Supracondylar Humeral Nonunions

Abstract

Nonunions of the distal humerus often lead to pain and stiffness of the forearm, elbow, and shoulder and are at times difficult to treat. A thorough assessment of the patient and of the local environment must be carried out in an effort to identify and reverse contributing factors. The assessment of the nonunion itself should include a detailed physical examination of the limb, radiographic imaging of the elbow and humerus (plain radiographs, and, on occasion, computed tomography scan) and laboratory investigations to determine whether or not an infection is present (complete blood count, erythrocyte sedimentation rate, and C-reactive protein). Occasionally, nuclear labeled scanning of the area is indicated, particularly if there is evidence of an infection. The use of magnetic resonance imaging has not been shown to help in the assessment and treatment of supracondylar nonunions. Treatment of supracondylar humeral nonunions should follow the development of an all-encompassing preoperative plan. This plan should anticipate the need for careful removal of often failed implants; freshening of the nonunion surfaces; reduction with re-establishment of limb length, alignment, and rotation; and stable internal fixation with or without the addition of autogenous bone graft or other osteoconductive or osteoinductive materials based upon the nature of the nonunion and the adequacy of the surrounding soft tissues. If an infection is present, then definitive treatment should be carried out in at least two stages and include prolonged administration of bacterial-specific systemic antibiotics. Additionally, residual stiffness of the elbow, forearm, and shoulder should be addressed at the time of definitive fixation.