Treatment of persistent non-union of the humerus using a vascularized bone graft from the supracondylar region of the femur

Six patients with recalcitrant post-traumatic humeral shaft non-unions were treated using vascularized bone grafts from the supracondylar region of the femur. The initial state of injury showed that four fractures were closed, while two were open fractures. At the acute stage, five fractures were fixed using intramedullary nailing, while one was fixed with a plate. In all patients, a bony flap was placed on the cortex after decortication. The size of the harvested bone flap ranged between 4 x 2.5 cm and 5 x 3 cm. After fixation of the bony flap, the inferior genicular artery and vein were anastomosed to the deep brachial artery and vein. The mean time required to obtain radiographic bone union was 3.3 months. The only graft-site complication involved transient mild paresthesia in the saphenous nerve area in one patient. This procedure was useful for atrophic nonunions without substantial bone defects of the humeral shaft.     

钢板内固定加植骨治疗肱骨干骨折术后骨不愈合的疗效分析

目的评价钢板内固定结合自体松质骨植骨治疗肱骨干骨折术后骨不愈合的疗效。方法2002年2月～2004年12月对41例肱骨干骨折术后骨不愈合患者均采用钢板内固定结合自体松质骨植骨治疗。其中男32例,女9例;平均年龄37．5岁(17～67岁)。骨不愈合类型：肥大型16例,萎缩型25例。结果所有患者获平均22．6个月(8～42个月)随访。40例(97．6%)患_者骨折愈合,骨折愈合时间平均为5．8个月(3～12个月)。并发症：桡神经损伤3例,伤口感染1例,骨折不愈合1例。最终随访时,肩关节和肘关节功能恢复满意。结论对于肱骨干骨折术后骨不愈合的患者,采用钢板内固定加自体松质骨植骨治疗是有效的方法。     

Marchetti nailing with decortication and bone graft in non-unions of the two upper thirds of the humerus

METHOD: Twelve patients with humeral shaft non-unions were treated using a Marchetti-Vicenzi nailing. The fractures site was decorticated and bone graft added. RESULTS: Fracture healing was obtained in all cases. The mean healing time was 4.7 months. The range of motion of the shoulder was excellent in nine patients, moderate in two and poor in one. The elbow had an excellent range of motion in ten patients, moderate in one and poor in one. The functional result was excellent in nine patients, good in two, and fair in one. CONCLUSION: Marchetti-Vicenzi nailing with bone grafting appears to be a good method for the treatment of humeral shaft non-unions. It is technically easy and its results are satisfactory.     

Fractures of the humeral shaft: a retrospective study of 240 adult fractures.

Of 240 humeral fractures, 60 per cent occurred in patients under 35 years old, 39 per cent of fractures being in the middle third of the shaft, 28 per cent were open with an infection rate of 4 per cent. Radial nerve palsy was present in 18 per cent; midshaft fractures accounting for 69 per cent, with 60 per cent of radial nerves recovering spontaneously; 24 per cent after 12 weeks post injury. One hundred and eleven fractures had documentation greater than 3 months. Closed treatment in 100 patients resulted in 5 non-unions and 15 delayed unions; 11 primary internal fixations resulted in 3 non-unions and 2 delayed unions. Subsequent operative procedures reduced the total non-union rate to 5 per cent with 1 per cent delayed union and 4 per cent unknown. Fractures of the humeral shaft that have not begun to unite at 6 to 10 weeks probably will go on to non-union unless the treatment plan is changed. Closed methods of immobilization, other than the sling and swathe, should be used in chronic brain syndrome patients to avoid compounding their fractures. Sixty-three patients with 64 fractures were evaluated in follow-up using Cave's AEF system (92% excellent and satisfactory results) and a modification of Neer's protocol for proximal humeral fractures, (87% excellent and satisfactory results). A functional evaluation on the Cybex machine, (torque through range of motion) gave a useful graphic end result.     

Anterior plating as a surgical alternative in the treatment of humeral shaft non-union

This study included 15 patients with humeral shaft fractures who had no clinical, radiological or bone scan signs of healing after eight months. The patients were followed for a mean of 35.8 months. No patient was lost to follow-up. Anterior plating of humeral shaft nonunion via an anterior approach was performed using a straight plate and compression for well-vascularised non-unions and wave plating with a tricortical graft for poorly vascularised non-unions. All non-unions healed within 6–18 weeks (mean, nine weeks) without local complication. One patient had a mild decrease in elbow and shoulder range of motion. No neurovascular injury was observed. Anterior plating is a simple, safe and effective treatment for humeral shaft non-union. As this approach avoids the need for radial nerve visualisation and extensive soft-tissue dissection, and the healing time is similar to that of other methods, we suggest this treatment as an alternative option.     

