Bilateral Proximal Humerus Lesser Tuberosity Avulsions in an Adolescent Patient: A Case Report.

CASE: Fourteen-year-old boy presented with bilateral proximal humerus lesser tuberosity avulsions after swinging between 2 desks. Injuries were not visualized on radiographs but identified on magnetic resonance imaging. He underwent bilateral open reduction and internal fixation of the bony avulsions. Following repair, he returned to full activities, including sports, without limitations. CONCLUSION: Lesser tuberosity avulsions are rare injuries in the pediatric population that can be missed. Our case is a low energy noncontact mechanism resulting in bilateral injury, highlighting the importance of having a high index of suspicion for this diagnosis in adolescent patients with shoulder pain with normal radiographs.

Mid- to long-term outcome of reverse total shoulder arthroplasty as revision procedure for failed hemiarthroplasty after proximal humerus fracture.

BACKGROUND: Insufficient tuberosity healing is the most common reason for poor outcome after treatment of proximal humerus fractures (PHFs) using hemiarthroplasty (HA). In these cases, revision to reverse total shoulder arthroplasty (RTSA) can improve function and reduce pain in the short term, however, long-term results remain scarce. Aim of this study was to evaluate the clinical and radiological mid- to long-term results in patients with a revision RTSA after failed HA for PHF. METHODS: In this retrospective study all patients that received a revision to RTSA after failed fracture HA between 2006 and 2018 were included. A total of 49 shoulders in 48 patients (38 female, 10 male; mean age 82 ± 9 years) were identified in our database. A total of 20 patients (17 female, 3 male; mean age was 79 ± 9 years) were available for follow-up examination after a mean time period of approximately eight years (3-14 years) after revision surgery. At final follow-up, patients were assessed using a subjective shoulder value (SSV), range of motion (ROM), visual analogue score (VAS), the Constant Score (CS) and the 12-Item Short Form Survey (SF-12). RESULTS: At final follow-up, mean CS was 55 ± 19 (19-91), VAS averaged 3 ± 3 (0-8) and mean SSV was 61 ± 18% (18-90%). Mean SF-12 was 44 (28-57) with a mean physical component summary (PCS) of 38 (21-56) and a mean mental component summary (MCS) of 51 (29-67). On average active forward flexion (FF) was 104° (10-170°), active abduction (ABD) was 101° (50-170°), active external rotation (ER) was 19° (10-30°) and active internal rotation (IR) of the lumbosacral transition was reached. Three patients presented with a periprosthetic humeral fracture after RTSA implantation and underwent a reoperation (15%) during follow-up period. CONCLUSIONS: Revision RTSA results in promising clinical results in patients after initial failed HA after PHF. A complication and reoperation rate of 15% is tolerable in consideration of satisfactory functional and psychological outcome. TRIAL REGISTRATION: Retrospectively registered.

A Retrospective Study of 1076 Cases of Shoulder Dislocation at a Single Center in Türkiye to Evaluate the Role of Post-Reduction Radiography in the Detection of Clinically Significant Fractures.

BACKGROUND The role of post-reduction radiography in patients with shoulder dislocation remains controversial. Therefore, this retrospective study of 1076 cases of shoulder dislocation at a single center in Türkiye aimed to evaluate the role of post-reduction radiography in the detection of clinically significant fractures. MATERIAL AND METHODS Patients with radiographically confirmed anterior shoulder dislocation were included in the study, and their demographic data, mechanism of injury, pre- and post-reduction radiograph readings, reduction method, and patient outcome were recorded. The study analyzed patients who had pre- and post-reduction anterior-posterior and axillary shoulder radiographs. RESULTS During the 44-month study period, a total of 1076 patients were examined, and their pre- and post-reduction radiographs were reviewed by an independent radiologist. Of these patients, 27 (2.6%) had a fracture on their pre-reduction radiographs, while 32 (3.1%) had a fracture on their post-reduction radiographs. The difference between the 2 groups was not statistically significant (P=0.142). The study found that patients who did not undergo a post-reduction radiograph spent an average of 106 min in the emergency department, while patients who had the radiograph and were discharged spent an average of 237 min. The hospital stay of patients who had the radiograph was also significantly longer (P<0.01). CONCLUSIONS Our study supports that routine use of post-reduction radiographs in all cases of anterior shoulder dislocation may not be necessary and could potentially expose patients to unnecessary radiation exposure and healthcare costs. Shortening the examination time in the emergency department by not taking a follow-up radiograph will help prevent overcrowding.

