Plating, Nailing, External Fixation, and Fibular Strut Grafting for Non-Union of Humeral Shaft Fractures

Purpose. To compare various treatment modalities (plating, Ilizarov external fixation, and non-vascular fibular cortical strut grafting) for non-union of humeral shaft fractures. Methods. Records of 9 women and 26 men aged 24 to 71 (mean, 42) years who presented with non-union of humeral shaft fractures were reviewed. The humeral shaft fractures were secondary to low-energy trauma (n=22) or vehicular accidents (n=13) and involved the proximal (n=9), middle (n=15), and distal (n=11) regions. 13 of the fractures were open. Infection was evident in 8 of the non-unions. For non-unions with infection (n=8), a 2-stage procedure entailing temporary Ilizarov fixation followed by plating was used. For non-unions without infection (n=23), one-stage plating and cancellous bone grafting was used. For non-unions of osteoporotic bone (n=4), one-stage non-vascularised fibular strut grafting was used. Outcome was measured using the Disabilities of the Arm, Shoulder and Hand (DASH) scoring system. Results. The 35 patients were followed up for a mean of 16 (range, 6–60) months. All achieved bone union except for one (who had persistent infection). Respectively for non-unions with infection, nonunions without infection, and non-unions of osteoporotic bone, the mean times to bone union were 6.5 (range, 4–10), 5 (range, 4–8), and 10 (range, 6–14) months, the mean improvement in DASH score was 30, 43, and 18, and malalignment was noted in 5, 2, and one patient. Three patients had a preoperative radial nerve palsy for which standard tendon transfer was performed 6 weeks after treatment for non-union. Conclusion. Compression plating achieved the best results. An external fixator may be used temporarily for infected non-unions. Fibular strut grafting may be used when non-unions warrant additional stability.