Review Article

Proximal Humerus and Humeral Shaft Nonunions

Abstract
Edwin R. Cadet, MD Bob Yin, MD Brian Schulz, MD Christopher S. Ahmad, MD Melvin P. Rosenwasser, MD

From Raleigh Orthopaedic Clinic, Raleigh, NC (Dr. Cadet) and the Department of Orthopaedic Surgery, Columbia University Medical Center, New York, NY (Dr. Yin, Dr. Schulz, Dr. Ahmad, and Dr. Rosenwasser). Dr. Ahmad or an immediate family member serves as a paid consultant to Acumed and Arthrex and has received research or institutional support from Arthrex, Major League Baseball, and Stryker. Dr. Rosenwasser or an immediate family member has received royalties from Biomet, serves as a paid consultant to Stryker, and serves as a board member, owner, officer, or committee member of the Osteosynthesis & Trauma Care Foundation. None of the following authors or any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Cadet, Dr. Yin, and Dr. Schulz. J Am Acad Orthop Surg 2013;21: 538-547 http://dx.doi.org/10.5435/ JAAOS-21-09-538 Copyright 2013 by the American Academy of Orthopaedic Surgeons.

The rate of nonunion is estimated to be 1.1% to 10% following closed treatment of proximal humerus fracture and 5.5% following closed treatment of humeral shaft fracture. Surgical management should be considered for fractures that demonstrate no evidence of progressive healing on consecutive radiographs taken at least 6 to 8 weeks apart during the course of closed treatment. In the case of proximal humerus nonunion, recent series have demonstrated union in >90% of patients treated with reconstruction using locking plates and autogenous bone graft. Shoulder arthroplasty is reserved as a salvage option in cases in which the humeral head is not viable or the proximal fragment will not support osteosynthesis. For humeral shaft nonunions, open reduction and internal xation with compression plating and bone graft remains the standard of care, with a >90% rate of union and good functional outcomes. Recent studies support the use of locked compression plates, dual plating, and cortical allograft struts in patients with osteopenic bone.

umerus fractures comprise approximately 5% to 8% of all fractures.1-3 Most humeral shaft fractures and proximal humerus fractures initially are managed nonsurgically (>95% and 89.1%, respectively),4 with some progressing to delayed union or nonunion. Humeral fractures that fail nonsurgical management are challenging to treat surgically because the same patient-related risk factors that predisposed the fractures to nonunion with closed treatment impede fracture healing postoperatively, as well. The humerus is among the most common locations for fragility fractures, and surgeons must be prepared to manage increasing numbers of humeral nonunions. The risk factors for developing nonunion vary by fracture location. In general, however, both biologic factors (eg, disrupted blood supply, smoking, med-

ical comorbidities) and mechanical factors (eg, inadequate immobilization, fracture pattern and displacement) may cause nonunion. These factors must be identified and addressed to maximize fracture healing. In patients with humerus fracture nonunions, the surgical goals are to provide a stable mechanical construct that allows for early motion and to create a biologic environment favorable to fracture healing. Various surgical strategies have been proposed, but the standard of care is open reduction and internal fixation (ORIF) with rigid compression plating and autogenous bone grafting.5 Other techniques that have been recently described include intramedullary fibular strut allograft for atrophic proximal nonunions and dualcompression plating for osteopenic humeral shaft nonunions.6-8

