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Humeral Head Nonunion

  • Stefano Di Fabio
  • Corrado D’Antimo
Chapter

Abstract

Fractures of the proximal humerus are common, and the majority of them unite successfully, many without surgical operation. A small percentage develop into nonunion. Nonunion of the proximal humerus presents different challenges due to biological insults from the initial injury and previous surgeries, bone loss, humeral head cavitation, osteopenia, soft tissue contractures, and infection.

Risk factors for developing a nonunion include facture characteristics, such as increased fracture translation and bonny comminutions, but the relationship of these parameters is not simple. Patients-related risk factors include nutritional or metabolic deficiencies, smoking, and medical comorbidities.

Once a nonunion has been identified, every effort should be made to address the problem before 6 months after the initial injury and prior to developing glenohumeral soft tissue contractures which may further limit the patient’s function and increase pain level creating a vicious circle potentially very dangerous.

Treatment options in case of nonunion are wide and range from nonsurgical management for minimally symptomatic patients to surgical option including osteosynthesis with last generation locking plates, interlocked intramedullary implant, and arthroplasty ranging from hemiarthroplasty to total or reverse shoulder prosthesis. Reconstruction surgery may include augments such as autograft, allograft, or structural grafts. The surgical goals are to provide a stable mechanical construct that allows early mobilization and to create a biological environment favorable to fracture healing.

Keywords

Proximal humerus Fracture Nonunion Plate fixation Bone graft Shoulder arthroplasty 

