyapol B, Apivatthakakul T. Humerus shaft fractures, approaches and management. J Clin Orthop Trauma. 2023;43:102230.
6. Beeres FJP, Diwersi N, Houwert RM, et al. ORIF versus MIPO for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies. Injury. 2021;52(4):653-663.
7. Apivatthakakul T, Phornphutkul C, Laohapoonrungsee A, Sirirungruangsarn Y. Less invasive plate osteosynthesis in humeral shaft fractures. Oper Orthop Traumatol. 2009;21(6):602-613.
8. Apivatthakakul T, Arpornchayanon O, Bavornratanavech S. Minimally invasive plate osteosynthesis of the humeral shaft fracture: is it possible? A cadaveric study and preliminary report. Injury. 2005;36(4):530-538.
9. Claes L. Biomechanical principles and mechanobiologic aspects of flexible and locked plating. J Orthop Trauma. 2011;25 Suppl 1:S4-S7.
10. Claes L, Heitemeyer U, Krischak G, Braun H, Hierholzer G. Fixation technique influences osteogenesis of comminuted fractures. Clin Orthop Relat Res. 1999;(365):221-229.
11. Oh CW, Byun YS, Oh JK, et al. Plating of humeral shaft fractures: comparison of standard conventional plating versus minimally invasive plating. Orthop Traumatol Surg Res. 2012;98(1):54-60.
12. Lal Y, Mishra A, Kushwaha A, Badoni N. A clinical study of anterior bridge plating for humerus shaft fractures by minimal invasive technique. Int J Orthop Sci. 2019;5(3):122-125.
13. Mazumder G, Choudhary RK. Comparison of outcomes of diaphyseal humeral shaft fractures treated with anterior bridge plating versus open reduction internal fixation by posterior approach. IOSR J Dent Med Sci. 2020;19(7):40-49.
14. Sidhu GA, Jain D, Selhi HS, et al. A prospective cohort study: promising results with minimally invasive plate osteosynthesis of anterior bridge plating in adult humeral shaft fractures. Clin Shoulder Elb. 2024;27(4):479.
15. Mahajan AS, Kim YG, Kim JH, D'sa P, Lakhani A, Ok HS. Is anterior bridge plating for mid-shaft humeral fractures a suitable option for patients predominantly involved in overhead activities? Clin Orthop Surg. 2016;8(4):358-366.
16. Thamyongkit S, Wanitchanont T, Chulsomlee K, et al. The University of California-Los Angeles shoulder scale: translation, reliability and validation of a Thai version in patients with rotator cuff tear. BMC Musculoskelet Disord. 2022;23(1):65.
17. Cusick MC, Bonnaig NS, Azar FM, Mauck BM, Smith RA, Throckmorton TW. Accuracy and reliability of the Mayo Elbow Performance Score. J Hand Surg Am. 2014;39(6):1146-1150.
18. Rand JA, An KN, Chao EY, Kelly PJ. A comparison of the effect of open intramedullary nailing and compression-plate fixation on fracture-site blood flow and fracture union. J Bone Joint Surg Am. 1981;63(3):427-442.