Updated: 8/24/2019

Humeral Shaft Nonunion

Topic
Review Topic
0
0
Questions
8
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0
Evidence
1
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0
Cases
1
https://upload.orthobullets.com/topic/12767/images/nonunion_humerus.jpg
https://upload.orthobullets.com/topic/12767/images/nonunion_humerus2.jpg
https://upload.orthobullets.com/topic/12767/images/humerus_pseudarthrosis.jpg
Introduction
  • Characterized by the arrest of the fracture repair process of a humeral shaft fracture
    • treated operatively with compression plating with or without bone grafting
  • Epidemiology
    • incidence of primary nonunion
      • 2 to 33% with nonoperative management
      • 5 to 10% with surgical management
    • location
      • proximal third humeral shaft fractures are felt to have higher rates of nonunion
    • risk factors
      • biologic
        • metabolic/endocrine abnormalities (osteoporosis, Vitamin D deficiency most common)  
        • infection
        • patient factors (smoking, obesity, malnutrition, noncompliance)
        • open fracture
      • mechanical
        • unstable fracture patterns with inadequate stability
        • shoulder or elbow stiffness (motion directed to fracture site)
  • Pathophysiology
    • pathophysiology
      • inadequate stability at fracture site with operative or nonoperative treatment
    • pathobiology
      • inadequate biology as a result of metabolic/endocrine abnormalities, infection, smaller bone surface area for healing
  • Associated conditions
    • radial nerve palsy
  • Prognosis
    • with operative treatment of nonunion, 83%-100% of patients go on to union
Anatomy
  • Blood Supply
    • nutrient vessel of humerus courses along the medial aspect of the mid to distal third of the diaphysis 
  • Muscles
    • pectoralis major and deltoid create strong deforming forces on proximal diaphyseal fractures 
  • Tendon
    • biceps tendon interposition in proximal diaphyseal fractures may lead nonunion
Presentation
  • Symptoms
    • pain with use of the extremity
  • Physical exam
    • inspection
      • assess the fit of functional brace and skin irritation
      • atrophy
      • angulation
    • motion
      • gross motion at the fracture site
    • neurovascular
      • assess radial nerve function
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of the humerus, shoulder, and elbow
    • findings
      • lack of fracture consolidation  
      • hypertrophic callous formation 
      • pseudarthrosis  
  • CT
    • indications
      • to evaluate for the extent of bridging callous and preoperative planning
Studies
  • Serum Labs
    • CRP, ESR, CBC
      • must rule out infection 
    • total protein and serum albumin
    • vitamin D, TSH, PTH
Treatment
  • Nonoperative
    • functional bracing +/- bone stimulation
      • indications
        • rarely indicated unless low demand, high-risk surgical candidate, and asymptomatic nonunion
      • modalities
        • continued functional brace
        • bone stimulators
          • nonunion over a period greater than 9 months or no progressive healing 3 months from injury
          • contraindicated if pseudarthrosis, fracture gap >5mm, or poor blood supply
  • Operative
    • compression plating with bone grafting (gold standard)      
      • indications
        • symptomatic nonunion
      • outcomes
        • shown to be superior IM nailing
    • dual plating 
      • indications
        • very proximal or distal fracture nonunion
        • poor metaphyseal bone quality
        • micromotion noted at fracture site following single plate fixation
      • outcomes
        • 92-100% union at 16 weeks
    • cortical strut allograft/autograft 
      • indications
        • severe osteopenia from disuse, age, or prior surgery
        • severe bone loss
        • recalcitrant nonunion
      • outcomes
        • 95-100% union rate
    • bone morphogenic proteins (BMP's)
      • indications
        • limited role as no studies show improved outcomes
Techniques
  • Compression plating with or without bone grafting
    • approach
      • anterior 
      • anterolateral 
      • posterior 
        • radial nerve exploration and neurolysis or release of nerve entrapment
    • soft tissue
      • radial nerve protection and neurolysis
    • bone work
      • debridement of fibrous tissue and bone ends to stimulate healing
      • fracture reduction with maximal cortical contact and stability
      • autologous bone grafting from ICBG if atrophic nonunion
      • DBM, RIA, or local callous autograft as alternative grafts 
    • instrumentation
      • 4.5mm compression plate placed anterior, lateral, or posterior
    • complications specific to this treatment
      • radial nerve neuropraxia or injury
      • ICBG donor site morbidity
    • outcomes
      • nearly 100% union rate reported
      • 44% rate of ICBG donor site morbidity
  • Dual plating
    • instrumentation
      • place additional plate orthogonal to the first plate
  • Cortical strut allograft/autograft
    • bone work
      • place strut intramedullary and then place the plate 
      • place strut medially and place laterally based compression plate 
Complications
  • Nerve injury 
    • radial nerve most common
  • Persistent nonunion
    • treatment
      • free fibular grafting
        • indications
          • recalcitrant atrophic nonunions
 