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Proximal Humerus Nonunion

Proximal humerus fractures are among the most common orthopaedic injuries worldwide,9,10 with the vast majority being low-energy, nondisplaced or minimally displaced fractures. Such fractures heal uneventfully without surgical intervention, but those that progress to nonunion have a negative effect on overall glenohumeral function and the ability to perform activities of daily living as early as 6 months following injury.4,11 Hanson et al10 prospectively followed 124 patients with proximal humerus fractures that were managed nonsurgically. At 1-year follow-up, only 3% required surgery for fracture nonunion. Similarly, Court-Brown and McQueen4 reported a nonunion rate of 1.1% in their prospective study of patients treated nonsurgically for proximal humerus fracture. Several risk factors have been implicated in the development of nonunion following proximal humerus fracture. Court-Brown and McQueen4 found an 8% rate of nonunion in patients with metaphyseal comminution and a 10% rate in patients with surgical neck translation between 33% and 100%. Fracture pattern may contribute to the risk of nonunion. Two-part surgical neck fracture is the most common fracture pattern associated with fracture nonunion.11-14 It is possible that these seemingly disparate risk factors lead to nonunion via the same general mechanismall are signs of increased disruption to the medial soft tissues and blood supply that are important for fracture healing. Persons who smoke are at 5.5 times higher risk than nonsmokers for developing nonunion.10 Significant medical comorbidities (eg, diabetes, osteopenia, obesity) may contribute to nonunion, and patients with such conditions should be referred to
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an internist or endocrinologist for preoperative optimization before any surgical procedure.11,13

Patient Evaluation
Patients with proximal humerus nonunion typically report pain, stiffness, and disability associated with shoulder dysfunction. Physical examination usually reveals diminished forward elevation, with or without disuse atrophy of the deltoid and periscapular musculature. Axillary nerve function must be assessed, and electromyography is warranted if neurologic injury is suspected. True AP radiographs are taken in the scapular plane with the shoulder in neutral, internal rotation, and external rotation. Outlet and axillary radiographs should also be included in the radiographic series. The type of nonunion (eg, hypertrophic versus atrophic) should be defined. Radiographically, hypertrophic nonunions are characterized by hypertrophic and sclerotic bone ends with fracture callus, whereas atrophic nonunions appear osteopenic with the absence of callus. In general, hypertrophic nonunions develop when insufficient mechanical stability and/or axial alignment exists and the vascularity and biologic environment for fracture healing is preserved. With atrophic nonunion, vascularity and the biologic environment are often compromised, which causes an inadequate fracture healing response. Radiographs also should be evaluated for evidence of osteonecrosis of the humeral head, pathologic fracture, and extent of bone loss. Comparison views of the contralateral shoulder may be helpful. CT is a useful modality if the diagnosis of nonunion is unclear.

ing injury.11 The median time to union or bridging callus of nonsurgically managed proximal humerus fractures is 13 weeks, and an appropriate workup should be performed at that time in the absence of healing.4,10 The diagnosis of nonunion in the proximal humerus can also be made when there is no evidence of interval healing on two consecutive radiographs taken 6 to 8 weeks apart during the period of closed treatment. Surgical management is recommended at approximately 3 to 6 months following injury if an impending nonunion is suspected, given patient- and fracture-related risk factors (eg, preexisting osteopenia or significant fracture displacement with disruption of the soft-tissue envelope). By intervening at this time point, such action may help to prevent disabling glenohumeral dysfunction that is associated with chronic proximal humerus nonunions.

Nonsurgical Management
Nonsurgical management for symptomatic proximal humerus nonunions is typically reserved for patients with medical comorbidities that place them at an unacceptable risk for surgical management and for patients who may be at risk for noncompliance with postoperative rehabilitation and precautions. Patients with minimal pain and mild functional losses may be appropriate candidates for nonsurgical management.15

Surgical Management
Osteosynthesis Osteosynthesis using locking plate fixation techniques is preferred in the presence of good bone quality and a viable humeral head in the absence of significant medial calcar comminution or osteopenia that may compromise adequate fixation. Clinical and radiographic assessment of tu-

Timing of Surgery
Nonunion in long bone fractures is typically diagnosed 6 to 9 months follow-