Clinical validation of artificial intelligence-based preoperative virtual reduction for Neer 3- or 4-part proximal humerus fractures.

BACKGROUND: If reduction images of fractures can be provided in advance with artificial-intelligence (AI)-based technology, it can assist with preoperative surgical planning. Recently, we developed the AI-based preoperative virtual reduction model for orthopedic trauma, which can provide an automatic segmentation and reduction of fractured fragments. The purpose of this study was to validate a quality of reduction model of Neer 3- or 4-part proximal humerus fractures established by AI-based technology. METHODS: To develop the AI-based preoperative virtual reduction model, deep learning performed the segmentation of fracture fragments, and a Monte Carlo simulation completed the virtual reduction to determine the best model. A total of 20 pre/postoperative three-dimensional computed tomography (CT) scans of proximal humerus fracture were prepared. The preoperative CT scans were employed as the input of AI-based automated reduction (AI-R) to deduce the reduction models of fracture fragments, meanwhile, the manual reduction (MR) was conducted using the same CT images. Dice similarity coefficient (DSC) and intersection over union (IoU) between the reduction model from the AI-R/MR and postoperative CT scans were evaluated. Working times were compared between the two groups. Clinical validity agreement (CVA) and reduction quality score (RQS) were investigated for clinical validation outcomes by 20 orthopedic surgeons. RESULTS: The mean DSC and IoU were better when using AI-R that when using MR (0.78 ± 0.13 vs. 0.69 ± 0.16, p < 0.001 and 0.65 ± 0.16 vs. 0.55 ± 0.18, p < 0.001, respectively). The working time of AI-R was, on average, 1.41% of that of MR. The mean CVA of all cases was 81%±14.7% (AI-R, 82.25%±14.27%; MR, 76.75%±14.17%, p = 0.06). The mean RQS was significantly higher when AI-R compared with MR was used (91.47 ± 1.12 vs. 89.30 ± 1.62, p = 0.045). CONCLUSION: The AI-based preoperative virtual reduction model showed good performance in the reduction model in proximal humerus fractures with faster working times. Beyond diagnosis, classification, and outcome prediction, the AI-based technology can change the paradigm of preoperative surgical planning in orthopedic surgery. LEVEL OF EVIDENCE: Level IV.

Evaluating the association of radiographic parameters of proximal humerus fractures managed conservatively with functional outcomes.

INTRODUCTION: Treatment of proximal humerus fractures remains controversial. Understanding the factors that can affect the long-term functional outcomes can aid with management choices. This primary aim of this paper is to evaluate the association of radiographic parameters with functional outcomes. METHODS: Radiographic parameters [Caput-collum-diaphyseal (CCD) angles, Y-scapular angles, and humeral head height (HHH)] were studied. The patients were split into varus and valgus groups based on the CCD angles and retroverted and anteverted groups based on Y-scapular angles. Functional outcome was measured by Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), and quick Disabilities of Arm, Shoulder and Hand score at 1 year follow-up. Intra- and interrater reliability were measured with the intraclass correlation coefficients (ICCs). Receiver operator curve (ROC) analysis and logistic regression analysis defined the optimal value for abnormalities on radiographic evaluation as an outcome predictor. RESULTS: 111 patients were recruited (mean age 69, 78% female). Median final radiographic assessment was at 7 months. Mean initial/final CCD was 119o /111o (varus, n = 36) and 153o/140o (valgus, n = 75). Mean initial/final Y-scapula angle was 27o/27o (retroversion, n = 101) and 70o/40o (anteversion, n = 9). There was a significant relationship between OSS and final Y-scapular angle in the retroverted group (adj coeff 0.034, p = 0.009) with optimum predictive retroversion angulation of 25o predicting poor functional outcome (OSS < 40), area under the ROC curve of 0.614. Higher initial valgus and retroversion significantly predicted more change in the final angle (adj coeff - 0.349, p = 0.002, adj coeff - 0.527, p < 0.001 respectively). Both intra-rater and inter-rater reliability for the radiographic parameters were excellent (ICC > 0.9). CONCLUSION: Radiographic parameters whilst having excellent reliability, have a limited ability to predict short-term functional recovery. The extent of retroversion is the most important predictor for functional recovery with 25o a cut-off guide. Fractures with a higher initial valgus and retroversion tend to displace more.

