INTRODUCTION: Coaptation splints require skillful application, are difficult to maintain, and are prone to skin complications. Our study evaluates if immediate application of a sarmiento fracture brace produces equivalent radiographic alignment when compared with coaptation splinting. METHODS: Using a retrospective cohort design 51 patients were identified via CPT code and review of radiographs between January 2008 and March 2015. Demographic data, patient factors including BMI, and associated nerve palsies were recorded. Orthogonal radiographs at the time of injury, post - reduction, and where available, at union were measured for sagittal and coronal plane angulation. Initial immobilization was selected by staff preference and 20 patients were placed in fracture braces and 31 in coaptation splints. Acceptable alignment was considered to be <30 degrees of varus angulation, <20 of sagittal plane angulation, <2cm shortening. RESULTS: Of the 20 patients with immediate sarmiento bracing the average varus alignment after brace application was 13.5 vs. 11.4 degrees for those with immediate coaptation splinting. The percentage of patients with acceptable alignment after reduction was 84% in both groups. Of patients with complete radiographs at union all in the sarmiento group healed in acceptable alignment as compared to 92% in the coaptation group. Five patients in the coaptation group required repeat reductions as compared to one in the sarmiento group. All five nonunions were in the coaptation splinting group. Patients in both groups were similar with regards to initial injury displacement and radial nerve palsy. In the sarmiento group, similar proportions of patients were lost to follow up or converted to operative fixation. DISCUSSION AND CONCLUSION: The initial management of humeral shaft fractures is only superficially discussed in the current literature and to our knowledge this is the first report to compare the immediate and final radiographic outcomes of patients initially treated with either a sarmiento brace or coaptation splint. Our data show that post-reduction alignment was similar between patients and equal proportions of patients had acceptable post-reduction alignment. However, patients immediately placed into a sarmiento brace required fewer repeated reduction attempts. Given the difficult nature of coaptation splinting, these findings support the role of immediate sarmiento bracing for the initial management of humeral shaft fractures.