Surgical Technique: Treatment of Distal Humerus Nonunions

Abstract

Background: Open reduction and internal fixation of distal humerus fractures is standard of care with good to excellent outcome for most patients. However, nonunions of the distal humerus still occur. These are severely disabling problems for the patient and a challenge for the treating physician. Fortunately, a combination of standard nonunion techniques with new plate designs and fixation methods allow even the most challenging distal humeral nonunion to be treated successfully.

Questions/purposes: The purpose of this manuscript is to describe our current technique in treating distal humeral nonunion as it has evolved over the last four decades. We have now follow-up on 62 treated patients.

Methods: A few key steps are essential to obtain bone healing while regaining or preserving elbow motion. These include careful planning, extensile exposure, release of the ulnar nerve, capsular release and mobilization of the distal fragment, debridement, and finally stable fixation after alignment with application of bone graft.

Results: The vast majority of distal humeral nonunions can be treated successfully with open reduction and internal fixation.

Conclusion: Important components of the treatment plan are careful preoperative planning, extensile approach, debridement, and solid fixation with-locking-plates and liberal use of bone graft.

Keywords: bone graft; distal humerus; internal fixation; nonunion.

Fig. 1

A 60-year-old female presents 8 months following ORIF of a right-sided distal humeral fracture with complaints of pain at the fracture site and limited range of motion of the elbow. Radiographs (a, b) and CT scan images (c–e) reveal a nonunion, and loss of fixation with plate breakage (medial side).

Fig. 2

For complex cases, a 3D CT and 3D models of the affected and the mirror-imaged healthy elbow will provide better insight in the nonunion and associated deformity. This patient had a war-related injury to his elbow as a child and presented 11 years later. Plain radiographs suggested an elbow dislocation as seen on the lateral radiograph (a). 2D CT imaging (b) and 3D-reformatted CT imaging (c) showed a malunion of the distal humerus with associated medial condyle nonunion. In addition, there was overgrowth of the radial head and capitellum. The proximal radio-ulnar joint, the radio-capitellar joint, and the relation between the proximal ulna and medial condyle nonunion are intact. 3D-printed models of the affected (d) and mirror-imaged healthy side (red) (e) provide valuable insight.

Fig. 3

Good preoperative planning will greatly facilitate the surgical procedure. Preoperative anteroposterior (AP) and lateral radiographs (from left to right) show a distal humerus nonunion with failed hardware (a), detailed pre-op plan (b), and final AP and lateral radiographs (from left to right) illustrating a healed distal humerus nonunion (c).

Fig. 4

The olecranon osteotomy is angulated (as shown in inset), forming an apex to facilitate reduction and providing additional rotational stability for fixation (from: Helfet DL, Kloen P, Anand N, Rosen HS. ORIF of delayed unions and nonunions of distal humerus fractures. Surgical technique. J Bone Joint Surg Am. 2004;suppl 1:18–29. Reprinted with permission from The Journal of Bone and Joint Surgery, Inc).

Fig. 5

Intraoperative photographs showing the amount of motion of the distal fragment after an extensile release.

Fig. 6

Anatomic locking plates (3.5 mm proximal and 2.7 mm distal) provide an increased number of fixation options. This patient had a nonunion of her distal humerus fracture that showed positive cultures for Enterobacter cloacae (a). Revision internal fixation with new plates bone graft and antibiotics resulted in healing as demonstrated on AP and lateral radiographs (from left to right); (b).

Fig. 7

Using parallel plating, there can be “crowding” of the screws distally. Cross threading of these screws might actually increase the holding power of the fixation.

Fig. 8

The Ilizarov can be an extremely useful tool in complex cases not amenable to open reduction and internal fixation. A 26-year-old medical student presented with a distal humerus nonunion. As an 8-year-old, he underwent chemotherapy and radiation for an Ewing sarcoma of the humerus. At age 12, he sustained a distal humerus fracture treated with a cast for 2 years. Numerous surgeons were consulted during these years but surgical therapy was felt too risky as his upper arm had essentially remained the same size as when he was 8 years old with a thickened stiff skin and soft tissue cuff around the nonunion. He functioned reasonably well and entered medical school anticipating a career in plastic surgery. During his medical school, he developed increasing pain and instability of the arm and presented to us. Motion was limited to the nonunion site with a stiff elbow joint as seen on the lateral radiograph (a). Formal ORIF using an open approach was not an option. We referred the patient to an expert in Ilizarov techniques (Dr. Dror Paley) who agreed to operate in a combined procedure with the authors. Via a minimal approach the nonunion was debrided and an intramedullary nail was placed as an internal strut and an Ilizarov frame with an elbow hinge was then placed (b). Autologous bone graft was added locally. AP radiograph, clinical photo and lateral flexion radiograph (from left to right) illustrates final construct (c). In the next 24 hours, he developed increasing swelling and a median and radial nerve deficit (likely because of anasarca because of compromised lymph outflow). Exploration of the median and radial nerves was done on post-operative day two; additional bone graft was added at 6 months. At that time, the Ilizarov frame was removed and the nail was locked proximally. His nonunion healed as seen in AP and lateral radiographs (from left to right), (d). The median nerve fully returned; the radial nerve deficit remained complete. Eleven years later, he is pleased with the outcome—despite the radial nerve deficit. There is no pain and his elbow is stable. He is now working as a radiologist and has returned to all athletic activities including downhill skiing.