Early Clinical Efficacy of Small Incision Reduction and Superior Closed Pin Fixation of Goss-Ideberg Type III Glenoid Fractures using X-ray and CT Scan.

BACKGROUND: Imaging techniques such as X-rays and 3D Computed Tomography (CT) are used to diagnose and evaluate a patient's shoulder before and after surgery. Identifying the kind, location, and severity of a shoulder fracture helps surgeons choose the right treatment and surgery. OBJECTIVES: The study examines the effectiveness of small incision reduction and superior closure pinning in treating Ideberg type III glenoid fractures identified by X-ray and CT scans. MATERIALS AND METHODS: From October 2017 to June 2022, 40 patients with Ideberg type III glenoid fractures underwent mini-incision reduction and superior closed pinning fixation using the Anterior (AA) and Posterior (PA) approaches. Pre- and post-surgery shoulder scores and imaging data were analyzed. Outpatient review and shoulder anteroposterior radiographs were collected at 1, 3, 6, and 12 months after surgery. We assessed shoulder joint function using the American Shoulder and Elbow Society (ASES) shoulder score, VAS score, Constant-Murley Shoulder Outcome (Constant) score, and DASH score. RESULTS: A total of 40 patients were monitored for 14-16 months, averaging 15.2 ± 0.3 months. All fractures were healed between 14-25 weeks from X-rays, averaging 17.6 ± 5.4 weeks. Both the AA and PA groups had similar shoulder score changes. However, the AA group did better. In all cases, ASES shoulder scores were outstanding at 80%. Radiographs demonstratedno traumatic arthritis or internal fixation failure consequences like screw loosening or breakage. CONCLUSION: It was concluded that Ideberg type III glenoid fracture reduction with an anterior small incision and superior closed pinning hollow lag screw internal fixation could be successful.

Axillary Artery Injury Associated with Dislocated or Displaced Proximal Humeral Fracture: A Report of 3 Cases.

CASE: (1) A 69-year-old man sustained a proximal humeral fracture-dislocation. During emergency surgery, copious bleeding occurred. A pseudoaneurysm was identified 30 days postoperatively. (2) A 69-year-old man sustained a proximal humeral fracture and axillary artery injury. Physical examination demonstrated a cold but pink hand. Hemiarthroplasty and bypass vein grafting were performed. (3) An 86-year-old woman sustained a proximal humeral fracture and axillary artery injury. Her hand had turned cold and pale. Reverse shoulder arthroplasty and bypass vein grafting were performed. CONCLUSION: In cases of proximal humeral fractures with significant displacement, concomitant axillary artery injury must be assessed and if there is a high index of suspicion, prompt advanced imaging is necessary.

Results of transosseous suture fixation in four-part valgus impacted fractures of the proximal humerus.

BACKGROUND: The osteonecrosis ratio in valgus impacted fractures of the proximal humerus is low (<10 %), giving osteosynthesis all its meaning. However, the optimal fixation technique remains controversial. After recentering the humeral head, osteosuture is stable enough to allow bone healing in an adequate position as well as a good long-term shoulder functionality. METHODS: Our cohort included 22 patients with a mean age of 65 (28-83). Patients were placed in a beach-chair position. Surgical exposure was done through an anterolateral, transdeltoid approach. Stay sutures were placed on both tuberosities. Elevation of the humeral head was obtained for 9 patients using iliac crest bone graft, for 7 patients using bone substitutes, for 6 without any graft needed. Both tuberosities were approximated and tied together using two horizontal non-absorbable double-threaded sutures. The whole head was also tied to the humeral metaphysis by cerclage wiring using the same suture. Patients were immobilized in a sling for 4 weeks with no passive or active mobilization; then began rehabilitation starting with passive and active-assisted mobilization. Functional outcome was assessed with the Constant score. Radiographic follow-up was used for fracture healing and osteonecrosis signs. RESULTS: All fractures united within the first 3 months. One patient had radiographic signs of osteonecrosis and one had a secondary displaced fracture without osteonecrosis. At an average follow-up of 35 months, the median Constant score was 83.7 % (63-100) in comparison to the uninjured side. DISCUSSION: A preserved posteromedial periosteal hinge in a valgus impacted fracture of the proximal humerus is key to the success of osteosuture. This hinge provides mechanical stability to the humeral head once elevated, as well as blood-supply from the branches of the posterior circumflex humeral artery. Computed Tomography with Three-Dimensional reconstructed images allow for a precise analysis of this hinge as well as the vascularity of the humeral head. Osteosuture being a minimally invasive surgical procedure plays a predominant role in sparing the remaining vascularization of the humeral head. CONCLUSION: Osteosuture in four-part valgus impacted fractures of the proximal humerus is a minimally invasive procedure as well as a reliable technique yielding good long-term results.

