Shoulder: Proximal humerus nonunion ORIF

Orthopedic implants used for fracture treatment are designed to last long enough to allow the bone to heal. However, sometimes fractures do not heal quickly for various reasons. When the bone does not heal, it is a matter of time before the implant breaks, pulls out, bends, etc.

Case study

Patient in her late 50's, fell from a height and sustained a widely displaced proximal humerus fracture.

Based on fracture pattern and presence of other orthopedic injuries, I made a firm recommendation for surgical treatment. Nonoperative treatment would have been unwise.

Fractures that are so greatly displaced are exactly the type of fractures that sometimes refuse to heal. This is because of the injury to the soft tissues, in particular the stretching and tearing of the blood vessels that supply the bone.

Bridge plating was performed, without directly handling the metaphyseal comminution. Xrays in the postoperative recovery area are shown below.

Immediate physical therapy and mobilization were started after surgery.

Patient regained mobility quickly, including ability to move the left shoulder without restrictions. Xrays however failed to show bony healing.

The xrays below were done at 4 and 6 months after the injury.

Xray on the right at 6 months shows the development of "windshield wipering." The humeral head is losing stability relative to the plate and the shaft of the humerus.

At this point, I judged that the fracture was developing into a nonunion, I recognized that there was a risk of hardware failure, and I recommended bone grafting with ICBG (iliac crest bone graft).

Patient consented and the fracture healed 2 months after the second surgery, 8 months from the injury. Patient obtained full shoulder motion.