A 32-year-old woman with blast injury to left shoulder. Proximal humerus comminuted fracture with extensive soft-tissue loss. Multiple debridement of necrotic tissue and latissimus dorsi muscle flap for coverage of the defect. (a–c) Application of external fixator and bone transport . (d) Persistent nonunion of the proximal humerus fracture site. (e, f) Plating of the proximal humerus nonunion with bone grafting. Trapezius muscle transfer to allow abduction. Abduction brace seen in X-ray. Adequate union was achieved 8 months later with 60° of shoulder abduction
If the remaining bone stock allows fixation of the fractures, a reconstruction of the shoulder girdle is recommended (Fig. 8.2). Severely comminuted acromion or glenoid fractures are not reconstructed as a floating humeral head can have a reasonable function . However, when the humeral head is shattered, primary prosthetic replacement can be done if a good soft-tissue envelope exists or can be achieved, and there is no evidence of infection (Fig. 8.3). Reverse total shoulder arthroplasty may be of value in reconstruction but would require an intact glenoid . Rarely, we may plan for arthrodesis  of the glenohumeral joint at this stage, as the risk of complications is high .
A 41-year-old man with gunshot injury to left shoulder girdle. (a, b) Radiographs of left shoulder, severely comminuted glenoid fracture with shrapnel. (c–e) CT scan of the shoulder, comminuted glenoid facture, scapula fracture, and acromion fracture. (f, g) Reconstruction of the shoulder girdle with fixation of scapula, acromion arch, and glenoid
A 26-year-old man with left shoulder blast injury. (a, b) Loss of humeral head and acromion, fracture of glenoid fossa . Nonfunctional shoulder. (c, d) Coronal and axial cuts of CT scan showing the humeral head comminution, glenoid fracture, and loss of bone. (e, f) 3D reconstruction of the left shoulder. (g, h) Total shoulder arthroplasty, cemented stem, and cerclage over the humeral shaft; simultaneous latissimus dorsi muscle flap for coverage and teres major muscle transfer to allow external rotation. Patient recovered 40° of abduction and 10° of external rotation
Functional muscle transfer can be done simultaneously with the bony reconstruction or as part of a staged procedure. The trapezius muscle  is an option for reconstruction of the rotator cuff because the latissimus dorsi would have been transferred based on its humeral attachment to close the soft-tissue defect  (see Fig. 8.3).
Humeral Diaphyseal Fracture
These fractures are often comminuted with multiple fragments reaching the distal or proximal end. External fixation can be used as the definitive treatment  (Fig. 8.4), with bone transport to manage bony defects . Alternatively, a two-stage procedure using the Masquelet technique and autologous bone grafting may provide good results when there is a large bone defect . However, these patients usually require additional procedures for bone grafting, adjustment of the fixator for better alignment, and possibly exchange to plating if nonunion persists . Also, early conversion to internal fixation is recommended if soft-tissue conditions permit  (Fig. 8.5). Shortening up to 5 cm is well tolerated and is an acceptable means to decrease the duration of treatment in such injuries .
A 44-year-old man with injury to right arm . (a) Presented with infected nonunion distal humerus fracture (treated with a plate). (b, c) Plate removed, debridement of nonunion, insertion of antibiotics-impregnated beads, acute shortening and application of external fixator . (d–f) Healing of the fracture site. (g, h) Removal of external fixator. Healed fracture
A 46-year-old man with a right humerus comminuted diaphyseal fracture with extensive soft-tissue defect and radial nerve palsy. (a) Presented with external fixator applied at a field hospital. (b) Radial nerve was not reconstructable during exploration. Realignment of external fixator with bone shortening and grafting. (c, d) Bone fragments healed. Fracture transformed into nonunion of two fragments. External fixator removed, double plating performed. Fracture healed in 4 months. Tendon transfer : FCR to EPL and pronator teres to EDC
The radial nerve is seldom intact and any attempt for reconstruction will fail due to severe scarring and retraction of the nerve edges. The radial nerve injury is treated with tendon transfer once the soft-tissue status allows. The aim is to prevent contracture of the wrist and restore active extension of the wrist and fingers .
In this group of patients, there are comminuted fractures of the distal humerus, olecranon, and radial head. The bone is exposed, mainly posteriorly, and the ulnar nerve is often injured . These patients have no chance to recover a mobile elbow even if the fractures on either side of the joint were fixed. They are best treated with multiple debridement procedures, early elbow fusion , and a latissimus dorsi flap for coverage .
Fusion of such elbows may involve a complex reconstruction such as bone transport if there is a considerable bone loss at either the humerus or the ulna . In such instances, external fixation is the method of choice for fusion (Fig. 8.6). Single or double plating can be used if local soft-tissue conditions are satisfactory . Custom-made elbow prostheses  are an alternative in low-demand patients who wish to preserve elbow motion  (Fig. 8.7). However, this would require a sterile field and a good soft-tissue envelope.
A 38-year-old man with gunshot injury to right elbow. Severe comminution. (a) Presented with an external fixator on elbow. (b) Decision was made to fuse the elbow joint using Ilizarov external fixator . (c, d) Proximal ulna fracture failed to heal. Fixator was modified and compression plate applied to heal proximal ulna. (e–g) External fixator removed. Elbow arthrodesis achieved
A 38-year-old woman with blast injury to left distal humerus with soft-tissue defect (a, b). Multiple debridement followed by total elbow arthroplasty using custom-made prosthesis and latissimus dorsi muscle flap for coverage (c, d)
The ulnar nerve may be repaired  if identified but the results are usually poor and the patient would need further procedures, such as tendon transfers , to improve hand function [23, 24].