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berosity function and its integrity is critical in deciding whether osteosynthesis is the appropriate treatment choice for proximal humerus nonunions. With surgical neck nonunion, rigid fixation can be achieved with a variety of plates, including 3.5- and 4.5-mm plates made for the proximal humerus, blade plates, and 4.5-mm T plates. Fixed-angle locking or blade plates provide a biomechanically stable construct in the setting of osteoporotic bone. Isolated greater and lesser tuberosity nonunions are less common than surgical neck nonunions. The bone quality of the tuberosity fragment and rotator cuff function are critical components in determining the most appropriate surgical option. In patients with large tuberosity fragments and a viable rotator cuff, osteosynthesis may be achieved with lag screw compression and/or buttress plating with autogenous bone graft. Tension band techniques, transosseous suture fixation, or current suture anchor configurations used in modern rotator cuff repair techniques that provide compression across the fracture site with autogenous bone grafting augmentation can be used for comminuted tuberosity fragments, only if rotator cuff function is determined to be intact clinically. A deltoid-splitting or deltopectoral approach can be used for greater tuberosity osteosynthesis. A deltopectoral approach is suggested for lesser tuberosity nonunions. Arthroscopic techniques have also been described for managing greater tuberosity nonunions.16 Autogenous or allograft bone augmentation is recommended to facilitate osteosynthesis. Large amounts of cancellous bone autograft can be obtained from the iliac crest, but the patient must be advised of the possibility of donor site pain. Allograft may be used instead if donor site morbidity is unacceptable.11 More

recently, large volumes of autogenous bone graft have been harvested using the Reamer-Irrigator-Aspirator (RIA) system (Synthes) to fill large cortical defects, facilitate osseous fusions, and in the treatment of nonunions.17-19 The RIA is an intramedullary canal reaming system that collects large amounts of autogenous corticocancellous bone from the intramedullary canal in a relatively minimally invasive manner. This technique may lessen the donor site morbidity that is sometimes seen with iliac crest autograft harvest. Compared with iliac crest bone graft, RIA may also generate a larger volume of autogenous bone graft material and pluripotential mesenchymal stem cells, especially in elderly patients.20,21 Free vascularized fibular autograft may be considered for patients who need significant biologic augmentation along with mechanical support. ORIF with osteosynthesis and bone graft has yielded good results. Healy et al13 reported union in 12 of 13 patients following ORIF with bone graft in a retrospective review of 25 patients with proximal humerus nonunions. Ring et al22 used blade plating and autogenous iliac crest cancellous bone graft (ICBG) to treat 25 patients with proximal humerus fracture nonunion. Fracture union was achieved in 23 patients (92%), and functional results were classified as good to excellent in 20 (80%). Two patients had complications due to iliac crest harvest. Allende and Allende23 reported union in all seven patients treated with a locking 90 blade plate (average follow-up, 22 months). The average time to union was 5.9 months. Average Disabilities of the Arm, Shoulder, and Hand and Constant scores at latest follow-up were 25 and 72.7 points, respectively. More recently, Tauber et al24 reported significantly improved Constant scores in 55 pa-

tients treated with ORIF using a blade plate or Humerusblock device (Synthes) without bone grafting to manage humeral surgical neck fractures (P < 0.01). Radiographic evidence of fracture healing was seen in 51 patients (93%).

Fixed-angle Locked Plating With Fibular Strut Allograft Use of an intercalary strut allograft with fixed-angle locked plating to manage proximal humerus fracture nonunion was first described by Badman et al15 in 2006. Fibular strut allograft has several advantages. It provides additional biologic and structural support to the often poorquality bone found at the proximal humerus, it is mechanically stronger than cancellous bone autograft or allograft, and it avoids the donor site morbidity associated with autograft harvesting. This technique is useful in both the acute proximal humerus fracture setting and chronic nonunion scenario when medial calcar support is compromised secondary to significant medial calcar comminution or osteopenia (Figure 1). Intramedullary Nailing Historically, results were disappointing following intramedullary nailing to manage proximal humerus nonunions. Early intramedullary devices were prone to postoperative subacromial impingement, necessitating a second surgery following union for nail removal. Most patients, however, progressed to union and regained good shoulder function.11 Recently, Yamane et al14 published encouraging results with the use of interlocking intramedullary nails to manage proximal humerus fracture nonunion in 13 patients. The average follow-up was 37.8 months. All patients achieved union. All patients were satisfied with the results and had improved shoulder range of motion postoperatively. Two patients

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subsequently underwent removal of proximal interlocking screws because of screw back-out.

