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[1/4] Humeral nonunion. I always get a CT to determine the status of the head, sometimes there are more pieces you have to reconstruct than you thought. In this case, the butterfly needed to be freed so that it could be rotated into proper position.
![[1/4] Humeral nonunion. I always get a CT to determine the status of the head, sometimes there are more pieces you have to reconstruct than you thought. In this case, the butterfly needed to be freed so that it could be rotated into proper position.](https://pbs.twimg.com/media/EZIJY4UXQAMTIF9.jpg "[1/4] Humeral nonunion. I always get a CT to determine the status of the head, sometimes there are more pieces you have to reconstruct than you thought. In this case, the butterfly needed to be freed so that it could be rotated into proper position.")
[2/4] For rigid fixation I don’t rely on plate alone, and use lag screws liberally. Long spikes like this are perfect to get reduction and compress the s*** out of it (just not too close to tip of the spike or it will crack!). Then take wires out and it becomes a “sawbone case.”
![[2/4] For rigid fixation I don’t rely on plate alone, and use lag screws liberally. Long spikes like this are perfect to get reduction and compress the s*** out of it (just not too close to tip of the spike or it will crack!). Then take wires out and it becomes a “sawbone case.”](https://pbs.twimg.com/media/EZIJZavWoAExnWX.jpg "[2/4] For rigid fixation I don’t rely on plate alone, and use lag screws liberally. Long spikes like this are perfect to get reduction and compress the s*** out of it (just not too close to tip of the spike or it will crack!). Then take wires out and it becomes a “sawbone case.”")
[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.
![[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.](https://pbs.twimg.com/media/EZIJZtEXsAIblsI.jpg "[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.")
![[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.](https://pbs.twimg.com/media/EZIJZtGXkAIir7e.jpg "[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.")
![[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.](https://pbs.twimg.com/media/EZIJZtJWsAQNT_7.jpg "[3/4] Final construct. This head (unlike a nonunion I posted recently) had poor bone so I maxed out on fixation. Aggregate anterior approach can go as far down as the fossa. You can either go to lateral epicondyle and find nerve, or split brachialis and leave nerve protected.")
[4/4] Aggregate anterior approach [deltopectoral extended to anterior, taking off deltoid in digastric sleeve (video here: http://links.lww.com/JOT/A358 )] just prior to closure. Retracted deltoid (yellow), digastric sleeve sewn back (green), biceps (black), cephalic vein (purple).
![[4/4] Aggregate anterior approach [deltopectoral extended to anterior, taking off deltoid in digastric sleeve (video here: http://links.lww.com/JOT/A358 )] just prior to closure. Retracted deltoid (yellow), digastric sleeve sewn back (green), biceps (black), cephalic vein (purple).](https://pbs.twimg.com/media/EZIJaCcXsAUIG_7.jpg "[4/4] Aggregate anterior approach [deltopectoral extended to anterior, taking off deltoid in digastric sleeve (video here: http://links.lww.com/JOT/A358 )] just prior to closure. Retracted deltoid (yellow), digastric sleeve sewn back (green), biceps (black), cephalic vein (purple).")
