Humeral Shaft Nonunion 733.82

synonyms:

Humeral Nonunion ICD-9

• ICD-9=733.82 (nonunion of fracture)

Humeral Nonunion Etiology / Epidemiology / Natural History

• Nonunion = no improvement clinically or radiologically in fracture healing over a 3 month period.
• @10% of Humeral shaft fractures result in nonunion with both operative and non-operative treatment.

Humeral Nonunion Anatomy

• Musculocutaneous N pierces coracobrachialis 5-8cm distal to coracoid, supplies biceps,coracobrachialis & bracialis
• See also Arm anatomy.

Humeral Nonunion Clinical Evaluation

• Pain, swelling, deformity of arm.
• Crepitus and motion at fracture site.
• Document neurovascular exam, especially radial nerve.

Humeral Nonunion Xray / Diagnositc Tests

• A/P and lateral views of the humerus generally clearly demonstrate fracture.
• Consider shoulder and elbow films if there is any concern for intraarticular extension.
• MRI /CT generally not needed.
• Consider infection work-up, especially if previously treated with surgery.

Humeral Nonunion Classification / Treatment

• Atrophic: Humeral Shaft ORIF with ICBG (Ring D, JBJS 2000;82Br:867) or DBM (Hierholzer C, JBJS 2006;88A:1442).
• Hypertrophic: Humeral Shaft ORIF:
• Atrophic with prior failed fixation and bone grafting: Humeral Shaft ORIF with fresh frozen allograft or autograft intramedullary fibular grafting. (Jupiter JB, JBJS 1990;72A:701).
• Radial nerve palsy: exploration of radial nerve palsy in closed fractures is not recommended. Radial nerve transection is associated with open fractures, but direct repair has not shown good functional outcomes. (RingD, J Hand Surg 2004;29A:144).

Humeral Nonunion Associated Injuries / Differential Diagnosis

• Radial nerve palsy
• Infection / osteomyelitis

Humeral Nonunion Complications

• Delayed union = failure to unite in 2-3 months
• nonunion 4-6 months
• malunion, nonunion, vascular, radial N(10%),
• Radial nerve palsy-most recover in 3-4 months, pts should be placed in cock-up wrist splint, given thumb abduction and finger/wrist extension exercises to avoid contracture.  EMG at 6 wks if no signs of recovery.  Brachioradialis should be first muscle to return.  11.1% of closed fx have associated Radial nerve palsy, 0.2% in closed fx's fail to recover.  18% open fx. 60% have nerve entrapped in fx. (Bostman O, Acta Orthop Scand 1986;57:316) . (Shaz JJ, Bhatti NA: CORR 1983;172:171. (Holstein A JBJS 1963;458:1382).

Humeral Nonunion Follow-up Care

• Immediate weight bearing on a plated humerus fx with the use of crutches of a walker has been shown to safe. (Tingstad, J Trauma 2000;49:278).

Humeral Nonunion Review References

• Rockwood and Green's Fractures in Adults 6th ed, 2006