Figure 1

Unconstrained and Reverse Total Shoulder Arthroplasty The decision to perform unconstrained arthroplasty (ie, hemiarthroplasty, total shoulder arthroplasty) to manage proximal humerus fractures depends in part on the degree of osteopenia present, the viability of the humeral head and, most important, tuberosity integrity and position as well as rotator cuff functional status. Total shoulder replacement is considered in the setting of concomitant glenohumeral osteoarthrosis with a functional rotator cuff. Boileau et al25 investigated factors important to successful patient selection for unconstrained arthroplasty (ie, hemiarthroplasty, total shoulder arthroplasty) in the setting of proximal humerus malunion or nonunion. They retrospectively reviewed 203 consecutive patients with sequelae of proximal humerus fractures that had been managed with unconstrained glenohumeral arthroplasty. Of the unconstrained arthroplasties performed, 59% were hemiarthroplasty. Total shoulder arthroplasty was indicated for patients with preexisting pain secondary to glenohumeral osteoarthrosis or glenoid erosions noted at the time of surgery. The authors suggested that tuberosity integrity and anatomic position is critical for a good functional outcome following unconstrained arthroplasty. Furthermore, they recommended reverse total shoulder arthroplasty in cases in which tuberosity osteotomy is unavoidable (eg, type 4 fractures). Although arthroplasty has been shown to reliably relieve pain in patients with proximal humerus nonunion, return to preinjury function is less predictable.11,13 Nayak et al26 retrospectively reviewed seven patients who underwent hemiarthroplasty for
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Intraoperative AP clinical photograph (A) and corresponding uoroscopic view (B) of an acute surgical neck fracture in an elderly patient with severe osteoporosis who was treated with proximal humeral locking plate xation and cortical intramedullary bular strut allograft. B, A locking screw was inserted through the plate (dashed arrow) to medialize the intramedullary allograft (solid arrow). Other locking screws were inserted through the allograft, and this push screw was exchanged for a longer locking screw that also crossed the graft. Intraoperative uoroscopic AP (C) and axillary (D) views demonstrating multiple locking screws placed through the allograft to enhance construct rigidity. The medialized position of the allograft provided additional medial calcar support. (Copyright Center for Shoulder, Elbow and Sports Medicine at Columbia University, New York, NY.)

proximal humerus fracture nonunion. All eventually were able to perform activities of daily living and had less pain as well as increased function and range of motion. However, no patients returned to their

preinjury level of activity. Antua et al12 published the results of 25 shoulders managed with unconstrained arthroplasty (mean followup, 6 years). Twenty-one patients underwent hemiarthroplasty, and 4

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Figure 2

union was noted in only 35 shoulders (52%). Anatomic or near anatomic union of the tuberosity was a significant factor in achieving greater active forward elevation (P = 0.02). Reverse total shoulder arthroplasty is a viable option in the setting of proximal humerus nonunion or malunion with humeral head collapse and/or a clinically dysfunctional rotator cuff, radiologic rotator cuff atrophy (Goutallier stage 2 or greater), or radiographic evidence of severe tuberosity malunion or resorption28 (Figure 2). In a study of 18 patients treated with reverse total shoulder arthroplasty for proximal humerus nonunion, Martinez et al29 reported significant improvements in average active forward elevation (35 to 90; P < 0.0001), external rotation (15 to 30; P < 0.0001), and internal rotation (25 to 55; P < 0.0001) at an average follow-up of 28 months. Fourteen patients were either satisfied or very satisfied with the result of the operation.

