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Proximal Humerus and Humeral Shaft Nonunions
Proximal Humerus and Humeral Shaft Nonunions
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Abstract
Edwin R. Cadet, MD The rate of nonunion is estimated to be 1.1% to 10% following
Bob Yin, MD closed treatment of proximal humerus fracture and 5.5% following
closed treatment of humeral shaft fracture. Surgical management
Brian Schulz, MD
should be considered for fractures that demonstrate no evidence of
Christopher S. Ahmad, MD progressive healing on consecutive radiographs taken at least 6 to
Melvin P. Rosenwasser, MD 8 weeks apart during the course of closed treatment. In the case of
proximal humerus nonunion, recent series have demonstrated
union in >90% of patients treated with reconstruction using locking
plates and autogenous bone graft. Shoulder arthroplasty is
reserved as a salvage option in cases in which the humeral head
is not viable or the proximal fragment will not support
osteosynthesis. For humeral shaft nonunions, open reduction and
internal fixation with compression plating and bone graft remains
From Raleigh Orthopaedic Clinic, the standard of care, with a >90% rate of union and good
Raleigh, NC (Dr. Cadet) and the
functional outcomes. Recent studies support the use of locked
Department of Orthopaedic Surgery,
Columbia University Medical Center, compression plates, dual plating, and cortical allograft struts in
New York, NY (Dr. Yin, Dr. Schulz, patients with osteopenic bone.
Dr. Ahmad, and Dr. Rosenwasser).
an internist or endocrinologist for pre- ing injury.11 The median time to union
Proximal Humerus operative optimization before any sur- or bridging callus of nonsurgically
Nonunion gical procedure.11,13 managed proximal humerus fractures
is 13 weeks, and an appropriate
Proximal humerus fractures are
among the most common orthopae-
Patient Evaluation workup should be performed at that
Patients with proximal humerus time in the absence of healing.4,10 The
dic injuries worldwide,9,10 with the
nonunion typically report pain, stiff- diagnosis of nonunion in the proxi-
vast majority being low-energy, non-
ness, and disability associated with mal humerus can also be made when
displaced or minimally displaced
shoulder dysfunction. Physical exam- there is no evidence of interval heal-
fractures. Such fractures heal un-
ination usually reveals diminished ing on two consecutive radiographs
eventfully without surgical interven-
taken 6 to 8 weeks apart during the
tion, but those that progress to non- forward elevation, with or without
period of closed treatment. Surgical
union have a negative effect on disuse atrophy of the deltoid and
management is recommended at ap-
overall glenohumeral function and periscapular musculature. Axillary
proximately 3 to 6 months following
the ability to perform activities of nerve function must be assessed, and
injury if an impending nonunion
daily living as early as 6 months fol- electromyography is warranted if
is suspected, given patient- and
lowing injury.4,11 Hanson et al10 pro- neurologic injury is suspected. True
fracture-related risk factors (eg, pre-
spectively followed 124 patients with AP radiographs are taken in the
existing osteopenia or significant
proximal humerus fractures that scapular plane with the shoulder in
fracture displacement with disrup-
were managed nonsurgically. At neutral, internal rotation, and exter-
tion of the soft-tissue envelope). By
1-year follow-up, only 3% required nal rotation. Outlet and axillary ra-
intervening at this time point, such
surgery for fracture nonunion. Simi- diographs should also be included in
action may help to prevent disabling
larly, Court-Brown and McQueen4 the radiographic series.
glenohumeral dysfunction that is as-
reported a nonunion rate of 1.1% in The type of nonunion (eg, hyper-
sociated with chronic proximal hu-
their prospective study of patients trophic versus atrophic) should be
merus nonunions.
treated nonsurgically for proximal defined. Radiographically, hypertro-
humerus fracture. phic nonunions are characterized by
hypertrophic and sclerotic bone ends
Nonsurgical Management
Several risk factors have been impli-
with fracture callus, whereas atro- Nonsurgical management for symp-
cated in the development of nonunion
phic nonunions appear osteopenic tomatic proximal humerus non-
following proximal humerus fracture.
