Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table, with the arm placed on a radiolucent arm board to facilitate intraoperative imaging and manipulation.

Anatomical surgical approach:  An extended deltopectoral approach was utilized, beginning at the coracoid process and extending distally along the deltopectoral groove. The cephalic vein was identified and retracted laterally. Subperiosteal dissection was performed to expose the humeral shaft. The fracture site was debrided, and the radial nerve was carefully identified and protected throughout the procedure.

The fracture edges were refreshed to promote healing. Three cerclages using high-strength suture with Niza knot technique were applied for provisional stabilization. The radial nerve was explored and protected during the procedure. A proximal humerus locking plate was then applied for definitive fixation. Autologous bone graft harvested from the iliac crest was placed at the nonunion site to facilitate bone healing.

Postoperative protocol:   Postoperatively, the patient was advised to wear a sling for comfort. Passive range of motion exercises were initiated immediately, with active-assisted exercises introduced at 2 weeks post-surgery. Weight-bearing activities were restricted until radiographic evidence of union was observed.

Follow up:   Not specified.

Orthopaedic implants used:   Proximal humerus locking plate, high-strength suture cerclage (Nudo Niza), iliac crest bone graft.