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Unstable Nonunions of the Distal Part of the Humerus

Investigation performed at the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts

David Ring, MD
Lawrence Gulotta, BA
Jesse B. Jupiter, MD
Department of Orthopaedic Surgery, Massachusetts General Hospital, Hand and Upper Extremity Service, ACC 525 (D.R. and L.G.) and ACC 527 (J.B.J.), 15 Parkman Street, Boston, MA 02114. E-mail address for D. Ring: dring{at}partners.org

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: Some nonunions of the distal part of the humerus are so unstable that the hand and the forelimb cannot be supported against gravity. The purpose of the present retrospective study was to analyze the results of open reduction and internal fixation, joint contracture release, and autogenous bone-grafting in the treatment of these unstable nonunions of the distal part of the humerus.

Methods: Fifteen patients (average age, sixty years) with an unstable nonunion of the distal part of the humerus were treated with excision of fibrous and synovial tissues, opening of sclerotic fracture surfaces, internal fixation with multiple plates and screws, and autogenous bone-grafting. The average time from the original fracture to the index treatment of the nonunion was eleven months. Vascularized fibular grafts and supplemental external fixation were necessary in two patients with large bone defects after débridement at the site of a previous infection.

Results: Three nonunions failed to heal and were treated with total elbow arthroplasty. Twelve nonunions healed, but six of the twelve required additional surgery because of painful implants, ulnar neuropathy, or elbow contracture. After an average duration of follow-up of fifty-one months (range, twenty-four to 130 months), the twelve patients in whom the nonunion healed had an average arc of ulnohumeral motion of 95°, with an average flexion of 117° and an average flexion contracture of 22°. According to the Mayo Elbow Performance Index, the functional result was rated as excellent in two patients, good in nine, and fair in one.

Conclusions: Unstable nonunions of the distal part of the humerus can be treated successfully in most active, healthy patients with use of rigid internal fixation, joint contracture release, and bone-grafting.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.

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