Management of nonunions and
malunions of proximal humeral
fractures
Ilias Galanopoulos
Consultant orthopaedic surgeon
2nd Department of Orthopaedics
401 General Military Hospital of Athens

Introduction
• In elderly: the third most common fracture after hip # and distal
radius #
• Most fractures non-displaced or minimally displaced - conservative
treatment often successful
• Surgical treatment preferable in displaced # (15-20% of cases), where
anatomical reduction of tuberosities and restoration of medial hinge
are mandatory
• Cheung, E. V., & Sperling, J. W. (2008). Management of Proximal Humeral
Nonunions and Malunions. Orthopedic Clinics of North America, 39(4),
475–482.

• Nonunion and malunion still remain important issues in proximal
humerus fractures - reported after both operative and non-operative
treatment
• Can lead to persistent pain, limited ROM - can affect quality of life
• Prevention of nonunion or malunion is possible by early recognition
of fracture displacement with proper serial radiographs and close
clinical follow-up

Nonunions
• Nonunion: a fracture > 9 months old - has not shown radiographic
signs of progression toward healing for 3 consecutive months
• Atrophic nonunions lack adequate blood supply - adequate construct
stability
• Hypertrophic nonunions have adequate vascularization but
insufficient mechanical stability

• Biological causes of failures related to multiple factors:
• Severe displacement - inadequate reduction
• Insufficient neutralization of the forces generated by R.C.
• Insufficient support of the medial bone arch (calcar)
• Soft tissue interposition – early aggressive mobilization
• failure to fill voids made by the impact
• Patient factors: poor bone quality, age, female sex, smoking, medical
comorbidities or lack of compliance with treatment

• Rate of nonunion after plating reported up to 13%
• Some patients can be asymptomatic and a nonsurgical treatment can
be feasible
• Smith AM, Sperling JW, Cofield RH. Complications of operative fixation of
proximal humeral fractures in patients with rheumatoid arthritis. J Shoulder Elbow
Surg 2005;14:559–64.

• In atrophic nonunions an attempt at improving biologic capacity of
healing should be done
• Growth factors/PRP injections can be options
• Hypertrophic nonunions require rigid fixation and nearly always these
will have a good bone stock
• Open reduction with a more stable fixation and fracture freshening is
adequate treatment

• Most often nonunions involve two-part
fractures at surgical neck
• Nonoperative treatment: appropriate for
patients with minimal or no pain and
satisfactory ROM and function
• ORIF: recommended for patients with
acceptable bone stock and no OA - bone
grafting may be used to augment fixation
• A femoral head allograft in low energy
fractures - a fibula bone graft (or similar) in
high energy fractures

• Arthroplasty: recommended when there is
severe cavitation of the humeral head,
advanced age, osteoporosis, AVN, severe
OA
• Hemiarthroplasty and anatomical TSA in
patients with preserved cuff, otherwise the
choice is RSA

• Literature on results of surgical treatment for nonunions
• Duralde et al: satisfactory results in 55% of 20 nonunions treated with either ORIF or
hemiarthroplasty
• 9/10 patients in the ORIF group required reoperation because of hardware removal,
lysis of adhesions, or continued nonunion
• Surgical reconstruction usually resulted in pain relief, but function and motion were
fair to poor
• Surgery should be considered carefully in terms of risks and benefits
• Duralde XA, Flatow EL, Pollock RG, et al. Operative treatment of nonunions of the surgical neck
of the humerus American Shoulder and Elbow Surgeons. J Shoulder Elbow Surg 1996;5:169–80.

• Healy et al: results of 25 proximal humeral nonunions
• Overall results were fair
• Best results were noted after ORIF with a T-plate and tension band placed
from the RC to the plate/humeral shaft composite with bone grafting
• Pain relief was more consistently achieved, but function and motion were
ultimately limited
• Healy WL, Jupiter JB, Kristiansen TK, et al. Nonunion of the proximal humerus. A
review of 25 cases. J Orthop Trauma 1990;4:424–31.

