Troubleshooting in the Treatment of Pseudoarthrosis After a Humeral Diaphyseal Fracture: A Case Report

We report a case of a patient with a history of surgery for insufficient pseudoarthrosis after a humeral diaphyseal fracture. Although most humeral nonunions are successfully treated with a single procedure, some humeral nonunions are more difficult to heal and require multiple procedures. A-61-year-old man presented at our hospital with pain and deformity in his left upper arm. The humeral diaphyseal fracture had been previously treated elsewhere with open reduction and internal fixation. Some days prior to his visit at our hospital, he had had pain in his left upper arm, without a particular cause, and was admitted to our hospital for initial evaluation. After a complete physical examination, symptoms of infection and any neurovascular deficit were ruled out. Radiographic examination revealed atrophic nonunion of the middle third of the humeral shaft associated with disuse osteopenia. Anterograde intramedullary nailing and bone grafting were performed for the resistant atrophic nonunion of the humeral diaphysis. In addition to the intramedullary nailing, additional fixation was performed for residual rotational instability. A postoperative evaluation revealed a periprosthetic fracture in the distal part of the humerus. Poor bone quality or a deficient plate technique might have lead to the facture. We performed open reduction and internal fixation (ORIF): he underwent fixation with a 2-plate construct for the nonunion of the humeral diaphyseal fracture, together with decortication, debridement, and bone grafting. Eight months after surgery, the patient's bone had healed and he had recovered flexion (110°) and extension (-30°) without complications. An orthopedic surgeon should be aware of these complications when choosing open reduction and internal fixation for the treatment of a history of insufficient pseudoarthrosis. Patients should be closely followed up for evidence of any complications such as infections and malunions. Fracture fixation in patients with pseudoarthrosis requires strategies to overcome the technical difficulties faced during the procedure.