Nonunited Fractures Research Articles

Pulsed Electromagnetic Field and Extracorporeal Shock Wave in Treatment of Delayed or Non-United Tibial Fracture, A Comparative Study

Objectives: To compare the effect of pulsed electromagnetic field (PEMF) extracorporeal shock wave therapy (ESWT) on healing of delayed as well as non-united tibial fractures. Methods: This study was carried out on 60 adult patients suffering from delayed or non-union tibial fractures in spite of previous conservative treatment by (closed reduction and casting), or operative treatment by: ORIF by (IMN, plate and screws or gliding nail), or external fixation. They were divided according to line of treatment into 2 equal groups. The first group received (PEMF) therapy at the site of fracture of 12 Hz, 3 mT for 60 minutes per session, for 3 months, the patient of the second group were treated by focused (ESWT) at the site of fracture 3 sessions of 2500-3000 impulses each given at 0.25-0.84 mJ/mm2, at interval of 48-72 h between sessions, a maximum of 3 cycles of treatment was given at 3 months intervals. Clinical and radiological assessments were done before, after and then 6 months later as follow up. However functional assessment was done after treatment and 6 months later as follow up. Results: Our results showed better and earlier improvement of clinical, radiological as well as functional scores in group II more than group I. Conclusion: The best significant as well as more rapid clinical, radiological and functional improvement in cases of delayed or non-united tibial fractures was obtained with ESWT compared to PEMF therapy.

Ulnar styloid fracture in distal radius fractures managed with volar locking plates: to fix or not?

Distal radius fracture is usually associated with ulnar styloid fracture. Whether to fix the ulnar styloid or not remains a surgical dilemma as some surgeons believe that their repair is imperative while others feel that they should be managed conservatively. This prospective study involved 47 patients with unilateral fracture of the distal radius who met the inclusion criterion and underwent open reduction and internal fixation with volar locking plates; 28 patients (12 males and females = 16) had an associated ulnar styloid fracture (Group A) while 19 (7 males; 12 females) did not have any ulnar styloid fracture (Group B). At the time of final evaluation both the groups were compared clinically by measuring the grip strength and range of motion around the wrist and the radiologically by measuring radial angle, radial length, volar angle and ulnar variance. Subjective assessment was done using DASH score and final assessment using Demerit point system of Saito. In Group A, average time for consolidation was 9.4weeks, 17 patients developed non-union of the ulnar styloid, average DASH scores was 4.4 and according to Demerit point system of Saito, there were 78.5% excellent, 17.9% good and 3.6% fair results; there were 2 cases of loss of reduction out of which one had persistent ulnar sided wrist pain. In Group B the average time for consolidation was 10.2weeks, average DASH score was 3.8.and Demerit point system of Saito yielded 78.9% excellent, 15.8% good and 5.3% fair results. There was one case of loss of reduction and one case of carpal tunnel syndrome which was managed conservatively. Both groups attained excellent range of motion, grip strength and well maintained the post operative radiological parameters. The comparison of clinico-radiological parameters in both groups was found to be statistically insignificant. To conclude, ulnar styloid fracture or its non union does not affect the outcome of an adequately fixed distal end radius fracture. We urge caution in electing operative treatment of non-united fracture of the ulnar styloid until better scientific report for treatment of pain associated with these fracture is available.

Extensor pollicis longus dysfunction associated with non-united fracture of the trapezium

A 26 year old man was referred to us with extensor pollicis longus dysfunction (EPL), and investigation revealed a fracture of the trapezium (left) and carpo-metacarpal joint dislocation of the thumb. Operative exploration revealed mechanical displacement of the tendon secondary to fracture dislocation of the trapezium as the cause for EPL dysfunction. The lesion was managed with an open reduction and screw fixation resulting in good functional outcome.

