274
Injury, 7, 274-278
Non-union in fractures of the humeral shaft R. Loomer and P. Kokan Division of Orthopaedic Surgery, University of British Columbia. Vancouver Summary Twenty-nine patients with non-union of the humeral shaft, who were treated in 3 major Vancouver hospitals, were studied. Reasons for non-union, effectiveness of various treatment methods, and complications are discussed. Fractures occurring in the middle third of the humeral shaft, comminuted or open fractures and those treated early by open reduction, are more prone to non-union. Nearly 50 per cent of the patients with non-union were chronic alcoholics. Compression plating with cancellous bone grafting gave the best rate of healing. However, both early and late operative treatment gave a relatively high complication rate. WATSON-JONES (1955) described the treatment of recent fractures of the humeral shaft as being simple and easy, but that of non-united fractures, very difficult. Reports by Hindmarsh and Unander-Sharin (1962) on the use of Ktintscher nailing, and by Mnaymeh et al. (1963) on the use of long Eggers plates, with bone grafting in both instances, suggest much more favourable results. A review of the records of 29 patients treated in Vancouver hospitals with non-united fractures of the humeral shaft was carried out, to assess the factors involved in the production of the non-union.
SERIES A retrospective review was made of all patients from the 3 major hospitals in the Vancouver area with the diagnosis of non-union of the humeral shaft. Only those patients for whom all records were available were included. This limited our series to 29 patients, treated between 1967 and 1973. Of these, 21 were males and 8 females. The age range was from 20 to 78, with a mean of 49.
The injury was a result of a motor vehicle accident in 8 cases, a fall in 13, and a direct blow in 5. The right humerus was fractured in 14 patients and the left in 15, The fracture was in the proximal third in 8 patients, the middle third in 19, and the distal third in 2. This compares with a series in one of these 3 hospitals of 111 fractures of the humeral shaft compiled in the years 1967 to 1973, in which 30 were in the proximal third, 57 in the middle third, and 24 in the distal third. In the series of fractures of the shaft of the humerus, 51 per cent (57) of the fractures were in the mid shaft, and 22 per cent (24) in the distal third; in the nonunion series 66 per cent (19) were in the mid shaft and only 7 per cent (2) in the distal third. Ten fractures were transverse, 3 short oblique, 5 long oblique, 11 comminuted and 3 fractures were open.
TREATMENT Treatment of the original fracture was conservative in most cases, with only 5 of 29 treated by an operation. Hanging plaster casts were used in 9 cases, ' sugar-tong ' plasters in 10, shoulder spicas in 3, Velpeau in 2, and Dunlop's traction in 1. Operative treatment included applying Rush rods with cerclage wires in 2 cases, 1 was treated with a KiJntscher nail, 1 with screw fixation, and 1 with Roger Anderson pins. All complications of the original treatment followed operative intervention. There were 2 cases of palsy of the radial nerve, 1 case of Volkmann's ischaemia of the forearm, and 1 case of osteomyelitis. In all 5 cases of operative treatment the fixation of the fracture was not adequate, resulting in non-union.
Loomer and Kokan : Fractures of Humeral Shaft
275
MANAGEMENT OF PSEUDARTHROSIS
united in 3 months, 1 united and refractured, and 1 developed non-union. A Ktintscher nail in addition to a bone graft was used in 2 patients. One united in 4 months and the other died f r o m unrelated causes. A shoulder and arm cast with a graft, a proximal humeral plate, a supracondylar Y-plate, and 2 right-angle plates were used in 4 remaining patients. They all united, except in the patient with 2 right-angle plates, and 1 died from unrelated causes (Table I). O f the 26 patients treated by operation, 23 had adequate follow-up. Eighteen of these united, 2 united and refractured, and 3 (13 per cent) failed to unite. The average time to union was 13 weeks.
F o u r t e e n patients had a history o f chronic alcoholism, 6 had chronic bronchitis, 4 had cardiovascular disorders, and 7 had other injuries. Local conditions included the 2 cases o f palsy of the radial nerve, and the case o f V o l k m a n n ' s ischaemia of the forearm due to laceration o f the brachial artery. The time f r o m fracture to treatment o f nonunion ranged f r o m 2 to 36 months, with an average o f 8 months. There was no correlation between time lapsed and success o f treatment. T w o patients had no treatment and remained non-united. One was treated in a shoulder and Table I.
