Shoulder and Elbow Cases to Consider.

Last updated Friday, February 11, 2005

Figure 1

Figure 2

ORIF of proximal humerus fracture nonunion

Clinical presentation

This is the radiograph of the right shoulder of a 50 year old woman who presented with a chronic atrophic non-union of her humerus (see figure 1). She sustained the subtuberous fracture in a fall 6 months ago. She was treated with closed reduction and sling immobilization. At 6 weeks mobilization was started, however over the ensuing months she had progressively increasing pain in her arm.

At her consultation visit with us, examination revealed pain and crepitance on movement of the arm. There was no evidence of sepsis or neurovascular impairment. Her general health was excellent.

Our concerns included:

1. The loss of bone around the fracture site.
2. The local osteopenia.
3. The method of internal fixation (if a prosthesis was not used).
4. The challenge of obtaining union between the tuberosities and humeral shaft if a prosthesis was used.

Management

In our view the primary problem here was not the articular surface nor the length of the bone, but rather the challenge of getting the tuberosities to heal to the shaft. We elected a method of treatment which respected the compromised bone quality and which maximized the contact between bone of the proximal and distal fragments. On these bases, neither interpositional bone graft, metallic internal fixation nor a prosthesis was used. The shoulder was approached through a deltopectoral incision to protect the deltoid muscle. The distal aspect of the proximal fragment was carefully carved to receive and interlock with the proximal end of the distal fragment. The insertion of the peg of the humeral shaft in to the hole in the head was secured with six large (#5) non nonabsorbable sutures passed through holes in the proximal shaft and then through the proximal humeral metaphysis, out the cuff insertion and around the tuberosities. Iliac crest autograft was added around the non-union site. The fixation was robust, so early gentle active motion was started immediately.

Radiographs taken 6 months later show a united fracture (see figure 2). The arm is one inch short and the deltoid lag is resolved. The patient is now pain free, has good use of the shoulder, and is pleased.

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