Humeral Shaft Nonunion

The vast majority of humeral shaft fractures heal uneventfully with functional bracing. Residual angulation of up to 20 in the AP and lateral planes is well tolerated by most patients and typically does not lead to functional deficits.5,30 However, in a recent systematic review of diaphyseal fractures managed nonsurgically, Papasoulis et al31 showed an overall nonunion rate of 5.5%. Studies published in the past decade that included more than 50 patients demonstrate a 10% to 23% rate of humeral shaft nonunion following functional bracing.32-35 This is significantly greater than the rate of zero to 2% reported in earlier studies by Sarmiento and colleagues.30,36 Many attempts have been made to identify which fracture patterns pre-

AP (A) and axillary (B) radiographs demonstrating longstanding right proximal humeral nonunion with humeral head osteonecrosis and resorption of the tuberosities in an 81-year-old right handdominant woman. Preoperative range of motion was limited to 40 of forward elevation. AP (C) and axillary (D) radiographs obtained following reverse total shoulder arthroplasty. Forward elevation had improved to 160 by 4 months postoperatively. (Copyright Center for Shoulder, Elbow and Sports Medicine at Columbia University, New York, NY.)

underwent total shoulder arthroplasty. Although significant pain relief and subjective patient satisfaction were achieved, function was not completely restored. Duquin et al27 reported the results of 67 patients treated with unconstrained shoulder arthroplasty to manage proximal hu-

merus nonunion. Fifty-four patients underwent hemiarthroplasty, and the remaining 13 underwent total shoulder arthroplasty. Significant improvement was noted in active forward elevation (46 to 104) and external rotation (26 to 50) (P < 0.001). Radiographic tuberosity

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dispose to delayed union or nonunion so that the patient can be counseled regarding the chance of achieving bony union with nonsurgical treatment. In the classic report on diaphyseal nonunions by Healy et al,5 transverse fractures were most susceptible to nonunion (11 of 26 [42%]), followed by short oblique fractures (7 of 26 [27%]). In one study, 9 of 67 fractures managed with functional bracing went on to require surgery for nonunion; 6 of those 9 fractures exhibited a transverse fracture pattern.33 In contrast, Ring et al37 reported that, of the 32 consecutive humeral shaft fracture nonunions managed at their institution over a 10-year period that went on to surgical management, most had spiral or oblique fracture patterns (84.4%), with only 12.5% having transverse fracture patterns. In a study of 78 fractures, Ekholm et al32 observed a trend toward more frequent nonunions in Orthopaedic Trauma Association type A fractures (simple, >90% cortical contact) compared with type B (wedge) and type C (complex) fractures (P = 0.08). The location of the fracture may also play a role in the development of nonunion. Several studies have noted that fractures in the proximal diaphysis are at greater risk of nonunion compared with middle- or distal-third shaft fractures, presumably due to greater deforming forces generated by the deltoid and pectoralis insertions, greater risk of muscle and long of head of the biceps tendon interposition within the fracture, and difficulty with immobilization of the proximal humerus fracture fragments with current functional brace designs.7,34,35,37

Patient Evaluation
Patients with established nonunions most often report an inability to engage in repetitive activities using the
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upper extremity for activities of daily living and for work. Higher-energy mechanisms of injury as well as patient comorbiditiesboth medical and psychosocialincrease the risk of nonunion. On physical examination, a thorough assessment of the functional brace for proper fit and associated skin irritation will improve patient compliance with use of the orthosis. A careful neurovascular examination is needed to rule out neurologic injury, particularly in the radial, median, and ulnar nerve distributions. Gross motion at the fracture site is an obvious sign of nonunion; however, this finding may be difficult to elicit in the presence of significant arm edema, arm girth, and pain. On plain radiographs, nonunion may demonstrate lack of fracture consolidation, increased interfragmentary diastasis or angulation, and the presence of hypertrophic callus without clinical stability. When it is difficult to evaluate fracture consolidation on plain radiographs (eg, hypertrophic callus, comminuted angular deformity), CT may be used to evaluate for bridging callus. Routine laboratory studies should include a complete blood count and a basic metabolic panel to evaluate for active medical conditions that may impede fracture healing. In the setting of previous open fracture or surgery, infection must always be excluded and appropriate laboratory workup (eg, complete blood count with differential, erythrocyte sedimentation rate, C-reactive protein level) obtained. For the patient whose nutritional status is in question, total serum protein and serum albumin tests may be performed. More advanced markers of bone metabolism (eg, vitamin D level) and an endocrinology consult may be needed to investigate biologic causes of poor osteosynthesis potential.