References

  1. 1.
    Lind T, Kroner K, Jensen J. The epidemiology of fractures of the proximal humerus. Arch Orthop Trauma Surg. 1989;108(5):285–7.CrossRefGoogle Scholar
  2. 2.
    Court-Brown CM, Caesar B. Epidemiology of adult fractures: a review. Injury. 2006;37(8):691–7.CrossRefGoogle Scholar
  3. 3.
    Court-Brown CM, Garg A, McQueen MM. The epidemiology of proximal humerus fractures. Acta Orthop Scand. 2001;72(4):365–71.CrossRefGoogle Scholar
  4. 4.
    Palvenen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humerus fractures. Clin Orthop Relat Res. 2006;442:87–92.CrossRefGoogle Scholar
  5. 5.
    Green A, Norris TR. Proximal humeral fractures and glenohumeral dislocation. In: Browner BD, Levine AM, Jupiter JB, Trafton PG, Krettek C, editors. Skeletal trauma: basic science, management, and reconstruction. 4th ed. Philadelphia, PA: Saunders Elsevier; 2009. p. 1623–754.Google Scholar
  6. 6.
    Warner JP, Costouros JG, Gerber C. Fractures of the proximal humerus. In: Buchholz RW, Heckman JD, Court-Brown C, editors. Rockwood and Green’s fractures in adults. 6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 1039–105.Google Scholar
  7. 7.
    Court-Brown CM, McQueen MM. Nonunions of the proximal humerus: their prevalence and functional outcome. J Trauma. 2008;64(6):1517–21.CrossRefGoogle Scholar
  8. 8.
    Hanson B, Neidenbach P, de Boer P, Stengel D. Functional outcomes after nonoperative management of fractures of the proximal humerus. J Shoulder Elb Surg. 2009;18(4):612–21.CrossRefGoogle Scholar
  9. 9.
    Iyengar JJ, Devcic Z, Sproul RC, Feley BT. Non-operative treatment of proximal humerus fractures: a systematic review. J Orthop Trauma. 2011;25(10):612–7.CrossRefGoogle Scholar
  10. 10.
    Galatz LM, Iannotti JP. Management of surgical neck nonunions. Orthop Clin North Am. 2000;31(1):51–61.CrossRefGoogle Scholar
  11. 11.
    Yamane S, Suenaga N, Oizumi N, Minami A. Interlocking intramedullary nailing for nonunion of the proximal humerus with the straight nail system. J Shoulder Elb Surg. 2008;17(5):755–9.CrossRefGoogle Scholar
  12. 12.
    Antuña SA, Sperling JW, Sánchez-Sotelo J, Cofield RH. Shoulder arthroplasty for proximal humeral non unions. J Shoulder Elb Surg. 2002;11(2):114–21.CrossRefGoogle Scholar
  13. 13.
    Nayak NK, Schickendantz MS, Regan WD, Hawkins RJ. Operative treatment of nonunion of surgical neck fractures of the humerus. Clin Orthop Relat Res. 1995;(313):200–5.Google Scholar
  14. 14.
    Duralde XA, Flatow EL, Pollock RG, Nicholson GP, Self EB, Bigliani LU. Operative treatment of nonunions of the surgical neck of the humerus. J Shoulder Elb Surg. 1996;5(3):169–80.CrossRefGoogle Scholar
  15. 15.
    Brinker MR, O’Connor DP, Monla YT, Earthman TP. Metabolic and endocrine abnormalities in patients with nonunions. J Orthop Trauma. 2007;21(8):557–70.CrossRefGoogle Scholar
  16. 16.
    Checchia SL, Doneux P, Miyazaki AN, Sir IA, Bringel R, Ramos CH. Classification of non-unions of the proximal humerus. Int Orthop. 2000;24(4):217–20.CrossRefGoogle Scholar
  17. 17.
    Beredjiklian PK, Iannotti JP, Norris TR, Williams GR. Operative treatment of malunion of a fracture of the proximal aspect of the humerus. J Bone Joint Surg Am. 1998;80(10):1484–97.CrossRefGoogle Scholar
  18. 18.
    Badman B, Mighell M, Drake G. Proximal humeral nonunions: surgical technique with fibular strut allograft and fixed-angle locked plating. Tech Shoulder Elbow Surg. 2006;7(2):95–101.CrossRefGoogle Scholar
  19. 19.
    Rockwood CA, Pearce JC. Management of proximal humerus nonunions. Orthop Trans. 1989;13:644.Google Scholar
  20. 20.
    Cadet ER, Yin B, Schulz B, Ahmad CS, Rosenwasser MP. Proximal humerus and humeral shaft nonunions. J Am Acad Orthop Surg. 2013;21(9):538–47.PubMedGoogle Scholar
  21. 21.
    Healy WL, White GM, Mick CA, Brooker AF Jr, Weiland AJ. Nonunion of the humeral shaft. Clin Orthop Relat Res. 1987;(219):206–13.Google Scholar
  22. 22.
    Rubel IF, Kloen P, Campbell D, et al. Open reduction and internal fixation of humeral nonunions: a biomechanical and clinical study. J Bone Joint Surg Am. 2002;84(8):1315–22.CrossRefGoogle Scholar
  23. 23.
    Volgas DA, Stannard JP, Alonso JE. Nonunions of the humerus. Clin Orthop Relat Res. 2004;419:46–50.CrossRefGoogle Scholar
  24. 24.
    Thanasas C, Kontakis G, Angoules A, Limb D, Giannoudis P. Treatment of proximal humerus fractures with locking plates: a systematic review. J Shoulder Elb Surg. 2009;18(6):837–44.CrossRefGoogle Scholar
  25. 25.
    Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Matti RK. Open reduction and internal fixation of three and four-part fractures of the proximal part of the humerus. J Bone Joint Surg Am. 2002;84-A(11):1919–25.CrossRefGoogle Scholar
  26. 26.
    Cadet ER, Ahmad CS. Hemiarthroplasty for three- and four-part proximal humerus fractures. J Am Acad Orthop Surg. 2012;20(1):17–27.PubMedGoogle Scholar
  27. 27.
    Martinez AA, Bejarano C, Carbonel I, Iglesias D, Gil-Albarova J, Herrera A. The treatment of proximal humerus nonunions in older patients with the reverse shoulder arthroplasty. Injury. 2012;43(Suppl 2):S3–6.CrossRefGoogle Scholar
  28. 28.
    Clavert P, Adam P, Bevort A, Bonnomet F, Kempf JF. Pitfalls and complications with locking plate for proximal humerus fracture. J Shoulder Elb Surg. 2010;19(4):489–94.CrossRefGoogle Scholar
  29. 29.
    Tauber M, Brugger A, Povacz P, Resch H. Reconstructive surgical treatment without bone grafting in nonunions of humeral surgical neck fractures. J Orthop Trauma. 2011;25(7):392–8.CrossRefGoogle Scholar
  30. 30.
    Allende C, Allende BT. The use of a new locking 90 degree blade plate in the treatment of atrophic proximal humerus nonunions. Int Orthop. 2009;33(6):1649–54.CrossRefGoogle Scholar
  31. 31.
    Gartsman GM, Taverna E. Arthroscopic treatment of rotator cuff tear and greater tuberosity fracture nonunion. Arthroscopy. 1996;12(2):242–4.CrossRefGoogle Scholar
  32. 32.
    Healy WL, Jupiter JB, Kristiansen TK, White RR. Nonunion of the proximal humerus: a review of 25 cases. J Orthop Trauma. 1990;4(4):424–31.CrossRefGoogle Scholar
  33. 33.
    Ring D, McKee MD, Perey BH, Jupiter JB. The use of a blade plate and autogenous cancellous bone graft in the treatment of ununited fractures of the proximal humerus. J Shoulder Elb Surg. 2001;10(6):501–7.CrossRefGoogle Scholar
  34. 34.
    Walch G, Badet R, Nove Josserand L, Levigne C. Nonunions of the surgical neck of the humerus: surgical treatment with an intramedullary bone peg, internal fixation, and cancellous bone grafting. J Shoulder Elb Surg. 1996;5(3):161–8.CrossRefGoogle Scholar
  35. 35.
    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):173–9.CrossRefGoogle Scholar
  36. 36.
    Garrison KR, Shemilt I, Donell S, et al. Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database Syst Rev. 2010;(6):CD006950.Google Scholar
  37. 37.
    Friedlaender GE, Perry CR, Cole JD, et al. Osteogenic protein-1 (bone morphogenetic protein-7) in the treatment of tibial nonunions. J Bone Joint Surg Am. 2001;83(Suppl 1 Pt 2):S151–8.PubMedGoogle Scholar
  38. 38.
    Boileau P, Chuinard C, Le Huec JC, Walch G, Trojani C. Proximal humerus fracture sequelae: impact of a new radiographic classification on arthroplasty. Clin Orthop Relat Res. 2006;442:121–30.CrossRefGoogle Scholar
  39. 39.
    Duquin TR, Jacobson JA, Sanchez-Sotelo J, Sperling JW, Cofield RH. Unconstrained shoulder arthroplasty for treatment of proximal humeral nonunions. J Bone Joint Surg Am. 2012;94(17):1610–7.CrossRefGoogle Scholar
  40. 40.
    Zafra M, Udeca P, Flores M, Carpintero P. Reverse total shoulder replacement for nonunion of a fracture of the proximal humerus. J Bone Joint Surg Br. 2014;96-B:1239–43.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Stefano Di Fabio
    • 1
  • Corrado D’Antimo
    • 1
  1. 1.Orthopaedics DepartmentSan Martino HospitalBellunoItaly

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