osteoporosis is defined by the who as a bone mineral density ( bmd ) of 2.5 standard deviations or more below the young normal  mean . on this basis 26 million people in america are osteoporotic.1 , 2 most of the fractures in the osteoporotic individuals occur in the proximal humerus , distal forearm , vertebrae , pelvis , hip and tibial condyles . however diaphyseal fractures are also common . with nearly 120,000 osteoporotic humerus fractures occurring annually , it is important to understand the methods of treatment and indications for such treatments of these fractures.3 , 4 nonunion of the humerus is an uncommon complication of diaphyseal fractures . its reported rate in the literature is quite variable , ranging from 1% to 10%.5 , 6 it can be successfully managed by various surgical methods with the principles being open reduction , freshening of edges and stabilization using plate and screws , interlocking nails , or an external fixator . nonunion in the osteoporotic bone is an even bigger surgical challenge as the degree of osteoporosis increases during the period of immobilization and can complicate osteosynthesis significantly . reports about the management of nonunion of the humeral diaphysis in severely osteoporotic bone are uncommon . the purpose of this study is to highlight the use of a combination  of a locking plate and an intramedullary fibula in the management of nonunion of the humerus in a severely osteoporotic bone . we included 5 patients in the study due to the relative rarity of this type of combination in patients . the average age of the patients in our study was 57 years ( range , 5167 ) . all the patients had a midshaft involvement and radiologically the nonunion could be classified as atrophic . all patients had mild pain , tenderness and gross abnormal mobility at the nonunion site , and limitation of activities of daily living . the average delay at presentation from the time of injury was 14 months ( range , 1218 months ) . preoperative disability of arm , shoulder and hand ( dash ) score averaged 84    5 ( range , 7991 ) . the preoperative assessment included a dual energy x - ray absorptiometry ( dexa ) scan and a radiogrammetric measurement of the humerus for osteoporosis assessment . however we were aware that disuse would have worsened the condition of the humerus even further . we added the thickness of the two cortices and divided it by the width of the bone at a relatively unaffected level of the humeral diaphysis . in all cases the five cases had been operated on at least once with an average of 1.2 ( range 13 times ) . fracture fragments were freshened and debridement carried out until bleeding bone ends , and the medullary canal were exposed . both fragments were then reamed progressively using serial hand reamers gently to open the canal for the placement of the fibula . the mid - shaft of the fibula was harvested and shaped to fit the medullary canal . the length of the fibula harvested was equal to the length of the plate that was planned to be used preoperatively . the graft was slid up the medullary canal of one fragment and then slid backwards down the other fragment after the fragment was held in slight distraction in an aligned position . all patients were protected in an arm sling for a period of three weeks after the surgery . lifting of weights using the operated limb was deferred for a period of three months or until osseointegration of the fibular ends or fracture healing . at final follow - up , fractures were considered united if at least three of the cortices on radiographs showed evidence of bony trabeculae crossing the fracture site . all fractures had solid clinicoradiologically evident fracture union by the six month follow - up . this was assessed when 3 of the four cortices on seen on 2 plane radiographs showed bridging . the average arm shortening was 2  cm ( range , 13  cm ) . none of the patients had pain over the fracture site and the dash score at the last follow - up averaged 27 . interestingly 2 patients complained of some amount of discomfort at the graft harvest site in the immediate postoperative period only due to peroneal muscle movement . one patient continued to have significant stiffness of the shoulder at final follow - up . in the other four there was minimal restriction in shoulder rotation at final follow - up in these four cases . all the patients had a full range of motion at the elbow at final follow - up ( fig .  1 , fig .  2 , fig . nonunion of long bones is likely to be related to the severity of initial injury , transverse pattern of fracture , or soft - tissue interposition . failure to unite after surgical treatment may be due to poor  contact between the bone ends , inadequate stabilization , devitalization of bone , osteopenia , and bone defects . obesity , alcoholism , and method of treatment may also be contributory factors . the lack of mechanical stability due to a flail arm may interfere with personal hygiene , dressing , and simple activities of daily living . the goal of surgery is to achieve a stable fixation and institute early mobilization of stiff joints . while a number of methods of managing atrophic fracture nonunion have been suggested , each has its drawbacks . most surgeons favour the use of an interlocking nail , ilizarov external fixator , or locking compression plate ( lcp ) for stabilization and vascularised fibular graft or cancellous iliac crest bone graft for enhancement of fracture union . disadvantages of ilizarov fixation include the presence of a bulky implant on the arm , pin track infection ; painful impingement of the frame on the chest wall and the possibility of neurovascular injury due to the wires . the use of a long compression plate requires extensive tissue stripping in the upper arm causing considerable impairment of blood supply and a significant risk of radial nerve injuries . double plating using two dynamic compression plates at right angles to each other has been described . on - lay grafts and double plating entail more extensive soft tissue stripping and devascularization of the humerus locking plates are designed with screws that thread into the plate creating fixed - angle anchorage of the screws into the plate . locking plates behave mechanically more like external fixators in that they achieve stability without the need for direct contact with the periosteal surface . in addition , the screws act in concert gaining purchase in regions of bone rather than individual sites as with traditional screws . in locking plates , screw failure is an all or nothing event . locking plate designs do provide enhanced fixation in fragile bone but can not be expected to perform in situations where the applied loads to the fracture repair exceed the strength of the host bone . locking - plate technology has renewed interest in plate fixation for treating proximal humerus fractures . complications associated with these devices , including loss of reduction , screw cutout , and intra - articular penetration , are frequent . laboratory studies have also shown that locking plate constructs were superior to unlocked plate and screw constructs in osteoporotic diaphyseal humeral fracture models tested in  vitro using cyclical torsional loading . the primary mode of failure of internal fixation in osteoporotic bone results from bone failure rather than implant breakage . since bone mineral density correlates linearly with the holding power of screws , osteoporotic bone often lacks the strength to hold plates and screws securely . optimal management of osteoporotic proximal humeral fractures has evolved and may now include use of locking plates and augmentation with intramedullary fibular grafts , calcium phosphate or sulfate cement , and iliac crest bone graft . it also has some osteogenic potential in addition to acting like a strut across the fracture site when used as an intramedullary bone graft . fibula is probably the most suitable donor bone for reconstruction of defects in a long bone because of its length , geometrical shape , and mechanical strength . however grafts of cortical bone revascularise slowly and incompletely . in our series of five cases we included cases the radiogrammetry methodology of the humeral bone cortices also was supportive of the fact that the affected bones had severe osteoporosis . immobilization of the humerus in itself tends to cause disuse osteoporosis in all the nonunion cases . however in all our cases it can be safely said that disuse osteoporosis is an addition to the already existent osteoporosis . our results show that this combination is useful and reproducible for the management of nonunion of the humerus in a severely osteoporotic bone .
nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse . 
 the management of such a combination is a challenge . 
 most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis . 
 the challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely . 
 we used a combination of an intramedullary fibula with a locking plate in 5 cases . 
 the results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely .