Ovid: Chapman’s Orthopaedic Surgery

Editors: Chapman, Michael W.
Title: Chapman’s Orthopaedic Surgery, 3rd Edition
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Michael W. Chapman
M. W. Chapman: Department of Orthopaedics, University of California Davis, Sacramento, California, 95817.
This chapter in the
second edition was written by Deborah F. Bell and James F. Kellam.
Portions of their chapter were used in this revision. Their
contribution is greatly appreciated.
Because the upper extremity does not normally bear
weight unless crutches or a cane are used routinely, osteoarthritis
resulting from malalignment does not appear to be a major problem.
However, malalignment compromising precise mobility of the hand or the
ability to place the hand in space may be a major disability. The
decision to correct malunions or nonunions in the upper extremity
depends on the patient’s functional demands and the presence of pain.
If function is suitable without correction


and pain is not a problem, surgery is not indicated.

Because the scapula is totally enclosed in an envelope
of heavy muscles and lies on the posterior aspect of the thoracic cage,
fractures that progress to symptomatic nonunion or malunion are
exceedingly rare. Personally, I have never had to treat surgically
either a nonunion or a malunion of the scapula. There are reports of
nonunions of the base of the coracoid process, the scapular body and
spine, and the acromion (2,21,33,52,55,105). Gupta et al. (33)
reported successful treatment of a nonunion of the inferior third of
the body of the scapula (the only case reported in the literature) with
plate fixation and bone graft, resulting in dramatic improvement in
function and relief of pain.
The epiphysis of the acromion is one of the last to
unite and occasionally does not unite, remaining as an os acromiale.
This should not be mistaken for a nonunion. True nonunions, if
displaced inferiorly, can interfere with motion and cause impingement
on the rotator cuff tendons. If symptoms justify, a small fragment can
be excised. Reattachment of the deltoid must be solid and protected
until healed to avoid deltoid deficiency. Excision of any substantial
part of the acromion can lead to permanent deltoid weakness, and
therefore, nonunions producing large fragments deserve repair. Repair
can be challenging because of the thin cortical bone of the acromion,
in which it is difficult to obtain secure fixation. Dounchis et al. (21)
reported successful treatment of a nonunion of a fracture at the base
of the acromion with plate and screw fixation combined with a tension
band wire construct and autologous bone graft.
Nonunions of the coracoid process are more likely to be
secondary to an osteotomy performed for reconstructive shoulder surgery
as opposed to a fracture. If the nonunion is symptomatic, most can be
successfully treated with freshening of the fracture site and internal
fixation with a compression screw. Excision is also possible with
reattachment of the muscles originating from the coracoid to
surrounding soft-tissue structures.
Although the clavicle is probably the most commonly fractured bone, nonunions are rare (82). The incidence of nonunion in clavicle fractures managed nonoperatively is between 0.1% and 1.9% (16,41,68,109). In those managed operatively, the incidence is higher, particularly with intramedullary fixation (91). Functionally disabling malunions are probably even rarer. In the series of 33 patients reported by Wilkins and Johnston (106), nonunion appeared to be more common after refracture or when associated with severe trauma (108).
Patients with atrophic nonunions seemed to have fewer symptoms than
those with hypertrophic pseudarthroses. Atrophic nonunions seem to be
much more common than hypertrophic nonunions (39).
A nonunion of the clavicle in an adult is defined as an
ununited fracture at least 16 weeks after injury. The anatomic location
of the fracture affects the union rates; distal clavicular fractures
have a higher rate of nonunion than middle-third fractures. A
displaced, interligamentous distal-third fracture (Neer type II), in
which the proximal fragment is detached from the coracoclavicular
ligament, is unstable and has a higher nonunion rate (68,69,72).
Malunion of a clavicle is rarely a functional or
clinically significant problem. Most clavicles heal in a malunited
position, because they are usually treated in a figure-eight sling,
which does not provide adequate enough immobilization to ensure
anatomic position (see Chapter 15). It is very uncommon to require any form of treatment for a malunion of the clavicle, except for a cosmetic deformity (69).
Occasionally, brachial plexus impingement can occur when there is
abundant callus. Shortening of more than 15 mm can produce shoulder
The indications for operative intervention in a nonunion
or malunion of the clavicle include significant pain with use of the
ipsilateral shoulder, compromising upper extremity function.
Occasionally, hypertrophic nonunions cause extrinsic compression of the
brachial plexus and the subclavian artery and vein (45). This problem may also be responsible for a thoracic outlet syndrome (16).
Thorough preoperative assessment, including a bone scan, appropriate
angiography, electromyographic studies, and a thoracic or vascular
surgical evaluation, may be indicated. The final indication for
surgical correction of clavicular nonunion or malunion is correction of
unsightly deformities. The patient must be aware that he or she is
exchanging a deformity for a scar. Comparison of radiographs to the
opposite, normal side are useful for planning a repair or osteotomy,
particularly to estimate restoration of length. Operative techniques
most commonly used today include plate fixation and bone graft (6,8,18,51,75,77,92,107), intramedullary Hagie pin and bone graft (4,12,107), and as a last resort, partial or total claviculectomy (59).


  • Position the patient in a modified beach-chair position on the operating table (Fig. 27.1).
    Because it is difficult to position an x-ray plate beneath the shoulder
    once the patient is positioned and draped, place a cassette in position
    before the prep and drape. Pad it to protect the patient.
    Figure 27.1. Repair of nonunion of the clavicle by plate fixation and bone graft. A: Surgical approach in Langer’s lines. B: Compression plate fixation with an interfragmentary compression screw. C: Top view—note placement of bone graft superiorly and posteriorly.
  • Prepare and drape the patient, with the
    involved shoulder and extremity free. Be certain to prep all the way up
    to the corner of the mandible and drape widely to ensure adequate
    access to the clavicle.
  • Make an incision of sufficient length,
    usually 10 to 12.5 cm, using Langer lines to minimize scarring. Carry
    the incision directly down to the clavicle and expose the superior
    surface by subperiosteal dissection. There usually is no need to
    develop subcutaneous flaps. In malunions and in hypertrophic nonunions,
    the main shaft of the clavicle can be buried and quite difficult to
    identify. Palpate the bone carefully as the incision down to bone is
    made. Simpson and Jupiter (92) mention
    identifying and preserving the cutaneous supraclavicular nerves
    crossing the anterior border of the clavicle in order to avoid
    dysesthesia postoperatively. I have not found it practical to preserve
    these nerves in the midportions of the wound. At the distal and
    proximal ends, they can be retracted. In spite of having transected
    these nerves in the midportion of the wound routinely, I have never had
    a patient complain of postoperative dysesthesia due to neuromas.
  • Identify the nonunion. In the case of an
    oligotrophic or atrophic nonunion, try to identify the original
    fracture ends so that the fracture can be repaired as anatomically as
    possible. In most cases, it is worthwhile to plate the clavicle in
    anatomic position rather then fix it in malposition, because patients
    are much happier and function is better. In most cases, this requires
    taking down the nonunion, freshening the bone ends, and drilling the
    medullary canal to help revascularization.
  • If there is a reasonably stable fibrous union in nearly anatomic position, then occasionally plate fixation in situ is adequate. In my experience, this is rare.
  • In hypertrophic nonunions, it is
    worthwhile to shave the hypertrophic callus off the clavicle, taking
    care to identify the original clavicle encased in the callus (Fig. 27.1A). Morcelize this bone and use it for bone graft, because this saves harvesting an iliac crest graft.
  • A gap may be present owing to bone
    resorption, extensive comminution, or bone loss in the case of open
    fractures. Plan to restore the full length of the clavicle, placing an
    intercalary tricortical bone graft of equal size to the clavicle.
    Harvest it from the superior rim of the anterior iliac crest (see Chapter 9).
  • Once the nonunion has been reduced, apply
    a 3.5 AO limited contact compression plate, Alta 3.7 reconstruction
    plate, or equivalent to the superior surface of the


    obtaining eight cortices of solid fixation both proximally and
    distally, if possible. Whenever possible, try to obtain
    interfragmentary compression across the nonunion site either
    independently of the plate or through the plate (Fig. 27.1B). Plates fit best on the superior clavicle and act as a tension band, requiring less molding than plates placed anteriorly (Fig. 27.1C).
    Superior plates also have the advantage of protection of the underlying
    structures on the inferior aspect of the clavicle by the subclavius

  • Petal the superior and posterior surfaces
    of the clavicle adjacent to the plate on both sides of the nonunion,
    and then apply a cancellous bone graft.
  • Do a meticulous layered closure of the
    periosteum, deep fascia, and platysma. Use a plastic skin closure to
    provide the best scar. See Figure 27.2 for a typical case.
    Figure 27.2. Nonunion of the clavicle. A: A midshaft oblique fracture of the right clavicle at the time of injury. B: Six months after nonoperative treatment, this fracture is still grossly displaced and mobile with no evidence of union. C:
    Open reduction and internal fixation using a 3.5 mm dynamic compression
    plate. Notice the oblique lag screw across the nonunion site. A bone
    graft was also added. D: At 4 years,
    consolidation has occurred. The patient is asymptomatic and has not
    requested that the internal fixation be removed.
  • The technique is nearly identical to that
    described earlier for repair of nonunion. The only difference is that
    the old fracture site must be identified and an osteotomy


    as much as possible through the old fracture site. I find that this
    usually works better than an arbitrary osteotomy, because an arbitrary
    osteotomy frequently results in a compensating deformity.

