Arch Orthop Trauma Surg (2011) 131:79–84

DOI 10.1007/s00402-010-1110-7

TRAUMA SURGERY

Management of non-union of humeral fractures with the Stryker T2™ compression nail

Paul Fenton · Ford Qureshi · Nithin Bejjanki · David Potter

Received: 9 December 2009 / Published online: 16 May 2010© Springer-Verlag 2010

AbstractIntroduction Fractures of the humeral shaft are relativelycommon injuries and the majority achieve union unevent-fully; however, non-union rates of up to 13% are reportedwhen managed either conservatively or operatively.Despite the many surgical techniques described for themanagement of non-unions, including plate Wxation, intra-medullary nailing or external Wxation, some cases remainresistant to treatment with ongoing problems achievingunion.Method We describe a technique using the Stryker T2™humeral nail which incorporates a compression systemallowing closure of the non-union fracture gap. Twelvepatients underwent compression nailing for establishedhumeral fracture non-union. All achieved radiologicalunion at an average of 4.5 months (range 3–12 months).

Results All patients reported a return to their normal pre-injury level of activities.Conclusion We conclude that this technique of intramed-ullary nailing with a novel compression technique is eVec-tive in the treatment of humeral shaft fracture non-union.

Keywords Humerus · Fracture · Non-union · Intramedullary nail

Introduction

Humeral diaphyseal fractures account for 5–8% of allfractures [1]. Most fractures heal well, but when non-union occurs it is diYcult to treat. Non-union can com-plicate both conservative and operative management andhas been reported to occur in up to 13% of humeral shaftfractures [2, 3]. The risk factors for non-union include ashort oblique fracture pattern, inadequate stabilisation,osteopenia, infection, poor contact between bone ends,smoking, alcohol, obesity, increasing age and patientco-morbidities [3–6]. Treatment options in non-unionafter conservative or previous surgical treatment includeinternal Wxation with plates and screws, intra-medullarynailing, external Wxation and bone grafting [4, 7–9].Varying degrees of success and complication have beennoted with the above methods [4, 7, 8, 10]. A few frac-tures are resistant to intervention and develop a refrac-tory non-union. Post-operative recovery, rehabilitationand patient compliance are important considerations indeciding the treatment methods for these humeral non-unions.

We describe our experience with using the Stryker T2™Stryker humeral compression nailing system for treatmentof humeral non-unions.

P. FentonTrauma and Orthopaedics, Royal Orthopaedic Hospital, Birmingham, UK

F. QureshiOrthopaedics and Trauma, Doncaster Royal InWrmary, Doncaster, UK

N. BejjankiTrauma and Orthopaedics, York District Hospital, York, UK

D. PotterThe Shoulder and Elbow Unit, Department of Orthopaedics and Trauma, Northern General Hospital, SheYeld, UK

P. Fenton (&)87 Russell Bank Road, Sutton ColdWeld B74 4RQ, UKe-mail: fenton1977@hotmail.com

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Patients and methods

We performed a retrospective study of 12 consecutivepatients treated between November 2002 and July 2006with humeral shaft fractures who had established non-union. The details of the patients are described in Table 1.

All of the patients presented with complaints of eitherpainful instability at the fracture site or an inability to per-form activities of daily living. All non-unions were treatedwith the T2™ Stryker humeral compression nail regardlessof the aetiology or prior treatment.

There were 8 females and 4 males with a mean age of53.3 years (range 19–80 years) and a mean BMI of 29(range 22.7–35.7). Two patients were heavy smokers.Seven patients had signiWcant medical co-morbidities asshown in Table 1.

The mechanism of injury varied with six patients sus-taining their original facture from a low energy fall fromstanding height and six patients from a high energy injury:four patients from road traYc accidents, one patient hadfallen from horse and one patient fell 8 feet. All fractureswere closed injuries. Ten of the patients were treated con-servatively with nine being treated in humeral braces. Twopatients were treated operatively as outlined below. Fourhad progressed to hypertrophic non-union, seven to atro-phic non unions.

There was a single case of an infected non-union in afracture initially treated with a locked intramedullary nail(patient 2, Table 1). As much as 10 months later the distallocking screw was removed because of a non-union. Thepatient made no progress and was referred to our centrewith an established infected non-union. The nail was

removed and the patient underwent a 6-week course of oralantibiotics. Once the infection was satisfactorily controlledit was deemed safe to proceed with internal Wxation usingthe compression nail.