with the absence of callus. In gen- unions is typically reserved for pa-
Court-Brown and McQueen4 found an
eral, hypertrophic nonunions de- tients with medical comorbidities
8% rate of nonunion in patients with
velop when insufficient mechanical that place them at an unacceptable
metaphyseal comminution and a 10%
stability and/or axial alignment ex- risk for surgical management and for
rate in patients with surgical neck
ists and the vascularity and biologic patients who may be at risk for non-
translation between 33% and 100%.
environment for fracture healing is compliance with postoperative reha-
Fracture pattern may contribute to the
preserved. With atrophic nonunion, bilitation and precautions. Patients
risk of nonunion. Two-part surgical
vascularity and the biologic environ- with minimal pain and mild func-
neck fracture is the most common frac-
ment are often compromised, which tional losses may be appropriate can-
ture pattern associated with fracture
causes an inadequate fracture heal- didates for nonsurgical manage-
nonunion.11-14 It is possible that these
ing response. Radiographs also ment.15
seemingly disparate risk factors lead to
nonunion via the same general mech- should be evaluated for evidence of
anism—all are signs of increased dis- osteonecrosis of the humeral head, Surgical Management
ruption to the medial soft tissues and pathologic fracture, and extent of Osteosynthesis
blood supply that are important for bone loss. Comparison views of the Osteosynthesis using locking plate
fracture healing. Persons who smoke contralateral shoulder may be help- fixation techniques is preferred in the
are at 5.5 times higher risk than non- ful. CT is a useful modality if the di- presence of good bone quality and a
smokers for developing nonunion.10 agnosis of nonunion is unclear. viable humeral head in the absence
Significant medical comorbidities (eg, of significant medial calcar commi-
diabetes, osteopenia, obesity) may con- Timing of Surgery nution or osteopenia that may com-
tribute to nonunion, and patients with Nonunion in long bone fractures is typ- promise adequate fixation. Clinical
such conditions should be referred to ically diagnosed 6 to 9 months follow- and radiographic assessment of tu-
berosity function and its integrity is recently, large volumes of autoge- tients treated with ORIF using a
critical in deciding whether osteosyn- nous bone graft have been harvested blade plate or Humerusblock device
thesis is the appropriate treatment using the Reamer-Irrigator-Aspirator (Synthes) without bone grafting to
choice for proximal humerus non- (RIA) system (Synthes) to fill large manage humeral surgical neck frac-
unions. With surgical neck non- cortical defects, facilitate osseous fu- tures (P < 0.01). Radiographic evi-
union, rigid fixation can be achieved sions, and in the treatment of dence of fracture healing was seen in
with a variety of plates, including nonunions.17-19 The RIA is an in- 51 patients (93%).
3.5- and 4.5-mm plates made for the tramedullary canal reaming system
proximal humerus, blade plates, and that collects large amounts of autog- Fixed-angle Locked Plating With
4.5-mm T plates. Fixed-angle lock- enous corticocancellous bone from Fibular Strut Allograft
ing or blade plates provide a biome- the intramedullary canal in a rela- Use of an intercalary strut allograft
chanically stable construct in the set- tively minimally invasive manner. with fixed-angle locked plating to
ting of osteoporotic bone. This technique may lessen the donor manage proximal humerus fracture
Isolated greater and lesser tuberos- site morbidity that is sometimes seen nonunion was first described by Bad-
ity nonunions are less common than with iliac crest autograft harvest. man et al15 in 2006. Fibular strut al-
surgical neck nonunions. The bone Compared with iliac crest bone graft, lograft has several advantages. It
quality of the tuberosity fragment RIA may also generate a larger vol- provides additional biologic and
and rotator cuff function are critical ume of autogenous bone graft mate- structural support to the often poor-
components in determining the most rial and pluripotential mesenchymal quality bone found at the proximal
appropriate surgical option. In pa- stem cells, especially in elderly pa- humerus, it is mechanically stronger
tients with large tuberosity fragments tients.20,21 Free vascularized fibular than cancellous bone autograft or al-
and a viable rotator cuff, osteosyn- autograft may be considered for pa- lograft, and it avoids the donor site
thesis may be achieved with lag tients who need significant biologic morbidity associated with autograft
screw compression and/or buttress augmentation along with mechanical harvesting. This technique is useful
plating with autogenous bone graft. support. in both the acute proximal humerus
Tension band techniques, transosse- ORIF with osteosynthesis and fracture setting and chronic non-
ous suture fixation, or current suture bone graft has yielded good results. union scenario when medial calcar
anchor configurations used in mod- Healy et al13 reported union in 12 of support is compromised secondary
ern rotator cuff repair techniques 13 patients following ORIF with to significant medial calcar commi-
that provide compression across the bone graft in a retrospective review nution or osteopenia (Figure 1).
