René K. Marti and Christian van der Werken
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In general, surgical neck fractures of the proximal humerus heal with nonoperative treatment. Good and excellent results can be expected after anatomic reduction and sta- ble internal fixation of fractures of the proximal humerus.1 Therefore, the prevalence of delayed union and nonunions after conservative and operative treatment is low. The etiology of nonunions following conservative treatment is severe displacement or interposition of soft tissue. Failed internal fixations are based on excessive soft tissue dissec- tion, neglect of the basic principles of internal fixation, and finally vascular disturbance of the fracture area itself. For both treatment modalities, aggressive physiotherapy and poor patient compliance might be reasons for the nonunion as well.2
Established nonunions of the surgical neck pose a sig- nificant disability to the patient, causing pain, instability, and limitation of motion of the shoulder joint. In general, the patients are elderly and often have associated medical problems, posing a treatment challenge to the surgeon.
Despite these obstacles, we believe that a joint-preserving approach is indicated because the functional outcome of hemiarthroplasty is questionable.3
Classification
In comparison with femoral neck fractures, a proximal humeral fracture should unite within 4 months, other- wise we consider it a nonunion. These nonunions are usu- ally atrophic as a consequence of motion in the nonunion, leading to bone resorption with cavitation of the humeral head and producing a true pseudarthrosis. The combina- tion of nonunion and humeral head necrosis is theoreti- cally possible, but not seen in our series because most proximal humeral nonunions develop after two-part frac- tures of the surgical neck. Nonunions after three- and four-part fractures are rare.4
We might classify the proximal humeral nonunions in two specific types: Type A are nonunions with a rather big, well-vascularized head-metaphyseal fragment; type B are nonunions of the surgical neck leading to resorption with excavation of the humeral head.
Patient Assessment
History
Previous operation reports and analysis of the available x-rays will give the necessary information concerning the quality of the bone and rotator cuff.
Physical Examination
Range of motion (ROM) and neurovascular examination should be assessed before the operative intervention. A detailed examination of the axillary nerve function is crit- ically important as well. Most or all of the shoulder mo- tion results generally from motion at the false joint rather than at the glenohumeral joint (Fig. 8–1). In those hyper- mobile nonunions, forward elevation is impossible or at least modest. Severe muscle atrophy is present and the rotator cuff function is difficult to assess.
Radiologic Evaluation
Standard anteroposterior and axillary radiographic exam- ination is generally sufficient. Computed tomography (CT) or magnetic resonance imaging (MRI) has no influence on the indication for operative treatment. Fluoroscopy allows the evaluation of the ROM in the glenohumeral joint and in the nonunion. Stiffness occurs only when the tuberosi- ties are involved. The goal of the preoperative evaluation is to decide which technique is most suitable and if bone grafting is indicated.
Laboratory Studies
Infection can be excluded by clinical examination and ap- propriate blood studies including complete blood count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein screening, and radionuclear scanning. All con- comitant comorbid medical conditions need optimal treatment before the intervention.
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Treatment
Nonsurgical Treatment
Not every nonunion needs surgical treatment: Operative interventions are indicated in patients whose nonunions cause relevant pain and result in a nonfunctional shoulder.
Surgical Treatment
Different stabilization techniques are used–intramedullary rods (Rush, Ender, etc.), intramedullary cortical bone grafts, open reduction, and internal fixation with tension- band techniques and plates.2–10Recently, the use of proxi- mal humeral locking plate fixation techniques has been advocated for these nonunions. Those techniques are de- scribed in Chapter 4.
Fixation problems that one encounters in the treat- ment of acute proximal humeral fractures are often mag- nified in the setting of a nonunion. Nevertheless, the same principles, techniques, and implants are used to cre- ate the optimal stability that is necessary for any nonunion treatment. Approach and implant should not compromise the vascularity of the nonunion and the humeral head. Extra stability and biological stimulation by autologous bone grafting are often required, especially in atrophic nonunions of the resorption type.
Analyzing the literature and our own experience with referred patients, we conclude that the overall results of surgi- cal treatments with nails of any type have not been satisfac- tory. Open reduction and internal fixation is the method of choice in the treatment of proximal humeral nonunions.