Another patient (patient 1, Table 1) had undergone priorsurgical interventions for an established non-union beforereferral to our centre. Initially, this patient had been treatedconservatively for 6 months which had led to a hypertro-phic non-union. The patient then underwent an open reduc-tion and internal Wxation with a plate, but 8 months laterhad to undergo a subsequent revision due to plate failure atwhich stage the fracture was re-plated and bone graftapplied at the fracture site. Following revision plating thepatient developed a radial nerve palsy which was managedconservatively and resolved after 6 months. The other 10patients with established non-union had been managed con-servatively prior to treatment with the T2™ Strykerhumeral compression nail. Figures 1, 2, 3 and 4 illustrateimaging performed for patient 8.

All patients were followed up post-operatively andscored according to the Oxford Shoulder [11] and Con-stant–Murley [12] scoring systems. The Oxford shoulderscore is a subjective assessment of pain and restriction ofactivities of daily living to give a score out of 60 withhigher scores reXecting worse outcomes. The Constant–Murley shoulder score is a validated scoring system thatassesses pain, function, range of motion and power. It isscored out of 100 with higher scores reXecting better out-come. The Constant scores were compared with scores forage- and sex-matched normal shoulders [13]. Radiographswere performed to record evidence of radiological union atthe fracture site as demonstrated in Figs. 1 and 2.

Table 1 Details of patients treated with compression nailing

RTA road traYc accident, COPD chronic obstructive pulmonary disease, CVA cerebrovascualar accident, HTN hypertension

Case Age Mechanism of injury

Fracture classiWcation (AO)

Duration fracture to surgery (months)

Previous treatments Type of non-union

Comorbidity

1 48 Simple fall 12-A2 36 Plate and screws, revisionplate and bone graft

Hypertrophic Nil

2 75 RTA 12-B2 28 IM nail, plate + bone graft Infected COPD

3 43 Simple fall 12-A2 3.5 Humeral brace Atrophic Nil

4 79 Fall oV horse 12-A3 24 Humeral brace Hypertrophic Nil

5 77 Simple fall 12-A1 4 Humeral brace Atrophic HTN

6 71 Simple fall 12-A2 4 Humeral brace Hypertrophic HTN, CVA, rheumatoid arthritis

7 22 RTA 12-B2 4 Collar and cuV Atrophic Nil

8 22 Fall from 8 feet 12-A2 4 Humeral brace Atrophic Epilepsy

9 78 Simple fall 12-A2 6 Humeral brace Atrophic Asthma, Hypothyroid

10 80 Simple fall 12-A1 3 Humeral brace Hypertrophic COPD,

11 50 RTA 12-A3 3 Humeral brace Hypertrophic Nil

12 19 RTA 12-B3 18 Humeral brace Atrophic Nil

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Arch Orthop Trauma Surg (2011) 131:79–84 81

Surgical technique

All patients were placed in the beach chair position. A stan-dard approach for antegrade humeral nailing was made.Reamed antegrade nailing was performed and followingnail insertion freehand distal locking was performed usingone or two screws. If a signiWcant gap was present at thefracture site the nail was then back-slapped to reduce thegap. Radio-opaque grooves on the proximal end of the nailallow the nail position to be checked under X-ray control inorder to avoid proximal nail protrusion and subacromialimpingement. We had no problems with subacromialimpingement in our group of patients. Two proximal lock-ing screws were then inserted using the proximal targetingdevice. Finally, the compression screw was insertedthrough the top of the nail and using a driver the fracturesite was compressed up to 6 mm under image guidancebefore an appropriate end cap was inserted.

Bone grafting was not used in any of our cases, even foratrophic non-union. Instead the fracture site was left undis-turbed and we relied on improved fracture stability andcompression together with the reamings produced duringnailing acting as a local bone graft to achieve union.

Fig. 1 Patient 3, radiograph showing atrophic non-union

Fig. 2 Patient 3, CT scan conWrming non-union

Fig. 3 Patient 3, radiograph showing bony union after compressionnailing

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Results

The mean time interval from fracture to surgery was11.5 months (range 4–36 months). The mean follow-upperiod was 26 months (range 8–48 months). All 12 patientsachieved clinical and radiological union at a mean of4.5 months (range 3–12 months) postoperatively.