Treatment of non-union
Type of treatment
Non-operative No treatment Shoulder and arm cast Operative Compression plate with graft Non-compression plate with sliding cortical graft Non-compression plate with iliac crest graft Non-compression plate and 2 screws Screw plus graft
No. of cases
2 1 10
1 4
Kiintscher nail plus graft Shoulder and arm plaster cast plus graft Proximal humeral plate Supracondylar Y-plate Two right-angle plates
arm cast and united in 5 months. Twenty-six were treated by operation (Table 1). The most c o m m o n f o r m of internal fixation was a compression plate with an iliac bone graft, which was used in 10 cases. In 9 cases which were followed-up, union occurred in all, in an average time of 289 months. Non-compression plates were the next most frequently used. These were combined with sliding cortical bone grafts in 2 patients, resulting in union in 289 months. Three patients had iliac crest bone grafts combined with non-compression plates, and of these, 1 united in 3 months, l failed to unite, and 1 united and refractured. One patient had a noncompression plate plus 2 screws and a bone graft. The screws pulled out and the fracture went on to non-union. F o u r patients were treated with screws and bone grafts. O f these, 2
Results and time to union
Both remained non-united United in 5 months 9 united, average time 2.6 months, 1 inadequate follow-up Both united, average time 2-5 months 1 united at 3 months, 1 non-union, 1 united but refractured Non-union, screws pulled out 2 united, average time 3 months, 1 non-union 1 united probable refracture 1 united at4 months, 1 died (unrelated causes) United at 3 months United at 10-12 months United at 3 months Patient died (unrelated causes)
A n example of the further difficulty encountered in several of these patients where treatment failed, is the following case history (Fig. 1). A 57-year-oid woman fell and fractured her left humerus on 19 April, 1963. She was treated with a hanging cast and the fracture was healing clinically and radiologically when she fell again 3 months later and refractured it. This was again treated by a hanging cast, but showed no evidence of union 2 months later, and so open reduction and fixation with 3 screws and a cancellous bone graft was undertaken. The fracture united clinically in 3 months, though she was left with limited extension of the elbow. Fourteen months after the original injury she carried a large suitcase to mobilize her elbow, and refractured the humerus. The screws were then removed and an Eggers plate and more iliac crest bone applied. This healed, but she fell again 3 years later and refractured the bone and the plate. The
276
Injury : the British Journal of Accident Surgery Vol. 7/No. 4
A
B
C
D
E
Fig. 1. A, Refracture after 3 months. B, Second refracture 14 months after original injury. C, After application of Eggers plate and iliac crest graft. D, Refracture of bone and plate. E, Fixation of third refracture. Permanent union was achieved. fracture was again exposed, the plate removed, the bone ends reduced and mortised, a tibial corticocancellous graft added, and 2 Eggers plates with 6 screws and 3 bolts were applied. This fracture united in 4 months and has remained so.
nerve, both of which recovered. Three patients required further operation for removal of fixation devices that caused symptoms, and one had infection of the iliac crest donor site.
Operative treatment of non-union of the humerus in this series has a high complication rate (TableII). Mild limitation of shoulder and elbow movement was present in 24 patients. Nonunion occurred in 3 patients (13 per cent), and refracture in 2. There were 2 palsies of the radial
The reported rate of non-union in fracture of the humeraI shaft varies with the series and treatment method. Kennedy and Wyatt (1957) found only one non-union in 78 fractures of the mid shaft treated in hanging casts, while Klenerman (1966) reports 10 cases of delayed union in 87 shaft
DISCUSSION
Loomer and Kokan : Fractures of Humeral Shaft
fractures also treated in casts. Fenyo (1971) reported on 98 patients, of whom 55 were treated by operation. There was one case (2.2 per cent) of non-union of a humeral shaft fracture among 43 patients treated non-operatively, and 4 cases (7'4 per cent) among 55 patients treated by operation. The total incidence of pseudarthrosis calculated from the Vancouver General Hospital series was 3"7 per cent or 8 our of 217 patients. In this retrospective review a study of the various factors leading to non-union was not Table II.
