Conservative treatment for humeral surgical neck non-unions

Acta of Shoulder and Elbow Surgery | Volume 2 | Issue 2 | July-Dec 2017 | Page 12-15 | Federico Alfano

Authors: Federico Alfano [1].

[1] Spanish Hospital of Buenos Aires

Address of Correspondence
Dr. Federico Alfano
Spanish Hospital of Buenos Aires


Introduction: 2-part non-union of the surgical neck fracturesof the humerus after conservative treatment may result from initial displacement, secondary disimpaction,interposition of soft tissue, synovia fluid at the site of fracture, aggressive rehabilitation, bad patient compliance, and many other intrinsic causes. A wide variety of treatments for this condition have been proposed. They include conservative treatment, ORIF (with or without bone grafting), hemiarthroplasty and reverse arthroplasty. Most reports emphasize possible treatment options and their results. Nonetheless, it is hard to address conservative treatment since it is a very disabling disease. The aim of the present study is to evaluate the results achieved with conservative treatment for surgical neck non-unions in elderly patients. Although we advocate for surgical treatment for 2-part non-union of the surgical neck fractures, the group of patients included in the study didn’t accept our surgical indication or surgery was contraindicated because of increased operative or anesthetic risks.
Materials and Method: Retrospectively, 13 shoulders with a 2-year follow-up period were included in the study. 9 of the 13 patients were female. The mean age of the patients was 83.3 years (range 75–91 years). The dominant arm was affected in 4 patients. In the current study it was found that bone cavitation may occur early in the course of the disease, even in cases of hypertrophic non-union. It seems clear that 2-part surgical neck fractures can develop non-union in distinct manners. We found an association between hypertrophic non-union andgleno-humeral arthritis. In these cases, it looks like the limited range-of-motion in the gleno-humeral joint causes fracture instability and continuous movement between fragments, leading to hypertrophic non-unions. As stabilization of a fracture provides the essential mechanical component to allow calcification of the fibrous cartilage,on the contrary, early active mobilization exercises of a stiff joint leads to early mobilization of the fracture sitebefore bone healing had occurred.
Results: All patients complained of pain and functional impairment within the first year (with a mean Constant Score of 13.1, 15.1, 17.2 at 3, 6 and 12 months respectively). After that period most patients complained mainly about poor active range of motion (with a mean Constant Score of 24.7 and25.6 at 18 and 24 months respectively). The mean pain score improved from 8.4 at 6 months to 4.1 at the time of follow-up (p < 0.05).Mean active elevation didn´t improve although home-based exercises or supervised strengthening was carried out. All patients had internal and external rotation lag signs. At the time of last follow-up, the average active shoulder range of motion was 73° of total elevation, 20° of external rotation; on internal rotation, the ipsilateral thumb could reach the ipsilateral buttock. The two patients with combined preexisting gleno-humeral arthritis and hypertropic non-unions had worse outcome in terms of pain and range of motion.
Conclusions: Pain relief after 12 months was associated to three anatomical changes during the natural course of the disease. These are the development of a capsule-like formation of connective tissue in the non-union site, a varus cephalic displacement and bone cavitation process interruption (which was represented by the proximal humerus metaphyseal region and subcapital head sclerosis). In cases of preexisting gleno-humeral arthritis we advocate for reverse arthroplasty. If the hypertropic non-unions had occurred we would advocate for surgical stability and earlier mobilization. In all other cases, we still prefer the surgical indication if the patient has an unacceptable pain. If surgery is not possible, we can still expect reduction of pain but any improvement in terms of range of motion after 12 months of conservative treatment.
Key words: Conservative treatment, humeral surgical neck non-unions, elderly patients.


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How to Cite this article: Alfano F .Conservative treatment for humeral surgical neck non-unions. Acta of Shoulder and Elbow Surgery July – Dec 2017;2(2):12-15.

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