Case description

A 55-year-old man with a history of alcohol abuse presented at the author′s institution with a nonunion of his right humeral shaft. More than 7 years prior the patient had sustained a car accident which left him with a fractured right humerus. The fracture was initially treated nonoperatively. A nonunion developed and 1.5 years later a retrograde nail was placed at an outside hospital. According to the patient he was relatively free of pain for 5 years. He then noticed increased pain when he rolled over in bed one night and according to the patient, he was diagnosed with a new fracture and an intramedullary nail failure. It is unclear whether the nonunion had healed and there was a refracture or whether the nonunion had never healed. This last scenario seemed more logical. The fracture was revised at the same hospital to an antegrade locked nail. A few months later it was noted that the pin was prominent with one of the proximal locking screws being displaced. The patient then developed increasing pain and limited range of motion. He presented for a second opinion at the author′s department. When the author first saw him he had severe pain in his right shoulder and was not able to use his right dominant arm for daily activities. There were no signs of neurovascular symptoms or infection. The patient admitted to smoking 30 cigarettes and drinking six units of alcohol per day.

On physical examination there was a painful prominent swelling in the right upper arm. Anteflexion of the shoulder was limited to 45°, abduction to 30°, external rotation was 70°, internal rotation limited to reaching his hand to L1.

Preoperative planning

The operative report of the previous surgery was requested from the referring hospital to determine what nail was used. The appropriate removal set was obtained. As the nail was in suboptimal position the option of plating the nonunion while leaving the nail in situ was not possible. Although it was felt that rigid fixation with lag screws and a customized plate might be sufficient, the patient consented to obtaining bone graft in order to augment biological healing potential.

Related posts:

Hypertrophic nonunion of the humeral shaft Principles: Nonoperative treatment Bone-graft substitutes Wave plate fixation of an atrophic midshaft clavicular nonunion Lateral clavicular nonunion with intact coracoclavicular ligaments Midshaft clavicular nonunion

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