CASE 1

Patient

An 82-year-old man had an unobserved fall. He sustained a fracture of the right humerus ( Fig 3.2-1a–b ).

Comorbidities

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  Alcoholism

  
  
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  Renal failure

  
  
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  Failure to thrive

Treatment and outcome

Decision making—Due to the fracture type, general state of the patient (eg, alcoholism and frailty), and concerns for noncompliance, nonoperative fracture treatment was chosen. The x-rays showed the initial position in a hanging cast ( Fig 3.2-1c–d ).

Course of treatment—After 3 weeks, the fracture was significantly displaced by the traction of the deltoid muscle with fracture angulation of 45°. Due to inability to comply with immobilization the fracture reduction could not be maintained with bracing ( Fig 3.2-1e–f ). The patient had little pain and no soft-tissue problems. After 5 weeks the situation was unchanged so the treatment decision was revised ( Fig 3.2-1g–h ).

Operative treatment—The nonunion was explored and reduced using an anterior approach by pushing the biceps muscle medially and performing a centric split of the upper portion of the brachialis muscle. Reduction was retained temporarily with a reduction clamp, while the antegrade nailing was performed ( Fig 3.2-1i–j ). The anterolateral approach was used for nailing and the anterior approach to the humeral shaft was used for addressing the nonunion (Fig 3.1-2k).

Postoperative—Anatomical fracture fixation was achieved with no soft-tissue complications and little pain ( Fig 3.2-1l–m ). At the 6-month follow-up, the fracture had healed with restoration of adequate function ( Fig 3.2-1n–r ).

CASE 2

Patient

A 92-year-old woman with left humeral shaft fracture related to low-energy trauma.

Comorbidities

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  Dementia

  
  
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  Hypertension

  
  
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  Diabetes mellitus

  
  
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  Osteoporosis

Treatment and outcome

History—The patient was initially treated with a sugar-tong splint and arm sling in another hospital ( Fig 3.2-2a–b). There was significant displacement and angulation. At the 3-month follow-up ( Fig 3.2-2c ), the alignment was unacceptable and the skin was tenting with a bone spike. The patient still had pain and there was no sign of bone union. Despite this, this treatment plan was continued for 4 months.

Current situation—The treatment decision was revised to operative treatment. Soft-tissue irritation also was a cause of pain ( Fig 3.2-2d–f ).

Diagnosis and classification—The initial diagnosis was closed fracture of the proximal shaft of the left humerus (AO/OTA 12A1). The current diagnosis is nonunion.

Indication for surgery—A painful nonunion of the proximal shaft of the left humerus. Skin complication due to bony spike.

Treatment planning:

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  Fixation: open reduction and internal fixation (ORIF) with a narrow locking compression plate and iliac bone grafting

  
  
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  Positioning: supine on transparent x-ray table

  
  
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  C-arm: located on the opposite side

  
  
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  Preparation and draping: from shoulder to hand and free to move in any direction

  
  
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  Surgical approach: anterolateral, direct reduction

Intraoperative technique—Soft tissues were removed at the fracture site and the bone ends were freshened ( Fig 3.2-2g ). The sharp spike of the proximal fragment ( Fig 3.2-2h ) and the V-shaped cortical fracture site of the distal fragment corresponding with the shape of the proximal end (behind the sharp spike in Fig 3.2-2g ) could be seen. The incision was extended distally to identify and protect the radial nerve. The sharp spike of the proximal fragment was pushed into the intramedullary canal through a V-shaped opening of the distal fragment to create a stable bone construction before plating ( Fig 3.2-2i ). This provides significant stability of fixation in osteoporotic bone, which even with the use of many locking head screws may not be able to withstand the bending and rotational deforming forces. Through a proximal incision of the deltoid split, PHILOS was inserted submuscularly into position on the lateral aspect of the humerus. Correct positioning of the plate was confirmed through a true AP x-ray of the proximal humerus using image intensification, then temporarily fixed with a K-wire ( Fig 3.2-2j–k ). The sharp bony spike of the proximal fragment was pushed into the intramedullary canal of the distal fragment to create primary stability and the screws were fixed in compression holes close to the fracture site to add more stability ( Fig 3.2-2l–m ). An iliac bone graft was impacted in the fracture gap on the medial side after complete plate fixation ( Fig 3.2-2n–p ). Immediate postoperative x-rays showed good alignment and stable bone-implant construction ( Fig 3.2-2q–r ).

Postoperative care—Gentle active assistive exercise for range of motion (ROM) of the shoulder and elbow were started on the second day postoperatively. No pushing or pulling were allowed until bone union ( Fig 3.2-2s–t ). The patient could flex the shoulder forward ( Fig 3.2-2u–v ), though her ROM was limited due to her prolonged preoperative immobility and her dementia, both of which limited rehabilitation capabilities. She could perform adequate, pain-free flexion and extension of the elbow. Rotational movement of the humerus was done gently in light of risk of screw failure due to severe osteoporosis. The patient had no pain and had good ability to perform daily living activities ( Fig 3.2-2s–v ).

CASE 3

Patient

A 68-year-old woman fell and had right arm pain and swelling.

Comorbidities

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  Hypertension

  
  
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  Diabetes mellitus

  
  
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  Previous cerebrovascular accident

  
  
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  Osteopenia

Treatment and outcome

Diagnosis—The diagnosis was a closed fracture of the right humeral shaft (AO/OTA 12A3). There was minimal displacement and no distraction ( Fig 3.2-3a ).

Treatment plan—Nonoperative treatment with a coaptation splint and arm sling. After closed manipulation and immobilization in a U-slab, AP and lateral x-rays of the right humerus showed adequate apposition ( Fig 3.2-3b–c ), the axial alignment was acceptable in both views. X-ray at the 2-week follow-up with coaptation splint showed that alignment was maintained ( Fig 3.2-3d ). At the 2-month follow-up, there were signs of callus formation at the fracture site ( Fig 3.2-3e–f ). The patient had minimal pain, good elbow flexion/extension ( Fig 3.2-3g–h ), and forward flexion of the shoulder ( Fig 3.2-3i ). At the 3-month follow-up, there was adequate callus formation. The patient was pain free, and the splint was removed ( Fig 3.2-3j–k ).

Discussion

Nonoperative treatment was possible in this case as there were many favorable factors including:

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  Mild displacement with adequate apposition visible on the initial x-rays

  
  
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  Axial alignment was adequate with acceptable angulation

  
  
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  No distraction at the fracture site

These x-ray findings reflect the condition of the periosteum around the fracture which might be intact.