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Non Union of Humeral Fractures

- Discussion:
    - Non Union - General Discussion:
    - definition of fracture union: defined as bridging callus (ideally both cortices) on 2 orthogonal views with the
          disappearance of fracture lines
    - care must be taken not to mistake a pseudoarthrosis for a simple hypertrophic nonunion;
          - treatment of the pseudoarthrosis requires complete resection of the synovial tissue, and a closed IM nail does not suffice;
          - bone scan is helpful in diagnosis of pseudoarthrosis, which appears as a cold cleft between hot ends;
    - atrophic non union is most common for humeral shaft fracture:
          - failure of biology;
          - if bone ends appear avascular, then bone grafting or BMP grafting is necessary;

- Proximal Humeral Non Union:

                                  Inital Frx                                                 Non Union                         Rigid Fixation

          - references:
                 Nonunion of the proximal humerus. A review of 25 cases.
                 Blade plate fixation of proximal humeral non-unions.                
                 Management of nonunions of the proximal humeral diaphysis

- Humeral Shaft Non Union:
     - risk factors:
            - open fracture
            - segmental, transverse, or highly comminuted fracture pattern;
                   - ref: Nonunion of the humeral shaft: long lateral butterfly fracture--a nonunion predictive pattern? 
            - significant displacement of the fracture fragments (>100% of the shaft diameter);
            - smoking, diabetes, nonsteroidal anti-inflammatory drugs
            - infection (at the time of surgical revision, multiple cultures from the fracture site are required
                    to rule out infection);
            - hypothyroidism, metabolic bone disease

    - management:
         1) plate fixation as exchange IM nailing gives poor results;
                    - minimum of 8 cortices on each side of nonunion (may add augmentation plate if more
                            cortices are required)
                    - references:
                          - Anterior plating as a surgical alternative in the treatment of humeral shaft non-union
                          - Anterior augmentation plating of aseptic humeral shaft nonunions after intramedullary nailing
                          - Internal fixation of fractures and non-unions of the humeral shaft. Indications and results in a multi-center study.
                          - Treatment of humeral pseudarthroses by open reduction and internal fixation
                          - Open reduction and internal fixation of humeral non-unions: radiological and functional results.
                          - Treatment of atrophic diaphyseal humeral nonunions with locked plating and augmented with IM strut allograft.
                          - Locking compression plates for osteoporotic nonunions of the diaphyseal humerus.
                          - Plate fixation of ununited humeral shaft fractures: effect of type of bone graft on healing.
                          - Revision with dynamic compression plate and bone graft for aseptic nonunion after treatment of humeral shaft fracture.
                          - Outcome of locking compression plates in humeral shaft nonunions

         2) aggressive debridement or shortening osteotomy of non union site;
                - references:
                      - Shortening osteotomy and compression plating for atrophic humeral nonunions: surgical technique
                      - Step-Cut Osteotomy for Recalcitrant Humeral Shaft Nonunion
                      - Judet decortication and compression plate fixation of long bone non-union: Is bone graft necessary?
                      - Treatment of nonunion in neglected long bone shaft fractures by osteoperiosteal decortication

         3) bone grafting (bone graft menu / BMPs)
                 - application of 1/2 of a fibular strut graft in the IM canal and the other half on the far (anterior cortex) is one good option;
                 - references:
                      - Humeral shaft aseptic nonunion: treatment with opposite cortical allograft struts
                      - Humeral shaft nonunions treated with fibular allograft and compression plating.
                      - Use of IM fibular strut graft: a novel adjunct to plating in the treatment of osteoporotic humeral shaft nonunion.
                      - Endosteal Strut Augment Reduces Complications Associated With Proximal Humeral Locking Plates
                      - Non-vascularised fibular graft as an intramedullary strut for infected non-union of the humerus
                      - Treatment of diaphyseal humeral nonunions with compressive locked plating and augmented w/ IM strut allograft.
                      - Locking plate and fibular allograft augmentation in unstable fractures of proximal humerus
                      - Results of non-vascularised fibular grafting in gap non-union of long bones in paediatric age group
                      - Plating, nailing, external fixation, and fibular strut grafting for non-union of humeral shaft fractures
                       - Early outcomes of proximal humerus fracture fixation with locking plate and intramedullary fibular strut graft.

         - other references:
                    - Treatment of humeral shaft nonunions: nailing versus plating.
                    - Failure of reamed nailing in humeral non-union: an analysis of 26 patients.
                    - Locked intramedullary nailing for difficult nonunions of the humeral diaphysis.
                    - Comparison of the use of humerus IM nail and DC plate for management of diaphyseal frx of  humerus.
                    - Complex non-union of humeral diaphysis. Treatment with medial approach, anterior plate, and a vascularized fibular graft.
                    - Refractory humeral pseudoarthrosis: case report
                    - Review of Salvage Surgery for Refractory Humeral Shaft Nonunion following Two or More Prior Surgical Procedures
                    - The treatment of nonunions and pseudarthroses of the humeral shaft.
                    - Nonunion of the humerus. Clinical, response characteristics to treatment with constant DC stimulation of osteogenesis.
                    - The management of nonunions of the humerus.   
                    - Nonunion of the humeral shaft.
                    - Nonunion of the humerus.
                    - A combined therapeutic protocol for aseptic nonunion of the humeral shaft: a report of 25 cases.
                    - Management of non-union of humeral fractures with the Stryker T2™ compression nail
                    - The functional outcome of operative treatment of ununited fractures of the humeral diaphysis in older patients
                    - Case of the Month: Infected Humeral Non Union
                    - Nonunion of Humeral Shaft Fractures Following Flexible Nailing Fixation
                    - Union rate after operative treatment of humeral shaft nonunion--A systematic review.
                    - Treatment of humeral shaft nonunions: nailing versus plating.
                    - Comparison of the use of humerus IM nail and DCP for management of diaphyseal frx of the humerus. A RCS.

- Distal Humeral Non Union:
     - nonunion of fractures of the distal humerus usually occurs when stable
           internal fixation has not been achieved;
     - references:
           Open reduction and internal fixation of delayed union and nonunion of the distal humerus.
           Reconstruction after malunion and nonunion of intra-articular fractures of the distal humerus. Methods and results in 13 adults.
           Non-union of fractures of the distal end of the humerus.
           Plate-and-bone-strut fixation of distal third humeral shaft aseptic non-unions: A consecutive case series.

       - references:
             - Application of recombinant BMP-7 on persistent upper and lower limb non-unions.
             - Application of rhBMP-7 and PRP in treatment of long bone non-unions: a prospective randomised clinical study on 120 patients.
             - Judet decortication and compression plate fixation of long bone non-union: is bone graft necessary?
             - Clinical application of BMP 7 in long bone non-unions