  • Even a year or more after a malunion of a
    clavicle, the callus surrounding the original bone is more vascular,
    pink in appearance, and softer than the hard white native cortical bone
    of the clavicle.
  • Slide an osteotome along the normal cortex of the clavicle, shaving off the callus until the malunion site is obvious.
  • Use a small water-cooled oscillating saw
    to osteotomize through the old fracture site. Refashion the bone ends
    to make the clavicle as anatomic as possible, and then plate the
    clavicle as described earlier. Bone graft is not usually necessary, but
    any callus removed at the fracture site can be morcelized and packed
    about the osteotomy site.
This is the technique described by Boehme et al. (Fig. 27.3) (4,5).
Figure 27.3. Hagie pin fixation and bone graft of a nonunion of the clavicle. A: A skin incision exposing the nonunion. B: Drilling the medullary canal of the medial fragment. C: Drilling the medullary canal of the lateral fragment. D: Petaling the ends of the clavicle. E: Drilling the Hagie pin out the hole in the lateral fragment. F: Superior view of E. G: Reducing the fracture and driving the Hagie pin retrograde into the medial fragment. H: Superior view. A nut is applied to the Hagie pin to compress the fracture. (Redrawn from Matsen FA, III, and Rockwood CA, Jr. The Shoulder. Philadelphia: W. B. Saunders, 283, with permission.)
  • Proceed as described earlier for plate
    fixation to the point where the nonunion is ready for internal
    fixation. Somewhat more exposure is needed because of the need to have
    access to both bone ends at the nonunion site for the intramedullary
    pin (Fig. 27.3A). Because a plate will not be
    placed, exposure of the entire superior surface is not necessary.
    Elevate the periosteum 2.5 cm off of each segment next to the fracture,
    trying to maintain the deep soft-tissue attachments to the clavicle.
  • Drill the medullary canal of the proximal
    (medial) fragment with an appropriately sized drill point for the Hagie
    pin to be used (Fig. 27.3B). Be careful not to penetrate the clavicle anteriorly accidentally.
  • Drill the medullary canal of the distal
    (lateral) fragment, exiting the clavicle medial and posterior to the
    acromioclavicular joint. Drill until the bit can be palpated on the
    posterolateral aspect of the shoulder where a stab wound is made (Fig. 27.3C).
  • Freshen (petal) the ends of the clavicle at the nonunion site (Fig. 27.3D).
  • Select a Hagie pin of the appropriate
    length and diameter so that the course threads on the tip of the pin
    will lie entirely within the medial fragment. Drill the Hagie


    retrograde with its fine-threaded ends laterally out from the nonunion
    site down the medullary canal of the lateral fragment, to bring the tip
    to the fracture site (Fig. 27.3E, Fig. 27.3F).

Figure 27.4. Nonunion of a distal clavicle fracture. A:
A 25-year-old skier suffered a displaced fracture of the distal third
of his clavicle. Nonoperative treatment was unsuccessful. He had pain
and an unsightly deformity at 6 months. The atrophic nonunion was
completely mobile. B: Internal fixation
was performed using a third-tubular plate. There is an interfragmentary
screw across the fracture site and a coracoclavicular screw. The most
distal screw runs obliquely through the longest portion of the
acromion. A cancellous bone graft was applied. C:
At 8 weeks, the coracoclavicular screw was removed. Before this, the
patient had been allowed pendulum exercises with abduction of his
shoulder to only 90°. After screw removal, full range of motion was
instituted. D: A radiograph 1.5 years
after operative intervention shows that the plate has been removed, and
there is solid union of the nonunion.
  • Reduce the fracture, then drill the Hagie
    pin into the medial fragment. When the pin is in place, the fracture
    site should be in excellent apposition and compression. If there is a
    gap, apply the nut to the lateral end of the pin and compress the
    fracture (Fig. 27.3G, Fig. 27.3H).
  • Finish petaling the bone ends at the
    nonunion site for a distance of 2.5 cm on either side of the nonunion.
    Bone graft the fracture on all exposed surfaces except the anterior
    subcutaneous border. Boehme et al. (4) use osteal/periosteal rib
    grafts, as described by Dineen and Greshman (19); however, cancellous graft from the iliac crest works well also.
  • Closure is as described previously.
Postoperative Care
Assuming that good fixation has been achieved, the
postoperative care for all three of the above-mentioned procedures is
similar. Protect the shoulder in a sling until the patient is
comfortable. Begin passive circumduction exercises (Codmen’s),
progressing as quickly as the patient can tolerate. Patients can use
the extremity for light activities of daily living but should avoid any
strenuous use of the extremity, lifting of other than very light
objects, and overhead activities until 6 weeks after the surgery.
Between 6 and 12 weeks, depending on the state of union, progress with
gentle overhead pulley exercises but avoid raising the arm against
gravity or any strenuous use until the nonunion is solidly healed,
which generally takes 10 to 12 weeks.
In many malunions, function is normal and the patient
has no pain. The major concern is the bump from the malunion. In these
cases, simple removal of the bump with an osteotome and smoothing of
the clavicle suffices.
The results of treatment of clavicular nonunions using
the techniques described above are excellent, with success rates of 92%
to 100% after the first operation (4,5,6,8,12,16,18,23,25,39,41,45,51,66,75,77,83,91,92,103,106,107).
Removal of the clavicle is rarely indicated and usually results in only minimal morbidity (59).
Patients usually complain of weakness and early fatigue when working
with the extremity above the head. Some have chronic pain.
Claviculectomy is usually indicated for some infected nonunions, major
bone loss, or a painful nonunion that is unresponsive to surgical
treatment. Sometimes, claviculectomy is necessary to relieve thoracic
outlet syndrome. Claviculectomy may be combined with simultaneous
resection of the first rib, which is usually done through an
independent axillary exposure. To avoid an unsightly, painful, unstable
clavicle, resect it only as indicated in Figure 27.5.
Figure 27.5.
Partial claviculectomy. Note that the remaining segment is always
stabilized by ligaments. Shaded areas indicate resected parts of bone. A: Distal claviculectomy, usually done for acromioclavicular arthritis. This can be part of a Weaver-Dunn procedure (102). B:
Resection of the medial intercalary two thirds. The lateral and medial
segments are stabilized by their ligamentous attachments. C: Resection of the lateral two thirds, leaving a stable medial fragment. D:
Resection of the medial end for arthritis or instability of the
sternoclavicular joint. Instability of the remaining clavicle at its
medial end may require stabilization to the first rib (see Chapter 78)
  • Expose the clavicle, as described earlier
    for repair of a nonunion. Expose only that portion of the clavicle
    planned for resection.
  • When resecting the mid two thirds of the
    clavicle or the distal two thirds, you can facilitate resection by
    entering the nonunion site or making an osteotomy just lateral to the
    ligaments, stabilizing the medial end of the clavicle. Expose it with
    careful circumferential subperiosteal exposure.
  • Grasp this free end of the clavicle with
    a bone-holding forceps and then excise the clavicle in a subperiosteal
    manner from its bed to the distal resection site.
  • Resection of the medial end of the clavicle as illustrated in Figure 27.5D requires special consideration because of the underlying major neurovascular structures. (See Chapter 78 for a description of this exposure and resection.)
  • When resecting the clavicle distal to the
    attachments of the coracoclavicular ligaments, it is essential that
    these ligaments be intact or reconstructed (see Chapter 78) (102).



Fractures of the proximal humerus account for 4% to 5% of fractures and occur most frequently in the elderly (40).
Failure of this fracture to unite within 6 to 8 weeks constitutes a
delayed union. At 12 weeks, an unstable fracture with no evidence of
callus formation is unlikely to heal. Therefore, operative treatment is
usually indicated. Nonunion of the surgical neck of the humerus is rare
(93). Displaced fractures that remain unreduced
owing to muscle forces, interposed deltoid or biceps, or treatment
producing distraction may result in nonunion. In Neer’s series (70,71),
nonunions were more commonly associated with hanging casts or skeletal
traction and displaced four-part fractures. The incidence of proximal
humerus fractures in women is twice that in men. Osteoporosis and a
short proximal fragment covered for the most part by articular
cartilage makes treatment difficult (Fig. 27.6) (35).
Therapeutic alternatives include symptomatic treatment only, open
reduction, and internal fixation combined with a bone graft or
prosthetic replacement. Because of the challenge of obtaining fixation
in the proximal articular fragment, many different approaches have been
used, including simple plate and screw fixation, double plate fixation,
multiple stiff and malleable wires, Rush rods or Ender pins combined
with malleable wires in a figure eight, and various types of blade
plates or specially designed reconstruction plates for the proximal
humerus (30,34,40,48,100).
In elderly and in middle-aged adults with severe avascular necrosis of
the humeral head, a reasonable alternative is prosthetic replacement of
the proximal humerus. Because the nonunion is typically through the
surgical neck, restoration of the insertion of the rotator cuff is
important. If there is coexisting osteoarthritis of the shoulder joint,
consider total shoulder replacement. In young patients who require a
stable pain-free shoulder for heavy labor, consider arthrodesis (see Chapter 103) (Fig. 27.7).
Figure 27.6.
Bilateral painless pseudarthrosis of the proximal humerus in a
72-year-old woman. This patient had adequate motion in her shoulders
for her activities of daily living.
Figure 27.7. Hemiarthroplasty for a malunited fracture of the proximal humerus. A:
Malunion of a displaced four-part proximal humeral fracture. The
glenoid is empty, and the humeral head fragment is rotated 180°
laterally. This patient had significant pain and limited shoulder
function. B: A CT scan of the shoulder
shows the malunited humeral head in its rotated position. The greater
tuberosity can be seen laterally to the head and appears to be not
united in this picture. Notice the sclerotic humeral head, indicating
avascular necrosis. C, D: A Neer
hemiarthroplasty was inserted for the primary relief of pain. At the
time of surgery, the humeral head was osteotomized and excised, and 90°
of forward motion was obtainable in the operating room under
anesthesia. The patient has done relatively well after surgery; he has
mild residual pain with adequate function.
Isolated fractures of the tuberosities leading to
nonunion are usually accompanied by major ruptures in the rotator cuff.
The most likely avulsion fracture to progress to nonunion is one
involving the posterolateral aspect of the greater tuberosity,
involving the insertions of the infraspinatus and teres minor. On an
anteroposterior (AP) view, these tend to be visualized posterior to the
humeral head and, therefore, are easily missed. The major focus in
repair of these is reconstruction of the rotator cuff, which is
described in Chapter 79. Fixation of the
tuberosity is usually best accomplished by placing it back into its bed
and securing it with multiple figure-eight or horizontal nonabsorbable
sutures interwoven through the insertion of the rotator cuff and the
proximal fragment, and tied through drill holes in the proximal shaft
of the humerus. Screws and other metallic fasteners usually fail
because the avulsed fragment is a thin cortical shell and is usually
full of multiple cracks.


