This is the case of a 75 year old female with multiple medical problems. She fell in January and sustained this long spiral humeral shaft fracture. Due to her medical conditions, I opted to treat her without surgery. Her films are below.
After 4 months of nonoperative treatment using a humeral fracture brace, her films below demonstrated very little healing and there was still significant motion at the fracture site. She said she could feel the fracture moving a clicking every time she moved the arm despite wearing the brace.
Many of these fractures will heal without surgery. As with any fracture, there is no such thing as a 100% union rate with nonoperative treatment. So after recognizing that this fracture would no heal on its own, she was brought to the operating room for a surgical repair. After 4 months of healing the normal anatomy is distorted by scar tissue. Nerves and arteries are not easily definable as they are bound in this scar tissue and displaced by the fracture. Surgical dissections under these circumstances are very tedious and difficult. As I sit there doing the surgery, I often realize how much easier this would be if it were done 4 months earlier. But, as I said, these fractures often heal by themselves.
Getting a nonunion to heal is not easy either. We always use some bone graft. The best bone is usually the patient’s own bone taken from the iliac crest (lateral aspect of pelvis). How we harvest the bone varies. A great technique is to use a small acetabular reamer usually used for total hip replacements. This device works like a power grater to grind the outer wall of the pelvis creating bone graft with consistency of grated cheese. Perhaps that’s too much information for some of you.
After plating the fracture, as shown below, I created an oval window in the cortex of the bone through which I injected the bone graft. This enable me to fill the canal of the humeral shaft with new bone graft that makes healing of the fracture possible.
Anyway, the final x-rays are below. She is doing very well. The pain is gone and the shoulder function is improving. The fracture is now healed. There is a bit of stiffness of the shoulder that will improve over time.
Despite her medical conditions, she is now doing better 3 months after surgery than she was doing after 4 months of nonoperative treatment. She can now use both arms without any restrictions and can use her walker normally. We don’t rush in to do surgery if there is a chance that things will heal without it, but sometimes surgery is the best answer.
Thanks.
JTM, MD