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Non Union of Humeral Fractures

- Discussion:
Non Union - General Discussion:
- definition of fracture union: defined as bridging callus (ideally both cortices) on 2 orthogonal views with the
disappearance of fracture lines
- care must be taken not to mistake a pseudoarthrosis for a simple hypertrophic nonunion;
- treatment of the pseudoarthrosis requires complete resection of the synovial tissue, and a closed IM nail does not suffice;
- bone scan is helpful in diagnosis of pseudoarthrosis, which appears as a cold cleft between hot ends;
- atrophic non union is most common for humeral shaft fracture:
- failure of biology;
- if bone ends appear avascular, then bone grafting or BMP grafting is necessary;

- Proximal Humeral Non Union:

Inital Frx                                                 Non Union                         Rigid Fixation

- references:
Nonunion of the proximal humerus. A review of 25 cases.
Blade plate fixation of proximal humeral non-unions.
Management of nonunions of the proximal humeral diaphysis

- Humeral Shaft Non Union:
     - risk factors:
- open fracture
- segmental, transverse, or highly comminuted fracture pattern;
- ref: Nonunion of the humeral shaft: long lateral butterfly fracture--a nonunion predictive pattern?
- significant displacement of the fracture fragments (>100% of the shaft diameter);
- smoking, diabetes, nonsteroidal anti-inflammatory drugs
- infection (at the time of surgical revision, multiple cultures from the fracture site are required
to rule out infection);
- hypothyroidism, metabolic bone disease

- management:
1) plate fixation as exchange IM nailing gives poor results;
- minimum of 8 cortices on each side of nonunion (may add augmentation plate if more
cortices are required)
- references:
- Anterior plating as a surgical alternative in the treatment of humeral shaft non-union
- Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing
- Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study.
- Treatment of humeral pseudarthroses by open reduction and internal fixation
- Open reduction and internal fixation of humeral non-unions: radiological and functional results.
- Treatment of atrophic diaphyseal humeral nonunions with locked plating and augmented with IM strut allograft.
- Locking compression plates for osteoporotic nonunions of the diaphyseal humerus.
- Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing.
- Revision with dynamic compression plate and bone graft for aseptic nonunion after treatment of humeral shaft fracture.
- Outcome of locking compression plates in humeral shaft nonunions

2) aggressive debridement or shortening osteotomy of non union site;
- references:
- Shortening osteotomy and compression plating for atrophic humeral nonunions: surgical technique
- Step-Cut Osteotomy for Recalcitrant Humeral Shaft Nonunion
- Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?
- Treatment of nonunion in neglected long bone shaft fractures by osteoperiosteal decortication

3) bone grafting (bone graft menu / BMPs)
- application of 1/2 of a fibular strut graft in the IM canal and the other half on the far (anterior cortex) is one good option;
- references:
- Humeral shaft aseptic nonunion: treatment with opposite cortical allograft struts
- Humeral shaft nonunions treated with fibular allograft and compression plating.
- Use of IM fibular strut graft: a novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion.
- Endosteal Strut Augment Reduces Complications Associated With Proximal Humeral Locking Plates
- Non-vascularised fibular graft as an intramedullary strut for infected non-union of the humerus
- Treatment of diaphyseal humeral nonunions with compressive locked plating and augmented w/ IM strut allograft.
- Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus
- Results of non-vascularised fibular grafting in gap non-union of long bones in paediatric age group
- Plating, nailing, external fixation, and fibular strut grafting for non-union of humeral shaft fractures
- Early outcomes of proximal humerus fracture fixation with locking plate and intramedullary fibular strut graft.

- other references:
- Treatment of humeral shaft nonunions: nailing versus plating.
- Failure of reamed nailing in humeral non-union: an analysis of 26 patients.
- Locked intramedullary nailing for difficult nonunions of the humeral diaphysis.
- Comparison of the use of humerus IM nail and DC plate for management of diaphyseal frx of  humerus.
- Complex non-union of humeral diaphysis. Treatment with medial approach, anterior plate, and a vascularized fibular graft.
- Refractory humeral pseudoarthrosis: case report
- Review of Salvage Surgery for Refractory Humeral Shaft Nonunion following Two or More Prior Surgical Procedures
- The treatment of nonunions and pseudarthroses of the humeral shaft.
- Nonunion of the humerus. Clinical, response characteristics to treatment with constant DC stimulation of osteogenesis.
- The management of nonunions of the humerus.
- Nonunion of the humeral shaft.
- Nonunion of the humerus.
- A combined therapeutic protocol for aseptic nonunion of the humeral shaft: a report of 25 cases.
- Management of non-union of humeral fractures with the Stryker T2™ compression nail
- The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients
- Case of the Month: Infected Humeral Non Union
- Nonunion of Humeral Shaft Fractures Following Flexible Nailing Fixation
- Union rate after operative treatment of humeral shaft nonunion--A systematic review.
- Treatment of humeral shaft nonunions: nailing versus plating.
- Comparison of the use of humerus IM nail and DCP for management of diaphyseal frx of the humerus. A RCS.

- Distal Humeral Non Union:
- nonunion of fractures of the distal humerus usually occurs when stable
internal fixation has not been achieved;
- references:
Open reduction and internal fixation of delayed union and nonunion of the distal humerus.
Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults.
Non-union of fractures of the distal end of the humerus.
Plate-and-bone-strut fixation of distal third humeral shaft aseptic non-unions: A consecutive case series.

- references:
- Application of recombinant BMP-7 on persistent upper and lower limb non-unions.
- Application of rhBMP-7 and PRP in treatment of long bone non-unions: a prospective randomised clinical study on 120 patients.
- Judet decortication and compression plate fixation of long bone non-union: is bone graft necessary?
- Clinical application of BMP 7 in long bone non-unions