A Rare Neglected Ipsilateral Humeral Triad: Comminuted Proximal Humerus Nonunion with Avascular Necrosis, Mid-Shaft Fracture, and High Radial Nerve Palsy Managed with Staged Reconstruction

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Abstract

Introduction: Ipsilateral humeral shaft and proximal humerus fractures are rare and typically an outcome of high-energy trauma. The coexistence of humeral head avascular necrosis (AVN) and high radial nerve palsy in a delayed presentation makes management particularly challenging and is rarely reported in the literature. This case is important as it highlights a unique combination of bony and neural pathology requiring a carefully staged reconstructive approach. Case Report: A 39-year-old Indian man arrived 4 months after a road traffic accident with left shoulder and arm discomfort, deformity, and inability to extend wrists and fingers. He had initially undergone traditional splinting by a local bone setter. Clinical examination revealed wrist as well as finger drop suggestive of high radial nerve palsy. Imaging demonstrated a comminuted fracture nonunion of the proximal humerus with AVN of the humeral head and a fracture of the mid-shaft of the humerus. The patient was managed with a staged surgical approach that included radial nerve exploration as well as grafting, fixation of the humeral shaft fracture, and subsequent shoulder hemiarthroplasty. Conclusion: This case demonstrates that delayed presentation of complex ipsilateral humeral injuries can be successfully managed with a staged approach addressing both skeletal and neural components. The combination of prosthetic replacement, stable fracture fixation, and nerve reconstruction can lead to satisfactory functional outcomes. This report adds to the limited literature on such rare injury patterns. It provides a practical framework for managing similar complex cases, thereby contributing to improved decision-making in orthopaedic trauma care. Keywords: Proximal humerus fracture, humeral shaft fracture, radial nerve palsy, avascular necrosis, hemiarthroplasty, nerve grafting.