277
study to answer this question. However, we did find that 3 of 5 patients whose original fractures were treated by operation developed complications, whereas none of the 24 cases managed conservatively did. In Fenyo's study, operatively treated patients had more than double the rate of non-union when compared with patients treated in casts (Fenyo, 1971). In this series, many patients were alcoholic or had chronic lung disease, which probably contributed to poor healing of the fracture.
Complications of treatment of non-union
Complication Limitation of shoulder and elbow movements Non-union Refracture Radial nerve palsy Pain requiring removal of plate Migration of rod requiring removal Screws through humeral head into glenoid Infection of lilac crest graft site
possible. Nonetheless we came to the conclusion that fractures of the middle third are more prone to non-union than fractures of the proximal or distal thirds of the humerus. This may be owing to injury of the main nutrient artery at the time of fracture. Laing (1956) demonstrated a main nutrient artery entering the distal part of the middle third of the humeral shaft and suggested that it accounts for the increased incidence of non-union at that level. This may also explain the good prognosis in fractures of the lower third when the proximal fragment has its nutrient vessel intact, and the distal fragment derives its supply from the vessels around the rnetaphysis. Comminuted (11) and open (3) fractures were relatively frequent among our group of patients, but are obviously not the major factors leading to non-union. In our 5 cases treated by primary operation, the non-union was caused by inadequate fixation. Here operation caused further damage to the vascular supply of the bone fragments. Our findings are in agreement with the report by Mnaymeh et al. (1963) who lists factors leading to non-union as site of fracture, cornminution, open injury, operative intervention and traction. Considerable controversy exists over the best method of treating closed fractures of the shaft of the humerus. N o attempt was made in our
No. of cases 24 3 2 2 (both recovered) 1 1 1 1
Contrary to previous warnings by WatsonJones about patients requiring 14-17 operations before achieving union, the present series suggests a relatively optimistic view of successful union using compression plates combined with cancellous bone grafting. However, casual surgical treatment of pseudarthrosis of the humeral shaft is still associated with a relatively high complication rate, which includes joint stiffness, nerve injuries, infection of donor graft area, and a noteworthy rate of non-union (Table H). CONCLUSIONS
Although this study was retrospective and the series small, the data and a review of the literature suggest the following factors leading to nonunion in fractures of the humeral shaft: 1. a. Fractures in the middle third and which are comminuted and/or open; b. those occurring in alcoholics; c. those treated by early open reduction and inadequate internal fixation. 2. Operative treatment, using inferior fixation methods, is associated with a high rate of nonunion. Injuries of neurovascular structures and infection can occur in the operative treatment of recent or non-united humeral fractures. Compression plates and cancellous bone grafts gave excellent results (9 out of 9 united) and if used earlier, perhaps at 3 or 4 months,
278
c o u l d n o t only result in a h i g h e r rate o f u n i o n , b u t c o u l d also help to p r e v e n t j o i n t stiffness by a l l o w i n g early m o b i l i z a t i o n a n d to r e d u c e t h e rate o f refracture, especially in alcoholics. REFERENCES
FENYO G. (1971) On fractures of the shaft of the humerus. Acta Chir. Scand. 137, 221. HINDMARSH J. and UNANDER-SHARIN L. (1962) Osteosynthesis in pseudarthrosis of the humerus diaphysis. Acta Orthop. Scand. 32, 120.
Injury : the British Journal of Accident Surgery Vol. 7/No. 4
KENNEDY J. C. and WYATT J. K. (1957) An evaluation of the management of fractures through the middle third of the humerus. Can. J. Surg. 1, 26. KLENERMAN L. (1966) Fractures of the shaft of the humerus. J. Bone Joint Surg. 48B, 105. LAING P. G. (1956) Blood supply of the humerus. J. Bone Joint Surg. 38A, 1105. MNAYMEH W. A., SMITH-PETERSEN M. and AUFRANC O. E. (1963) Proceeding of t h e A . A. O. S. J. Bone Joint Surg. 45A, 1548. WATSON-JONES R. (1955) Fractures and Joint Injuries, 4th ed. Edinburgh, Livingstone.
Requestsfor reprints shouldbe addressedto: Dr R. Loomer, Suite 607, 625 Fifth Avenue, New Westminster, B. C., Canada, V3M IX4.