Most fractures of the proximal humerus occur in elderly
individuals, who, if sedentary, may function reasonably well with a
painless pseudarthrosis or a malunion that does not interfere
significantly with their activities of daily living. Consequently,
premorbid patient activity, age, occupation, and hand dominance play
important roles in the decision whether to surgically repair a proximal
humerus nonunion (Fig. 27.6).
Malunions in the proximal humerus that require surgical
correction are rare, because most patients get along well as long as
the opposite shoulder is normal. Osteotomy to correct a malunion is
most commonly indicated in active patients who are still working and
require full use of their upper extremities for their occupational or
sports activities. The most frequent malunion requiring correction is a
surgical neck or a somewhat more distal fracture that has healed with
apex anterior or lateral angulation, which limits forward flexion and
abduction. Occasionally, this can be painful. Osteotomy has been used
to treat recurrent anterior dislocation of the shoulder as well (104).
Repair of a nonunion of the proximal humerus or
osteotomy to correct a malunion requires careful preoperative planning
because of the challenge of obtaining adequate fixation in the proximal
fragment. Rigid fixation is important to allow patients to begin fairly
vigorous circumduction exercises immediately; otherwise, unacceptable
shoulder stiffness may result. It is usually advisable to have a backup
plan with the necessary implants and instrumentation available. In
suitable patients, the backup to reconstruction of the fracture may be
prosthetic replacement. Be certain to discuss this alternative with
your patient, and have the prosthesis and instrumentation available in
the event that repair of the nonunion is not technically feasible.
I have had a high rate of success treating difficult
nonunions of the proximal humerus through the use of small fragment
double plate fixation combined with iliac crest bone graft through a
modified deltopectoral approach, which is described below.
  • Expose the proximal humerus through a Henry’s deltopectoral approach (see Chapter 1).
    Do not take down any of the origin of the deltoid or pectoralis major
    muscles. If more extensive exposure is required, take down the
    insertion of the deltoid in a subperiosteal manner, using a sharp knife
    or electrocautery knife. Take this down in continuity with the
    brachialis muscle. Identify and coagulate the large bleeders in this
    area. This provides ample exposure but does not require direct
    reattachment of the deltoid insertion to the humerus, because simple
    closure of this musculofascial sleeve restores the continuity of the
  • Occasionally, exposure of the joint is
    necessary, in which case a partial take down of the origin of the short
    head of the biceps and coracobrachialis from the tip of the coracoid
    are useful. This step provides excellent



    exposure, making the spiral compression plate described by Gill and Torchia (30) unnecessary.

  • Expose the nonunion site laterally and
    anteriorly. Try to maintain soft-tissue attachments on the posterior
    and medial borders. These nonunions are nearly always pseudoarthroses
    or atrophic nonunions.
  • Remove soft tissues from the fracture
    site and freshen the fracture ends, fashioning them to fit together in
    a manner that restores anatomic alignment and maximizes the contact of
    the bone surfaces. Open the medullary canal of the distal fragment and
    use a 2 mm drill point to drill the sclerotic surface of the nonunion
    in multiple places on the proximal fragment.
  • Reduce the nonunion and secure the
    position with a bone-holding forceps. Often, these nonunions are
    oblique, and initial fixation can be done with an interfragmentary
    compression screw.
  • Fashion two Alta small fragment
    reconstruction plates (or another, similar plate) to fit along the
    lateral and anterior borders of the fracture, extending up to the
    articular surface. The bevelled ends of the plates permit fixation
    close to the articular surface without impingement on the acromion or
    rotator cuff. Locate these plates as close to 90° to each other as
    possible. Secure the plates to the humerus with 3.7 cortical screws,
    which are bicortical where there is not articular cartilage. In the
    proximal fragment, it is often possible to obtain bicortical fixation
    on the proximal fragment through the anterior plate, whereas with the
    lateral plate, the direction of the screws is toward the articular
    surface; therefore, the screws must be placed short of the subchondral
    bone. Cortical screws inserted without tapping tend to get a better
    hold than cancellous screws. If they strip out, replace them with the
    larger cancellous screws. To improve fixation in osteoporotic bone, try
    cross-threading the screws against each other in the proximal fragment
    or, as a last resort, inject methacrylate into each screw hole
  • Gently petal the nonunion site up to the
    articular surface on the proximal fragment for at least 2.5 cm on the
    distal fragment, and apply finely morcelized cancellous bone in a solid
    layer along all available bone surfaces. The small, narrow profile of
    the Alta plates usually leaves ample room for application of a bone
    graft. If space is insufficient, further medial exposure makes a good
    location for bone graft (Fig. 27.8) .
    Figure 27.8. Nonunion in the surgical neck of the humerus. A:
    An AP radiograph of the right shoulder of an 82-year-old man with a
    nonunion of the surgical neck of the humerus of 18 months’ duration
    after treatment in a sling. B: An atrophic
    nonunion with an interposed biceps tendon was found at surgery and
    repaired with two Alta 3.7 plates. The screws were cross-threaded to
    improve fixation. An autologous iliac graft was applied. This was
    healed by 12 weeks, as seen here.
  • Close the deltopectoral interval and the
    brachialis-deltoid interval, if necessary, in a single layer with
    interrupted resorbable sutures. Perform a plastic closure of the
    subcutaneous fat and skin.
  • Immobilize the shoulder in a shoulder immobilizer.
  • Alternative methods of internal fixation include blade plates fashioned out of third-tubular or semitubular plates (22).
    Although these plates are useful and low profile, I have found them to
    be weak. The construct can be reinforced by placing an oblique screw
    from the portion of the plate along the shaft up through the tip of the
    plate (see Chapter 26), but this is technically tricky. Specialized blade plates and reconstruction plates are now available as well (21,45,51).
  • I no longer use large fragment T or L
    plates because they are difficult to bend and conform to the proximal
    humerus, and they can cause acromial impingement. Their broad surface
    area inhibits revascularization of the nonunion site.
If the construct is stable, most patients can begin
gentle pendulum circumduction exercises within a few days. Allow
patients to remove the shoulder immobilizer to shower once the wound is
sealed. Otherwise, have patients wear the shoulder immobilizer both
night and day for the first 6 weeks to protect the repair. If at 6
weeks union seems to be progressing, then a more vigorous circumduction
exercise program to maximize shoulder range of motion can begin. Avoid
resistive exercises and active elevation of the arm until solid union
has occurred, which usually requires 12 weeks. Thereafter, patients can
engage in a full range-of-motion and strengthening program.


patients with nonunions have very stiff shoulders, but I have found
that they reacquire good (although rarely normal) functional range of
motion and strength after about a year of vigorous rehabilitation.

Correction of a malunion at the same site employs
essentially the same techniques except that a closing wedge osteotomy
is made through the nonunion site to correct the deformity.
Before the current functional methods of treatment, nonunion rates were as high as 30% for humeral fractures (42,72). With functional bracing, union can now be achieved in 92% to 95% of these fractures (72,88).
Nonunion has been associated with inadequate immobilization,
distraction of the fracture, soft-tissue interposition (particularly at
the deltoid tubercle), and use of inappropriate nonrigid internal
fixation (24,29). A
fracture that is mobile and shows no evidence of callus at 12 weeks is
unlikely to heal, particularly if a gap can be seen on radiographs (13,43).
Hypertrophic delayed unions may be worth treating nonoperatively until
6 months, but I tend to intervene soon after 12 weeks to prevent
long-term permanent joint stiffness from prolonged immobilization. As
with nonunions in the proximal humerus, nonunions in the diaphysis are
frequently challenging. Esterhai et al. (26)
found that, in 46 nonunions, 62% were in elderly patients who were
senile and had disuse osteoporosis. Forty-two percent were synovial
pseudoarthroses; 20% were obese; and 5% had osteomyelitis. Of the
patients they elected to treat with electrical stimulation, only 46%
healed despite the fact that their group is the most expert in the
world in electrical stimulation. For that reason, I do not believe that
electrical stimulation is worth using in nonunions of the humerus
unless it is a hypertrophic nonunion, proven by computed tomographic
(CT) scan and bone scan not to be a synovial pseudoarthrosis. It must
be well immobilized. Internal fixation is best for most patients, but
consider electrical stimulation for patients in whom surgery is
contraindicated or risky.
Malunion of the humeral diaphysis is rarely a functional
or cosmetic problem. The soft-tissue coverage of the arm can obscure up
to 20° of anterior or posterior angulation and up to 30° of varus.
Shortening of as much as 2.5 cm does not lead to disability, and
rotational malalignment can easily be compensated through the shoulder (24).
Treatments of nonunion and malunion are similar. Indications for surgery include
  • An unstable delayed union of the humerus
    at approximately 8 weeks after injury, with an obvious gap on
    radiographs owing to bone loss or soft-tissue interposition, which
    precludes healing.
  • An established nonunion of the humerus at
    12 weeks that is unstable and painful or, if free of pain, is so mobile
    that effective functional use of the extremity is not possible.
  • A severe malunion of the humerus, usually
    in younger, active patients, that is absolutely cosmetically
    unacceptable to the patient (usually severe varus with loss of carrying
    angle) or causes a functional deficit sufficient to interfere with
    normal activities of daily living, vocational activities, or sports.
Completely assess the patient’s needs and current
function in order to establish appropriate goals for the surgery. The
shoulder and elbow may be quite stiff, and the patient may be using the
nonunion as a false joint, particularly if it is a more distal nonunion
close to the elbow. Stabilization of the nonunion may result in
significant loss of motion, which the patient may find more disabling
than the nonunion. Concomitant soft-tissue procedures and capsular
release to increase elbow and, on occasion, shoulder motion may be
essential to achieve a satisfactory result. The prolonged
immobilization and disuse associated with nonunions of the humerus
frequently lead to osteoporosis, which diminishes the holding power of
screws. Pre-existing hardware with large radiolucent areas around the
fixation device can also destroy bone stock. A thorough preoperative
plan with alternatives is important so that the procedure will be
successful. Operative techniques include the following:
  • When a preexisting intramedullary nail is
    in place and alignment is acceptable, closed reamed locked exchange
    nailing is a good technique, but the bone stock must be adequate to
    provide good fixation for the cross-locking screws. Union is usually
    slower and less dependable then plate fixation with bone grafting (57).
  • Initial primary intramedullary nailing
    with or without bone grafting almost always requires an open reduction,
    particularly because the radial nerve is at risk of injury with closed
    techniques. Nonlocked nails and the Seidel nail do not give a high
    enough success rate to justify their use for nonunions (15,17,78).
    Intramedullary techniques do not provide as good fixation as plates and
    necessitate opening the humerus proximally, which can lead to rotator
    cuff dysfunction and chronic shoulder pain. The loss of the
    intramedullary blood supply may slow union. For that reason, I believe
    the only role for intramedullary nailing for treatment of nonunions of
    the humerus is exchange nailing for a preexisting nail.
  • P.899

