Failed Fixation of the Humeral Neck Fracture

The humeral neck is under complex biomechanical forces, which can make it prone to nonunion following fracture fixation. Lack of medial column support, poor bone quality in the humeral head, and the risk of avascular necrosis may predispose the patient to fixation failure. Prior to considering reoperation on these patients, the surgeon should develop a thorough biomechanical and physiologic understanding of the etiology of fixation failure. Patient comorbidities and functional needs as well as the pattern of fixation failure must be carefully considered, and the possibility of deep infection should be thoroughly investigated. When considering reconstruction, detailed imaging to determine the quality and quantity of bone in the humeral head is critical to decision-making. For revision fixation, reconstruction of the medial column either with an intramedullary strut graft, bone graft substitute, or an intramedullary nail is important for future success. In patients with inadequate bone for fixation, arthroplasty should be considered.