Review Question - QID 220071

The most appropriate surgical option for this patient with a proximal humerus nonunion would be compression plating with bone grafting (Answer 1).

Compression plating with bone grafting is the preferred treatment for proximal humerus nonunions in young patients due to its demonstrated biomechanical and clinical superiority in achieving union compared to intramedullary nailing. Biomechanical studies have shown that locking compression plates provide superior rigidity and load-sharing capacity compared to other fixation methods. Union rates exceed 90% with this approach, even in complex cases. The use of autograft enhances osteogenesis, osteoinduction, and osteoconduction. The benefits of a minimally invasive surgery with nailing are also less relevant since an open approach is often still needed to debride the nonunion site and insert bone graft. For these reasons, plate fixation +/- bone grafting is the preferred surgical technique for humeral nonunions.

Boileau et al. investigated the outcomes of third-generation percutaneous intramedullary nailing for displaced humeral surgical neck fractures, emphasizing advancements in implant design and surgical technique. The study classified fractures using a novel system and demonstrated high rates of fracture union, low complication rates, and satisfactory functional outcomes. The authors concluded that third-generation intramedullary nailing offers a reliable and minimally invasive option for managing these fractures, providing improved biomechanical stability and facilitating early mobilization.

Cheung and Sperling reviewed the management strategies for proximal humeral nonunions and malunions, focusing on surgical approaches to restore function and alleviate pain. They highlighted that treatment should be individualized based on patient factors, fracture characteristics, and the degree of functional impairment, with options including open reduction and internal fixation, bone grafting, or shoulder arthroplasty. The authors concluded that while surgical intervention can achieve good outcomes in most cases, the complexity of these conditions requires meticulous planning to effectively address deformity, instability, and soft tissue challenges.

Meesters et al. examined the relationship between malnutrition, specific amino acid deficiencies, and the development of fracture nonunions. They found that deficiencies in amino acids such as arginine and glutamine, which play key roles in collagen synthesis and immune function, can impair fracture healing and increase the risk of nonunion. The authors concluded that addressing malnutrition and supplementing critical amino acids may improve fracture healing outcomes and reduce the incidence of nonunion.

Figure A demonstrated a proximal humerus fracture treated with intramedullary nailing without evidence of callus formation.

Incorrect answers:
Answer 2: Revision intramedullary nailing would not be the construct of choice.
Answer 3: The patient is relatively young and is not a good candidate for a hemiarthroplasty if compression plating is still a viable option. If she developed osteonecrosis of the humeral head, then hemiarthroplasty would be an appropriate treatment.
Answer 4: The patient’s young age puts her at greater risk of eventual failure after a reverse total shoulder arthroplasty.
Answer 5: Supplementing the existing fixation with percutaneous screws would not allow for debridement of the fracture site or adequate compression for this patient’s fracture pattern.