  • Plate fixation with bone graft is the
    most commonly used and most effective method for treating nonunions of
    the diaphysis of the humerus. It includes variations such as standard
    AO-type compression plating, adjunctive interfragmentary screw
    fixation, wave plates, and intramedullary plates (13,66,79,81).
  • A fibula split and then fixed on both
    sides of the nonunion as “plates” has been successful but, with modern
    internal fixation, is not indicated today. When bone stock is a major
    problem, however, use of a split fibula to provide a backup to the
    plate on the opposite cortex for screw fixation is quite useful and a
    good alternative to allograft (28).
  • Difficult atrophic nonunions with loss of
    bone continuity or nonunions with major bone loss can be treated with
    plate fixation and a vascularized fibular graft through a medial
    approach (38).
  • When osteopenia precludes good screw
    fixation, another alternative is the use of adjunctive bone cement,
    which must be combined with a copious bone graft, with recognition of
    the impact on the blood supply to bone (98).
  • External fixation is useful when
    osteomyelitis contraindicates the placement of implants at the fracture
    site but has the disadvantage of frequent loosening of pins due to
    poor-quality bone, pin track infection owing to the mobile soft tissues
    in the upper extremity, and interference with shoulder and elbow
    rehabilitation owing to tie down of muscles by the external fixation
    pins (47).
  • Use Henry’s extensile anterolateral approach to the humerus (see Chapter 1).
    The exploration of the radial nerve can be the most challenging part of
    this procedure, and bone quality may require a long plate; therefore,
    it is essential that the surgical approach be extensile to both ends of
    the humerus. Use a posterior approach only for supracondylar nonunions
    when exposure beyond the midshaft humerus is not necessary.
  • The position of the radial nerve can be
    nonanatomic, and it commonly is involved in the soft-tissue scar or
    fracture callus. Identify the nerve in the interval between the
    brachialis and brachioradialis muscles distally and trace it past the
    nonunion site into the spiral grove. If the nerve is embedded in scar,
    it is usually necessary to place it in a vascular loop and protect it
    during the repair of the nonunion.
  • It is rare to be able to fix the nonunion in situ;
    therefore, take the nonunion down, remove all fibrous tissue from
    between the bone ends, send a specimen for culture, freshen the bone
    ends, and open the medullary canals. Sculpt the ends of the bone
    fragments as necessary to maximize cortical contact and to ensure good
  • Shortening up to 2.5 cm in most patients
    is acceptable if it is necessary to obtain apposition over the full
    width of the cortex. In elderly patients, in whom functional demands
    are lower, even more shortening is acceptable.
  • Apply a broad plate with 4.5 to 5.0 mm
    cortical screws, obtaining at least eight cortices of solid fixation
    both proximally and distally. Many of the tricks for obtaining solid
    screw fixation are described earlier. Plates usually fit best along the
    anterolateral aspect of the humerus. In this location, they are free of
    the radial nerve and function as a tension band. Always try to obtain
    interfragmentary compression, either through the plate or, better,
    independent of the plate.
  • After the initial plate and
    interfragmentary screw are in place, gently stress the construct,
    looking for micromotion in the fracture site. If it is present, or the
    hold of the screws is tenuous, I always put a second plate at right
    angles to the first plate along the anteromedial cortex. This plate
    should be a small fragment plate shorter than the original plate, with
    at least six cortices of fixation above and below. The shorter, lighter
    plate leaves more humerus exposed for revascularization and bone graft,
    and minimizes the risk of a stress riser at the end of the double
  • Petal the available bone surface with a
    quarter-inch osteotome for at least 2.5 cm proximal and distal to the
    fracture, and lay a morcelized cancellous bone graft along the humerus.
    If there is cortical deficiency, cortical cancellous grafts are useful.
  • Place a suction drain and meticulously
    close the soft tissue. Close the intermuscular interval in which the
    radial nerve lies with a layer of sutures deep to the radial nerve to
    separate it from the plate and bone graft. This method prevents
    reincorporation of the nerve into the scar and fracture callus.
    Document this change in location in the dictated operative note. Then
    close the muscle envelope around the fracture site to ensure full
    muscle coverage, and close the subcutaneous fat and skin in a routine
    fashion. A drain is usually advisable.
  • Place the arm in a sterile dressing and shoulder immobilizer.
Postoperative Care
Fixation is solid enough that most patients do not
require protection, although I have them wear a shoulder immobilizer
for the first 6 weeks to remind them not to use the arm for anything
but the lightest of activities of daily living. A Sarmiento-type
fracture brace is also useful. Begin gentle, active range-of-motion
exercises for the elbow and shoulder immediately, using circumduction
exercises for the shoulder to avoid bending stresses on the plate. At 6
weeks, if healing is progressing well, overhead pulley exercises for
the shoulder can begin. Avoid resistive exercises or any use of the
extremity for other than light activities of daily living until solid
union is documented, which is


12 or more weeks after surgery. Once solid union occurs, continue a
vigorous range-of-motion and strengthening rehabilitation program to
restore shoulder and elbow function (Fig. 27.9).

Figure 27.9. A 25-year-old man who had previous plate fixation of a fractured humerus, which resulted in a painful nonunion. A: Notice the inadequate plate and the radiolucencies around the screws, demonstrating looseness of internal fixation. B: The contoured “wave” plate was placed on the tension side of the nonunion. C, D: The nonunion has consolidated. The most distal screw is unicortical, not blocking the olecranon fossa.
Plate fixation with bone grafting for nonunions of the
humerus is very successful, with union rates in various series reported
from 91% in a difficult group of nonunions in elderly patients to 100% (29,38,49,57,66,81,89,103). The results with intramedullary fixation are much less predictable, with union rates reported from 54% to 87% (15,32,78).
Osteotomies for malunions of the diaphysis of the humerus are exceedingly rare. Most are performed for supracondylar


nonunions with varus deformity and loss of the carrying angle. (See the
next section.) The surgical technique is nearly identical to that
described earlier for the nonunion. In most cases, a single-plane
osteotomy permits correction of the deformity, and some length can be
regained if the osteotomy is long enough. Stabilize it with an
interfragmentary screw and a broad plate, as described earlier.

Nonunions of the distal humerus can be classified as
nonarticular (that is, supracondylar) or intraarticular (usually
involving the lateral condyle, but involvement of the medial condyle is
possible as well) (56). Nonunions in this
region are exceedingly rare, because acute fractures about the elbow
make up only 2% of all fractures and the cancellous bone in this region
usually leads to union. Malunion is more common. Ackerman and Jupiter (1)
treated only 20 patients with nonunions of the distal humerus during a
16-year period at a major referral center. A general orthopaedic
surgeon may encounter only one of these nonunions in his or her career.
Patients treated nonoperatively and those with neglected fractures
frequently have considerable stiffness in the elbow joint and use the
nonunion as a false joint to gain additional motion at the elbow.
Knowledge of the available range of motion in the elbow is essential
for preoperative planning. Lateral radiographs of the elbow joint in
flexion and extension and the distal humerus usually demonstrate the
true range of motion in the elbow and the instability in the fracture.
In supracondylar nonunions, the cartilage of the joint is usually well
preserved; therefore, a comprehensive soft-tissue release to regain
elbow motion not only greatly enhances function but makes it more
likely that the nonunion will heal by relieving stress on the nonunion
site through the increased motion of the elbow joint. Previously open
supracondylar fractures with nonunion, such as in side-swipe injuries,
may have occurred because of bone loss. In a neglected nonunion that is
functioning as the elbow joint, mechanical erosion of the bone ends
frequently leads to shortening and loss of bone substance (Fig. 27.10 and Fig. 27.11). Reconstruction



of these injuries can be difficult owing to the short articular
fragment and the differential in size between the articular fragment
and the shaft. Although the risk of failure is somewhat higher, use of
a structural intercalary bone graft is sometimes necessary to
reconstruct these difficult nonunions, as illustrated in Figure 27.11.