Comparison of classical and minimally invasive superolateral approach for reconstruction of proximal humerus fractures with locking plates.

CONTEXT: Minimally invasive (MI) approaches are purported to present advantages for osteosynthesis when compared with conventional approaches. This study aimed to compare the medium-term clinical and radiological outcomes of patients with proximal humerus fractures treated by plate osteosynthesis with conventional and MI superolateral approaches. METHOD: The study carried out was a retrospective monocentric comparative analysis. Forty-three cases were followed up - 18 were treated with an MI approach and 25 with a conventional approach. Constant-Murley, DASH and SSV scores were established and standard complications were investigated. RESULTS: No significant differences in functional scores or complications were found between the 2 groups. The only significant difference was for pain which was significantly lower for the MI group. The overall revision rate was 18.3 %. The mean adjusted Constant-Murley for the entire population was 80.1 ± 20.2; the mean DASH score was 17.8 ± 15.9 and the mean SSV was 73.2 ± 19.5. CONCLUSION: This study did not demonstrate any significant differences between the 2 approaches. Given the low patient population in our series, the superiority of the MI approach - as indicated in the literature - was not proven.

Combination of Anatomical Plates and Rotator Cuff Reinforcement for Minimally Invasive Treatment of Greater Tuberosity Fractures of the Humerus.

Greater tuberosity fractures of the humerus can be challenging to manage due to their complex anatomy and the potential for compromised shoulder function. We present a novel technique for treating greater tuberosity fractures utilizing specialized anatomical plates and rotator cuff reinforcement. The technique involves the use of an anatomically T-shaped plate designed specifically for the greater tuberosity region of the humerus, allowing for precise fixation and stability. Additionally, rotator cuff reinforcement is performed using sutures to enhance structural integrity and promote early mobilization. The simplified process is as follows: After administering anesthesia, a 3 cm incision is made along the lateral aspect of the shoulder to precisely expose the fracture site of the greater tuberosity. A suture of size 5 is skillfully threaded through the tough rotator cuff tendon to securely attach the proximal humerus to the anatomical plate after the greater tuberosity has been reduced. Intraoperative fluoroscopy is utilized to verify the accurate positioning of plates and screws. After ensuring everything is correct, the surgery concludes.

Straight intramedullary MultiLoc nails for displaced proximal humeral fractures: health status, radiographic results, clinical outcome, and complications.

BACKGROUND: The treatment of the displaced proximal humerus fractures (PHF) still facing a lot of unsolved problems. The aim of this study was to evaluate the clinical effect of MultiLoc nails for the treatment of PHF and present outcomes of patients with different Neer's classification and reduction quality. METHODS: Adult patients with PHFs were recruited and treated with MultiLoc nail. Intraoperative data, radiographic and functional outcomes, as well as occurrence of postoperative complications were assessed. RESULTS: 48 patients met inclusion and exclusion criteria and were included in this study. The DASH Score were 32.2 ± 3.1 points at 12 months, and 37.3 ± 2.5 points at the final follow-up. The mean ASES score at 12 months and final follow-up were 74.4 ± 6.2 and 78.8 ± 5.1, respectively. The mean CM Score in all 48 patients reached 68 ± 6.4 points at the final follow-up, relative side related CM Score 75.2 ± 7.7% of contralateral extremity. The incidence rate of complications was 20.8%. Patients with fracture mal-union, adhesive capsulitis were observed but no secondary surgeries were performed. There was no significantly difference of DASH Score 12 months after surgery and at the last follow-up among patients with different Neer's classification or reduction quality. However, functional outcomes such as ASES score and CM score were significantly influenced by severity of fracture and the quality of fracture reduction. CONCLUSIONS: Our study demonstrated that MultiLoc nails is well suited for proximal humeral fractures, with satisfactory health status recovery, good radiographic results, positive clinical outcomes and low rates of complications. The treatment for four part PHF still faces great challenges. Accurate fracture reduction was an important factor for good functional result.