The principles of internal fixation are the same as in the primary fracture treatment.1 Simple tension-band techniques may be sufficient if impaction of the shaft into the head of the humerus leads to intrinsic stability.1,7
Concerning surgical approaches, the use of blade plates is less invasive than those of T-plates, but for both similar results have been reported.1,5,6Double plat- ing in combination with bone grafting using semi- or third-tubular plates is a valid alternative when there is cavitation of the humeral head (Fig. 8–2). In all these techniques, the purchase of the screws in the head of the humerus is compromised. Therefore, these have to be combined with impaction and tension bands that—if correctly applied—rely on the soft tissue attachments of the rotator cuff. Even in severe osteoporosis, the ten- dons and their attachment to the bone are able to with- stand forces elicited by the wires. The new angle-stable plates provide a better fixation in the head of the humerus, but they will not eliminate the tension forces of the rotator cuff and will also rely on additional tension bands. The use of locking plate technology described in previous chapters can be helpful in some cases of diffi- cult proximal fragment bone insufficiency.
Endoprosthetic replacement is only indicated in the presence of a split or necrotic humeral head and in preex- istent glenohumeral arthrosis in the elderly patient. For the younger patient group, shoulder arthrodesis is still a valid option especially in case of associated infection.
Authors’ Recommended Treatment
The surgical approach is classical and the same for all three techniques we will describe. Beach-chair position, shoulder, and ipsi- or contralateral iliac crest are draped freely. Full motion of the arm during the operation is a must.
A standard deltopectoral approach is used, respecting scars of earlier interventions. The placement of a Blount retractor under the deltoid allows visualization of the proximal humerus and the rotator cuff (Fig. 8–3). Release Figure 8–1 Type B nonunion – technique II (see Fig. 8–6).
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Solutions for Complex Upper Extremity TraumaFigure 8–2 (A–D)Type B nonunion – technique IV. Severe excavation after primary tension-band internal fixation. Impaction and medializa- tion of the shaft, lateral waved T-plate and iliac grafts, double tension
band fixed below the plate around the first distal screw. There was uneventful healing and excellent functional results.
Figure 8–3 (A–D) Deltopectoral approach.
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of the deltoid or pectoralis insertion is almost never nec- essary. To prevent injuries to the neurovascular struc- tures, extended medial dissection should be avoided; the landmark to use is the biceps tendon.
Technique I
The treatment of type A proximal humeral nonunions be- low the surgical neck is similar to any other metaphyseal nonunion. Plate fixation in the big, well-vascularized head fragment is no problem. If both fragments are sclerotic, then impaction is not possible. The interposed fibrous tis- sue has to be removed, callus is decorticated, and both ends of the nonunion are débrided until bleeding bone is encountered. Now that the two fragments are adapted and compressed, a bridging graft may be necessary (Fig. 8–4).
All available implants can be used, angle blade plates, T-plates, the new angle stable plates (locking plates), and in delayed unions even a proximal humeral nail.
The challenge is the type B nonunion: the very proxi- mal surgical neck nonunion. Analyzing our more than 30 years’ experience, we developed a certain algorithm leading to three different techniques (II, III, and IV).
Technique II
The first step is, independent of the amount of bone re- sorption, the impaction of the shaft into the excavated head of the humerus. If the realized intrinsic stability is adequate, a pure, single or double tension-band technique can be applied (Figs. 8–5and 8–6).1,7
Technique III
If the intrinsic stability created by impaction is insuffi- cient, the plate tension-band technique is our method of
choice (Fig. 8–7). The first step is the optimal placement of one or two tension-band wires under the insertion of the supraspinatus tendon to avoid secondary varisation.
The second step is the impaction of the nonunion in a slight valgus overcorrection followed by the plate fixa- tion, in former times with a T-plate, nowadays with angu- lar stable plates (and/or locking plates). Important are the basic principles, independent of the chosen implant. Full compression using pointed reduction forceps must be ap- plied before the eccentric distal holes are used for the final compression. The tension-band wire is placed beyond the plate around a screw and is tightened in a figure eight around the plate. The cerclage wire will not only elimi- nate the bending forces, but also avoid a breakout of a nonangle stable plate. Additional stability can be achieved by crossing the screws in the humeral head.