Injury, 7, 274-278
Non-union in fractures of the humeral shaft R. Loomer and P. Kokan Division of Orthopaedic Surgery, University of British Columbia. Vancouver Summary Twenty-nine patients with non-union of the humeral shaft, who were treated in 3 major Vancouver hospitals, were studied. Reasons for non-union, effectiveness of various treatment methods, and complications are discussed. Fractures occurring in the middle third of the humeral shaft, comminuted or open fractures and those treated early by open reduction, are more prone to non-union. Nearly 50 per cent of the patients with non-union were chronic alcoholics. Compression plating with cancellous bone grafting gave the best rate of healing. However, both early and late operative treatment gave a relatively high complication rate. WATSON-JONES (1955) described the treatment of recent fractures of the humeral shaft as being simple and easy, but that of non-united fractures, very difficult. Reports by Hindmarsh and Unander-Sharin (1962) on the use of Ktintscher nailing, and by Mnaymeh et al. (1963) on the use of long Eggers plates, with bone grafting in both instances, suggest much more favourable results. A review of the records of 29 patients treated in Vancouver hospitals with non-united fractures of the humeral shaft was carried out, to assess the factors involved in the production of the non-union.
SERIES A retrospective review was made of all patients from the 3 major hospitals in the Vancouver area with the diagnosis of non-union of the humeral shaft. Only those patients for whom all records were available were included. This limited our series to 29 patients, treated between 1967 and 1973. Of these, 21 were males and 8 females. The age range was from 20 to 78, with a mean of 49.
The injury was a result of a motor vehicle accident in 8 cases, a fall in 13, and a direct blow in 5. The right humerus was fractured in 14 patients and the left in 15, The fracture was in the proximal third in 8 patients, the middle third in 19, and the distal third in 2. This compares with a series in one of these 3 hospitals of 111 fractures of the humeral shaft compiled in the years 1967 to 1973, in which 30 were in the proximal third, 57 in the middle third, and 24 in the distal third. In the series of fractures of the shaft of the humerus, 51 per cent (57) of the fractures were in the mid shaft, and 22 per cent (24) in the distal third; in the nonunion series 66 per cent (19) were in the mid shaft and only 7 per cent (2) in the distal third. Ten fractures were transverse, 3 short oblique, 5 long oblique, 11 comminuted and 3 fractures were open.
TREATMENT Treatment of the original fracture was conservative in most cases, with only 5 of 29 treated by an operation. Hanging plaster casts were used in 9 cases, ' sugar-tong ' plasters in 10, shoulder spicas in 3, Velpeau in 2, and Dunlop's traction in 1. Operative treatment included applying Rush rods with cerclage wires in 2 cases, 1 was treated with a KiJntscher nail, 1 with screw fixation, and 1 with Roger Anderson pins. All complications of the original treatment followed operative intervention. There were 2 cases of palsy of the radial nerve, 1 case of Volkmann's ischaemia of the forearm, and 1 case of osteomyelitis. In all 5 cases of operative treatment the fixation of the fracture was not adequate, resulting in non-union.
Loomer and Kokan : Fractures of Humeral Shaft
275
MANAGEMENT OF PSEUDARTHROSIS
united in 3 months, 1 united and refractured, and 1 developed non-union. A Ktintscher nail in addition to a bone graft was used in 2 patients. One united in 4 months and the other died f r o m unrelated causes. A shoulder and arm cast with a graft, a proximal humeral plate, a supracondylar Y-plate, and 2 right-angle plates were used in 4 remaining patients. They all united, except in the patient with 2 right-angle plates, and 1 died from unrelated causes (Table I). O f the 26 patients treated by operation, 23 had adequate follow-up. Eighteen of these united, 2 united and refractured, and 3 (13 per cent) failed to unite. The average time to union was 13 weeks.
F o u r t e e n patients had a history o f chronic alcoholism, 6 had chronic bronchitis, 4 had cardiovascular disorders, and 7 had other injuries. Local conditions included the 2 cases o f palsy of the radial nerve, and the case o f V o l k m a n n ' s ischaemia of the forearm due to laceration o f the brachial artery. The time f r o m fracture to treatment o f nonunion ranged f r o m 2 to 36 months, with an average o f 8 months. There was no correlation between time lapsed and success o f treatment. T w o patients had no treatment and remained non-united. One was treated in a shoulder and Table I.
