Nonunions of the humerus - Treatment concepts and results of the last five years

Abstract

Purpose: Fractures of the humerus account for 5%-8% of all fractures. Nonunion is found with an incidence of up to 15%, depending on the location of the fracture. In case of a manifest nonunion the surgeon faces a challenging problem and has to conceive a therapy based on the underlying pathology. The aim of this study was to describe our treatment concepts for this entity and present our results of the last five years.

Methods: Twenty-six patients were treated for nonunion of the humerus between January 2013 and December 2017. Their charts were reviewed retrospectively and demographic data, pathology, surgical treatment and outcome were assessed.

Results: The most frequent location for a nonunion was the humeral shaft, with the most common trauma mechanism being multiple falls. Most often atrophic nonunion (n = 14), followed by hypertrophic and infection-caused nonunion (each n = 4), were found. Our treatment concept could be applied in 19 patients, of which in 90% of those who were available for follow-up consolidation could be achieved.

Conclusion: Humeral nonunion is a heterogeneous entity that has to be analyzed precisely and be treated correspondingly. We therefore present a treatment concept based on the underlying pathology.

Keywords: Delayed union; Humeral fractures; Humerus; Nonunion.

Fig. 1

Fracture of the humeral shaft after car crash. Initially treated with locked intramedullary nail in Turkey. (A) Postoperative lesion of nervus radialis caused by the distal locking screw with complete loss of function of nervus radialis. (B) Removement of the nail and interposition of nervus suralis three months after initial accident. (C) Nonunion and revision with RIA and locking plate 16 months after suralis-interposition. After one year complete consolidation, active wrist extension 60°, no sensorial deficiency.

Fig. 2

Treatment algorithm for nonunions of the humerus.

Fig. 3

A 53-year old female patient with multifragmentary shaft-fracture (AO type 12C3) and open reduction and fixation with PHILOS. (A) After 12 weeks no signs of consolidation. (B and C) After 18 weeks and 4 weeks of low-intensity pulsed ultrasound (LIPUS) distinctly progredient consolidation and boney bridging.

Fig. 4

A patient with gunshot injury of left elbow and forearm in Lebanon. (A) Extensive destruction of supracondylar humerus, olecranon and proximal radius with loss of function of radial and ulnar nerve. Primary treatment with external fixator, ESIN and K-wires. Humeral and radial nonunion after 11 months. (B) Revision humerus with removal of initial osteosynthesis, neurolysis (kinking of nervus radialis), debridement, cancellous bone from iliac crest, double plating (locked, radial and ulnar). Revision of the proximal radius with debridement, internal reduction and defect filling with cancellous bone from iliac crest. (B1: intraoperative situs, B2: radial and ulnar locking plate humerus, B3: radial defect filled with cancellous bone and stabilized with plate). (C) After 12 weeks consolidation radius, progredient consolidation humerus, range of motion 0°/5°/45° ext/flex, 30°/0°/15° pro-/supination. Active wrist extension above horizontal level.

Fig. 5

(A) Nonunion after periprosthetic fracture with open reduction and internal fixation with locking plate and cerclage. (B) Revision after 17 months with metal removal, debridement, defect-filling with RIA, allogenic strut graft in sandwich-technique and fixation with locking plate and cerclages.