Surgical Discussion

Underappreciated in the preoperative planning is the humoral equivalent of a Door C femoral diaphysis - in other words stovepipe bone. Stove pipe diaphyseal bone allows for significant toggle of intramedullary fixation and does little to aid maintenance of reduction. This became evident intraoperatively so a mini open anatomic reduction of the spiral was performed before insertion of the nail to ensure correct proximal nail trajectory to help maintain reduction mid to long-term. Bone quality and the proximal humeral metaphysis and head was poor and although intraoperative fluoroscopy suggested acceptable maintenance of reduction loss of reduction is evident at post-operative follow-up along with osteolysis around the proximal nail and screws. The patient was minimally symptomatic of the nonunion and a revision was initially not desired. Subsequently the patient developed a seroma at at the fracture site which produced a local swelling in the proximal arm. Concerned for infectious non-union this aroma was open the braided and soft tissue samples from the fracture site were taken. The samples demonstrated no bacterial colonisation or indication of septic non-union. The patient presented some 6 months later again with soft tissue swelling and local fluctuance at the fracture site and was a game debrided full stop on this occasion all tissue samples demonstrated bacterial colonisation. A two-stage septic revision with planned plating has been initiated.