Meta analysis of different methods used for joint preserving procedures in the management of delayed, neglected and non-united femoral neck fractures in young adults

BackgroundNeglected fractures in young adults can be amongst the most difficult to treat in the spectrum of fractures of the femoral neck. Because of its complex anatomy and blood supply, timely fixation is paramount. When this does not occur, non-union and avascular necrosis are common complications. Here, we present a meta-analysis of three common options available to the surgeon treating such complications.MethodsWe identified 97 relevant papers by the keywords ‘femoral neck fractures’; ‘neglected’; ‘joint preserving’ and ‘young adults’; 23 met the inclusion criteria and reported on an overall population of 725 patients.ResultsOsteotomy with internal fixation had a union rate of 91.33% (95% CI 84.91–92.87). Fractures fixed by internal fixation with pedicled muscle graft proceeded to union in 86.25% (95% CI 78.92%–88.54%) of cases and those managed with free fibular graft in 88% (95% CI 78.35%–90.84%), respectively. Internal fixation alone, in this study, used as an illustrative control group, was successful in 76.5% (95% CI 65.58%–83.81%) of cases.ConclusionThese findings show superiority of osteotomy with internal fixation in the management of non-united femoral neck fractures, and more complex options with potentially higher morbidity confer no patient benefit.

Total shoulder arthroplasty with an augmented component for anterior glenoid bone deficiency

Glenoid bone loss is a challenging problem when performing total shoulder arthroplasty (TSA). Posterior glenoid bone deficiency is more common than anterior deficiency, and so the literature on methods to treat anterior glenoid deficiency in the setting of TSA is not common. The purpose of this case series was to describe preoperative factors, surgical technique, and clinical outcomes in select patients who underwent placement of an anteriorly augmented glenoid component during TSA. This was a retrospective case series of 5 patients who underwent TSA with an anteriorly augmented component. The medical records were reviewed, including preoperative demographics, clinical examination, radiographs, Penn Shoulder Score and American Shoulder and Elbow Surgeons score. Preoperative diagnoses were anterior glenoid erosion in 2 patients, and 1 patient each with malunited glenoid fracture, nonunited glenoid fracture, and post-traumatic arthritis. The mean age at the time of surgery was 67.4 years (range, 53-75 years). No patient demonstrated radiographic or clinical signs of glenoid component loosening at final follow-up. Postoperative Penn Shoulder Scores averaged 84.4 points (range, 58-100 points), and postoperative American Shoulder and Elbow Surgeons scores averaged 88.0 points (range, 68-100 points). Average postoperative active forward elevation was 140° (range, 80°-170°), and active external rotation was 29° (range 10°-45°). There were no dislocations or revision surgeries at an average of 33.2 months (range, 21.9-43.2 months) after surgery. In the short term, glenohumeral arthrosis in the setting of anterior glenoid deficiency can be treated with an anteriorly augmented glenoid component. Further follow-up and a larger series of patients are necessary to determine the long-term outcomes and complications associated with this technique.

Dorsal Plating of Unstable Scaphoid Fractures and Nonunions.

Achieving stable fixation of displaced acute and chronic nonunited scaphoid fractures continues to be a challenge for the treating surgeon. The threaded compression screw has been the mainstay of treatment of these fractures for the last 3 decades; however, persistent nonunion after screw fixation has prompted development of new techniques. Recent results of volar buttress plating have been promising. We describe a novel technique of dorsal scaphoid plating. In contrast to volar plating, the dorsal plate is biomechanically more favorable as it utilizes the tension side of the scaphoid bone for dynamic compression. Dorsal scaphoid plating provides a more stable construct than the traditional Herbert screw and mitigates the need for vascular or corticocancellous bone grafting in most cases.

Management of non-united extra-articular proximal tibial fractures by combined intramedullary nail and plate

Background Nonunion of the proximal tibia is a relatively rare clinical entity. The clinical series that exist in the literature concerning extra-articular proximal tibia fractures mostly document nonunion rates less than 3 %. Management with intramedullary devices alone often led to malalignment and nonunions. When laterally based plates are used alone, the potential for varus deformity and collapse especially with the use of non-locked implants or medial comminution exists. The purpose of this study was to assess the results of combined intramedullary nailing and minimal proximal tibial plating for non-united extra-articular proximal tibial fractures.

Triple attack technique for non-union of femoral neck fractures.

The purpose of this study was to describe the technique and clinical results following the utilization of biomechanical and biological means for adequate fracture healing in management of non-union of the neck of femur while preventing distortion of normal hip biomechanics. Twenty-two patients with non-united fractures of femoral neck in adults were treated with what was termed the 'triple attack' procedure. This constituted iliac autogenous bone grafting, valgus subtrochanteric osteotomy together with static fixation across the non-union fracture site of the neck to avoid delayed femoral neck shortening. All patients were classified as Pauwel's type III fractures. The mean time interval between the last operation and the current procedure was 4.6 months. Average operative time was 58.6 minutes. Patients were followed up for an average of 43.6 months. Complete union was achieved in all cases at an average of 4.3 months. Significant improvement of all radiological parameters was noticed together with the Harris hip score from an average of 21.2 pre-operatively to 89.6 at the last follow-up. The present study provides encouraging clinical and functional results to suggest that this newly described procedure ('triple attack') might be a valuable option in the management of non-united femoral neck fractures.

