Treatment of bone nonunion of the humerus after multiple failed open reduction internal fixation with plate in an elderly patient with bone loss and osteoporosis. Case report

The management of comminuted, severely displaced proximal humerus fractures in elderly patients with osteoporosis poses a significant challenge in trauma surgery, due to both their frequency and complexity, both in initial management and in the treatment of complications. The patient’s condition, motivation, expectations, and anatomical conditions are all determining factors in the choice of treatment. In cases requiring surgical intervention, we must choose between different osteosynthesis methods (locking plates, intramedullary nail), hemiarthroplasty, and reverse shoulder prosthesis implantation, based on individual assessment. Complications of osteosynthesis are not uncommon. Implant displacement, screw cutout, secondary displacement of the fracture, and non- and malunions can raise serious problems in terms of treatment. Aggravating factors include pre-existing osteoporosis, altered local conditions resulting from previous surgery, scarring, possible bone defects, and pre-existing pathology of the shoulder joint. We would like to present the “forced” solution we chose in the case of a 77-year-old female patient, which we performed on a twice re-operated humeral pseudarthrosis, in this case with a satisfactory outcome. After analyzing the available imaging procedures, we decided on intramedullary nailing, taking into account the patient’s medical history, multiple surgeries, and inclination towards the simplest solution. Due to the patient’s personal preference, we rejected the option of implanting a reverse-type, long-stemmed prosthesis that would allow for faster rehabilitation. Due to local factors observed during surgery, we performed a long Philos type plate osteosynthesis.