Figure 27.10.
AP and lateral radiographs of a 42-year-old man with a supracondylar
nonunion of the humerus. He had only a 40° arc of motion in the elbow
joint and had been using this pseudarthrosis for motion. Note the
resorption of the proximal fragment and the size mismatch at the
fracture site. See Figure 27-11 for management of this problem.
Figure 27.11. A:
Nonunion of a supracondylar fracture of the humerus in a 50-year-old
woman. AP view shows 2.5 inches (7.5 cm) of bone loss. This fracture
was open and was initially fixed with K-wires. No infection occurred,
but it did not heal. A second operation at another institution, using
bone graft and the K-wire fixation seen in this radiograph, was
unsuccessful. B: Lateral view. C: The nonunion was treated with bone grafting and internal fixation in the following manner:
•Through a posterior approach, the hardware was removed, fracture ends curetted, and length restored.
•A bicortical graft from the ilium was harvested.
•The graft was shaped and fitted into the defect with
some tension in the surrounding soft tissues to produce compression
across the graft.
•Internal fixation with two AO 4.5 mm reconstruction plates, one on each pillar of the distal humerus was achieved.
D: Anteroposterior view 12
weeks after surgery, at which time union appears to have occurred. The
plates stop at different levels proximally to reduce the stress-riser
effect, and six screws were placed in the short distal fragment. E: Lateral view. F: AP view of the pelvis showing the bone graft donor site.
Intraarticular nonunions are exceedingly rare and occur
most commonly in the lateral condyle of the humerus. More commonly,
fractures of the lateral condyle heal in malposition with cubitus
valgus and continue to function fairly well throughout life. Patients
with symptoms that require surgery usually present with tardy ulnar
nerve palsy, decreased range of motion, and pain and apprehension with
use of the elbow (53). Sometimes, corrective
osteotomy must be performed at the time of repair of the nonunion to
improve position using a tricortical graft in the nonunion site (53). Intraarticular debridement and release and balancing of the soft tissues may be necessary to improve or maintain motion.
Indications for surgery include
  • Intolerable pain from the nonunion.
  • Deformity that is not compatible with the level of function the patient expects or is cosmetically unacceptable.
  • Enough instability in the nonunion that the patient can no longer function at the level needed.
  • Cubitus valgus with progressive ulnar nerve palsy. Treatment alternatives include
  • Nonoperative treatment with supportive bracing.
  • Surgical treatment, with repair of the nonunion through double plate fixation and bone graft.
  • For cubitus valgus with a healed malunion
    of the lateral condyle or a stable fibrous union, a closing-wedge or
    opening-wedge osteotomy with plate fixation and a structural bone
    graft, if an opening wedge is performed. Anterior transfer of the ulnar
    nerve for tardy ulnar nerve palsy is usually necessary.
  • In some cases, direct repair of a
    nonunion of the lateral condyle is possible, but usually there is
    sufficient remodeling that a satisfactory intraarticular contour is
    exceedingly difficult to obtain.
  • Position the patient in a lateral
    decubitus position on a regular operating table, with the operated
    extremity uppermost. Support the arm on a well-padded obstetrics and
    gynecology leg holder or similar device, permitting gravity to allow
    the forearm to dangle at an angle of 90°.
  • Prepare and drape the extremity free up to the shoulder, and prepare the iliac crest for bone graft harvest as well.
  • Approach the distal humerus and elbow joint through a straight midline incision just off the tip of the olecranon.
  • Dissect along the deep fascia medially to
    the medial epicondyle, and identify the ulnar nerve. If tardy ulnar
    nerve palsy is present or if the nerve will be at risk because of the
    type of internal fixation to be done, perform an anterior transfer of
    the ulnar nerve. I prefer to place it in a subcutaneous pocket, taking
    care to release the medial intermuscular septum. Be certain that the
    nerve has no tension or impingement upon it.
  • From here, the approach varies according
    to the needs of the particular situation. In a nonarticular
    supracondylar nonunion that is at least 4 cm proximal to the joint
    line, a midline triceps splitting approach often suffices for the
    procedure. If the nonunion is closer to the joint, or if there are
    significant intraarticular adhesions requiring a soft-tissue release,
    then full exposure of the articular surface of the humerus and the
    elbow joint is required. Do this through either an extended triceps
    splitting approach, as described in Chapter 1,
    or a chevron-type olecranon osteotomy. I prefer the triceps-splitting
    approach. For this approach to be successful, the joint capsule,
    triceps, and origins of the flexor and extensor muscle groups of the
    forearm are reflected to beyond the epicondyles in medial and lateral
    full-thickness flaps. Take care to preserve the triceps aponeurosis as
    it crosses the tip of the olecranon to avoid disrupting the continuity
    of the triceps mechanism.
  • Now take down the nonunion, freshen the
    bone ends, and reshape them to obtain maximum cortical apposition and
    to correct deformity. Open the medullary canal proximally, and multiply
    drill the face of the distal fragment distally with a 2 mm drill point.
  • Now internally fix with double plates,
    one on the posterior aspect of the lateral condyle and another along
    the medial supracondylar ridge at right angles to the posterolateral
    plate. Molding the plates to the bone is challenging; therefore, use
    3.5 mm reconstruction plates or their equivalent.
  • On the lateral side, fashion the plate to
    fit down to the articular surface of the lateral condyle, taking care
    to be certain that there is no impingement with the radial head when
    the elbow is in full extension. Try to obtain at least three cortical
    screws of fixation in the distal fragment. The most distal screws
    running from posterior to anterior are opposite the articular surface
    and therefore cannot be bicortical. I prefer to use nontapped cortical
    screws, because this seems to provide better


    than cancellous screws. Approximately four bicortical screws of solid
    fixation in the proximal fragment are usually adequate. On the medial
    side, usually the plate does not need to extend around the medial
    curvature of the medial epicondyle unless the distal fragment is quite
    small. This plate normally provides excellent fixation, because the
    distal screws can extend transversely across the condyles in a
    bicortical fashion. Try to place a similar number of screws in both
    fragments medially as well.

  • If an intercalary defeat is present that
    cannot be handled by direct apposition of the two fragments, use a
    technique similar to that described in Figure 27.11.
  • Examine the elbow to determine the range
    of motion. A range of -20° of extension to 120° of flexion provides
    reasonably good function. If this is not present, consider a
    soft-tissue release (60,63).
  • Excise all intraarticular adhesions.
  • Inspect the olecranon and remove any osteophytes that are preventing full extension.
  • Inspect the olecranon fossa and remove
    any osteophytes that are blocking full extension. If there is a block
    to flexion, make a window in the olecranon fossa to provide access to
    the coronoid fossa and permit removal of anterior osteophytes that may
    be blocking motion. This should provide extension to within 10° of
  • If extension appears to be limited owing
    to a tight anterior capsule, then dissect carefully along the anterior
    aspect of the capsule from lateral to medial, isolating the capsule
    from the anterior soft-tissue structures. Then carefully excise the
    anterior capsule, taking care to avoid injury to the anterior
    neurovascular structures. This also provides excellent exposure for
    removal of any anterior osteophytes that might be impeding full flexion.
  • When carrying the elbow through range of
    motion, be certain that the articular surface of the olecranon remains
    completely congruent with the distal end of the humerus rather than
    hinging open, which gives a false measurement of the available motion
    in flexion.
  • Apply cancellous bone graft along the edges of the nonunion, taking care to not encroach on the joint.
  • If a tourniquet is used, deflate it now
    and ensure good hemostasis. Drain the elbow. Meticulously close the
    posterior longitudinal wound. In the case of a triceps-splitting
    approach, close the deep capsule and deep triceps in a separate layer
    and then close the triceps aponeurosis and approximate the fascia of
    the extensor and flexor compartments of the forearm in a single layer
    with interrupted #0 resorbable sutures. Close the subcutaneous fat and
    skin in the usual manner. Take care to be certain that the ulnar nerve
    remains in good position.
  • Most patients tolerate immobilization
    better in a position of about 20° of flexion than in one of 90°. Apply
    a bulky dressing and medial and lateral splints to support the elbow
    just short of full extension. Elevate the arm 10 cm above the heart.
Postoperative Care
  • Considerable swelling and occasionally
    even skin blistering or compartment syndrome can occur after extensive
    reconstructive procedures about the elbow. Monitor the patient
    carefully during the first 48 hours postoperatively. If the patient has
    pain beyond that expected, be certain to release the dressing fully and
    inspect the arm carefully. If swelling is excessive or compartment
    syndrome threatens, early release of the surgical incision down to the
    deep fascia, and occasionally even deeper, may be necessary. After
    swelling subsides, the wound is usually easily reapproximated.
  • As soon as swelling subsides and the
    patient becomes comfortable, remove the bulky dressing and splint,
    apply a lightweight Bledsoe-type brace, and immediately begin active
    range-of-motion exercises. With this procedure, it is absolutely
    essential that the patient begin early aggressive, active motion under
    the supervision of a therapist. The goal is to achieve the full motion
    expected by 6 weeks after surgery. On the operative table, before
    awakening the patient, it is possible to examine the elbow under
    anesthesia to establish what the safe range of motion is before
    excessive stress is placed on the reconstruction of the nonunion. A
    brace can be set for this range of motion to protect the nonunion
    during this rehabilitation. When bone-to-bone apposition has been
    achieved, reasonably good stability is present at 6 weeks, but full
    union usually requires 12 to 16 weeks. Do not allow resistive exercises
    or use of the extremity for other than light activities of daily living
    until full union has occurred. I have not found continuous passive
    motion for the elbow to be of value.
  • Position the patient in the supine
    position on an operating table, and prepare and drape the operated
    extremity free as well as the iliac crest for bone graft.
  • Make a longitudinal incision, beginning
    over the radial head and extending proximally along the midlateral
    aspect of the humerus. Dissect directly down to the lateral
    supracondylar ridge of the humerus, and expose the distal humerus down
    to the joint capsule by subperiosteal dissection. Place a sharp-tipped
    Hohmann retractor posteriorly and anteriorly to expose the distal
    humerus. Take care to avoid injury to the radial nerve. Under
    fluoroscope control, drill a 2 mm K-wire transversely


    across the humerus just proximal to the olecranon fascia and parallel to the elbow joint.

  • While protecting the soft tissues, make a
    transverse osteotomy to but not through the medial cortex. Open the
    osteotomy by manipulation, which results in a greenstick fracture of
    the opposite cortex. Confirm restoration of the anatomic position on
  • Harvest a tricortical iliac graft from
    the anterior ilium. Insert this into the defect, compress the defect,
    and internally fix it with a 3.5 reconstruction plate along the
    posterolateral supracondylar ridge. Try to place at least one screw in
    an interfragmentary fashion.
  • An alternative is to perform an oblique
    osteotomy in the frontal plane, which then permits correction of the
    deformity by simply rotating through the osteotomy site. Fix it with an
    anterior-to-posterior interfragmentary screw and a lateral
    neutralization plate. Although this technique is technically more
    difficult, I prefer it because union is faster and it eliminates the
    need to harvest a bone graft.
  • Postoperative treatment is as described earlier.
From the standpoint of achieving union in nonunions, the results are quite good. Ackerman and Jupiter (1) achieved union in 17 of 18 patients, Sanders and Sackett (84)
achieved union in five of five patients, and in my personal series of
12 patients, I achieved union in 100%. Those who required a soft-tissue
release to achieve elbow motion or who have intraarticular fractures do
less well from the standpoint of regaining elbow motion. Usually,
pronation and supination are nearly normal. In some patients, we have
had astoundingly good results, with gains in total motion of over 100°,
and in others we have seen no improvement from the preoperative range
of motion. The determining factors appear to be the degree of
intraarticular adhesion and arthritis, and the ability of the patient
to exercise in the face of discomfort during the postoperative recovery.
Failed salvage of supracondylar nonunions can leave
patients with a painful flail extremity with which they are unable to
perform even the minimal activities of daily living. In these patients,
particularly if they are elderly, total elbow arthroplasty provides a
method for salvage (27,64). Morrey and Adams (64)
reported on 36 consecutive patients with an average age of 68 years who
underwent semiconstrained elbow replacement for distal humeral
nonunion, with an average follow-up of somewhat more than 4 years. Of
these patients, 86% had a satisfactory result and only two had a poor
result. Patients showed a marked decrease in pain and an improvement in
the overall mean arc of motion from 74° to 111°. This is a challenging
procedure, however, as evidenced by the fact that seven patients had
complications and five of these required reoperation.
Nonunion of the olecranon is usually due to neglect of
the original fracture (such as in alcoholics who fail to seek
treatment) or failed internal fixation (usually a tension band wire),
or is secondary to major bone loss such as in side-swipe injuries.
Neglected nonunions can do surprisingly well. They generally are free
of pain with a 2- to 4-cm gap, and the only functional deficit is
weakness in extension, which causes functional limitations but is
compatible with light activities of daily living. In my experience,
failure of internal fixation is most common when lightweight wires are
used to fashion a tension band repair that is then subjected to
repetitive heavy use by an uncooperative patient. It also occurs in
patients who have been victims of multiple trauma, are on enforced bed
rest, and tend to use their elbows for moving themselves in bed.
Failure tends to occur early before these become established nonunions
and can usually be treated by repeated internal fixation with stronger
devices. Nonunions due to bone loss are much more challenging because
they often involve a segment of the articular surface. Indications for
surgery include pain and functional loss. Alternative methods of
treatment in addition to bone graft include compression-plate fixation
with a 3.5 reconstruction plate placed on either the medial or lateral
surfaces of the olecranon and ulnar shaft; tension band plating with a
hook plate, as illustrated in Figure 27.12; or repeat tension band wiring, using a combination of screws and 18-gauge wire for the tension band.
Figure 27.12. Nonunion of the olecranon. A: Inadequate tension band fixation of an olecranon fracture resulted in a nonunion. B:
Fixation has been removed, and a one third tubular plate has been
fashioned as a hook plate, using the end hole as two sharp prongs. The
tensioning device was applied after fixation of the plate to the
olecranon fragment by a lag screw across the fracture site. Tensioning
was then applied and supplemented by a long interfragmental fully
threaded 3.5 mm screw. C: At 9 months,
consolidation of the nonunion was occurring. This view also
demonstrates the hook plate with its firm attachment into the olecranon.
  • Expose the olecranon by subperiosteal dissection. If there is a stable fibrous nonunion in good position, internal fixation in situ is indicated.
  • Otherwise, excise the fibrous tissue from
    the nonunion site, freshen the bone ends and open the medullary canal
    of the distal fragment, and reduce the fracture.
  • Take care to not reduce the diameter of
    the olecranon fossa because this will produce incongruence in the elbow
    joint, which can lead to loss of motion, pain, instability, and
    precocious arthritis.
  • If a gap is present, harvest a
    tricortical bone graft from the anterior iliac crest to interpose in
    the nonunion site. Place this so that it does not impinge on the