Technique IV
The described technique will not function in the pres- ence of a severely excavated humeral head. Autogenous bone grafts are necessary to add extra stability and pro- mote biology. Reduction and tension-band principles are the same as in technique III; the plate internal fixa- tion is different. Either a T-plate or two flattened semi- tubular plates are waved laterally. The shaft fragment is displaced medially and the defect lateral in the humeral head and shaft is filled and bridged with solid cortico- cancellous grafts and free cancellous bone under the wave of the plates (Fig. 8–2). By placement of the grafts laterally any neurovascular damage is avoided. One or two tension bands around the supraspinatus insertion eliminate the tension forces. A tension band around the subscapularis insertion is only indicated if the medial translation of the humeral shaft and the lateral grafts do not provide sufficient stability. Then we prefer the less Figure 8–3 (Continued)
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Solutions for Complex Upper Extremity TraumaFigure 8–4 (A–G) Type A nonunion – technique I. Atrophic-interposition subcapital nonunion. Compressed T-plate, bridging graft. There were ex- cellent results and graft resorption followed Wolff’s law.
invasive application also used for primary fracture treatment (Fig. 8–5B). The cerclage wire is placed under the biceps tendon and anchored in the same drill holes as the supraspinatus tension band. Drilling holes me- dial/inferior, as described by Kloen et al7are difficult to
apply, require soft tissue stripping, and are a risk for the axillary nerve.
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Figure 8–5 (A)Simple supraspinatus tension band. Tension is applied on both sides with a small pointed retractor. (B)Double tension band.
Figure 8–6 (A–C) Type B nonunion – technique II (see Fig. 8–1). Hypermobile nonunion. Impaction, optimal intrinsic stability, secured by supraspinatus tension band. There were excellent functional results. Technique III would be the additional plate fixation.
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Solutions for Complex Upper Extremity Traumafractures, the tuberosities have to be osteotomized and fixed by the already described tension-band technique.10
Complications
Neurovascular complications are possible, but not reported in the literature and not seen in our series. A temporary shoulder subluxation may be the consequence of an over- looked axillary nerve palsy or rotator cuff atrophy. The shoulder function restores after the healing of the nonunion and remaining stiffness is well tolerated and does not need manipulation under anesthesia. An eventual open arthroly- sis could be combined with the hardware removal.
Postoperative Rehabilitation
Gentle pendulum exercises start on the first postoperative day, followed by passive shoulder mobilization up to 90 degrees elevation. Active motions in the same range are allowed after 4 weeks, full range after 6 weeks. Radiographs are obtained at 6 and 12 weeks to evaluate consolidation and a final control after 1 year.
Results
The best results of treatment of nonunions of the surgi- cal neck of the proximal humerus in the literature are those reported using blade plate fixation. Ring et al5doc- umented healing in 23 of 25 patients. Similar results were reported by Galatz et al6 using internal fixation
with blade plate or T-plate and autogenous bone graft in 13 patients.
The cases presented in those two articles do not show severe excavation of the humeral head (type B), compro- mising the anchorage of the blade plate. The impaction of the shaft into the excavated head does not allow the inser- tion of a seating chisel without destroying the achieved intrinsic stability. A valid alternative is certainly the new stable angle plates (locking compression plates [LCPs]) as long as the described basic principles of nonunion surgery are respected. Impaction and solid grafts create the neces- sary stability in the presence of an excavated head, secured by plate fixation and rotator cuff tension bands.
The relative lack of large numbers of patients and the multitude of fixation techniques make it difficult to com- pare the different studies and outline a standard protocol.
We conclude that the best results of treatment of type II nonunions occurred after open reduction and internal fix- ation combined with autogenous grafting.
All our cases are well documented with a follow-up to 32 years. The described techniques led to union in all cases, even after several earlier interventions (Fig. 8–8). The func- tional result was excellent in the type A nonunions (tech- nique I) and acceptable for the mostly elderly patients group in the type B nonunions (techniques II to IV).