The mean Oxford score was 21.6 (range 12–43). Themean Constant score was 70.4 (SD 22.63) which was lessthan mean score for age- and sex-matched normal shoul-ders (mean 87.83, SD 5.77), although the diVerence did notreach statistical signiWcance (p = 0.085, independent t test).All patients reported a return to their normal, pre-injury,functional activities at a mean of 4 months (range 3–6months) after surgery. There was a complication in onepatient (patient 6, Table 2) who developed a post-operativeradial nerve palsy. Symptoms completely resolved after7 months.

Discussion

The majority of humeral fractures heal well with conserva-tive management, but when a non-union occurs, it can bedebilitating for the patient. Treatment of establishedhumeral non-union has always been challenging. Tech-niques, such as open reduction and internal Wxation, intra-medullary nailing, external Wxation and bone grafting haveall been described with varying degrees of success andassociated complications [7, 14–16].

The T2™ nail (Stryker) combines the beneWts of con-ventional nailing, such as preservation of soft tissues at thefracture site and early rehabilitation with the ability to com-press the fracture site by up to 6 mm via the proximal lock-ing screw options. It is this feature that particularly makes ita potentially useful tool in the treatment of non-unions.

We hypothesized that the T2™ compression nail wouldbe an eVective method of treating humeral non-unions andrestoring function. All the patients in our series went ontoachieve union and reported a return to normal function at amean of 4 months. Our study is limited by the fact that it isa small retrospective case series including both atrophicand hypertrophic fractures.

Fig. 4 Patient 3, radiograph showing bony union after compressionnailing

Table 2 Results of patients treated with compression Nail system

Case Oxford score

Constant score

Predicted constant score

Complications Time to union(months)

1 38 54 93 Nil 4

2 12 85 86 Nil 12

3 26 67 93 Nil 5

4 12 84 81 Nil 4

5 16 68 81 Nil 4

6 43 16 81 Radial nerve palsy 6

7 41 49 94 Nil 3

8 1 90 94 Nil 3

9 20 76 81 Nil 3

10 12 70 86 Nil 3

11 12 100 90 Nil 4

12 16 86 94 Nil 3

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Arch Orthop Trauma Surg (2011) 131:79–84 83

Open reduction and plate Wxation with or without bonegrafting is an established technique in the treatment ofhumeral non-unions [17–19]. Healy et al. [4] suggest that astable plate Wxation with at least six cortices proximal anddistal to the non-union fracture site is required for a suc-cessful outcome. They reported union in 24 out of 26patients treated with rigid internal Wxation, compression offracture and autogenic cancellous iliac bone graft. In theirpaper, Marti et al. treated 51 aseptic humeral shaft non-unions with compression plating and use of autologousbone graft except in seven cases of hypertrophic non-union.They reported that all patients achieved consolidation byone year with 96% rating their outcome as excellent orgood [20]. Plating together with bone grafting is a proventechnique in the treatment of humeral non-unions favouredby many surgeons although we feel that most fracturescould be treated with compression nailing. The disadvan-tages of plating are that it requires a longer skin incision,extensive soft tissue stripping with an increased risk ofradial nerve injury, infection and can result in an unsightlyscar. The incidence of radial nerve palsy has been reportedbetween 3 and 29% [4, 9, 17]. For patients with osteopenia,screw purchase on bone is unreliable and increases thechances of hardware failure [16, 19, 21]. For patients whorequire removal of plate in future, operating on scarred softtissue signiWcantly increases the incidence of radial nervepalsy [22]. The use of locking plates may overcome someof the above disadvantages of internal Wxation; however,their use in the treatment of humeral non-union has notbeen described.

External Wxation for humeral non-unions has beendescribed with good results [23] and allows stability, com-pression and distraction at the fracture site. Lammens et al.[23] reported union in 28 out of 30 humeral non-unionsachieving union in 28 at a mean of 4.5 months using mono-focal compression with Ilizarov frames without bone graft.External Wxation devices and Ilizarov frames can be poorlytolerated by patients and problems including hardwareimpingement onto the chest, diYculty sleeping and pin siteinfections requiring antibiotics [24] have reduced patientcompliance and its popularity. They are also expensive andlabour intensive to manage for both the patient and the cli-nician [24].

