Humeral Shaft Fracture: Failed Intramedullary Nail Fixation

Humeral shaft fractures are relatively common injuries treated by orthopedic surgeons and account for 1.3–3% of all fractures. Humeral intramedullary (IM) nailing provides fixation without violating the periosteal blood supply adjacent to the fracture fragments when closed reduction techniques are used; however, nonunions occur more frequently in the humerus than with routine nailing of femoral and tibial shaft fractures likely associated with decreased stability from smaller diameter nails and decreased axial stability. Failure rates have ranged between 0% and 50% in multiple studies. In patients with humeral shaft nonunion, pain with shoulder and elbow range of motion are common and a detailed surgical history and physical exam help plan nonunion treatment. Radiographs should be analyzed for alignment, bone quality, nonunion characteristics, and evidence of hardware failure. CT may be a useful modality to evaluate bony healing when fracture characteristics and consolidation are difficult to assess on radiographs. Prior infection should be evaluated with a standardized protocol including complete blood count (CBC), C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) with elevation of infectious indices an independent risk factor for infection. Removal of hardware can be a challenge. Formulation of a preoperative plan with the appropriate equipment available is crucial for success. Patient and fracture failure characteristics should determine implant selection for revision. For failed humeral IM nails options include hardware removal with plate osteosynthesis, exchange nailing, plate augmentation to the current construct, and potential need for bone grafting, when appropriate. Each revision construct has a unique set of properties and advantages and the decision should be tailored to the individual situation.