Clinical and radiographic results of locking plate with medial support screw in Proximal Humerus fracture - the more, the better?

BACKGROUND: The calcar of the proximal humerus is a fundamental structure for medial humeral column support. This study aimed to assess the outcome of osteosynthesis across cases of unstable proximal humerus fractures (PHFs) with medial calcar comminution, following treatment with a PHILOS locking plate and medial support screw (MSS). METHODS: Between January 2010 and December 2018, we retrospectively analyzed the outcomes of 121 cases of osteosynthesis for PHFs with medial column disruption. For the medial support, at least one oblique screw was inserted within 5 mm of the subchondral bone in the inferomedial quadrant of the humeral head. All patients were categorized into two groups: 26 patients in the single MSS group, and 95 in the multiple MSS group. Follow-up after at least an year involved clinical and radiographic outcome evaluations, and correspondingly measuring the Constant-Murley score, University of California, Los Angeles (UCLA) shoulder scale, pain visual analogue scale (VAS), major complications, neck-shaft angle (NSA), humeral head height (HHH), and the eventual time to bone union. Risk factors for the major complications were assessed by multivariate logistic regression analyses. RESULTS: The cohort's mean age was 64.4 ± 15.4 years, and the mean follow-up duration was 19.5 ± 7.6 months. At the final follow-up, between the single MSS and multiple MSS groups, no significant differences in the Constant-Murley score (p = 0.367), UCLA score (p = 0.558), VAS (p = 0.571), time to bone union (p = 0.621), NSA loss (p = 0.424), and HHH loss (p = 0.364) were observed. The incidence of complications (p = 0.446) based on the number of MSS were not significantly different. The initial insufficient reduction after surgery (of NSA < 125°) was found to be a significant risk factor for post-surgical complications. CONCLUSIONS: To treat unstable PHFs, the use of at least one MSS along with a locking plate system is sufficient to achieve satisfactory outcomes. Successful operative treatment using a locking plate for PHF treatment is inherent in anatomical fracture reduction, coupled with medial column support.

The ballistic articular structure injury classification (BASIC) system: clarifying ballistic articular injuries.

PURPOSE: This study aims to (1) devise a classification system to categorize and manage ballistic fractures of the knee, hip, and shoulder; (2) assess the reliability of this classification compared to current classification schemas; and (3) determine the association of this classification with surgical management. METHODS: We performed a retrospective review of a prospectively collected trauma database at an urban level 1 trauma centre. The study included 147 patients with 169 articular fractures caused by ballistic trauma to the knee, hip, and shoulder. Injuries were selected based on radiographic criteria from plain radiographs and CT scans. The AO/OTA classification system's reliability was compared to that of the novel ballistic articular injury classification system (BASIC), developed using a nominal group approach. The BASIC system's ability to guide surgical decision-making, aiming to achieve stable fixation and minimize post-traumatic arthritis, was also evaluated. RESULTS: The BASIC system was created after analysing 73 knee, 62 hip, and 34 shoulder fractures. CT scans were used in 88% of cases, with 44% of patients receiving surgery. The BASIC classification comprises five subgroups, with a plus sign indicating the need for soft tissue intervention. Interrater reliability showed fair agreement for AO/OTA (k = 0.373) and moderate agreement for BASIC (k = 0.444). The BASIC system correlated strongly with surgical decisions, with an 83% concurrence in treatment choices based on chart reviews. CONCLUSIONS: Conventional classification systems provide limited guidance for ballistic articular injuries. The BASIC system offers a pragmatic and reproducible alternative, with potential to inform treatment decisions for knee, hip, and shoulder ballistic injuries. Further research is needed to validate this system and its correlation with patient outcomes. LEVEL OF EVIDENCE: Level III, Diagnostic Study.

Proximal humeral fractures: association between displacement and fatty degeneration of the supraspinatus muscle.