Timing of Surgery
Although most authors define delayed union as no radiographic signs of osseous union 4 months after injury and nonunion 6 months after injury, the exact length of time recommended before functional bracing is discontinued in favor of surgery varies widely in the literature.2 Toivanen et al35 recommended surgery if fractures show no clinical or radiographic signs of consolidation after only 6 weeks of functional bracing. In a single-surgeon series by Rutgers and Ring,34 of 52 diaphyseal fractures managed nonsurgically, 5 established nonunions resulted; these fractures were managed surgically at an average of 28 weeks after injury (range, 10 to 55 weeks). In a Swedish series of 78 nonsurgically managed diaphyseal fractures, 9 patients failed to heal with bracing and underwent surgery at a mean of 8.7 months (range, 1.8 to 15.5 months) after injury.32 The systematic review by Papasoulis et al31 of 15 Englishlanguage studies on outcomes of nonsurgically managed diaphyseal fractures showed a mean time to union of 10.7 weeks. These results suggest that surgeons should broach the topic of surgical treatment to patients with fractures that have not healed by 10 to 12 weeks after injury. We recommend maintaining a high index of suspicion for nonunion in humeral shaft fractures that have demonstrated no interval healing on consecutive radiographs taken 6 to 8 weeks apart.

Nonsurgical Management
Nonsurgical management of established diaphyseal nonunion is unlikely to result in healing and should be reserved for select patients with medical comorbidities that place them at high risk for surgical and anesthesia-related complications and for patients with asymptomatic non-

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unions or pseudarthroses and low functional demands. Bone stimulation is another nonsurgical treatment option. These devices transmit lowpulsed direct current, pulsed electromagnetic fields, capacitive couplings, and/or ultrasound electromagnetic signals to augment fracture healing. Bone stimulators are contraindicated in the presence of a synovial pseudarthrosis, fracture gapping >5 mm, and poor vascular supply to the fracture site.38 The role of bone stimulators in facilitating osseous union of humeral shaft nonunion or fractures is not well defined in the literature. Ultrasound devices are approved for use in acute fractures, but all other bone stimulators have been approved for use by the FDA only in established nonunions, that is, fracture nonunion that persists 9 months following injury, or a fracture that demonstrates no visibly progressive radiographic signs of healing 3 months following injury.38

Surgical Management
ORIF With Compression Plating and Bone Graft ORIF using a broad, 4.5-mm compression plate along with autogenous bone graft is the standard of care for humeral diaphyseal nonunion in the absence of prior surgery. An extensile approach was advocated by Healy et al5 and in more recent reports.39,40 With an anterolateral approach, the radial nerve should be identified between the brachialis and brachioradialis muscles and protected along its course well beyond the zone of nonunion. Neurolysis can be performed if the nerve is encased in scar tissue. Depending on the location of the fracture site, a direct anterior approach is also a utilitarian approach to the humerus. In cases of proximal extension of the fracture line, the anterior approach