fracture site with autogenous bone of 25 patients with proximal hu-
grafting augmentation can be used merus nonunions. Ring et al22 used Intramedullary Nailing
for comminuted tuberosity frag- blade plating and autogenous iliac Historically, results were disappoint-
ments, only if rotator cuff function is crest cancellous bone graft (ICBG) to ing following intramedullary nailing
determined to be intact clinically. A treat 25 patients with proximal hu- to manage proximal humerus non-
deltoid-splitting or deltopectoral ap- merus fracture nonunion. Fracture unions. Early intramedullary devices
proach can be used for greater tuber- union was achieved in 23 patients were prone to postoperative sub-
osity osteosynthesis. A deltopectoral (92%), and functional results were acromial impingement, necessitating
approach is suggested for lesser tu- classified as good to excellent in 20 a second surgery following union for
berosity nonunions. Arthroscopic (80%). Two patients had complica- nail removal. Most patients, how-
techniques have also been described tions due to iliac crest harvest. Al- ever, progressed to union and re-
for managing greater tuberosity non- lende and Allende23 reported union gained good shoulder function.11
unions.16 in all seven patients treated with a Recently, Yamane et al14 published
Autogenous or allograft bone aug- locking 90° blade plate (average encouraging results with the use of
mentation is recommended to facili- follow-up, 22 months). The average interlocking intramedullary nails to
tate osteosynthesis. Large amounts time to union was 5.9 months. Aver- manage proximal humerus fracture
of cancellous bone autograft can be age Disabilities of the Arm, Shoulder, nonunion in 13 patients. The average
obtained from the iliac crest, but the and Hand and Constant scores at follow-up was 37.8 months. All pa-
patient must be advised of the possi- latest follow-up were 25 and 72.7 tients achieved union. All patients
bility of donor site pain. Allograft points, respectively. More recently, were satisfied with the results and
may be used instead if donor site Tauber et al24 reported significantly had improved shoulder range of mo-
morbidity is unacceptable.11 More improved Constant scores in 55 pa- tion postoperatively. Two patients
dispose to delayed union or non- upper extremity for activities of daily Timing of Surgery
union so that the patient can be living and for work. Higher-energy Although most authors define de-
counseled regarding the chance of mechanisms of injury as well as pa- layed union as no radiographic signs
achieving bony union with nonsurgi- tient comorbidities—both medical of osseous union 4 months after in-
cal treatment. In the classic report on and psychosocial—increase the risk jury and nonunion 6 months after in-
diaphyseal nonunions by Healy of nonunion. On physical examina- jury, the exact length of time recom-
et al,5 transverse fractures were most tion, a thorough assessment of the mended before functional bracing is
susceptible to nonunion (11 of 26 functional brace for proper fit and discontinued in favor of surgery var-
[42%]), followed by short oblique associated skin irritation will im- ies widely in the literature.2 Toivanen
fractures (7 of 26 [27%]). In one prove patient compliance with use of et al35 recommended surgery if frac-
study, 9 of 67 fractures managed the orthosis. A careful neurovascular tures show no clinical or radio-
with functional bracing went on to examination is needed to rule out graphic signs of consolidation after
require surgery for nonunion; 6 of neurologic injury, particularly in the only 6 weeks of functional bracing.