    cartilage. This will leave a gap in the articular surface, which is usually acceptable.

  • Place a reconstruction plate along the
    medial or lateral border of the olecranon, and mold it carefully to
    maintain anatomic position.
  • Apply a cancellous bone graft.
  • After completion of the fixation, examine
    the elbow under anesthesia to determine the safe range of motion that
    can be used postoperatively without excessively stressing the construct.
  • Close the wounds and apply a bulky soft dressing, splinting the elbow just short of full extension.
  • After swelling has subsided, apply a
    Bledsoe-type brace with the locks set to permit a safe range of motion,
    and immediately begin active gentle motion. Avoid use of the extremity
    for anything but light activities of daily living until union occurs,
    which is generally no earlier than 8 weeks. Most heal by 12 weeks, but
    some take as long as 16 weeks if an intercalary bone graft has been
    used (Fig. 27.13).
    Figure 27.13. Nonunion of the olecranon. A: AP and lateral radiographs showing failure of a third tubular plate, resulting in nonunion. B:
    AP and lateral radiographs. This fibrous nonunion was in an acceptable
    position and, therefore, was treated with compression plate fixation
    and an interfragmentary compression screw in situ, resulting in rapid healing.



This is an exceedingly rare nonunion; I was able to identify only one reported case of bilateral radial neck nonunion (58).
This was treated with an inlay cancellous iliac crest bone graft,
followed by long-arm cast immobilization for 4 weeks, resulting in
radiographic union by 10 weeks. Surprisingly, full pronation and
supination returned.
Open reduction and plate fixation of displaced fractures
of the diaphysis of the radius and ulna, whether both or only one is
involved, has generally been considered mandatory in adults (3,7,10,14,20,31,36,37,44,46,65,67,76,85,86,94,95,97).
Nearly anatomic reduction and early motion are necessary to avoid
restriction of pronation and supination. Although the ulna may be
treated with a closed reduction and functional bracing (87), plate fixation of the ulna and, on occasion, intramedullary nailing are necessary in significantly displaced fractures.
Current union rates for internally fixed forearm
fractures are 98% or better, with good to excellent functional results
and less than 30% loss of total pronation and supination (3,10,14,20,31,43,80). At least six to eight cortices of fixation, with a 3.5 mm system and compression techniques, should be used (65,94).
Nonunions of the fractures of the shafts of the radius and ulna are now
most commonly due to segmental bone loss, infection, or inadequate
internal fixation with mechanical failure. Poor surgical technique with
excessive soft-tissue striping can also lead to nonunion because of the
devascularization of the bone ends (61,62).
  • Treatment of nonunions of the diaphysis
    of the radius and ulna does not differ significantly from primary
    internal fixation. Approach the ulna through a longitudinal incision
    along the subcutaneous border and the radius through a modified
    Thompson’s dorsal radial approach. Making the skin incision on a line
    drawn from the tip of the radial styloid to the lateral epicondyle of
    the humerus, using the appropriate intermuscular interval, allows
    exposure of the radius from radial head to radial styloid (see Chapter 1).
  • In most cases, loose screws or broken
    plates, or both, are present. Remove these and identify the nonunion
    site. If the overall alignment is acceptable and there is a stable
    fibrous nonunion, then simple plate fixation and compression usually
  • In most cases, however, deformity is
    present. Most likely you will have to deal with shortening and
    angulation, and possibly intercalary bone loss. Restoring alignment in
    the ulna is not too difficult because, other than in the area of the
    olecranon, the bone for the most part is straight. Restoring the radial
    bow of the radius, however, can be difficult, and intraoperative
    radiographic guidance with either a fluoroscope or plain radiographs is
    very important. Occasionally, nonunions or malunions are complicated by
    synostosis or collapse of the interosseous membrane. This requires take
    down of the synostosis and shaving of the bone to restore the normal
    contour, as well as soft-tissue release in the area of the interosseous
    membrane. This can be quite challenging because of the presence of the
    neurovascular bundles in this area.
  • Restore normal alignment and length. A
    temporary distractor or an external fixator may be necessary to hold
    the radius out to length. Place cancellous bone or a structural
    tricortical iliac crest bone graft into any bone deficiency, and apply
    a 3.5 mm or equivalent plate, using interfragmentary compression and
    longitudinal compression where possible. Try to obtain at least eight
    cortices of fixation proximal and distal to the fracture. In some cases
    in which there is no bone loss, the internal fixation can be carried
    out first and the bone graft applied second.
  • Apply plates to the dorsal lateral aspect
    of the radius, where they act as a tension band, and on the ulna they
    can be placed on the subcutaneous border or slipped off to the side so
    that they are less prominent beneath the skin. When applying bone
    graft, do not impinge on the interosseous membrane because this may
    lead to synostosis or restriction in motion.
  • After internal fixation, determine the
    safe range of motion in flexion and extension of the wrist and elbow,
    and in pronation and supination. This will be useful in instructing the
    patient about postoperative exercises.
  • Close the muscle envelope over the
    fracture sites but leave the deep fascia open because of the
    predilection for swelling after these extensive procedures. Close the
    skin in a routine manner and place the arm in a bulky long arm splint
    with the elbow at 20° or so of flexion and the forearm in neutral
    supination and pronation. After swelling has abated, a lightweight
    brace or molded orthotic cuff is useful to remind the patient to be
    careful with the forearm. Have the patient begin active motion
    immediately, using the extremity only for light activities of daily
    living until union occurs. In the forearm, nonunions usually require at
    least 16 weeks and may require up to 6 months to heal solidly (Fig. 27.14 and Fig. 27.15).
    Figure 27.14. Delayed union of a Galeazzi fracture. A:
    An oblique fracture has been internally fixed using a semitubular plate
    with inadequate cortical purchase. There is no interfragmentary screw
    across the fracture. B: Union after
    fixation with a 3.5 mm dynamic compression plate placed on the dorsal
    radial surface with an interfragmentary screw, along with a cancellous
    bone graft.
    Figure 27.15. Atrophic nonunion of the ulna in a Monteggia fracture dislocation. A, B: Atrophic nonunion of the fracture of the ulna treated previously by cerclage wire and intramedullary fixation. C: A 3.5 mm dynamic compression plate and cortical cancellous bone grafting were used to stabilize the ulnar fracture. D:
    After 1 year, union had occurred. Restoration of the alignment and
    length of the ulna resulted in satisfactory position of the radius and
    functional forearm rotation.
Malunions in the forearm resulting in loss of forearm motion or rotation can be related to fixation of the radius in


malposition; loss of the normal arc and spacing between the radius and
ulna due to collapse of the bones toward the interosseous membrane; or
to subluxation or internal derangements in the proximal radioulnar
joint or the distal radioulnar joint. The latter problems in the joints
are addressed in Chapter 43.
It can be corrected by osteotomy to place forearm motion in a more
functional range. It is difficult to increase the total range of motion
because of intraosseous membrane contraction and soft-tissue scarring.

With increased dissection through the soft tissue,
cross-unions may occur. Rotational problems are best managed at the
time of acute fracture care. Radioulnar synostosis (3,5,50)
may follow closed or open treatment. It appears to be related directly
to the extent of injury to the interosseous membrane, because it is
more common in fractures that are at the same level, in open fractures,
and after internal fixation. Early motion can significantly reduce the
incidence of this problem in internally fixed fractures.
Operative intervention for malunion is not always
indicated. As long as the hand can be used appropriately and can be
placed in the appropriate positions to perform day-to-day activities,
no additional treatment is required. This usually is in the neutral or
somewhat pronated position, allowing shoulder and elbow motion to
The precise definition of what constitutes a malunion in
the forearm has been elusive, but recent work provides reasonably good
guidelines (54,90,96).
This is particularly an issue when one considers the need for open
reduction and internal fixation in adolescents, in whom the amount of
remolding that is possible following healing in a nonanatomic position
can be somewhat unpredictable. Matthews et al. (54)
showed that with 10° of angulation in the radius, there was minimal
functional loss in pronation and supination, whereas over 20° of
angulation functional loss occurred. Tarr et al. (96)
provided more specific information, in that they demonstrated in a
cadaver study that greater than 10° of angulation in both bones located
in the distal third of the forearm resulted in an average loss of range
of motion of 12.5% ±pm 4.5%. If this same angulation was present in the
middle third of the forearm, this loss increased to 16% ±pm 5.7%;
therefore, angulation in the middle third of the forearm is tolerated
less well than in the distal third. They found that the loss in
supination and pronation secondary to rotational malposition was
directly proportional to the degree of malrotation. Schemitsch and
Richards (90), in a retrospective review of 55
patients with forearm fractures who underwent plate fixation at 6 years
of follow-up, provided a new method of assessing radial bow and
relating this to loss of motion. Although angulation over 10° in both
bones has adverse functional effects, it appears that preservation of
the normal bow of the radius is the more critical factor. In their
patients, they compared the radial bow on comparison x-ray studies to
the normal side and measured this according to the maximum distance
between the radius and the ulna at the interosseous membrane. Their
overall results in this group of patients were excellent, in that 54 or
55 fractures in the radius and ulna healed and 84% of the patients had
satisfactory functional results. They demonstrated that restoration of
the radial bow was directly correlated with the functional outcome and
that completely normal motion



