Humeral Fractures in Metabolically Compromised Bone: Outcomes of Structural Strut Onlay Allograft with Open Reduction and Internal Fixation - A Case Series of Three Patients.

Introduction: Humeral fractures arising in bone of poor structural quality - whether secondary to osteoporosis-related non-union or primary metabolic bone disease such as osteogenesis imperfecta (OI) - present a significant surgical challenge. Achieving reliable fixation in deficient cortical bone requires augmentation strategies beyond standard plating. Structural strut onlay allograft, applied in conjunction with open reduction and internal fixation (ORIF), has been reported to address both the mechanical and biological shortfalls of fixation in such cases. Case Report: We report three patients managed with ORIF augmented by structural strut allograft for humeral fractures in metabolically compromised bone. The first two cases involve elderly women with osteoporosis presenting with established humeral shaft non-unions - one hypertrophic, one atrophic - both treated using locking plate constructs with cortical onlay allograft. The third case is a 78-year-old woman with known OI who sustained an acute distal third humerus fracture with associated sensory radial nerve palsy, managed with an elastic intramedullary (titanium elastic nail) nail supplemented by an allograft bone strut. In all three cases, the fixation construct was radiologically satisfactory, and early clinical outcomes were encouraging. Conclusion: Structural strut allograft augmentation is a versatile adjunct to ORIF for humeral fractures in bone of compromised quality. The technique can be adapted to different fracture configurations, bone pathologies, and fixation implants. These cases support its use across the spectrum of humeral fractures in metabolically deficient bone and highlight the importance of tailoring implant strategy to the underlying bone biology.