Ilizarov fixator in management of nonunited and infected tibial shaft fractures

Background: Management of nonunion with bony defect and infection in long bones is a challenging problem for orthopedic surgeons. Objectives: Evaluation of Ilizarov circular fixation method of treatment for the management of nonunited and infected fractures of tibia. Materials and Methods: This prospective study was conducted in a tertiary care hospital of eastern region of India on 30 subjects in a time span of 3 years after taking clearance of the Institutional Ethical Committee and informed consent of the patients. Results: All the patients had infected nonunion before undergoing Ilizarov procedure. Following initial injury, 22 patients were treated with external fixation and 8 cases were treated with internal fixation. At the time of presentation, 18 patients had infected gap nonunion, 5 patients had infected hypertrophic and 2 patients had atrophic nonunion. The Ilizarov fixator was kept for an average period of 303.7 days. Based on Association for the Study and Application of Methods of Ilizarov scoring system, bony and functional results were assessed. The bony result was excellent in 16 patients, good in eight, fair in four and poor in two. The functional result was excellent in 10 patients, good in 16, fair in two, poor in two. Conclusion: Ilizarov ring fixator still remains an excellent treatment modality for tibial nonunion with a defect, regarding bone union, deformity correction, infection eradication, limb-length achievement, and limb function.

Surgical treatment of distal femoral fractures using a distal femoral locked plate versus a condylar buttress plate

Objective The aim of the study was to evaluate the clinical and functional outcome of internal fixation of distal femoral fractures with a condylar buttress plate versus a distal femoral locked plate. Background Distal femoral fractures are serious injuries that are difficult to treat and carry an unpredictable prognosis requiring special preoperative planning and close follow-up. Surgical treatment has become the standard treatment after considerable improvement in surgical techniques and the implants used, which avoid the complications of conservative treatment. Patients and methods We conducted a randomized prospective study including 30 patients (17 men and 13 women) with distal femoral fractures who were treated by means of open reduction, internal fixation (ORIF), using a distal femoral locked plate in 15 patients and a condylar buttress plate in 15 patients. Fractures were of types A, B, and C according to the AO/ASIF classification. Patients were followed up for 6 months. The exclusion criteria included open fractures, periprosthetic fractures, and old nonunited fractures. The clinical and functional outcomes were classified according to the functional evaluation scoring system described by Sanders and colleagues . Results The functional outcome was excellent in 33.3 versus 20%, good in 46.7 versus 26.7%, fair in 13.3 versus 20%, and poor in 6.7 versus 33.3% of patients treated with the distal femoral locked plate and the condylar buttress plate, respectively. The range of motion was significantly superior in patients treated with the distal femoral locked plate. Complications were significantly fewer with the distal femoral locked plate than with the condylar buttress plate with respect to infection, varus deformity, nonunion, and implant failure. Conclusion The distal femoral locked plate fixation provided better functional outcome and achieved better degree of knee flexion compared with the condylar buttress plate in the treatment of distal femoral fractures in the same fracture pattern.

Missing the 'window' might shut the light forever: Central retinal artery occlusion following spine surgery.

Missing the 'window' might shut the light forever: Central retinal artery occlusion following spine surgery.

The use of pedicled vascularized bone graft from the dorsum of distal radius for the treatment of scaphoid nonunion