restoration of the radial bow to normal. In spite of the efforts made
in their series to achieve anatomic reduction of both bones, their
results show that this is difficult; the mean outcomes in their series
were 64° in pronation and 74° in supination. The normal maximum radial
bow, as measured at the interosseous membrane, in their series was 15
mm. To get 80% of normal range of motion, this had to be within 1.5 mm
of normal. They found the same direct relationship to grip strength.
Stated another way, if the maximum radial bow was within 4% to 5% of
normal, then 80% of forearm range of motion and grip strength could be
expected. As emphasized in the study conducted by Tarr et al. (96),
both the location and the amount of the loss of radial bow were
important. The overall results in their series were somewhat less good
than previously reported; the unsatisfactory functional outcomes in
their study were 16%, as compared to 15% for Anderson et al (3) and 9% for Chapman et al (14).
They attributed this to the fact that the severity of injury was
greater in their series in that all of their patients had fractures of
both bones and greater numbers of fractures were open.

There is little in the literature on the use of osteotomy for correction of forearm malunion. Trousdale and Linscheid (99)
reported on 27 osteotomies for malunion of the forearm, including 20 in
the radius, two in the ulna, and five in both. Their indications were
loss of motion in 20 (average loss 74°, range 20° to 120°), a painful
distal radioulnar joint in six, and poor cosmesis in one. One of the
most important findings in their study was that time had a significant
effect on the improvement in range of motion. Patients operated on
sooner than 12 months after the original injury gained an average of
29° of supination and pronation (range 20° to 160°, and in those
operated on more than 12 months after injury the gains were less than
half, averaging 30° (range -25° to 95°). Of the six patients operated
on for distal radioulnar joint pain, three experienced marked
improvement of their pain and achieved a stable joint, but the average
loss of range of motion in the six patients was 7° (range -25° to 25°).
The patient operated on for cosmetic problems was pleased with the
appearance of the forearm but lost 10° of rotation. Their outcomes
point out that it is possible to achieve significant improvement in
patients with forearm malunions, but the surgery is better done earlier
than later and does not have consistent results, and the fact that
Trousdale and Linscheid had complications in 11 of their 27 patients
demonstrates that the surgery is challenging.
  • Interoperative radiographic evaluation of
    the correction achieved is important; therefore, use a radiolucent hand
    table and fluoroscopy or plain radiographs, or both.
  • Depending on whether osteotomies are
    planned for an isolated forearm bone or both bones, use the surgical
    approaches described earlier. Expose the site for osteotomy in a
    subperiosteal fashion. This should be at the maximum point of
    deformity. Use gentle technique to minimize soft-tissue injury and to
    avoid invading the interosseous space. When performing osteotomies of
    both the radius and ulna at the same level, it is important to try to
    prevent communication of the hematomas from the two operative sites
    because this could lead to synostosis.
  • Perform an appropriate osteotomy,
    depending on the deformity to be corrected. In many cases, it is
    possible to identify the old fracture site and reassemble the fracture
    in anatomic position after removing excess callus and refashioning the
    bone ends. In more mature malunions, it is necessary to perform a
    formal osteotomy. Often this must be in an oblique plane to allow
    correction of angulation and rotary deformity, which are frequently
    combined. This can be challenging because the rotational component of
    the deformity is difficult to assess by radiography preoperatively.
    Some repeat shaping of the osteotomy site after intraoperative
    radiographs and examination for range of motion are usually necessary.
  • Internally fix the osteotomy, taking care
    to place an appropriate bow in the plate on the radius to restore fully
    the radial bow. Obtain eight cortices of fixation proximal and distal
    to the osteotomy site with an interfragmentary screw across the
    osteotomy, if possible. The plates are best located just off the
    subcutaneous border of the ulna and on the dorsal radial aspect of the
    radius. You may make an exception for a very distal radius osteotomy,
    where the plate might be better placed palmerly.
  • If the patient has pathology in the
    interosseous membrane or at the distal radioulnar joint (DRUJ),
    additional procedures to release contractures of the interosseous
    membrane or to address problems in the DRUJ may be necessary. See the
    discussion of treatment of synostosis below; see Chapter 43 for DRUJ problems.
  • Perform a meticulous soft-tissue closure,
    leaving the deep fascia open. Initially immobilize the extremity in a
    well-padded long-arm splint, with the elbow at 90° and the forearm in
    neutral pronation and supination. As soon as pain subsides and the
    swelling is controlled, begin a supervised range-of-motion exercise
    program under the supervision of a hand therapist. Solid stability of
    the internal fixation is obviously necessary to obtain an optimal
    result, the latter requiring fairly vigorous early active range of
    motion without resistance.
Malunions of the radial head and neck can be
reconstructed with an osteotomy, but in most cases, assuming that the
radius and ulna are longitudinally stable and there are no major DRUJ
problems, the easiest procedure producing the best results is radial
head excision.


  • Approach the radial head through a Kocher incision (see Chapter 1).
    Expose the radial head and proximal neck as far as the annular
    ligament. Take care to avoid injury to the posterior interosseous nerve.
  • With a water-cooled mini-oscillating saw
    or high-speed burr, transect the radial neck just proximal to the
    radial head and smooth the edges to remove any osteophytes or malunited
  • Leave the annular ligament intact. If it is disrupted and the proximal radius is unstable, reconstruct it.
  • Close the wound in a routine fashion,
    apply a bulky sterile dressing and splint, and begin elbow and forearm
    exercises as soon as the patient will tolerate them.
The complications of treating malunions and nonunions of
the upper extremity are similar to those of all major surgery in the
upper extremity, including infection, neurovascular injury, failure of
the fixation, loss of joint motion, and others. The risk of these
problems can be minimized by careful attention to patient selection and
details of the surgery. The outcome depends strongly on a fully
cooperative patient who is capable of performing exercises in the face
of discomfort and who is completely compliant with postoperative
In my experience, synostosis between the radius and ulna
is most common after severe proximal forearm fractures. It can be
managed by radial head resection with excision of the synostosis, as
described earlier. Restoration of forearm motion through excision of a
synostosis is challenging because soft-tissue contracture and scarring
frequently compromise the motion that can be gained, and avoiding
injury to the anterior and posterior interosseous neurovascular bundles
can be challenging. To prevent reformation of the synostosis, fat,
muscle, and Silastic membranes have been used to fill the space between
the radius and the ulna (9,50,74,101,108,109).
If large raw areas of bone are left after excision of the synostosis, I
find that coating these with a thin layer of bone wax and then filling
the gap where the synostosis was present with autologous fat helps
prevent reformation (Fig. 27.16).
Figure 27.16. Synostosis of both bones of the forearm. A:
A 25-year-old man sustained an open fracture of both bones of the
forearm, which was treated with plate fixation. He developed a
synostosis of his forearm in a nonfunctional position. B:
This postoperative radiograph shows excision of the synostosis with a
free fat graft packed in the area of the synostosis. At 9 months, he
had functional forearm rotation, lacking the last 20° of supination and
Posttraumatic contracture of the elbow is a complex and challenging problem. Refer to the excellent review articles by Morrey (63) and Modabber and Jupiter (60)
for a detailed discussion. For most activities of daily living, an
elbow flexion and extension arc of motion from 30° to 130° is
necessary. A marked impairment of the ability to position the hand in
space occurs when a flexion contracture exceeds 45° and flexion is less
then 110°. These are indications for operative treatment of contracture
of the elbow. Lesser degrees of loss of motion may be an indication,
depending on the patient’s functional needs. Loss of motion can be
caused by extrinsic contractures involving the joint capsule,
ligaments, and osseous structures, and intrinsic contractures can be
caused by intra-articular incongruity or malunions and adhesions. If
there is significant loss of articular cartilage or if posttraumatic
degenerative arthritis is present, fascial interposition arthroplasty
may be necessary to gain a satisfactory outcome. This usually requires
use of distraction with a specialized external fixator.
Release with Fascial Arthroplasty
Methods for addressing both intrinsic and extrinsic
contracture, with and without distraction, are available. Morrey’s
technique (63) is utilitarian and is commonly used for treatment of contractures (Fig. 27.17).
Figure 27.17. Morrey fascial arthroplasty of the elbow. A: The reflected extensor mechanism, resected tip of the olecranon, released forearm extensors, and exposed anterior capsule. B: The reflected lateral collateral ligament and the anterior capsule resected to the medial side (broken lines). C: Joint surfaces to be smoothed with a burr (dotted areas). A fascial graft attached to the humerus and ulna, with sutures through bone. D: Medial approach. E: Location of the anatomic axis of rotation of the elbow in the frontal plane. F: Lateral view of the axis of rotation of the elbow. G: Mayo Clinic distraction device. H: Repair of the lateral collateral ligament to the humerus. (From Morrey BF. Post-traumatic Contracture of the Elbow. J Bone Joint Surg 1990;72-A:601.)
  • Place the patient supine on an operating table with a sandbag under the operated side. Drape the upper extremity free.
  • Prep and drape the ipsilateral lateral thigh for possible harvest of a fascial graft.
  • Make an extensile posterolateral approach, using the interval between the anconeus and extensor carpi ulnaris (see Chapter 1).
    Expose as much of the elbow joint as necessary to achieve an adequate
    release by elevating the triceps from the posterior aspect of the
    humerus in continuity with the lateral forearm musculature and triceps
    aponeurosis. Dissect medially along the anterior aspect of the humerus
    joint capsule to expose the anterior structures (Fig. 27.17A).
  • Excise the posterior tip of the olecranon
    process and any osteophytes, and remove the posterior capsule. Excise
    or release anterior capsular adhesions and structures as necessary.
    Lyse all intracapsular adhesions.
  • If possible, preserve the lateral
    collateral ligament. If release is necessary, reflect it distally,
    releasing its humeral origin. Resect the anterior capsule (Fig. 27.17B). If anterior impingement is found, excise any bony osteophytes.
  • If 50% or more of the articular surface
    of the elbow is not covered by hyalin cartilage, or if a significant
    malunion is present, recontour the joint and perform an interpositional
    fascial arthroplasty. Smooth the joint surfaces of the humerus and ulna
    with a burr (Fig. 27.17C).
  • Make an 18 cm long incision over the lateral aspect of


    the thigh, and harvest a sheet of fascia 4 to 5 cm wide and 12 to 15 cm long.