• Ring et al reported healing in 92%
of proximal humeral nonunions
treated with blade plate and
autogenous bone grafting
• 20/25 patients reported good to
excellent results
• Ring D, McKee MD, Perey BH, et al. The
use of a blade plate and autogenous
cancellous bone graft in the treatment of
ununited fractures of the proximal humerus.
J Shoulder Elbow Surg 2001;10:501–7.

• Galatz et al: good results of ORIF with bone
grafting in a series of 13 patients
• 12/13 patients had an excellent or good result
• Galatz LM, Williams GR Jr, Fenlin JM Jr, et al. Outcome of
open reduction and internal fixation of surgical neck nonunions of
the humerus. Journal 2004;18:63–7.

• Antuna et al: results of shoulder arthroplasty
for patients with proximal humeral nonunions
at Mayo Clinic
• Significant pain relief and improvement in ROM, but
results inferior to those of arthroplasty for the
primary indication of osteoarthritis
• Function not restored completely with arthroplasty,
but pain relief and motion can be improved
• Antuna SA, Sperling JW, Sanchez-Sotelo J, et al. Shoulder
arthroplasty for proximal humeral non- unions American Shoulder
and Elbow Surgeon. J Shoulder Elbow Surg 2002;11:114–21.

Flow-chart for surgical treatment of atrophic
nonunions

Malunions
• Proximal humerus malunions: defined as > 45° of
angulation or 1 cm of displacement according to Neer
classification
• Treatment of a not tolerated nonunion or malunion is
surgical
• The empty space in metaphyseal cancellous bone may
lead to complications in low energy fractures
• In high energy fractures the main issue is medial hinge
insufficiency - can bring the head to a collapse or in
varus displacement

• Mechanism of malunion can be related to
initial reduction or to secondary displacement
after non-operative treatment or after surgery
• Varus angulation of the humeral head in
relation to the shaft
• It is mandatory to understand structures
involved and their position, amount of
misalignment and the
functional/biomechanical consequences
• X-Ray, CT and MRI are recommended

• Classification of proximal humerus
malunions (Beredjiklian):
• Type 1: misalignment of greater or lesser
tuberosity > 1 cm
• Type 2: incongruity of the articular surface
• Type 3: malunion of the tuberosities and the
humeral head relative to the shaft
• Beredjiklian PK, Iannotti JP, Norris TR, et al. Operative
treatment of malunion of a fracture of the proximal aspect of the
humerus. J Bone Joint Surg Am 1998;80:1484–97.

• Boileau’s classification of proximal
humeral fracture sequelae

• Surgical treatment of malunion must have a
precise and realistic goal - any other source
of shoulder pain must be excluded
• Subacromial impingement, cuff tears, labrum
tears and post traumatic stiffness should be
considered - need specific evaluation and
treatment
• Based on localization of the malunion,
treatment can vary widely

• A preserved articular surface and a
humeral head with intact blood supply
are the requirements for surgery
which preserves the humeral head
• Arthroscopy: good option for
tuberosity malunions which leads to
an impingement - release of soft
tissues (bursectomy, capsular release,
debridement, acromioplasty)

• Treatment of malunion has a higher complication rate and lower
functional outcome than treatment of the acute fracture
• Glenohumeral incongruity with OA, osteonecrosis or long lasting
severe deformity are indications for an arthroplasty

• Corrective osteotomy of proximal humerus
• Indicated in younger, active patients with no degenerative changes on
glenoid/humeral articular surfaces
• Loss of active motion of the shoulder – impingement-type shoulder
pain
• CT with 3D reconstruction useful in complex cases for pre-op planning

• Benegas et al: described pre-op planning
and surgical technique
• Lateral based closing wedge osteotomy for varus
malunions of proximal humerus
• Internal fixation with T plate
• Results: significant improvement in forward
elevation and pain relief
• Benegas E, Zoppi Filho A, Ferreira Filho AA, et al. Surgical
treatment of varus malunion of the proxi- mal humerus with
valgus osteotomy. J Shoulder Elbow Surg 2007;16:55–9.

