Approach to Humeral Shaft Nonunion

Evaluation and Surgical Techniques

Emily H. Naclerio, MD; Michael D. McKee, MD, FRCS(C)


J Am Acad Orthop Surg. 2022;30(2):50-59. 

In This Article

Abstract and Introduction


Humeral shaft fractures account for 1% to 3% of all fractures. Traditional nonsurgical treatment with a functional brace is still the standard treatment of these fractures; however, modern studies have reported that nonunion rates may be as high as 33%. Recent information suggests that the development of nonunion after nonsurgical treatment may be identified as early as 6 to 8 weeks postinjury. Even with surgical treatment, nonunion rates as high as 10% have been reported. Regardless of the original treatment method, nonunion results in poor quality of life for the patient and therefore should be addressed. A thorough preoperative evaluation is important to identify any metabolic or infectious factors that may contribute to the nonunion. In most cases, surgical intervention should consist of compression plating with or without bone graft. Although most patients will achieve union with standard surgical intervention, some patients may require specialized techniques such as cortical struts or vascularized fibular grafts. Successful treatment of humeral shaft nonunion improves function, reduces disability, and improves the quality of life for patients. In this article, we outline our approach to the treatment of humeral shaft nonunion in a variety of clinical settings.


Humeral shaft fractures are estimated to account for 1% to 3% of all fractures and lead to approximately 60,000 emergency visits in the United States annually.[1,2] Historically, most humeral shaft fractures were managed nonsurgically. Functional bracing treatment was originally described by Sarmiento et al[3] who asserted that this method of treatment offered high union rates with low complication rates. However, many modern studies have found that nonunion rates with nonsurgical treatment are as high as 20% to 33%.[4–7] When functional bracing treatment is pursued, studies have found a 30% crossover to surgical treatment because of nonunion, delayed union, or inability to tolerate or accept the brace.[8,9]

Nonunion is not exclusive to nonsurgical treatment because studies have shown that even with surgical intervention, nonunion rates range from 4% to 10%.[5–7] Regardless of the original treatment method, nonunion is associated with pain, delayed return to function, and poor patient quality of life; therefore, appropriate identification of delayed or nonunion of the humeral shaft and prompt intervention is an important skill for orthopaedic surgeons.

Different surgical techniques to address humeral nonunion have been described including open reduction and plate fixation with or without bone graft, intramedullary fixation, cortical strut augmentation, and external fixator application. Although no universally agreed upon method to address humeral nonunion exists, open reduction and plate fixation with cancellous autograft is generally recognized as the benchmark.[10] Regarding graft material, others have advocated for the use of alternative bone substitutes such as demineralized bone matrix (DBM), which has been shown to result in high union rates while avoiding donor site morbidity.[11] The purpose of this article was to perform a comprehensive review of the relevant literature in the past 10 years, in addition to definitive reference studies, and describe our approach to the evaluation and treatment of humeral shaft nonunion.