Purpose: Nonunion of the humeral shaft is an uncommon complication of diaphyseal fractures. The rate of nonunion reported in the literature is nevertheless very variable, ranging from 1 to 10%. There are many causal and favouring factors often related to a technical error or poor therapeutic indication. There are several ways to treat humeral shaft fractures (orthopaedic treatment, locked centromedullary nail, ascending pinning, plate fixation, external fixation). Rigorous technique and rigorous indications are the key to success.

Material and methods: We reviewed 35 patients with aseptic nonunion of the humeral shaft between 1995 and 2000. The nonunion resulted from imperfect initial treatment in 24. Mean age was 44 years; fracture of the mid third of the shaft was oblique or transverse in general; all types of initial treatments had been used but ascending pins predominated (16 cases). All patients were reoperated for external plate fixation with a cancellous or corticocancellous bone graft after identifying the radial nerve.

Results: All patients achieved consolidation within a mean delay of 15 weeks with good shoulder (mean elevation 135°) and elbow (mean 10–130°) amplitudes. There were two cases of transient radial paresis with spontaneous recovery. Only two patients experienced mild arm pain that did not required long-term antalgesic treatment. There were no injuries to the femorocutaneous nerve at the site of graft harvesting.

Discussion: Plate fixation for nonunion of the humerus is widely described in the literature. The main complications with this method include radial paralysis and infection. For this reason, several recent reports have advocated locked nailing or external fixation of the Ilizarov type. These methods are technically difficult and are not free of their own complications. We thus recommend screw plate fixation (eight cortical screws on either side of the nonunion) associated with cancellous bone grafts. The results in our series with almost no complications favour this option.

Purpose: The serratus anterior, innervated by the Charles Bell nerve, contributes to dynamic abduction and elevation of the shoulder by stabilising the scapula on the thorax. Abduction and elevation beyond 90° or movement of the spinal border of the scapula is impossible in case of serratus anterior paralysis.

Material and methods: This series included 16 patients with traumatic damage to the Charles Bell nerve leading to unique paralysis of the serratus anterior. Mean age of the patients at diagnosis was 27.5 years. Nine patients underwent scapulothoracic arthrodesis or scapulopexia and seven patients were not operated due to spontaneous total or partial recovery.

Results: Initial elevation in the non operated group was 125°. At five years elevation was 145°, Constant score was 85, and shoulder abduction force was 12 kg (83% of the contralateral force). Final outcome was very good in four patients, good in one, fair in one and poor in one (the fair and poor outcomes involved severe pain for one and major loss of force for the other). Preoperative elevation in the operated group was 95°, reaching 104° at last follow-up. At four years, elevation was 104°, Constant score was 75, and shoulder abduction force was 9 kg (72% of the contralateral force). One case of infection required revision and healed satisfactorily. Outcome was very good in six patients and good in three.

Discussion: Several types of treatment can be proposed: non-surgical care, muscle transfer basically with the pectoralis major, and scapulothoracic arthrodesis. The principal series reported in the literature on scapulothoracic arthrodesis concern patients with fascioscapulohumeral dystrophy and are not comparable with our series. It would be possible to compare our patients with series of post-trauma paralysis using muscle transfer which have given good results for mobility but limited improvement in global muscle force. In our patients, scapulothoracic arthrodesis gave good results in terms of muscle force, pain and overall shoulder function; mobility was fixed by the position of the scapula in the arthrodesis. We advocate this method for the treatment of serratus anterior paralysis mainly in manual labourers.