summary Humeral Shaft Nonunion is characterized by the arrest of the fracture repair process of a humeral shaft fracture which may occur following nonoperative or operative management. Diagnosis can be made with plain radiographs. CT studies are helpful to assess the extent of bridging callous and for preoperative planning. Treatment is generally open reduction 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 Anatomic 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) Etiology 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 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 to 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 Prognosis With operative treatment of nonunion, 83-100% of patients go on to union
QUESTIONS 1 of 9 1 2 3 4 5 6 7 8 9 Previous Next (OBQ18.214) A 50-year-old male sustained a humeral shaft fracture treated operatively 6 months ago. He denies medical problems but smokes 10 cigarettes per day. His current radiograph is shown in Figure A. He continues to have pain in his arm that is affecting his quality of life. On physical examination, there is motion at the fracture site. C-reactive protein and erythrocyte sedimentation rate are within normal limits. Which is the most appropriate definitive treatment for this fracture? QID: 213110 FIGURES: A Type & Select Correct Answer 1 Exchange humeral nailing 2% (39/2124) 2 Augmentative plating 2% (51/2124) 3 Nail removal with open reduction compression plating 8% (164/2124) 4 Smoking cessation and medical optimization 5% (114/2124) 5 Nail removal with open reduction and compression plating with bone grafting 82% (1743/2124) N/A Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 4873 FIGURES: A B Type & Select Correct Answer 1 Vitamin A deficiency 1% (17/2443) 2 Low serum testosterone 0% (8/2443) 3 Low serum thyroxine 3% (65/2443) 4 Vitamin D deficiency 90% (2201/2443) 5 Hypocalcemia 6% (145/2443) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12TR.27.1) A 71-year-old man presents after 9 months of functional bracing for a closed right humeral shaft fracture. Current radiographs are shown in Figure A. Infectious workup was negative. Appropriate next steps in evaluation will most likely reveal which of the following? QID: 212627 FIGURES: A Type & Select Correct Answer 1 Vitamin D deficiency 92% (2309/2497) 2 Low testosterone 1% (32/2497) 3 Iron deficiency 0% (10/2497) 4 Thyroid deficiency 4% (100/2497) 5 Magnesium deficiency 1% (22/2497) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 3942 FIGURES: A Type & Select Correct Answer 1 Vitamin D deficiency 68% (2305/3398) 2 Central hypogonadism 3% (88/3398) 3 Thyroid disorder 2% (60/3398) 4 Parathyroid hormone disorder 7% (249/3398) 5 Calcium deficiency 20% (673/3398) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 971 FIGURES: A Type & Select Correct Answer 1 Exchange nailing 12% (293/2536) 2 Manipulation under anesthesia 0% (7/2536) 3 Nail removal and plate fixation 79% (2014/2536) 4 Nail removal and placement of Sarmiento brace 1% (35/2536) 5 Nail dynamization 7% (182/2536) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ04.96) A 33-year-old male presents 9 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? QID: 1201 FIGURES: A Type & Select Correct Answer 1 Reassurance and appropriate followup 1% (11/922) 2 Sarmiento bracing 1% (7/922) 3 Use of a bone stimulator 3% (27/922) 4 Exchange humeral nailing 10% (95/922) 5 IM nail removal, open reduction internal fixation with bone grafting 84% (773/922) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (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? QID: 1334 FIGURES: A Type & Select Correct Answer 1 ultrasound therapy to nonunion site 1% (10/1567) 2 oral bisphosphonates 0% (4/1567) 3 open reduction internal fixation with autologous bone graft 94% (1480/1567) 4 antegrade intramedullary nail 4% (58/1567) 5 retrograde intramedullary nail 0% (4/1567) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (1) Podcasts (1) Login to View Community Videos Login to View Community Videos Posterior Approach to Humerus. Kemal Gokkus Trauma - Humeral Shaft Nonunion B 7/11/2020 417 views 3.0 (2) Trauma⎪Humeral Shaft Nonunion Orthobullets Team Trauma - Humeral Shaft Nonunion Listen Now 17:25 min 1/14/2020 518 plays 4.6 (5)
Distal Humeral Shaft Fracture (C101441) Alex J. Kelsheimer Trauma - Humeral Shaft Nonunion E 4/20/2020 597 13 0 Humeral Shaft Fracture Nonunion in 22M (C101375) Justin Kelley Trauma - Humeral Shaft Nonunion E 2/5/2020 103 10 1 2021 Orthopaedic Trauma & Fracture Care: Pushing the Envelope Humeral Shaft Nonunion in a 42M (C2700) Mark A. Mighell Trauma - Humeral Shaft Nonunion A 10/12/2016 11141 56 34