can be extended proximally and incorporated into the deltopectoral interval. A posterior approach to the humerus can be used for fractures involving the distal three fourths of the humerus and in cases of suspected entrapment of the radial nerve on its course along the posterior humeral shaft. Fracture reduction must correct any angular deformity and achieve good joint alignment, with maximal cortical contact to enhance mechanical stability and osteosynthesis. The fracture ends should be dbrided and lightly decorticated to stimulate bone healing. Depending on the type of fracture exposure, rigid fixation is obtained with a laterally, anteriorly, or posteriorly placed 4.5-mm compression plate with at least six bicortical fixation points proximal and distal to the fracture site. Eight fixation points are preferred. Special attention should be paid to plate length. To ensure balanced fixation across the construct, we recommend that the plate be long enough to span the nonunion site a distance of at least two to three times the cortical diameter, both proximal and distal to the fracture site. If a 3.5-mm plate is used for a patient with a particularly narrow humeral diaphysis, a minimum of eight points of proximal and distal cortical fixation and a long plate should be used because rigid fixation is critical for successful fracture healing (Figure 3). Depending on the fracture configuration, the plate or lag screw insertion can be prestressed to maximize interfragmentary compression. In a study by Ring et al,37 all 32 consecutive diaphyseal nonunions in adults who were treated with functional bracing for 4 months achieved union with ORIF. However, three older patients with osteoporosis required a second procedure to address either failed fixation or persistent nonunion.

The use of bone graft from intramedullary reaming and/or autogenous ICBG is strongly recommended to facilitate healing. In hypertrophic cases, the existing callus can augment autogenous bone or RIA grafts.39 Success has been reported with demineralized bone matrix (DBM) with or without bone morphogenetic protein (BMP).7,41-43 Hierholzer et al41 retrospectively compared two consecutive cohorts of patients with aseptic delayed union or nonunion of the humeral shaft that was managed with rigid plate fixation with either autogenous ICBG or DBM and found no differences in union rates or functional outcome and found only a slight difference in union rate and no difference in overall functional outcome between the two groups. However, 44% of patients in the ICBG group had donor site morbidity; as a result, DBM was adopted as the standard bone graft option for humeral shaft nonunions at that institution. Marti et al39 observed 100% union after 1 year in 51 patients with diaphyseal nonunion who were treated with ORIF with compression plating; ICBG was added in atrophic cases. Livani et al40 also reported 100% union using a similar treatment algorithm. Thus, we recommend the use of autogenous ICBG in patients who can withstand the possibility of donor site morbidity at the harvest site.

Dual Plating Two studies have supported the use of dual orthogonal plating, which involves the use of an additional plate in the presence of micromotion at the fracture site following preliminary plate fixation.7,44 The additional plate may be particularly useful in cases of proximal shaft nonunion in which fixation is limited by the short proximal fragment, for distal shaft fractures that present with a short distal segment, in the presence of poor metaphyseal bone quality, and

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Figure 3

in cases at risk of glenohumeral joint penetration. Rubel et al44 noted no difference in healing rates and functional outcome in their retrospective comparison of two cohorts of patients with nonunion that was managed with either single- or dualcompression plating. The overall healing rate was 92% at an average of 4.8 months. Prasarn et al7 treated 19 elderly patients (mean age, 70 years) who presented with proximal shaft nonunions. Dual plating was used in 11 patients to achieve adequate fixation in the small metaphyseal proximal fragment, and all achieved union at an average of 15.2 weeks. No revision surgery was required.

A, AP radiograph demonstrating an acute comminuted midshaft left humerus fracture in a 19-year-old right handdominant woman who was initially treated with functional bracing. B, AP radiograph obtained 12 weeks after injury demonstrating no radiographic signs of fracture healing. The patient continued to have pain and gross motion at the fracture site, so the decision was made to proceed with surgical treatment. C, AP radiograph obtained following open reduction and internal xation of the atrophic nonunion. A conventional 4.5-mm plate was used to bridge the fracture comminution, and the fracture site was supplemented with local bone intramedullary autograft and demineralized bone matrix. D, AP radiograph demonstrating bony union 6 months postoperatively. (Courtesy of Melvin P. Rosenwasser, MD, Training Trauma Center, Columbia University, New York, NY.)

