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 Distal humerus - nonunion |
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 Отправлено M.J.Albert 25 Сентябрь 2006, 16:20
Attached are x-rays of a 21 year old male who is 3 years out from multiple injuries sustained in a motorcycle accident.
This was initially an open injury. Several attempts were made to fix this fracture at a nearby teaching facility. The most recent procedure was one year ago. His fixation failed last January. At that time he was told that he would have to wait for another doctor to care for him (rotation of residents I presume). No history of infection. Non-smoker. Due to his head injury his employment options are limited. He is capable of driving a truck if he had a functioning arm.
This is his non-dominant arm. He has a compete radial nerve palsy which has never been addressed. All previous humeral surgeries were done via a lateral approach.
I removed the floating hardware via the lateral approach through cement-like scar. Cultures and path were negative. The distal humeral segment, not surprising, is completely disvascular. Soft tissues will support further reconstruction via anterior or posterior approaches.
Any thoughts on the reconstructive options?
MJA
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Re: Distal humerus - nonunion
Jeffrey Anglen 25 Сентябрь 2006, 23:54
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Send some pics with the hardware out, it's hard to make out the distal fragment.
It looks to me like there is enough there to do bicolumnar plating through a posterior approach with olecranon osteotomy, cancellous bone grafting of the defect with BMP and a stimulator, explore the radial nerve and lysis of joint adhesions. If the bone is weak and porotic, a locking plate system might be useful. In my experience , it is certainly possible to graft and heal such a gap in the humerus in a young healthy person, getting the elbow function back is another issue. What is his function like now?
Jeff
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Re: Distal humerus - nonunion
T. I. George 25 Сентябрь 2006, 23:55
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Can we have a look at the post implant removal X-ray? Also a clinical picture of the affected arm. I am begining to think of a functional non-union which could be supported by a brace(under the presumtion that elbow is stiff). The brace could be adjusted in such a way as to have the non-union acting as the elbow.
At this stage the option available for radial nerve will be reconstructions using tendon transfers to restore funtion. If median nerve and ulnar nerve are funtional, if the hand is supple, you could get a good functioning hand after tendon transfers.
Keep us posted and good luck.
Dr. T. I. George,
Senior Orthopaedic Surgeon
And
Head of Orthopaedics Unit-III,
Little Flower Hospital and research Centre,
Angamaly, Kerala State,
India.
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Re: Distal humerus - nonunion
Bruce Ziran 25 Сентябрь 2006, 23:56
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The biggest concern is what you state as a dysvascular distal segment. It is probably why previous efforts had failed. It also appears that there is a trochlear deficiency, somewhat of a "fishmouth" as they used to call it.
I agree with Jeff, that the last chance is to try the high power stuff, in hopes of stirring up a bit of vascularity. I understand that BMP-2 works
earlier in the cascade, so it may lure angiogenesis a bit more. If all else fails, a resection and fascial interposition with shortening may work. I have seen poor results with total elbow in young and active. Tough problem.
Good luck.
Bruce H. Ziran, M.D.
Director of Orthopaedic Trauma
St. Elizabeth Health Center
Associate Professor of Orthopaedic Surgery
Northeast Ohio Universities College of Medicine
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Re: Distal humerus - nonunion
Nikolaj Wolfson 26 Сентябрь 2006, 00:07
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Interesting case, but not unusual.
My opinion:
Semicircular Ex Fix, small wires. This is to be done after the site of nonunion is excised, bone ends are refreshed, and appropriate frame construct is made. Possible use of bone graft, BMP, etc. The fixator might be extended to the forearm, to allow Range of Motion in the elbow joint while the nonunion site is compressed.
More proximal osteotomy can be done for the humerus lengthening, either same time (my preference, has better biomechanical stability on the nonunion site and likely more bone stimulating factors), or as a second stage. I would give this patient a chance to keep his own elbow joint. He has a chance and deserves it.
For reference see publications by Dr. O. V. Oganesyan.
Nikolaj Wolfson, MD, FRCSC
Assistant Professor of Clinical Orthopaedics,
Department of Orthopaedic Surgery,
LAC USC,
Los Angeles, California
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