those 9 fractures exhibited a trans- radial, median, and ulnar nerve dis- In a single-surgeon series by Rutgers
verse fracture pattern.33 In contrast, tributions. Gross motion at the frac- and Ring,34 of 52 diaphyseal frac-
Ring et al37 reported that, of the 32 ture site is an obvious sign of non- tures managed nonsurgically, 5 es-
consecutive humeral shaft fracture union; however, this finding may be tablished nonunions resulted; these
nonunions managed at their institu- difficult to elicit in the presence of fractures were managed surgically at
tion over a 10-year period that went significant arm edema, arm girth, an average of 28 weeks after injury
on to surgical management, most and pain. (range, 10 to 55 weeks). In a Swed-
had spiral or oblique fracture pat- On plain radiographs, nonunion ish series of 78 nonsurgically man-
terns (84.4%), with only 12.5% hav- may demonstrate lack of fracture aged diaphyseal fractures, 9 patients
ing transverse fracture patterns. In a consolidation, increased interfrag- failed to heal with bracing and un-
study of 78 fractures, Ekholm et al32 mentary diastasis or angulation, and derwent surgery at a mean of 8.7
observed a trend toward more fre- the presence of hypertrophic callus months (range, 1.8 to 15.5 months)
quent nonunions in Orthopaedic without clinical stability. When it is after injury.32 The systematic review
Trauma Association type A fractures difficult to evaluate fracture consoli- by Papasoulis et al31 of 15 English-
(simple, >90% cortical contact) com- dation on plain radiographs (eg, hy- language studies on outcomes of
pared with type B (wedge) and type pertrophic callus, comminuted angu- nonsurgically managed diaphyseal
C (complex) fractures (P = 0.08). lar deformity), CT may be used to fractures showed a mean time to
The location of the fracture may evaluate for bridging callus. Routine union of 10.7 weeks. These results
also play a role in the development laboratory studies should include a suggest that surgeons should broach
of nonunion. Several studies have complete blood count and a basic the topic of surgical treatment to pa-
noted that fractures in the proximal metabolic panel to evaluate for ac- tients with fractures that have not
diaphysis are at greater risk of non- tive medical conditions that may im- healed by 10 to 12 weeks after in-
union compared with middle- or pede fracture healing. In the setting jury. We recommend maintaining a
distal-third shaft fractures, presum- of previous open fracture or surgery, high index of suspicion for nonunion
ably due to greater deforming forces infection must always be excluded in humeral shaft fractures that have
generated by the deltoid and pectora- and appropriate laboratory workup demonstrated no interval healing on
lis insertions, greater risk of muscle (eg, complete blood count with dif- consecutive radiographs taken 6 to 8
and long of head of the biceps ten- ferential, erythrocyte sedimentation weeks apart.
don interposition within the fracture, rate, C-reactive protein level) ob-
and difficulty with immobilization of tained. For the patient whose nutri- Nonsurgical Management
the proximal humerus fracture frag- tional status is in question, total se- Nonsurgical management of estab-
ments with current functional brace rum protein and serum albumin tests lished diaphyseal nonunion is un-
designs.7,34,35,37 may be performed. More advanced likely to result in healing and should
markers of bone metabolism (eg, vi- be reserved for select patients with
Patient Evaluation tamin D level) and an endocrinology medical comorbidities that place
Patients with established nonunions consult may be needed to investigate them at high risk for surgical and
most often report an inability to en- biologic causes of poor osteosynthe- anesthesia-related complications and
gage in repetitive activities using the sis potential. for patients with asymptomatic non-
unions or pseudarthroses and low can be extended proximally and in- The use of bone graft from intramed-
functional demands. Bone stimula- corporated into the deltopectoral in- ullary reaming and/or autogenous
tion is another nonsurgical treatment terval. A posterior approach to the ICBG is strongly recommended to fa-
option. These devices transmit low- humerus can be used for fractures in- cilitate healing. In hypertrophic cases,
pulsed direct current, pulsed electro- volving the distal three fourths of the the existing callus can augment autog-
magnetic fields, capacitive couplings, humerus and in cases of suspected enous bone or RIA grafts.39 Success has
and/or ultrasound electromagnetic entrapment of the radial nerve on its been reported with demineralized bone
signals to augment fracture healing. course along the posterior humeral matrix (DBM) with or without bone