• Russo et al
• Posttraumatic malunion treated with 3 different types of osteotomies
• Surgery is technically challenging
• Effective treatment option for young active patients in whom arthroplasty
would be contraindicated
• Russo R, Vernaglia, Lombardi L, Giudice G, et al. Surgical treatment of sequelae of fractures of
the proximal third of the humerus. The role of osteoto- mies. Chir Organi Mov 2005;90:159–69.

Arthroplasty for malunions of proximal humeral fractures
• Arthroplasty may be technically difficult
• Shoulders tend to be stiff, with distorted anatomy, soft tissue damage,
subdeltoid adhesions, RC tears, AVN, articular incongruency
• Pain relief is more reliably achieved
• Boileau et al
• Reported good to excellent results in 42% of patients treated with shoulder
arthroplasty
• Patients who underwent GT osteotomy were not able to regain active elevation
above 90
• Boileau P, Trojani C, Walch G, et al. Shoulder arthroplasty for the treatment of the sequelae of fractures of the proximal
humerus. J Shoulder Elbow Surg 2001;10:299–308.

• Antuna et al
• Increased complications in cases with GT osteotomy
• Antuna SA, Sperling JW, Sanchez-Sotelo J, et al. Shoulder arthroplasty for proximal humeral malunions: long-term results.
J Shoulder Elbow Surg 2002;11:122–9.
• Torchia et al: systematic review comparing acute versus delayed RTSA
• No differences in FF, clinical outcome scores, or all-cause reoperation were found between
the 2 groups
• Patients undergoing delayed RTSA achieved 6° more ER than those undergoing acute RTSA
• initial trial of nonoperative treatment in these patients
• saving RTSA for those in whom nonoperative treatment fails without compromising ultimate
outcome
• Torchia MT, Austin DC, Cozzolino N, et al. Acute versus delayed reverse total shoulder arthroplasty for
the treatment of proximal humeral fractures in the elderly population: a systematic review and meta-
analysis. J Shoulder Elbow Surg (2019) 28, 765–773

• Mansat et al
• 28 patients treated with arthroplasty
• Based on Neer criteria: satisfactory results in only 64%
• Mean active elevation 107, 85% of patients reported no or slight pain
• Final result positively influenced by integrity of RC
• If osteotomy of GT needs to be performed, results are unpredictable
• Mansat P, Guity MR, Bellumore Y, et al. Shoulder arthroplasty for late sequelae of proximal
humeral fractures. J Shoulder Elbow Surg 2004; 13:305–12.

• Kristensen et al: inferior outcome and substantial risk of revision for patients
treated with shoulder arthroplasty after failed ORIF for a proximal humeral
fracture compared with primary arthroplasty for proximal humeral fracture
• Risk of additional surgery should be accounted for when deciding on primary
surgical procedure
• Kristensen MR, Rasmussen JV, Elmengaard B, et al. High risk for revision after shoulder arthroplasty for
failed osteosynthesis of proximal humeral fractures. Acta Orthopaedica 2018; 89 (3): 345–350

Flow-chart for treatment of malunion

Take-home messages
• Joint incongruity
• AVN
• Head split
• Hemiarthroplasty
• Fit head to existing anatomy
• Surgical neck nonunion/malunion
• ORIF if possible, procedure of choice
• Arthroplasty with tuberosity osteotomy: assoc with poor results
• RSA recommended over hemiarthroplasty

Take-home messages
• Tuberosity malunion
• Beware this scenario
• RC problem
• Osteotomy + arthroplasty: poor results
• ORIF in limited cases
• RSA

Thank you for your attention