Intramedullary nailing is a further option for treatinghumeral non-unions. As opposed to open reduction andhumeral plating it has the advantages of preserving the peri-osteal blood supply and soft tissue sleeve and allowing ear-lier rehabilitation of the patient together with lowerincidences of infection and iatrogenic radial nerve palsy[21, 22, 25]. Potential disadvantages of antegrade humeralnailing include shoulder pain and rotator cuV impingement.Wu [21] reported union in all 32 patients treated withSiedel interlocking nail. In their series of 27 non-unions

Kesemenli et al. [22] used autogenous bone grafting andinterlocked nailing. They achieved union in 26 patients at amean of 4.8 months. It is a better modality of treatmentwhen faced with patients who have osteoporotic bone orcomminuted fractures and has become the preferred treat-ment for long bone diaphyseal fractures [25, 26].

Compression across the fracture site helps to increasestability, close the fracture gap and its advantages havebeen emphasised in reports advocating plating [4, 27]. Thesame principle of compression has been tried with intra-medullary nails with various methods including interfrag-mentary wires [10], staples across the non-union site [21],compression nails with a dynamic screw hole [14] and alsoapplying manual axial compression during surgery [19]. Ina cadaveric study simulating an unstable humeral fractureVerbruggen et al. [28] found signiWcantly less distractionafter cyclical loading with reamed nails under compressioncompared to unreamed nails with no compression. Further-more, they reported greater stiVness under bending withreamed nails under compression than unreamed nails. TheT2™ compression humeral nail is a method of providingcompression across the fracture. Mückley et al. reviewedtreatment of humeral fractures with the T2™ humeral nail-ing system achieving union in 35 out of 36 fractures. Theyfelt that compression allowed the fracture gap to be closedand increased the biomechanical stiVness of the construct;however, they recommended the use of a static lockingscrew in addition to the compression screw in order to pre-vent loosening of the compression screw with consequentinstability of the fracture [25]. A further potential problemwith use of the compression screw is bending of the lockingscrew if the compression is over-tightened although this didnot occur in our series.

Bone grafting can be an eVective adjunct in the treatmentof non-unions and can be combined with plating or nailingof fractures. Autogenous bone graft has osteoconductive,osteogenic and osteoinductive properties making it an idealgraft in non-union treatment. However, signiWcant donorsite morbidity can occur and other sources of graft havebeen utilised including allogenic bone graft and recombi-nant bone morphogenic proteins. Grafting should be con-sidered in cases of atrophic non-union, cases with sizeablebone defects and all cases where treatment involves open-ing of the fracture site thereby readily allowing augmenta-tion with graft. In cases, where it is not felt necessary todisturb the fracture site, such as hypertrophic non-unions,graft may not be required. In our series all fractures, bothhypertrophic and atrophic, healed without the use of anybone graft in addition to that produced locally during ream-ing of the bone. Khan et al. [29] reported 25 cases ofhumeral non-union treated with plating and grafting achiev-ing union in all cases. In their review of intramedullary nail-ing of humeral non-unions Kontakis et al. [30] concluded

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that intramedullary nailing could lead to successful out-comes when associated with autologous bone grafting.Recently, the use of recombinant bone morphogenic protein7 in non-unions has been advocated. Dimitriou et al. [31]reported union in 24 out of 25 long bone fractures treatedwith BMP. A further type of bone graft available is the vas-cularised Wbular graft which Yajimi et al. [32] used to treatsix persistent humeral non-unions achieving union in all ata mean of 3 months.

Conclusion

All of our patients achieved fracture union without requir-ing bone grafting and all reported a return to pre-injuryfunctional levels. The technique of compression nailingallows preservation of the soft tissues around the fracturesite, compression of fracture ends and early commencementof physiotherapy. The procedure is well tolerated and hasshown good results to date. Despite the shortcomings ofthis study we believe the compression nail is an eVectiveaddition to the armamentarium of the surgeon treatinghumeral non-unions.

ConXict of interest statement The authors declare that they have noconXict of interest.

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