INTRODUCTION: To evaluate the relationship between initial displacement in proximal humeral fractures and fatty degeneration of the rotator cuff measured by CT according to the Goutallier classification. MATERIAL AND METHODS: This cross-sectional observational study evaluated patients with proximal humeral fractures over a six-month period. The study included patients ≥ 18 years old with complete radiological views (anteroposterior, lateral, and Grashey) and a CT scan of the affected shoulder; previous fracture or ipsilateral shoulder surgery were excluded. Neer's classification system and Goutallier stages were used to evaluate the patients. Demographic data were collected and, two groups were analysed according to age (≤ 50 years and > 50 years). RESULTS: Sixty-two patients were included (m = 36, f = 26, ratio 1.3:1); seven patients were excluded. Male patients (36, 58.1%), patients older than 50 years (33, 53.2%) and a low-energy injury mechanism (36, 58.1%) were the most frequent cases. According to the Neer system, the most common proximal humerus fracture was fracture-dislocation in 17 (27.4%) cases. The most common stage in Goutallier's classification was I (some fatty streaks) in 22 (35.4%) cases. Younger patients (≤ 50 years) had more displaced fractures with low fatty degeneration (p = < 0.001) than older patients (> 50 years), who had minimally displaced fractures with greater fatty degeneration (p = 0.567). CONCLUSIONS: High-energy mechanisms are associated with younger patients and a more displaced fracture according to the Neer classification. Older patients had a more advanced Goutallier stage and lesser displaced fracture. We should consider a more aggressive approach in the treatment of non-displaced fractures in elderly patients, less conservative and more surgical management, to obtain a better clinical evolution after the treatment of these kinds of fractures. LEVEL OF EVIDENCE: IV.

Proximal humeral fractures with vascular compromise.

Aims: Vascular compromise due to arterial injury is a rare but serious complication of a proximal humeral fracture. The aims of this study were to report its incidence in a large urban population, and to identify clinical and radiological factors which are associated with this complication. We also evaluated the results of the use of our protocol for the management of these injuries. Methods: A total of 3,497 adult patients with a proximal humeral fracture were managed between January 2015 and December 2022 in a single tertiary trauma centre. Their mean age was 66.7 years (18 to 103) and 2,510 (72%) were female. We compared the demographic data, clinical features, and configuration of those whose fracture was complicated by vascular compromise with those of the remaining patients. The incidence of vascular compromise was calculated from national population data, and predictive factors for its occurrence were investigated using univariate analysis. Results: A total of 18 patients (0.5%) had a proximal humeral fracture and clinical evidence of vascular compromise, giving an annual incidence of 0.29 per 100,000 of the population. Their mean age was 68.7 years (45 to 92) and ten (56%) were female. Evidence of a mixed pattern neurological deficit (brachial plexus palsy) (odds ratio (OR) 380.6 (95% CI 85.9 to 1,685.8); p < 0.001), complete separation of the proximal shaft from the humeral head with medial displacement (OR 39.5 (95% CI 14.0 to 111.8); p < 0.001), and a fracture-dislocation (OR 5.0 (95% CI 1.6 to 15.3); p = 0.015) were all associated with an increased risk of associated vascular compromise. A policy of reduction and fixation of the fracture prior to vascular surgical intervention had favourable outcomes without vascular sequelae. Conclusion: The classic signs of distal ischaemia are often absent in patients with proximal injuries to major vessels. We were able to identify specific clinical and radiological 'red flags' which, particularly when present in combination, should increase the suspicion of a fracture with an associated vascular injury, and facilitate early diagnosis and appropriate combined orthopaedic and vascular intervention.

Clinical and radiological outcome following trauma-related reverse shoulder arthroplasty.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a frequently used therapy for complex proximal humeral fractures and posttraumatic disorders. The present study's purpose was to assess the clinical and radiological outcome of primary and secondary RSA, and to analyze the impact of refixation of the greater tuberosity (GT). PATIENTS AND METHODS: 28 patients with primary fracture RSA and 18 patients with RSA due to posttraumatic disorders were examined with a mean clinical follow-up of 2.5 ± 1.73 years. Operative details and radiographs were retrospectively reviewed. Additional analyses were performed for healed and non-healed GT in primary RSA. RESULTS: Patients with fracture RSA had higher Constant-Murley score (CMS) than secondary RSA without reaching significance (p = 0.104). No significant difference was present for the quality of life measured by the Short Form 36 (SF 36) and the range of motion. In primary RSA, 78.6% GT healed anatomically. Compared to non-healed GT, patients with healed GT had a significantly higher CMS (p = 0.011), external rotation (p = 0.026) and forward flexion (p = 0.083), whereas DASH score was lower without a significant difference (p = 0.268). SF 36 showed no significant difference. Patients with healed GT had a more neutral glenoid version (p = 0.009). CONCLUSION: Superior range of motion and clinical outcome scores were present for anatomically healed GT. Therefore, refixation of the tuberosities is recommended. Secondary RSA can result in inferior results compared to primary RSA, so patients need to be adequately informed.

