Please confirm topic selection

Are you sure you want to trigger topic in your Anconeus AI algorithm?

Updated: 6/17/2021

Humeral Shaft Nonunion

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
10
N/A
N/A
Questions
9
0
0
0%
0%
Evidence
18
0
0
0%
0%
Videos / Pods
1
0%
0%
Cases
3
Topic
Images
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
  • 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
Flashcards (10)
Cards
1 of 10
Questions (9)

(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:

Exchange humeral nailing

2%

(39/2124)

Augmentative plating

2%

(51/2124)

Nail removal with open reduction compression plating

8%

(164/2124)

Smoking cessation and medical optimization

5%

(114/2124)

Nail removal with open reduction and compression plating with bone grafting

82%

(1743/2124)

N/A A

Select Answer to see Preferred Response

(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:

Vitamin A deficiency

1%

(17/2443)

Low serum testosterone

0%

(8/2443)

Low serum thyroxine

3%

(65/2443)

Vitamin D deficiency

90%

(2201/2443)

Hypocalcemia

6%

(145/2443)

L 1 A

Select Answer to see Preferred Response

(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:

Vitamin D deficiency

92%

(2309/2497)

Low testosterone

1%

(32/2497)

Iron deficiency

0%

(10/2497)

Thyroid deficiency

4%

(100/2497)

Magnesium deficiency

1%

(22/2497)

L 1 B

Select Answer to see Preferred Response

(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:

Vitamin D deficiency

68%

(2305/3398)

Central hypogonadism

3%

(88/3398)

Thyroid disorder

2%

(60/3398)

Parathyroid hormone disorder

7%

(249/3398)

Calcium deficiency

20%

(673/3398)

L 1 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
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:

Exchange nailing

12%

(293/2536)

Manipulation under anesthesia

0%

(7/2536)

Nail removal and plate fixation

79%

(2014/2536)

Nail removal and placement of Sarmiento brace

1%

(35/2536)

Nail dynamization

7%

(182/2536)

L 1 A

Select Answer to see Preferred Response

(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:

Reassurance and appropriate followup

1%

(11/922)

Sarmiento bracing

1%

(7/922)

Use of a bone stimulator

3%

(27/922)

Exchange humeral nailing

10%

(95/922)

IM nail removal, open reduction internal fixation with bone grafting

84%

(773/922)

L 1 B

Select Answer to see Preferred Response

(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:

ultrasound therapy to nonunion site

1%

(10/1567)

oral bisphosphonates

0%

(4/1567)

open reduction internal fixation with autologous bone graft

94%

(1480/1567)

antegrade intramedullary nail

4%

(58/1567)

retrograde intramedullary nail

0%

(4/1567)

L 1 B

Select Answer to see Preferred Response

Evidence (18)
VIDEOS & PODCASTS (2)
CASES (3)
EXPERT COMMENTS (2)
Private Note