Session VI - Geriatric Trauma

The Operative Management of Diaphyseal Nonunions in the Elderly Patient

Bertrand Perey, MD, Jesse Jupiter, MD, David Ring, MD

Massachusetts General Hospital, Boston, Massachusetts, USA

Introduction: An ununited fracture of the humeral diaphysis remains a clinical problem often requiring operative treatment. This is made more complex in the elderly due to osteopenia from both disuse and underlying osteoporosis; chronic medical illnesses; and problems with post-operative immobilization. This study reports on the successful treatment of those difficult conditions using newer designs and concepts of plate fixation with autogenous bone graft.

Methods: A consecutive series of 22 diaphyseal nonunions of the humerus in elderly patients (women > 59 years; men > 69 years) treated by a single surgeon between 1990 and 1996 were retrospectively reviewed. Twenty patients were female (av. age 72; range, 60-80 years) and 2 male (both 72 years). The average time from fracture to surgical treatment for the nonunion was 27 months (range, 5 - 192 months). Fourteen patients had failed prior surgery with 7 having a loose IM rod with associated rotator cuff impingement and 7 with failed plates. All nonunions were atrophic with 12 synovial and 5 associated with relative or true bone loss. The surgical tactics included extensile exposures; long 4.5 mm titanium LCDC plates (average length, 11 holes - range, 9-14), with 12 made into a blade plate; and a new design of screw-washer fixation (Schuri) in 8 more recent cases. In the 5 with bony loss, humeral shortening was combined with either a "wave plate"; (2) intra- and extramedullary plates (2); and an allograft strut (2). Autogenous iliac crest bone graft was used in 22. Post-operative immobilization was a sling for 7 - 10 days.

Results: Early complications included a transient radial nerve palsy and a post-operative delirium in 1 patient each. Follow-up averaged 29 months (range, 9-72 months). All 22 nonunions healed after the index procedure. Using the ASES shoulder-elbow scoring system, the functional outcome was excellent or good in 17 and fair in 5, all due to limitation in shoulder mobility from prior IM rods.

Discussion and Conclusion: A diaphyseal nonunion of the humerus represents a profound disability to the elderly patient as well as a threat to their functional independence. The operative tactics illustrated offer a high success rate, limited morbidity and substantial functional gains.