Review Question - QID 211342

This patient sustained a humeral shaft fracture and has no significant callus at 4 weeks. However, surgical intervention should not yet be considered at this time.

The vast majority of closed humeral shaft fracture may be treated conservatively and heal uneventfully. Functional bracing relies on hydrostatic compressive forces from the surrounding soft tissues to provide stability for healing. Recent studies have shown that gross motion at the fracture site and no callus formation on radiographs at 6-weeks has both a specificity and PPV of 100% risk of going on to nonunion. For patients that progress to nonunion, subsequent surgical stabilization is often indicated. However, this patient is only 4 weeks out from injury and additional time should be given to assess for callus formation.

Cadet et al. reported the rate of nonunion to be approximately 5.5% following closed treatment of humeral shaft fracture. They noted that surgical management should be considered for fractures that demonstrate no evidence of progressive healing on consecutive radiographs taken at least 6 to 8 weeks apart during the course of closed treatment. They concluded that for humeral shaft nonunions, open reduction and internal fixation with compression plating and bone graft remains the standard of care, with a >90% rate of union and good functional outcomes.

Hierholzer et al. retrospectively evaluated the healing of ununited fractures of the humeral shaft treated with the use of two different types of bone graft: autologous iliac crest bone graft and demineralized bone matrix. They reported that osseous union was noted clinically and radiographically following the index surgery in 100% and 97% of patients treated with autologous bone graft and demineralized bone matrix, respectively. They concluded that healing of an ununited humeral shaft fracture can be achieved consistently with rigid plate fixation and lag-screw compression augmented with either autologous cancellous bone graft or commercially available demineralized bone matrix, however the harvest of the autologous bone graft is frequently associated with complications.

Figures A&B are the AP and oblique radiographs of a left humeral shaft fracture with acceptable alignment and negligible callus formation

Incorrect Answers:
Answer 2: Low-intensity pulsed ultrasound (LIPUS) is most commonly started for delayed union and nonunions. This patient is only 4 weeks from injury and LIPUS is not needed at this time.
Answer 3-5: This patient is only 4 weeks out from injury and does not show evidence of callus formation. However, an addition period of time with reassessment of radiographs in 4 weeks is appropriate to evaluate for callus formation. Surgical intervention should not be considered at 4 weeks.