Cortical Strut Allograft and Autograft Augmentation of compression plating and bone graft with a cortical strut allograft can be considered in patients with severe osteopenia due to a combination of advanced age, disuse of the limb, or previous surgical treatment.45,46 The cortical allograft is placed in an intramedullary location or against the medial humeral cortex, opposite the lateral compression plate, and the screws are inserted from lateral to medial to sandwich the host humeral bone with the strut, thereby providing additional cortical fixation. Two recent series on atrophic humeral shaft nonunions demonstrated high rates of fracture union (95% to 100%) after fixation with dynamic compression plating augmented by intramedullary fibular struts.45,46 Biologic Augmentation Biologic augmentation of humeral nonunions with BMP-2 and BMP-7 has been performed. Although literature exists to support the use of BMPs in tibial fracture and nonunion, we know of no study that has reported on the use of BMP in hu-

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meral nonunion.47,48 A recent Cochrane review concluded that there is limited evidence to support the use of BMP for fracture healing in adults; further, it indicated that all randomized controlled trials to date have a high risk of bias due to industry involvement.49 The role of BMPs in humeral nonunions remains undefined. Thus, use of BMP should be guarded given the issues of additional cost without substantiated efficacy compared with ICBG or local autograft.

2.

Schemitsch EH, Bhandar M, Talbot M: Fractures of the humeral shaft, in Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, eds: Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 4. Philadelphia, PA, Saunders Elsevier, 2009, pp 15931622. Green A, Norris TR: Proximal humeral fractures and glenohumeral dislocation, in Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, eds: Skeletal Trauma: Basic Science, Management, and Reconstruction, ed 4. Philadelphia, PA, Saunders Elsevier, 2009, pp 16231754. Court-Brown CM, McQueen MM: Nonunions of the proximal humerus: Their prevalence and functional outcome. J Trauma 2008;64(6):15171521. Healy WL, White GM, Mick CA, Brooker AF Jr, Weiland AJ: Nonunion of the humeral shaft. Clin Orthop Relat Res 1987;(219):206-213. Badman BL, Mighell M, Kalandiak SP, Prasarn M: Proximal humeral nonunions treated with fixed-angle locked plating and an intramedullary strut allograft. J Orthop Trauma 2009;23(3):173-179. Prasarn ML, Achor T, Paul O, Lorich DG, Helfet DL: Management of nonunions of the proximal humeral diaphysis. Injury 2010;41(12):12441248. Cole PA: Endosteal allograft plating for the treatment of recalcitrant nonunions. Techniques in Orthopaedics 2004;18(4): 344-355. Court-Brown CM, Caesar B: Epidemiology of adult fractures: A review. Injury 2006;37(8):691-697. Hanson B, Neidenbach P, de Boer P, Stengel D: Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elbow Surg 2009;18(4):612-621. Galatz LM, Iannotti JP: Management of surgical neck nonunions. Orthop Clin North Am 2000;31(1):51-61. Antua SA, Sperling JW, Snchez-Sotelo J, Cofield RH: Shoulder arthroplasty for proximal humeral nonunions. J Shoulder Elbow Surg 2002;11(2):114-121. Healy WL, Jupiter JB, Kristiansen TK, White RR: Nonunion of the proximal humerus: A review of 25 cases. J Orthop Trauma 1990;4(4):424-431. Yamane S, Suenaga N, Oizumi N, Minami A: Interlocking intramedullary nailing for nonunion of the proximal humerus with the Straight Nail System. J Shoulder Elbow Surg 2008;17(5):755759.

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Summary
Historically, proximal humerus and humeral shaft nonunions have been regarded to be relatively rare injuries; however, more recent literature has suggested that such nonunions may be more prevalent than previously expected. Primary, nonsurgical management for aligned fracture patterns with proper immobilization remains the first line of treatment for fractures of the proximal humerus and humeral shaft. The precise time frame for diagnosing nonunion is controversial. However, the standard of care is achievement of a mechanically stable and biologically friendly construct with compression plating with the use of regional or autogenous bone grafting. Tuberosity position and function are critical in deciding between osteosynthesis, unconstrained arthroplasty, and reverse total shoulder arthroplasty for the management of proximal humerus nonunions.
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