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Humeral Shaft Nonunion
Posted: Oct 12 2016 #(C2700)
A

Humeral Shaft Nonunion in a 42M

HPI

Patient fractured his left humeral shaft and saw an outside surgeon, undergoing IM fixation. Fracture site initially looked promising, but soon went on to nonunion. One of the distal screws never seated properly and began to back out soon after his initial surgery. At 3 months post-op, the patient returned to the outside facility and was pronounced healed by the PA. 3 years later, he presented to my clinic with significant pain and dysfunction.

PMH

No significant PMHx, no tobacco or EtOH use.

PE

Significant pain at the fracture site. Pain with all range of motion and movement of the left arm. The previous surgical incision is clean, dry, and intact with no obvious sign of infection.

Poll
1 of 7
1. Would you recommend surgery in this patient?
No
4%
79/1811
Yes
95%
1732/1811
2. If performing operative treatment, what procedure would you recommend?
Removal of nail, no revision fixation, bracing.
0%
14/1710
Revision IM nail (withOUT exploration of fx site)
3%
66/1710
Revision IM nail (WITH exploration of fx site)
10%
171/1710
ORIF with plate and screw construct after IM nail removal
83%
1425/1710
External Fixation following nail removal
1%
34/1710
3. Would you use bone graft as part of your operative management in this patient?
No.
19%
331/1660
Yes - AUTOgraft - Iliac Crest
55%
919/1660
Yes - AUTOgraft - Reamer-irrigator-aspirator (RIA)
7%
126/1660
Yes - AUTOgraft - Bone Marrow Aspirate (BMA).
3%
64/1660
Yes - ALLOgraft - bone chips. (nonstructural)
8%
144/1660
Yes - ALLOgraft - Intramedullary Strut Allograft (structural)
4%
76/1660
4. If treating with ORIF, which approach would you use?
Anterolateral
63%
999/1572
Posterior
36%
573/1572
5. If choosing ORIF with plate fixation, what plate construct would you use?
Single Plate
84%
1349/1597
Dual Plate Construct
15%
248/1597
6. What would be your definitive criteria to RULE OUT infection in this case?
ESR, CRP, WBC are normal, pt afebrile
36%
599/1624
Intraop Gram Stain is Negative
2%
38/1624
Intraop Frozen Section is Negative
5%
86/1624
Intraop Cultures are Negative (after 1 week)
9%
154/1624
Intraop Cultures are Negative (after 2 weeks)
11%
182/1624
Intraop Cultures are Negative, including P. acnes (after 3 weeks)
29%
475/1624
NEGATIVE PCR
2%
45/1624
Indium labeled wbc scan
2%
45/1624
7. What studies would you do to evaluate for an abnormal metabolic process as the cause of the pseudoarthrosis?
Order labs, including chem 7 and CBC
9%
136/1420
Order labs in option #1, AND albumin, prealbumin, calcium, vitamin D
34%
483/1420
Order the labs in option #1 and #2 AND PTH, TSH, testosterone
28%
405/1420
Order the labs in option #1, #2, #3 AND get a DEXA scan
14%
199/1420
Get endocrinology consult
13%
197/1420
PROCEDURE #1 DOP: 8/14/2014

ORIF of humeral shaft

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OUTCOMES
5 weeks after
Post-procedure P1
21 months after
Post-procedure P1
2 years after
Post-procedure P1
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