Background The use of vascularized bone grafts from the dorsum of the distal radius for the treatment of scaphoid nonunion. Poor reduction or neglect of an unstable carpal scaphoid fracture may lead to scaphoid nonunion with or without avascular necrosis. When preoperative suggestion of avascular necrosis of the proximal pole is confirmed with intraoperative evaluation, conventional bone graft is not enough and a vascularized bone graft is strongly recommended. Patients and methods From May 2011 to September 2014, 12 patients with nonunited fracture of the scaphoid were treated with pedicled vascularized bone graft from the dorsum of the distal radius using of the 1,2 intercompartmental supraretinacular artery. Presurgical and postsurgical clinical evaluation included pain, range of motion, and grip strength. Radiographic evaluation included plain radiographs and MRI. The average follow-up period was 26 months (range = 12-40 months). Results At a mean follow-up period of 26 months, all patients clinically improved. Nine patients (75%) reported the absence of any discomfort, two patients (16%) reported slight discomfort after hard work, and only one case (8%) reported pain with light work. The wrist range of motion improved significantly, and the hand grip strength also improved. According to the modified Mayo wrist scoring chart, clinical results were rated as excellent in eight cases, good in three cases, and fair in one case. Radiographically, in eight of the 12 patients, union was achieved within 12 weeks after surgery, and in the other four patients trabecular bridging of the scaphoid fracture was achieved 16 weeks after the procedure. Conclusion 1,2 Intercompartmental supraretinacular artery is superficial to the extensor retinaculum and is a proper pedicle of vascularized bone graft due to the ease of visibility and dissection. The functional results and union rates were satisfactory in our study.

Treatment of nonunited fractures of the proximal humerus using locked plate, synthetic and autogenous bone grafting

BackgroundNonunion following fracture of the proximal humerus is not uncommon, particularly in the elderly. Stable internal fixation is essential to obtain healing of a nonunited fracture of the proximal humerus.AimThis study aimed at evaluation of the results of open reduction and internal fixation of nonunited fractures of the proximal humerus using the locked plate, synthetic and autogenous bone graft.Patients and methodsTwelve patients diagnosed with nonunited fracture of the proximal third of the humerus were included in this study conducted between 2009 and 2011 in Suez Canal University. Eight patients were female and four were male. The mean age of the patients was 72.3 years (range, 65-80 years). The time between injury and surgery ranged from 6 to 12 months (mean 8.7 months). Three patients had undergone previous operations for persistent nonunion. The follow-up period lasted for 7-12 months, with a mean of 9.3 months. Radiographic evaluation was carried out with biplane radiographs taken at the time of the most recent follow-up evaluation, to determine the presence of bridging osseous trabeculae, which is suggestive of healing, as well as any loosening or failure of the fixation. The objective results were assessed on the basis of the modified scoring system of Constant and Murley. The subjective results were assessed on the basis of the score derived from the Disabilities of the Arm, Shoulder, and Hand Questionnaire.ResultsRadiological bone healing was documented in 11 of 12 patients. Objective and subjective assessments documented marked functional improvement in patients with healing fractures. The results were classified as good in 11 of 12 patients, and few complications were encountered.ConclusionLocked plate used in conjunction with synthetic and autogenous bone grafting is an excellent device for the treatment of proximal humerus nonunions with minimal complications.

Functional and radiological evaluation of treatment of infected nonunited fracture shaft femur using Ilizarov external fixator

Background The treatment of infected nonunion of long bones has always been a challenge for orthopedic surgeons. Treatment goals were eradication of infection and bony union. During distraction osteogenesis, physiological bone loading and mobilization are very important. Aim This study aimed at evaluating the functional and radiological outcome of using Ilizarov external fixator in treating patients with infected nonunited fracture femoral shaft. Patients and methods Fifteen patients with infected nonunion of the shaft of the femur were included in the study between 2007 and 2009. The mean age of the patients was 39.5 years (range 19-68 years). The follow-up period lasted for 14-36 months with a mean of 25.7 months. Bone and functional results were measured and complications were categorized according to the Association for the Study and Application of the Method of Ilizarov guidelines. Results The infection was eradicated in 12 patients before the fixator removal. Excellent radiological bone healing was found in 12 patients, and excellent functional result in eight out of 15 patients. There were a total of 20 complications in 15 patients. Conclusion Ilizarov external fixator is an effective method for the treatment of infected nonunited fracture shaft femur with acceptable radiological and functional outcome and low serious complications.

Simultaneous soft tissue coverage of both medial and lateral ankle wounds: Sural and rotational flap coverage after revision fixation in an infected diabetic ankle fracture

AimsTo describe a case of simultaneous medial and lateral soft tissue coverage for exposed orthopaedic implants in the setting of revision fixation of a non-united ankle fracture. This was achieved using a sural flap as well as a propeller flap. MethodsCase report. ResultsBoth the sural and posterior tibial artery based rotational propeller flap healed without incident. The underlying fracture healed successfully and the patient returned to normal shoe wear. ConclusionsThe sural flap in conjunction with the posterior tibial artery based rotational flap is effective in providing simultaneous medial and lateral soft tissue coverage to the ankle.