Minimally invasive plating for complex humeral shaft fractures

INTRODUCTION: The treatment for humeral shaft fracture is still controversial, especially for complex fractures. The purpose of this study was to evaluate the clinical and radiographic outcomes of treating complex humeral shaft fractures by using locking compression plate with minimally invasive technique. MATERIALS AND METHODS: A total of 21 patients with 21 acute complex humeral shaft fractures (AO type C) were included in this study. All were treated with locking compression plate in a minimally invasive way. The average age of the patients was 42.9 years and there were 14 males and 7 females. Plain radiographs of humerus were used to assess bony union. Functional recovery of the shoulder joint was assessed using the Constant and HSS scoring systems. RESULTS: The patients were followed for a mean of 28.7 months (range 19-37). With one operation, nineteen fractures (90.4%) achieved a solid union in an average of 14.3 weeks. At final follow-up, 20 patients (95.2%) had satisfactory alignment, except for one associated with olecranon fracture, all patients had a good to excellent elbow function with a mean HSS score of 91.7 points. Eighteen patients (85.7%) achieved satisfactory shoulder function with a mean Constant score of 83.1 points. One superficial infection (4.8%) and two non-unions (9.6%) were found postoperatively. CONCLUSIONS: It was concluded that use of a minimally invasive plate osteosynthesis with locking compression plate is a safe alternative way to classic surgical methods in the treatment of complex humeral shaft fractures, which had a high union rate with less risk of complications.     

Unilateral external fixator in the treatment of lower third humeral shaft fractures

Lowerthirdhumeralshaftfracturesareoftenmanifestedbyoblique,spiralorcomminutedfractureswithahighincidenceofcomplicatingradialnerveinjury.Thispartofhumerusisirregularanatomicallyandneartheelbowjoint.Soitisdifficult toselectproperinternalfixationinstrumentswhile exploringradialnervethroughanterolateralapproach,whichaddsdifficultyinthetreatmentofthiskindof fractures.Inrecent6yearsweusedunilateralexternal fixatorstotreatsuchkindoffracturesinourdepartment andsatisfactoryresultswereachieved.METHOD…     

Complex non-union of the humeral diaphysis. Treatment with a medial approach, an anterior plate, and a vascularized fibular graft

Four obese patients who had atrophic synovial non-union of the humeral shaft were treated with a medial approach, application of a plate anteriorly, a vascularized fibular bone graft, and cancellous grafts from the iliac crest. The average age of the patients was forty years; the average weight, 105 kilograms (232 pounds); and the average duration of the non-union, 33.5 months. Each patient had had one to five unsuccessful previous operations in an attempt to gain union. At an average follow-up of twenty-seven months, all four non-unions had healed. Three patients had regained full function of the shoulder and elbow, and the fourth patient had some limitation of motion of the shoulder due to an antecedent lesion of the rotator cuff. In one patient, a second plate had been applied because of inadequate fixation of the original plate proximally. Another patient had a superficial, partial wound slough, which healed spontaneously.     

Humeral shaft non-union after intramedullary nailing

Background

The humerus shaft is one of the sites with the largest probability of developing pseudoarthrosis after fracture. We present the results of nine patients with atrophic pseudoarthrosis of humeral shaft treated with angular stability plate associated with allograft and platelet-rich plasma (PRP), after a first treatment with intramedullary nail to correct the fracture.

Material and Methods

From January 2012 to December 2014, nine patients were treated for atrophic pseudoarthrosis (PSA) of humeral shaft treated previously using intramedullary nail; seven humeral diaphysis fractures were located in the middle–proximal third and two in the middle third. In one case, a reverse shoulder prosthesis implant was associated to treat a co-existent rotator cuff massive lesion. The mean time between injury and treatment of non-union was 32 weeks (min 16–max 180); all patients were evaluated with Constant, DASH and UCLA score.

Results

At the final follow-up (23.7 months), the mean Dash score was 22.25 pt, the Constant score was 64 pt, and the UCLA score value was 27 pt. The average pain value was 2 for the arm interested and 0 into PSA focus. Radiographic healing was obtained at 7 months.

Conclusions

The humeral shaft non-union is an invalidating problem which affects the daily living. Our treatment with plate, cortical bone graft, and PRP can build a high-stability structure that can help healing and graft integration.

     

Compression plating for non-union after failed external fixation of open tibial fractures.

