The FISH trial is a multicenter RCT comparing ORIF with plate fixation versus functional bracing for closed displaced humeral shaft fractures. It addresses whether the rising surgical rate — reaching 60% of cases in the U.S. by 2011 — is supported by evidence of superior functional outcomes.
A 25% nonunion rate and 30% crossover-to-surgery rate are the numbers to carry out of this trial. They reframe the clinical conversation: functional bracing is not a reliably conservative option for every patient — roughly one in three will end up in the OR anyway, just later and with worse outcomes than if they'd gone initially.
The intent-to-treat result (no significant DASH difference at 12 months) is technically correct but misleading in isolation. The bracing group includes patients who eventually had surgery, which inflates that group's apparent outcomes and compresses the between-group difference. The per-protocol analysis (bracing-only patients who never crossed over: DASH 8.5 vs surgery 8.9) actually shows near-identical outcomes — meaning the patients who heal with bracing do just as well as surgical patients, but you cannot reliably predict who those patients will be upfront.
For the OITE, know the key numbers: DASH MCID = 10 points; 25% nonunion rate with bracing; 8% temporary radial nerve palsy rate with ORIF. Know that surgery's early functional advantage (clinically meaningful at 6 weeks and 3 months) disappears by 12 months.
The actionable clinical lesson is about shared decision-making. Patients who want faster recovery, have occupational demands, or are unlikely to tolerate brace compliance have a legitimate case for upfront surgery. Patients willing to accept the nonunion risk and crossover possibility can be offered bracing — but they must understand those odds.
The FISH trial is a multicenter RCT comparing ORIF with plate fixation versus functional bracing for closed displaced humeral shaft fractures. It addresses whether the rising surgical rate — reaching 60% of cases in the U.S. by 2011 — is supported by evidence of superior functional outcomes.
A 25% nonunion rate and 30% crossover-to-surgery rate are the numbers to carry out of this trial. They reframe the clinical conversation: functional bracing is not a reliably conservative option for every patient — roughly one in three will end up in the OR anyway, just later and with worse outcomes than if they'd gone initially.
The intent-to-treat result (no significant DASH difference at 12 months) is technically correct but misleading in isolation. The bracing group includes patients who eventually had surgery, which inflates that group's apparent outcomes and compresses the between-group difference. The per-protocol analysis (bracing-only patients who never crossed over: DASH 8.5 vs surgery 8.9) actually shows near-identical outcomes — meaning the patients who heal with bracing do just as well as surgical patients, but you cannot reliably predict who those patients will be upfront.
For the OITE, know the key numbers: DASH MCID = 10 points; 25% nonunion rate with bracing; 8% temporary radial nerve palsy rate with ORIF. Know that surgery's early functional advantage (clinically meaningful at 6 weeks and 3 months) disappears by 12 months.
The actionable clinical lesson is about shared decision-making. Patients who want faster recovery, have occupational demands, or are unlikely to tolerate brace compliance have a legitimate case for upfront surgery. Patients willing to accept the nonunion risk and crossover possibility can be offered bracing — but they must understand those odds.