Bone marrow injection in treatment of long bone nonunion

Objectives The goal of this study was to report the role of bone marrow injection in treatment of nonunited long bones fractures and to evaluate the relationship between bony union and bone marrow. Background Bone marrow injection has been used for the management of fracture nonunion since a long period of time. The main advantages for this technique are: it can be used in patient unfit for open grafting, is safe, uses osteogenic cells, has no complications in graft site, and can prevent nonunion development. Other advantages include: it is simple, quick, inexpensive, and causes minimal surgical trauma. Patients and methods From November 2009 to February 2013, 20 patients, 16 male patients and four female patients, mean age 36.5 years, suffering from nonunited lower limb fractures were treated in the Orthopedic Department, El-Menoufiya University Hospital by bone marrow injection in site of fracture nonunion. Results Of the 20 patients who had bone marrow injection for nonunion, 16 (80%) patients achieved union and four (20%) patients failed to achieve union. Of the four patients who were not healed, one patient had received three bone marrow injections, whereas three patients had received four bone marrow injections. Conclusion In our study, the patient's age and smoking were inversely proportional to healing after bone marrow injection. In addition, patients who had closed fracture at the time of initial injury achieved union more than patients who had open fracture at the time of initial injury.

Management of infected nonunion of the femur in adults using the Ilizarov technique

Infected nonunion encompasses a series of complex problems including osteomyelitis, bone and soft tissue loss, osteopenia, adjacent joint stiffness, complex deformities, limb length discrepancies, and multidrug resistant multibacterial infections. Several surgical techniques were proposed for management of this major complication including intramedullary devices, free tissue transfer and in situ reconstruction, and the Ilizarov technique. The aim of this study was to revaluate the results of management of infected non-united fractures of the femur in adults using the Ilizarov frame. There were 20 patients with infected femoral nonunion, whom were managed using Ilizarov technique. The mean age of the studied patients was 37.45 years. There was only one female. Of the included patients, ten had diaphyseal fractures, two suffered from proximal metaphyseal fractures, and eight presented with distal metaphyseal nonunion. No patient was able to bear weight on the infected limb. All the patients had had previous surgeries, with a mean of 1.95 (SD 1.050 and range 1–5 previous surgeries). Debridement of the infected bone and soft tissues was performed in all the studied cases. Techniques adopted were acute compression in 5 patients, acute shortening in 13, and acute shortening and distant corticotomy in 2 patients: one proximal and one distal corticotomies. Periodic regular clinical, as well as radiographic, evaluation was performed. A minimum follow-up period of 2 years was an inclusion criterion in this study. The bone, (radiological) results, functional results, and complications were evaluated. The mean time between injury and the application of the frame was 10.15 (SD 8.798, range 3–35 months). The mean follow-up period was 36.65 (SD 15.849, range 25–82 months). The mean external fixation time was 8.03 (SD 2.774, range 5–15 months). The mean limb length discrepancy was 1.45 (SD 1.134, range 0–3 cm). Bony union was achieved in all except two patients. One patient had refractured 1 month after frame removal and union was managed by reapplication of the frame. Bone grafting was not performed in this study. Infection was controlled in all but one patient, in which the fracture did not unite. The radiological results were excellent in ten patients (50 %), good in six (30 %), fair in one (5 %), and poor in three patients (15 %). The functional results were excellent in 4 patients (20 %), good in 13 (65 %), and poor in 3 patients (15 %) and no fair results. In the studied 20 patients, there were 63 complications in total, (25 problems, 6 obstacles, and 32 true complications). From the encountered 32 true complications, 4 were defined as minor and 28 were considered as major complications. Despite the high rate of complications, the Ilizarov technique was found to be effective in the treatment of infected femoral nonunion as it allowed simultaneous treatment of bone loss, nonunion, infection, shortening, and deformity.