Bone stimulators are contraindicated shaft. morphogenetic protein (BMP).7,41-43
in the presence of a synovial pseudar- Fracture reduction must correct Hierholzer et al41 retrospectively com-
any angular deformity and achieve pared two consecutive cohorts of pa-
throsis, fracture gapping >5 mm, and
good joint alignment, with maximal tients with aseptic delayed union or
poor vascular supply to the fracture
cortical contact to enhance mechani- nonunion of the humeral shaft that was
site.38
cal stability and osteosynthesis. The managed with rigid plate fixation with
The role of bone stimulators in fa-
fracture ends should be débrided and either autogenous ICBG or DBM and
cilitating osseous union of humeral
lightly decorticated to stimulate bone found no differences in union rates or
shaft nonunion or fractures is not
healing. Depending on the type of functional outcome and found only a
well defined in the literature. Ultra- fracture exposure, rigid fixation is slight difference in union rate and no
sound devices are approved for use obtained with a laterally, anteriorly, difference in overall functional out-
in acute fractures, but all other bone or posteriorly placed 4.5-mm com- come between the two groups. How-
stimulators have been approved for pression plate with at least six bicor- ever, 44% of patients in the ICBG
use by the FDA only in established tical fixation points proximal and group had donor site morbidity; as a
nonunions, that is, fracture non- distal to the fracture site. Eight fixa- result, DBM was adopted as the stan-
union that persists ≥9 months fol- tion points are preferred. Special at- dard bone graft option for humeral
lowing injury, or a fracture that dem- tention should be paid to plate shaft nonunions at that institution.
onstrates no visibly progressive length. To ensure balanced fixation Marti et al39 observed 100% union
radiographic signs of healing ≥3 across the construct, we recommend after 1 year in 51 patients with dia-
months following injury.38 that the plate be long enough to span physeal nonunion who were treated
the nonunion site a distance of at with ORIF with compression plat-
Surgical Management least two to three times the cortical ing; ICBG was added in atrophic
ORIF With Compression Plating diameter, both proximal and distal to cases. Livani et al40 also reported
and Bone Graft the fracture site. If a 3.5-mm plate is 100% union using a similar treat-
ORIF using a broad, 4.5-mm com- used for a patient with a particularly ment algorithm. Thus, we recom-
pression plate along with autogenous narrow humeral diaphysis, a mini- mend the use of autogenous ICBG in
bone graft is the standard of care for mum of eight points of proximal and patients who can withstand the pos-
humeral diaphyseal nonunion in the distal cortical fixation and a long sibility of donor site morbidity at the
absence of prior surgery. An exten- plate should be used because rigid harvest site.
sile approach was advocated by fixation is critical for successful frac-
Healy et al5 and in more recent re- ture healing (Figure 3). Dual Plating
ports.39,40 With an anterolateral ap- Depending on the fracture configu- Two studies have supported the use
proach, the radial nerve should be ration, the plate or lag screw inser- of dual orthogonal plating, which in-
identified between the brachialis and tion can be prestressed to maximize volves the use of an additional plate
brachioradialis muscles and pro- interfragmentary compression. In a in the presence of micromotion at
tected along its course well beyond study by Ring et al,37 all 32 consecu- the fracture site following prelimi-
the zone of nonunion. Neurolysis tive diaphyseal nonunions in adults nary plate fixation.7,44 The additional
can be performed if the nerve is en- who were treated with functional plate may be particularly useful in
cased in scar tissue. Depending on bracing for ≥4 months achieved cases of proximal shaft nonunion in
the location of the fracture site, a di- union with ORIF. However, three which fixation is limited by the short
rect anterior approach is also a utili- older patients with osteoporosis re- proximal fragment, for distal shaft
tarian approach to the humerus. In quired a second procedure to address fractures that present with a short
cases of proximal extension of the either failed fixation or persistent distal segment, in the presence of
fracture line, the anterior approach nonunion. poor metaphyseal bone quality, and
meral nonunion.47,48 A recent Co- 2. Schemitsch EH, Bhandar M, Talbot M: 15. Badman B, Mighell M, Drake G:
Fractures of the humeral shaft, in Proximal humeral nonunions: Surgical
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