Treatment of non-union
Type of treatment
Non-operative No treatment Shoulder and arm cast Operative Compression plate with graft Non-compression plate with sliding cortical graft Non-compression plate with iliac crest graft Non-compression plate and 2 screws Screw plus graft
No. of cases
2 1 10
1 4
Kiintscher nail plus graft Shoulder and arm plaster cast plus graft Proximal humeral plate Supracondylar Y-plate Two right-angle plates
arm cast and united in 5 months. Twenty-six were treated by operation (Table 1). The most c o m m o n f o r m of internal fixation was a compression plate with an iliac bone graft, which was used in 10 cases. In 9 cases which were followed-up, union occurred in all, in an average time of 289 months. Non-compression plates were the next most frequently used. These were combined with sliding cortical bone grafts in 2 patients, resulting in union in 289 months. Three patients had iliac crest bone grafts combined with non-compression plates, and of these, 1 united in 3 months, l failed to unite, and 1 united and refractured. One patient had a noncompression plate plus 2 screws and a bone graft. The screws pulled out and the fracture went on to non-union. F o u r patients were treated with screws and bone grafts. O f these, 2
Results and time to union
Both remained non-united United in 5 months 9 united, average time 2.6 months, 1 inadequate follow-up Both united, average time 2-5 months 1 united at 3 months, 1 non-union, 1 united but refractured Non-union, screws pulled out 2 united, average time 3 months, 1 non-union 1 united probable refracture 1 united at4 months, 1 died (unrelated causes) United at 3 months United at 10-12 months United at 3 months Patient died (unrelated causes)
A n example of the further difficulty encountered in several of these patients where treatment failed, is the following case history (Fig. 1). A 57-year-oid woman fell and fractured her left humerus on 19 April, 1963. She was treated with a hanging cast and the fracture was healing clinically and radiologically when she fell again 3 months later and refractured it. This was again treated by a hanging cast, but showed no evidence of union 2 months later, and so open reduction and fixation with 3 screws and a cancellous bone graft was undertaken. The fracture united clinically in 3 months, though she was left with limited extension of the elbow. Fourteen months after the original injury she carried a large suitcase to mobilize her elbow, and refractured the humerus. The screws were then removed and an Eggers plate and more iliac crest bone applied. This healed, but she fell again 3 years later and refractured the bone and the plate. The
276
Injury : the British Journal of Accident Surgery Vol. 7/No. 4
A
B
C
D
E
Fig. 1. A, Refracture after 3 months. B, Second refracture 14 months after original injury. C, After application of Eggers plate and iliac crest graft. D, Refracture of bone and plate. E, Fixation of third refracture. Permanent union was achieved. fracture was again exposed, the plate removed, the bone ends reduced and mortised, a tibial corticocancellous graft added, and 2 Eggers plates with 6 screws and 3 bolts were applied. This fracture united in 4 months and has remained so.
nerve, both of which recovered. Three patients required further operation for removal of fixation devices that caused symptoms, and one had infection of the iliac crest donor site.
Operative treatment of non-union of the humerus in this series has a high complication rate (TableII). Mild limitation of shoulder and elbow movement was present in 24 patients. Nonunion occurred in 3 patients (13 per cent), and refracture in 2. There were 2 palsies of the radial
The reported rate of non-union in fracture of the humeraI shaft varies with the series and treatment method. Kennedy and Wyatt (1957) found only one non-union in 78 fractures of the mid shaft treated in hanging casts, while Klenerman (1966) reports 10 cases of delayed union in 87 shaft
DISCUSSION
Loomer and Kokan : Fractures of Humeral Shaft
fractures also treated in casts. Fenyo (1971) reported on 98 patients, of whom 55 were treated by operation. There was one case (2.2 per cent) of non-union of a humeral shaft fracture among 43 patients treated non-operatively, and 4 cases (7'4 per cent) among 55 patients treated by operation. The total incidence of pseudarthrosis calculated from the Vancouver General Hospital series was 3"7 per cent or 8 our of 217 patients. In this retrospective review a study of the various factors leading to non-union was not Table II.
