Humeral Shaft Nonunion

Posted: Oct 12 2016 #(C2700) Current Solutions in Orthopaedic Trauma 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope

Humeral Shaft Nonunion in a 42M

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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.

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?

79/1793

Yes

95%

1714/1793

2. If performing operative treatment, what procedure would you recommend?

Removal of nail, no revision fixation, bracing.

14/1693

Revision IM nail (withOUT exploration of fx site)

66/1693

Revision IM nail (WITH exploration of fx site)

10%

170/1693

ORIF with plate and screw construct after IM nail removal

83%

1409/1693

External Fixation following nail removal

34/1693

3. Would you use bone graft as part of your operative management in this patient?

No.

20%

331/1644

Yes - AUTOgraft - Iliac Crest

55%

911/1644

Yes - AUTOgraft - Reamer-irrigator-aspirator (RIA)

122/1644

Yes - AUTOgraft - Bone Marrow Aspirate (BMA).

63/1644

Yes - ALLOgraft - bone chips. (nonstructural)

143/1644

Yes - ALLOgraft - Intramedullary Strut Allograft (structural)

74/1644

4. If treating with ORIF, which approach would you use?

Anterolateral

63%

986/1556

Posterior

36%

570/1556

5. If choosing ORIF with plate fixation, what plate construct would you use?

Single Plate

84%

1336/1580

Dual Plate Construct

15%

244/1580

6. What would be your definitive criteria to RULE OUT infection in this case?

ESR, CRP, WBC are normal, pt afebrile

37%

596/1608

Intraop Gram Stain is Negative

38/1608

Intraop Frozen Section is Negative

84/1608

Intraop Cultures are Negative (after 1 week)

153/1608

Intraop Cultures are Negative (after 2 weeks)

11%

181/1608

Intraop Cultures are Negative, including P. acnes (after 3 weeks)

28%

466/1608

NEGATIVE PCR

45/1608

Indium labeled wbc scan

45/1608

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

136/1404

Order labs in option #1, AND albumin, prealbumin, calcium, vitamin D

33%

476/1404

Order the labs in option #1 and #2 AND PTH, TSH, testosterone

28%

399/1404

Order the labs in option #1, #2, #3 AND get a DEXA scan

13%

196/1404

Get endocrinology consult

14%

197/1404

5 weeks

Post-procedure P1

21 months

Post-procedure P1

2 years ago

Post-procedure P1

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