Treatment of Posttraumatic Radial Club Hand With Distraction Lengthening

The clinical and radiological results of distraction lengthening in cases with posttraumatic radial club hand were evaluated. Five patients (3 men and 2 women, with average age of 21 years) with traumatic radial shortening (3 patients had nonunited fracture of distal end radius with bone loss and 2 patients had short radius after malunited fracture of radius or growth arrest of distal radial epiphysis, the average shortening was 4.2 cm) were treated with distraction lengthening using Ilizarov fixator and hybrid fixation technique. Patients were evaluated clinically for hand function and appearance, and radiologically for union. The average follow-up was 25 months. The preplanned length was achieved in all cases with good union and no bone graft was needed, clinically there was much improvement in hand function (the range of motion of the wrist increased and the power of hand grip increased) and appearance. Pin tract infection occurred in 3 cases, broken pin in 1 case, and stiff wrist in 1 case. These complications were treated and did not affect the final results. Acquired radial club hand is difficult to treat. Treatment with distraction lengthening is a good option with excellent results and mild complications that did not affect the overall results.

Treatment of complicated distal tibial fractures in diabetic patients

Background The treatment of fractures of the distal tibia is associated with high complication rates. Diabetes mellitus places patients at an increased risk for complications following distal tibia fractures whether treated conservatively or surgically. However, this risk is specific to patients with comorbidities of diabetes. There has been debate on the ideal method for the treatment of these patients because much of the literature has highlighted the extremes of potentially poor outcomes. Less invasive techniques for realignment of distal tibial fractures and reduction of the articular fragments using an Ilizarov fixator with or without minimal internal fixation have been recommended as reliable and safe methods for the treatment of these patients. Patients and methods Between June 2008 and January 2012, 25 patients with type II diabetes mellitus receiving oral and/or insulin for blood sugar control, with complicated distal tibia fractures, were treated using an Ilizarov fixator. All patients presented within 6 months from their primary treatment in other centers. Fifteen patients were treated conservatively in a cast or braces. Ten patients were treated surgically. All patients presented with nonunited fractures and 22 patients had varus malalignment. Ten of the 15 patients who were treated conservatively had deep pressure sores. Assessment of the ankle brachial index and vascular Doppler study were used as noninvasive techniques to verify the vascularity in the affected limb. Results In all patients, the fractures healed, with no need for any procedure to enhance healing. All patients were followed up for 12 months after fixator removal. The average time in an external fixator was 18.1 weeks (average12–22 weeks). On the final follow-up, none of the patients had a long-term sequel of infection. Malunion with less than 5π varus occurred in five patients. None of the patients developed Charcot neuroarthropathy or required amputation during the treatment or at the final follow-up. Long-term bracing for up to 6 months after frame removal was required in five patients with varus malalignment and in the patient who had a proximal fracture. Conclusion Diabetic patients with recent or complicated distal tibia fractures having one or more diabetic comorbidities, but with good peripheral vascularity and continuous control of blood sugar level, they can be treated using an Ilizarov external fixator with a lower complication rate than open reduction and internal fixation procedures and with results comparable to those of nondiabetic patients.

Treatment of Osteopenic or Non-united Fractures of the Humerus with Structure Bone Allograft and Non-locking Plates

Background: Treatment of osteopenic or non-united fractures of the humerus are difficult to achieve optimum mechanical stabilization before bone union. This report presents the clinical experience of structure bone allograft augmentation plus non-locking plates fixation for these complex fractures. Patients and methods: Twenty-four patients with osteopenic or non-united fractures of the humerus (thirteen proximal humerus and eleven humeral shaft fractures) were selected and treated with structure bone allograft augmentation and non-locking internal fixation. All patients were followed and evaluated using shoulder-joint range of motion, the American Shoulder and Elbow Surgeons (ASES) scale and radiographic examination for fracture union assessment. Results: The mean duration of follow-up was 45.3 months. The average time from surgery to the date of radiographic union was 3.6 months (range, 2.5-4.5 months). Twenty-three patients showed radiographically bony union. The total union rate was 95.8%. The average injured shoulder forward flexion was 120 degrees, the external rotation averaged 42 degrees and the internal rotation averaged to the 12th thoracic vertebra. The ASES score improved from an average of 37 preoperatively to 85 postoperatively. One patient had the complication of persistent non-union and loss of reduction. Conclusions: Structure bone allograft can be used as a strong adjuvant mechanical support for internal fixation for the weakened osteopenic humeral fractures. Through rigid fixation and good stabilization, this method can provide an effective treatment for the management of severely osteopenic or non-united fractures of the humerus.