  • Trim the fascial graft to the appropriate
    size and shape, and attach it to the articular surface of the distal
    humerus through sutures along the edges of the humeral joint surface.
    This can be aided by front-to-back drill holes. Then double the fascial
    membrane back on itself to form a continuous double layer covering the
    olecranon. Secure the graft to the olecranon in a similar manner (Fig. 27.17C).
  • Try to preserve the radial head, but excise it if it presents problems.
  • If an external fixator will be applied or
    there is a need to complete the soft-tissue release, make a medial
    approach over the medial epicondyle. Split the flexor-pronator muscles
    in line with their fibers and complete the medial part of the
    capsulectomy. If necessary, perform an anterior transfer of the ulnar
    nerve (Fig. 27.17D).
  • Apply a distraction or dial-compass external fixator.
  • Under fluoroscopic control, insert a
    guide pin through the center of the capitellum, transversely across the
    condyles of the humerus, to exit the trochlea dead center. It is
    important that this be directly in line with the instant center of
    rotation of the elbow (Fig. 27.17E, Fig. 27.17F).
  • Mount the external fixator on this pin,
    and then place two or more half pins into the distal humerus and two in
    the proximal ulna according to the directions of the manufacturer.
    Adjust the frame to ensure appropriate motion and to separate the joint
    surfaces 4 to 5 mm in all positions of the elbow. Remove the guide pin (Fig. 27.17G).
  • Repair the lateral collateral ligament, using a Bunnell stitch placed through the drill holes in the humerus (Fig. 27.17H).
  • Place a small suction drain and close the wounds in layers.
  • P.914



  • Apply a sterile dressing and a bulky compression dressing.
  • Begin motion as soon as possible. Morrey uses continuous passive motion.
Postoperative Management
After 3 to 4 weeks, Morrey (63)
removes the external fixator under anesthesia, gently examines the
elbow (avoiding manipulation) to assess the end points of motion, and
then uses turnbuckle splints, one for extension and one for flexion, to
help the patient gain range of motion while continuing on an active
daily exercise program. He uses the turnbuckle splints regularly for as
long as 6 months following the routine outlined in Table 27.1.
27.1. General Guidelines for Use of Turnbuckle Splints for the First
Three Postoperative Months in the Treatment of a Stiff Elbow
In six patients who Morrey (63)
treated by release without distraction external fixation, the
preoperative arc of total motion was 32°. Postoperatively, it increased
to 74°. In those treated with distraction arthroplasty without
interposition, total motion before operation was 32° and increased to a
total average arc of motion of 99°. In the six treated with
interpositional arthroplasty and distraction, motion increased from a
total of 27° to 107°. The increases in pronation and supination were
modest and were best in the interposition-distraction group.
It is somewhat hazardous to generalize about the
treatment of nonunions and malunions in the upper extremity, because
these are uncommon problems that may appear only one or two times in
the lifetime of an average surgeon. Large series are rare even in the
hands of surgeons working in major referral centers. In addition, each
patient’s problem is unique and requires an individualized approach.
Recognizing these limitations, my recommendations for the treatment of
nonunions and malunions in the upper extremity are as follows:
  • Use a careful soft-tissue technique with
    as limited exposure of bone as possible (usually two of the four
    quartiles of circumference available) in an effort to maintain the
    blood supply to the bone.
  • Take down the nonunion site in most cases
    by fashioning of the bone ends to correct deformity and maximize
    surface area, opening the medullary canal and placing multiple shallow
    drill holes on metaphyseal fragments to encourage revascularization.
  • Use solid internal fixation, eliminating
    any micromotion; try to obtain fixation in two planes, usually with a
    plate in one plane and an interfragmentary screw in the other, followed
    by autologous bone graft laid on a petaled cortical surface.
  • During surgery under anesthesia,
    establish the safe range of motion possible for early rehabilitation.
    Institute early motion and then progress the rehabilitation program as
    the fracture consolidates.
  • For nonunions of the surgical neck of the
    humerus, use 3.5 mm reconstruction double plate fixation combined with
    iliac crest bone graft.
  • For mid-diaphyseal nonunions of the
    humerus, use broad plate fixation with interfragmentary screws combined
    with autologous bone graft.
  • For supracondylar humerus nonunions, use
    double plate fixation with 3.5 mm or equivalent reconstruction plates,
    placing one plate on the posterior aspect of the lateral column and one
    on the medial aspect of the medial column combined with iliac crest
    bone graft.
  • For elbow arthroplasty, I follow the tenets advocated by Morrey (63,64)
    as outlined earlier; using a straight posterior approach when
    accompanying bony reconstruction makes this a more convenient approach.
  • For olecranon nonunion, use single and
    occasionally double plate fixation with small reconstruction plates
    combined with iliac crest bone graft (tricortical graft for bone
  • For nonunions of the radius and ulna, use
    small reconstruction plates or AO 3.5 LCDC plates with interfragmentary
    screws combined with cancellous bone graft or


    structural tricortical iliac crest graft for bone deficiencies.

  • For malunions, I try to use oblique
    single plane oblique osteotomies with interfragmentary screw fixation
    and neutralization plates.
  • Using these techniques, between 1980 and
    1995 I was able to achieve union in 36 of 37 nonunions of the humerus
    and 100% healing of five nonunions in the radius and ulna.
Each reference is categorized according to the following
scheme: *, classic article; #, review article; !, basic research
article; and +, clinical results/outcome study.
+ 1. Ackerman G, Jupiter JB. Non-union of Fractures of the Distal End of the Humerus. J Bone Joint Surg 1988;70A:1.
+ 2. Ada JR, Miller ME. Scapular Fractures. Analysis of 113 Cases. Clin Orthop 1991;2679:174.
+ 3. Anderson LD, Sisk TD, Tooms RE, Park WI. Compression Plate Fixation in Acute Diaphyseal Fractures of the Radius and Ulna. J Bone Joint Surg 1975;57-A:287.
+ 5. Boehme
D, Curtis RJ, DeHaan JT, et al. Treatment of Nonunion of Fractures of
the Midshaft of the Clavicle with a Modified Intramedullary Hagie Pin
and Autogenous Bone Grafting. J Bone Joint Surg 1991;73A:1219.
+ 6. Boyer MI, Axelrod TS. Atrophic Nonunion of the Clavicle. Treatment by Compression Plate, Lag-screw Fixation and Bone Graft. J Bone Joint Surg 1997;79B:301.
+ 7. Brackenburg PH, Corea JR, Blakemore ME. Non-Union of the Isolated Fracture of the Ulnar Shaft in Adults. Injury 1981;12:371.
+ 8. Bradbury N, Hutchinson J, Hahn D, Colton CL. Clavicular Nonunion. 31/32 Healed after Plate Fixation and Bone Grafting. Acta Orthop Scand 1996;67:367.
+ 9. Bret R. Post-Traumatic Radio-Ulnar Synostosis. Clin Orthop 1983;174:149.
* 10. Burwell HN, Charnley AD. Treatment of Forearm Fractures in Adults with Particular Reference to Plate Fixation. J Bone Joint Surg 1964;46-B:404.
+ 11. Butting TDJ. Post-Traumatic Radio-Ulna Gross-Union. J Trauma 1970;10:16.
+ 12. Capicotto
PN, Kingsbury GH, Wilbur JH. Midshaft Clavicle Nonunions Treated with
Intramedullary Steinmann Pin Fixation and Onlay Bone Graft. J Orthop Trauma 1994;8:88.
+ 13. Chacha PB. Compression Plating without Bone Grafts for Delayed and Non-Union of Humeral Shaft Fractures. Injury 1974;5:283.
+ 14. Chapman M, Gordon JE, Zissimos AG. Compression-plate Fixation of Acute Fractures of the Diaphyses of the Radius and Ulna. J Bone Joint Surg 1989;71A:159.
+ 15. Christensen NO. Kúntscher Intramedullary Reaming and Nail Fixation for Nonunion of the Humerus. Clin Orthop 1976;116:222.
+ 16. Connolly JF, Dehne R. Nonunion of the Clavicle and Thoracic Outlet Syndrome. J Trauma 1989;29:1127.
+ 17. Corradi
M, Petriccioli D, Panno B, Marenghi P. Seidel Locked Nailing for the
Treatment of Unstable Fractures and Nonunion of the Humerus. Chirurgia Degli Organi di Movimento 1996;81:189.
+ 18. Davids
PH, Luitse JS, Strating RP, van der Hart CP. Operative Treatment for
Delayed Union and Nonunion of Midshaft Clavicular Fracture: AO
Reconstruction Plate Fixation and Early Mobilization. J Trauma 1996;40:985.
+ 19. Dineen
JR, Greshman RB. Osteoperiosteal Grafts: A Preliminary Report of the
Treatment of Fresh and Ununited Fractures of the Long Bones. J Bone Joint Surg 1962;44A:1653.
+ 20. Dodge HS, Cady GW. Treatment of Fractures of the Radius and Ulna with Compression Plates. J Bone Joint Surg 1972;54-A:1167.
+ 21. Dounchis JS, Pedowitz RA, Garfin SR. Symptomatic Pseudarthrosis of the Acromion: Report of a Case and Review of the Literature. J Orthop Trauma 1999;13:63.
+ 22. Duralde XA, Flatow EL, Pollock RG, et al. Operative Treatment of Nonunions of the Surgical Neck of the Humerus. J Shoulder Elbow Surg 1996;5:169.
+ 23. Edvardsen P, Vital O. Treatment of Post-Traumatic Clavicular Pseudarthrosis. Acta Orthop Scand 1977;48:456.
# 24. Epps CH, Jr., Grant RE. Fractures of the Shaft of the Humerus. In: Rockwood CA, Green DP, eds. Fractures, 3rd ed. Philadelphia: J. B. Lippincott, 1991:843.
+ 25. Eskola A, Vainionpää S, Myllynen P, et al. Surgery for Ununited Clavicle Fractures. Acta Orthop Scand 1986;57:366.
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