277
study to answer this question. However, we did find that 3 of 5 patients whose original fractures were treated by operation developed complications, whereas none of the 24 cases managed conservatively did. In Fenyo's study, operatively treated patients had more than double the rate of non-union when compared with patients treated in casts (Fenyo, 1971). In this series, many patients were alcoholic or had chronic lung disease, which probably contributed to poor healing of the fracture.
Complications of treatment of non-union
Complication Limitation of shoulder and elbow movements Non-union Refracture Radial nerve palsy Pain requiring removal of plate Migration of rod requiring removal Screws through humeral head into glenoid Infection of lilac crest graft site
possible. Nonetheless we came to the conclusion that fractures of the middle third are more prone to non-union than fractures of the proximal or distal thirds of the humerus. This may be owing to injury of the main nutrient artery at the time of fracture. Laing (1956) demonstrated a main nutrient artery entering the distal part of the middle third of the humeral shaft and suggested that it accounts for the increased incidence of non-union at that level. This may also explain the good prognosis in fractures of the lower third when the proximal fragment has its nutrient vessel intact, and the distal fragment derives its supply from the vessels around the rnetaphysis. Comminuted (11) and open (3) fractures were relatively frequent among our group of patients, but are obviously not the major factors leading to non-union. In our 5 cases treated by primary operation, the non-union was caused by inadequate fixation. Here operation caused further damage to the vascular supply of the bone fragments. Our findings are in agreement with the report by Mnaymeh et al. (1963) who lists factors leading to non-union as site of fracture, cornminution, open injury, operative intervention and traction. Considerable controversy exists over the best method of treating closed fractures of the shaft of the humerus. N o attempt was made in our
No. of cases 24 3 2 2 (both recovered) 1 1 1 1
Contrary to previous warnings by WatsonJones about patients requiring 14-17 operations before achieving union, the present series suggests a relatively optimistic view of successful union using compression plates combined with cancellous bone grafting. However, casual surgical treatment of pseudarthrosis of the humeral shaft is still associated with a relatively high complication rate, which includes joint stiffness, nerve injuries, infection of donor graft area, and a noteworthy rate of non-union (Table H). CONCLUSIONS
Although this study was retrospective and the series small, the data and a review of the literature suggest the following factors leading to nonunion in fractures of the humeral shaft: 1. a. Fractures in the middle third and which are comminuted and/or open; b. those occurring in alcoholics; c. those treated by early open reduction and inadequate internal fixation. 2. Operative treatment, using inferior fixation methods, is associated with a high rate of nonunion. Injuries of neurovascular structures and infection can occur in the operative treatment of recent or non-united humeral fractures. Compression plates and cancellous bone grafts gave excellent results (9 out of 9 united) and if used earlier, perhaps at 3 or 4 months,
278
c o u l d n o t only result in a h i g h e r rate o f u n i o n , b u t c o u l d also help to p r e v e n t j o i n t stiffness by a l l o w i n g early m o b i l i z a t i o n a n d to r e d u c e t h e rate o f refracture, especially in alcoholics. REFERENCES
FENYO G. (1971) On fractures of the shaft of the humerus. Acta Chir. Scand. 137, 221. HINDMARSH J. and UNANDER-SHARIN L. (1962) Osteosynthesis in pseudarthrosis of the humerus diaphysis. Acta Orthop. Scand. 32, 120.
Injury : the British Journal of Accident Surgery Vol. 7/No. 4
KENNEDY J. C. and WYATT J. K. (1957) An evaluation of the management of fractures through the middle third of the humerus. Can. J. Surg. 1, 26. KLENERMAN L. (1966) Fractures of the shaft of the humerus. J. Bone Joint Surg. 48B, 105. LAING P. G. (1956) Blood supply of the humerus. J. Bone Joint Surg. 38A, 1105. MNAYMEH W. A., SMITH-PETERSEN M. and AUFRANC O. E. (1963) Proceeding of t h e A . A. O. S. J. Bone Joint Surg. 45A, 1548. WATSON-JONES R. (1955) Fractures and Joint Injuries, 4th ed. Edinburgh, Livingstone.
Requestsfor reprints shouldbe addressedto: Dr R. Loomer, Suite 607, 625 Fifth Avenue, New Westminster, B. C., Canada, V3M IX4.
