The purpose of the intramedullary fibular graft was primarily to add good quality cortical bone for screw purchase. In addition to improved screw purchase, the intramedullary fibular graft potentiates fixation by acting as a custom intramedullary rod. The final potential advantage of the intramedullary fibular graft is that it provides a vast surface area for bone healing between the fibula itself and the endosteal surface of the host humerus. A potential disadvantage of the intramedullary fibula is possible damage to the endosteal blood supply. However, in established nonunions, the endosteal blood supply near the nonunion site is absent or of poor quality.
Quadricortical fixation is contraindicated in humeral nonunions associated with active infection.
It is also difficult to use with very distal fractures because of tapering of the intramedullary canal. In some small female patients, it may be necessary to actually split the fibula in half. An effort should be made to stagger the ends of the fibula and plate so as not to create an unduly large stress riser. I recommend a wide 4.5 dynamic compression plate except in small patients, particularly females, where this device would represent a huge implant bone mismatch. All nonunions should be augmented with iliac crest bone graft.