Fifty non-unions of the tibia that were present in forty-nine patients after external fixation and immobilization in a cast for a high-energy fracture were subsequently treated by compression plating. Initially, there were forty-six open fractures and four closed fractures with a compartment syndrome. Twenty-two non-unions (44 per cent) had early soft-tissue reconstruction (thirteen rotational and nine free flaps). The duration of external fixation averaged ten weeks, and the mean time from injury to plating was eight months. None of the non-unions were infected at the time of plating. The average preoperative deformity in the sagittal (anterior-posterior) plane was 8 degrees and in the frontal (medial-lateral) plane, 9 degrees; after plate fixation, the residual angulation averaged 3 and 2 degrees. Autogenous bone graft was used in thirty-nine of the fifty non-unions. The patients were followed for an average of twenty-four months. Forty-six (92 per cent) of the non-unions united, in an average of seven months, without further intervention. In four patients (8 per cent), the plate broke, necessitating re-plating in three and external fixation in one (the latter patient had an infected non-union). A deep infection developed in three patients (6 per cent). Ultimately, forty-eight non-unions (96 per cent) healed without evidence of infection. Plate osteosynthesis is an effective method of treatment for patients who have had an open fracture of the tibia that has failed to unite after external fixation and immobilization in a cast.     

Non-union of the clavicle. Associated complications and surgical management

Twenty-three patients who had a clavicular non-union were treated operatively at the Massachusetts General Hospital from 1974 to 1985. Twenty-one non-unions were the result of fracture and two, secondary to osteotomy. Twenty non-unions were located in the middle third of the clavicle, while three were in the lateral third. Radiographically, eighteen non-unions were atrophic and three, hypertrophic. Two non-unions resembled pseudarthrosis. Of the etiological factors that were reviewed the extent of displacement of the original fracture was the most significant. Associated complications of the non-union included limited mobility of the shoulder in fourteen, neurological symptoms in eight, thoracic outlet syndrome in four, and arterial ischemia in one. Of the nineteen patients who were treated to obtain union, seventeen had a successful result at an average length of follow-up of 23.8 months. In sixteen (93.7 per cent) of the seventeen patients union was achieved by fixation with a plate; one patient required two procedures. Ancillary bone graft was used in eighteen patients, with three requiring a sculptured bicortical graft from the iliac crest to span a defect. Of the four other patients three were treated with a partial clavicular resection and one, with complete clavicectomy.     

Supracondylar Femoral Nail in the management of non-union of humeral shaft fractures

We reviewed seven patients with established non-union of a shaft of humerus fracture, treated by locked intramedullary nailing using the Intramedullary Supracondylar Nail (IMSC Nail; Smith & Nephew Richards, Memphis TN). The mean age of the patients was 65 years (range 48-78 years). Three of the fractures involved the proximal third of the diaphysis while the remaining four involved the middle third. Six of the original fractures were closed and one was an open fracture. The time interval between the original injury and final surgery averaged 9.3 months. All the nailings were done by the ante-grade approach with static locking. Six of the patients had closed nailing and one had open nailing with bone grafting. The mean follow-up was 8 months and osseous union was achieved in all seven cases at a mean of 5.6 months. We conclude that the Supracondylar Femoral Nail is a useful alternative implant in the management of non-union of fractures of the humeral shaft with wide medullary canals.     

Radial nerve transposition with humeral fracture fixation: preliminary results

Humeral shaft fractures traditionally have been managed with closed treatment. In patients with polytrauma, open fractures, and patients at risk for nonunion, open reduction and internal fixation and intramedullary nailing have been advocated. The current study describes a technique used in humeral shaft fractures that reduces the risk of iatrogenic radial nerve injury during plate osteosynthesis in fracture patterns at high risk of nonunion (highly comminuted, transverse fractures). Ten patients who had radial nerve transposition were reviewed retrospectively using the electronic records database at the authors' institution. The average age of the patients was 27 years and average followup was 25 months. All had humeral shaft fractures, AO class A3.2 in four patients, B3.2 in five patients, and C2.2 in one patient. All fractures were deemed to be at high risk for nonunion. There were no iatrogenic nerve palsies as a result of the transposition, and no infections. Two patients had delayed or nonunion, who achieved healing after a second intervention. Transposition of the radial nerve is a useful adjunct to plating of humeral shaft fractures in patients at high risk for nonunion. The technique is safe, does not cause iatrogenic injury, and protects the radial nerve during all subsequent approaches to the fracture site.     