In recent years, LCP largely replaced the angled blade plate, especially in type B nonunions. The LCP proved its versatility with a simple and smooth insertion technique resulting in outcomes that are comparable with those of the other described methods. All nonunions that were treated with a LCP finally healed despite considerable Figure 8–7 (A–C) Impaction, tension band around the plate.
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Figure 8–8 (A–G) Type B nonunion – technique IV. Remaining nonunion after three interventions and earlier plate fixation of a humerus shaft fracture. Mistake: no impaction, cerclage wires do not act as tension bands. Impaction-medialization of the shaft, two lat- eral, waved semitubular plates, iliac grafts. There was postoperative temporary subluxation because of the rotator cuff atrophy. Healing was uneventful; the patient had limited function, but was happy with her outcome.
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Solutions for Complex Upper Extremity Traumacomplications rates if the described basic principles, im- paction grafts, and tension band were not applied. The big advantage of the new plate is the safe anchorage of the screws even in an excavated head (Fig. 8–9).
Summary
Concerning treatment modalities the classification in type A and B nonunions is useful. Type A, the real subcapital nonunion, can be treated as a fresh subcapital fracture and as any other metaphyseal nonunion. In type B, the treatment depends on the amount of bone resorption of the head. If there is no excavation, impaction and a simple cerclage tension band around the supraspinatus allow a limited invasive technique.11In the case of severe bone resorption impaction, corticocancellous bone grafting, plates, and tension bands produce the necessary stability.
Following this algorithm, nonunions will heal, with func- tional results that mainly depend on the primary treat- ment. Secondary joint replacement is still an option as long as the rotator cuff is preserved.
Figure 8–9 (A,B) Fixation of a type B nonunion with a compressed locking proximal humerus (LPH) plate. Insufficient impaction. Lateral- ization of the shaft. No bone graft. Within 3 months, the screws broke out of the shaft, but the screws in the excavated head were still stable.
References
1. Wijgman AJ, Roolker W, Patt TW, Raaymakers EL, Marti 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: 1919–1925
2. Healy WL, Jupiter JB, Kristiansen TK, et al. Nonunion of the proximal humerus: a review of 25 cases. J Orthop Trauma 1990;4:424–431
3. Marti RK, Lim TE, Jolles CW. On the treatment of com- minuted fracture-dislocations of the proximal humerus:
internal fixation or prosthetic replacement. In: Koibel R, Helbig B, Blauth W, eds; Telger TC, trans. Shoulder Re- placement. New York: Springer; 1987:135–148
4. Neer CS. Displaced humeral fractures. Part II. The treat- ment of three-part and four-part displacement. J Bone Joint Surg Am 1970;52:1090–1103
5. Ring D, McKee MD, Perey BH, et al. The use of a blade plate and autogenous cancellous bone graft in the treat- ment of ununited fractures of the proximal humerus. J Shoulder Elbow Surg 2001;10:501–507
6. Galatz LM, Williams GR, Fenlin JM, et al. Outcome of open reduction and internal fixation of surgical neck nonunions of the humerus. J Orthop Trauma 2004; 18:63–68
7. Kloen P, Rubel IF, Helfet D. A two-tension-band technique for treatment of nonunions of the surgical neck of the humerus.
Tech Shoulder Elbow Surg 2001;2(3):187–193
8. Nayak NK, Schickendantz MS, Reagan WD, et al. Operative treatment of nonunion of surgical neck fractures of the humerus. Clin Orthop Relat Res 1995;313:200–205 9. Walch G, Badet R, Nové-Josserand L, et al. Nonunions of
the surgical neck of the humerus: surgical treatment with an intramedullry bone peg, internal fixation and cancel- lous bone grafting. J Shoulder Elbow Surg 1996; 5:161–168 10. Jupiter JB, Mullaji AB. Blade plate fixation of proximal
humeral nonunions. Injury 1994;25:301–303
11. Marti RK, Besselaar PP, Raaymakers EL. In: Ruedi TP, Murphy WM, eds. AO Principles of Fracture Manage- ment. Stuttgart/New York: Thieme Medical Publishing;
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