Review Question - QID 971

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Humeral Shaft Nonunion Treatment Operative QID: 971 (OBQ05.85)

QID 971 (Type "971" in App Search)

A 42-year-old man reports persistent arm pain after undergoing intramedullary nailing of a humeral shaft fracture 13 months ago. Physical exam shows near normal shoulder and elbow range-of-motion. Infection work-up is normal. A radiograph is shown in Figure A. What is the next most appropriate step in treatment?

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Exchange nailing

11%

298/2654

Manipulation under anesthesia

10/2654

Nail removal and plate fixation

80%

2114/2654

Nail removal and placement of Sarmiento brace

38/2654

Nail dynamization

188/2654

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Plate fixation (with bone graft as needed) is the procedure of choice for humeral shaft nonunions.

Rubel et al in a combined cadaveric and clinical study comparing one versus two plate constructs for humeral nonunions found that the two plate construct was significantly stiffer, but had no difference in healing rate compared with a single plate construct; 92% of the humeral shaft nonunion patients went onto union with rigid plate fixation.

Ring et al successfully treated a cohort of osteoporotic humeral shaft nonunions with locked plating. They
report 100% union rate with locking plate fixation of these humeral shaft nonunions, with use of autograft in >50% of their cases. Subjective shoulder scores were excellent or good in 22 of 24 patients.

Brinker and O'Connor analyzed the current available evidence for exchange nailing of nonunions and could not recommend this treatment for humeral shaft nonunions.