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Questions (8)

(OBQ13.238) A 58-year-old African-American female who sustained an injury to her upper arm six months ago presents with persistent arm pain. She was initially treated with splinting, with conversion to fracture bracing. She is neurovascularly intact. An injury radiograph and a current radiograph are shown in Figures A and B respectively. What nutritional or metabolic disturbance is the most likely associated with this patient's diagnosis? Review Topic

QID: 4873
FIGURES:
1

Vitamin A deficiency

1%

(12/1652)

2

Low serum testosterone

0%

(3/1652)

3

Low serum thyroxine

2%

(40/1652)

4

Vitamin D deficiency

90%

(1487/1652)

5

Hypocalcemia

6%

(107/1652)

ML 1

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(SBQ12TR.27) Figure A is a radiograph of an 80-year-old woman who sustained a closed injury to her left arm 10 months ago. She presents to office today complaining of persistent pain in her arm. What is the most likely metabolic or endocrine abnormality contributing to this patients presentation? Review Topic

QID: 3942
FIGURES:
1

Vitamin D deficiency

66%

(1864/2807)

2

Central hypogonadism

3%

(79/2807)

3

Thyroid disorder

2%

(46/2807)

4

Parathyroid hormone disorder

7%

(209/2807)

5

Calcium deficiency

21%

(589/2807)

ML 3

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PREFERRED RESPONSE 1
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(OBQ05.85) 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? Review Topic

QID: 971
FIGURES:
1

Exchange nailing

11%

(208/1835)

2

Manipulation under anesthesia

0%

(3/1835)

3

Nail removal and plate fixation

82%

(1496/1835)

4

Percutaneous locked plating

1%

(19/1835)

5

Nail dynamization

6%

(106/1835)

ML 1

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(OBQ04.229) A patient sustained a transverse humeral shaft fracture 6 months ago and presently complains of pain and instability at the area of injury. A plain radiograph is shown in Figure A and on exam there is gross motion at the fracture site. What is the most appropriate definitive treatment? Review Topic

QID: 1334
FIGURES:
1

ultrasound therapy to nonunion site

0%

(5/1184)

2

oral bisphosphonates

0%

(2/1184)

3

open reduction internal fixation with autologous bone graft

94%

(1118/1184)

4

antegrade intramedullary nail

4%

(47/1184)

5

retrograde intramedullary nail

0%

(3/1184)

ML 1

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(OBQ04.96) A 33-year-old male presents 7 months after a fall from 15 feet. He complains of continued pain over his left arm and you elicit pain and gross movement with palpation of his humerus. Infectious workup is negative and a radiograph is shown in Figure A. What is the most appropriate next step in his management? Review Topic

QID: 1201
FIGURES:
1

Reassurance and appropriate followup

1%

(6/497)

2

Sarmiento bracing

1%

(3/497)

3

Use of a bone stimulator

2%

(11/497)

4

Exchange humeral nailing

11%

(56/497)

5

IM nail removal, open reduction internal fixation with bone grafting

84%

(415/497)

ML 1

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PREFERRED RESPONSE 5
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CASES (1)
Topic COMMENTS (2)
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