The spiral compression plate for proximal humeral shaft nonunion: a case report and description of a new technique

We present a case of humeral nonunion managed with a dynamic compression plate (DCP) contoured in a spiral fashion to preserve the deltoid muscle insertion. A forty-one-year-old woman sustained a closed proximal third humeral shaft fracture with an associated supraclavicular brachial plexus injury. She presented five months later with an atrophic nonunion of the proximal humeral shaft, inferior subluxation of the humeral head, and a resolving brachial plexopathy. Autogenous cancellous bone grafting and open reduction and internal fixation with a narrow DCP was performed. The deltoid muscle insertion was preserved by contouring the plate to fix the proximal humerus laterally over the greater tuberosity and anteriorly over the mid-humeral shaft. During the postoperative period, the humeral head reduced spontaneously. Five months after surgery, the fracture healed, and an excellent clinical result was achieved. We recommend the use of the spiral DCP for proximal shaft fractures and nonunions when preservation of the deltoid insertion is desirable.     

交锁髓内钉在治疗肱骨干骨折中对肩关节功能的影响

目的　报告 1996～ 1998年间应用多种型号的交锁髓内钉治疗肱骨干骨折 2 5例的疗效。方法　对肱骨干骨折 2 5例采用交锁髓内针治疗。得到随访 2 1例。随访时间 8～ 32个月 ,平均 17个月。伤者年龄 18～ 70岁 ,平均 39岁。骨折类型 :横断形9例 ,粉碎形 2例 ,斜形 5例 ,螺旋形 5例。肱骨上 1/3骨折 4例 ,中 1/3骨折 16例 ,下 1/3骨折 1例。结果　按Neer评分法测定肩关节功能 ,13例 (6 2 % )合并有不同程度的功能障碍。结论　认为目前的交锁髓内针在治疗肱骨干骨折时会损伤到肩袖 ,因此在选用时应慎重。     

Diaphyseal fractures of the humerus. Treatment with prefabricated braces

Using a prefabricated brace, we treated 233 patients who had a fracture of the humeral shaft. One hundred and seventy patients were available for follow-up, which ranged from five weeks to forty-eight months. In these patients (forty-three open and 127 closed fractures), the average time to union was 10.6 weeks; the average varus-valgus angulation, 5 degrees; the average anterior-posterior angulation, 3 degrees; and the average shortening, as measured radiographically, four millimeters. All but three of the patients had an excellent or a good functional result with a nearly full range of motion of the extremity. There were a minimum of complications, including three non-unions. Because of the low morbidity and high rate of success, we concluded that the treatment of choice for diaphyseal fractures of the humerus is the prefabricated brace.     

Treatment of humeral shaft non-unions by the Ilizarov method

Thirty-five humeral shaft non-unions treated by the Ilizarov external fixator were studied after an average of 39 months. Bone union was achieved in all but one. The mean time to union was 5.5 months (range: 3-10 months). Major pin tract problems leading to removal of the Schanz screws occurred in three patients. A radial nerve palsy developed in three patients, two recovered spontaneously and one was treated with a triple tendon transfer.     

Management of fractures of the humerus in patients who have an injury of the ipsilateral brachial plexus

Twenty-one adults who had a fracture of the middle of the humeral shaft and an injury of the ipsilateral brachial plexus were followed for an average of twenty-eight months. Only two of these patients showed evidence of neurological improvement. Of the eleven patients who had an associated traumatic injury to the brain, eight were treated non-operatively and three, operatively. The presence of a fracture of the humerus in a flail extremity has been found to delay rehabilitation markedly and to result in prolonged hospitalization. Eleven fractures were treated non-operatively with a brace or cast, and there were five non-unions, two delayed unions, and two malunions. Of the ten fractures that were treated operatively, three that were treated by compression-plating all united. Two fractures were treated by external fixation; one had a delayed union and one, a malunion. In the remaining five patients, who were treated with an intramedullary rod, there were two non-unions, one delayed union, and one malunion.     

Indirect reduction and tension-band plating of tibial non-union with deformity.

Thirty-three patients who had a maligned non-union of the tibial diaphysis were treated by limited open exposure, indirect reduction with a femoral distractor, tension-band plating, lag-screw fixation, and autogenous bone-grafting. The time from the injury to treatment of the non-union averaged twenty-nine months. Twenty-two of the fractures were originally open and sixteen fractures had had a previous infection before treatment of the non-union. The non-unions were classified as hypertrophic in eight patients, oligotrophic in eighteen, and atrophic in seven. All had severe deformity, or the nature or level of the non-union, or both, precluded intramedullary nailing as a treatment option. All thirty-three non-unions healed at an average of four months; the average length of follow-up was nineteen months. The deformity was corrected, within acceptable limits, in thirty-two of the patients. Full motion of the knee was achieved in twenty-nine patients and of the ankle, in eighteen. Complications included four instances of superficial skin breakdowns, one deep infection, and one fracture of the plate. For non-unions of the tibial diaphysis with deformity that are not amenable to intramedullary nailing, the techniques of limited exposure, indirect reduction, tension-band plating, and bone-grafting can yield excellent anatomical and functional results.