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  • summary
    • Humeral Shaft Nonunion is characterized by the arrest of the fracture repair process of a humeral shaft fracture which may occur following nonoperative or operative management. 
    • Diagnosis can be made with plain radiographs. CT studies are helpful to assess the extent of bridging callous and for preoperative planning.
    • Treatment is generally open reduction with compression plating with or without bone grafting.
  • Epidemiology
    • Incidence of primary nonunion
      • 2 to 33% with nonoperative management
      • 5 to 10% with surgical management
    • Anatomic location
      • proximal third humeral shaft fractures are felt to have higher rates of nonunion
    • Risk factors
      • biologic
        • metabolic/endocrine abnormalities (osteoporosis, Vitamin D deficiency most common)
        • infection
        • patient factors (smoking, obesity, malnutrition, noncompliance)
        • open fracture
      • mechanical
        • unstable fracture patterns with inadequate stability
        • shoulder or elbow stiffness (motion directed to fracture site)
  • Etiology
    • Pathophysiology
      • pathophysiology
        • inadequate stability at fracture site with operative or nonoperative treatment
      • pathobiology
        • inadequate biology as a result of metabolic/endocrine abnormalities, infection, smaller bone surface area for healing
    • Associated conditions
      • radial nerve palsy
  • Anatomy
    • Blood Supply
      • nutrient vessel of humerus courses along the medial aspect of the mid to distal third of the diaphysis
    • Muscles
      • pectoralis major and deltoid create strong deforming forces on proximal diaphyseal fractures
    • Tendon
      • biceps tendon interposition in proximal diaphyseal fractures may lead nonunion
  • Presentation
    • Symptoms
      • pain with use of the extremity
    • Physical exam
      • inspection
        • assess the fit of functional brace and skin irritation
        • atrophy
        • angulation
      • motion
        • gross motion at the fracture site
      • neurovascular
        • assess radial nerve function
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral of the humerus, shoulder, and elbow
      • findings
        • lack of fracture consolidation
        • hypertrophic callous formation
        • pseudarthrosis
    • CT
      • indications
        • to evaluate for the extent of bridging callous and preoperative planning
  • Studies
    • Serum Labs
      • CRP, ESR, CBC
        • must rule out infection
      • total protein and serum albumin
      • vitamin D, TSH, PTH
  • Treatment
    • Nonoperative
      • functional bracing +/- bone stimulation
        • indications
          • rarely indicated unless low demand, high-risk surgical candidate, and asymptomatic nonunion
        • modalities
          • continued functional brace
          • bone stimulators
            • nonunion over a period greater than 9 months or no progressive healing 3 months from injury
            • contraindicated if pseudarthrosis, fracture gap >5mm, or poor blood supply
    • Operative
      • compression plating with bone grafting (gold standard)
        • indications
          • symptomatic nonunion
        • outcomes
          • shown to be superior to IM nailing
      • dual plating
        • indications
          • very proximal or distal fracture nonunion
          • poor metaphyseal bone quality
          • micromotion noted at fracture site following single plate fixation
        • outcomes
          • 92-100% union at 16 weeks
      • cortical strut allograft/autograft
        • indications
          • severe osteopenia from disuse, age, or prior surgery
          • severe bone loss
          • recalcitrant nonunion
        • outcomes
          • 95-100% union rate
      • bone morphogenic proteins (BMP's)
        • indications
          • limited role as no studies show improved outcomes
  • Techniques
    • Compression plating with or without bone grafting
      • approach
        • anterior
        • anterolateral
        • posterior
          • radial nerve exploration and neurolysis or release of nerve entrapment
      • soft tissue
        • radial nerve protection and neurolysis
      • bone work
        • debridement of fibrous tissue and bone ends to stimulate healing
        • fracture reduction with maximal cortical contact and stability
        • autologous bone grafting from ICBG if atrophic nonunion
        • DBM, RIA, or local callous autograft as alternative grafts
      • instrumentation
        • 4.5mm compression plate placed anterior, lateral, or posterior
      • complications specific to this treatment
        • radial nerve neuropraxia or injury
        • ICBG donor site morbidity
      • outcomes
        • nearly 100% union rate reported
        • 44% rate of ICBG donor site morbidity
    • Dual plating
      • instrumentation
        • place additional plate orthogonal to the first plate
    • Cortical strut allograft/autograft
      • bone work
        • place strut intramedullary and then place the plate
        • place strut medially and place laterally based compression plate
  • Complications
    • Nerve injury
      • radial nerve most common
    • Persistent nonunion
      • treatment
        • free fibular grafting
          • indications
            • recalcitrant atrophic nonunions
  • Prognosis
    • With operative treatment of nonunion, 83-100% of patients go on to union
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