Operative Versus Nonoperative Treatment of Displaced Proximal Humerus Fractures in Adolescents: Results of a Prospective Multicenter Study.

BACKGROUND: Proximal humerus fractures (PHFx) constitute around 2% of all pediatric fractures. Although younger children with displaced fractures often undergo nonoperative treatments, optimal treatment for adolescents is not well defined. The study aimed to assess the outcomes of operative versus nonoperative treatment of displaced proximal humerus fractures in adolescents via a prospective multicenter study. METHODS: This prospective study assessed adolescents aged 10 to 16 years with displaced PHFx from 2018 to 2022 at 6 level 1 trauma centers. Displacement criteria for inclusion were >50% shaft diameter or angulation >30 degrees on AP/lateral shoulder X-rays. Operative versus nonoperative treatment was decided by the treating physician. Radiographic and clinical data were collected at 6 weeks, 3, and 6 months. Patient-reported outcomes (PROs) included: Patient Reported Outcome Measures (PROMIS), Shoulder Pain and Disability Index (SPADI), and QuickDASH questionnaires. Patients were further grouped into a severe displacement cohort, defined as angulation >40° or displacement >75%. Clinical and radiographic data were compared between the 2 treatment cohorts. RESULTS: Out of 78 enrolled patients, 36 (46%) underwent operative treatment. Patients treated operatively were significantly older (13.5 vs. 12.2 y, P <0.001) and exhibited greater mean angulation on AP shoulder view at presentation (31.1° vs. 23.5°, P <0.05). All PROs improved over time. At 6 weeks, operative patients demonstrated superior PROMIS upper extremity scores based on the minimally clinically important difference (MCID) (46.4 vs. 34.3, P =0.027); however, this distinction disappeared by 3 months. In a subanalysis of 35 patients with severe displacement, 21 (60.1%) underwent surgical intervention. No metrics showed significant differences between treatment modalities, with all PROs achieving population norm values by 3 months. Range of motion showed no difference between operative and nonoperative treatments, irrespective of fracture displacement. CONCLUSION: We found no differences in PROs and ROM between operative and nonoperative treatments of PHFx. If not contraindicated, nonoperative treatment may reduce healthcare costs and risks associated with surgery and should be considered for displaced adolescent proximal humerus fractures, irrespective of fracture displacement. LEVEL OF EVIDENCE: II.

[Treatment of proximal humeral fractures in childhood and adolescence : Consensus report of the pediatric traumatology section of the German Society for Trauma Surgery]. / Die Behandlung der proximalen Humerusfraktur im Kindes- und im Jugendalter : Konsensusbericht der Sektion Kindertraumatologie der DGU.

BACKGROUND: Proximal humeral fractures are a relatively common injury in childhood and adolescence, accounting for 0.45-2% of all fractures [2, 18]. Treatment is usually conservative but is still the subject of a scientific debate [9, 12]. In addition to the S1-LL, there are different recommendations for the diagnostics and treatment of these fractures in the literature. METHODOLOGY: As part of the 10th scientific meeting of the SKT of the DGU, the existing recommendations and the relevant or current literature were critically discussed by a panel of experts and a consensus was formulated. An algorithm for the diagnostics, therapy and treatment was integrated into this. RESULTS: The measurement of axial deviation and tilt is not interobserver and intraobserver reliable [3]. The age limit for when complete correction is possible was set at an age of 10 years, as the correction potential changes around this age. For diagnostic purposes, well-centered X­ray images in 2 planes (true AP and Y­images without thoracic parts) is defined as the standard. At the age of less than 10 years, any malposition can be treated conservatively with Gilchrist bandaging for 2-3 weeks. Surgery can only be indicated in individual cases, e.g., in the event of severe pain or the need for rapid weight bearing. An ad latus displacement of more than half the shaft width should not be tolerated over the age of 10 years. Due to the variance in the measurement results, it is not possible to recommend surgical treatment depending on the extent of the ad axim dislocation. As a guideline, the greater the dislocation and the closer the child is to growth joint closure, the more likely surgical treatment is indicated. The development should be taken into account. The gold standard is retrograde, radial and unilateral ESIN osteosynthesis using two intramedullary nails. Osteosynthesis does not require immobilization. A follow-up X­ray is planned for unstable fractures without osteosynthesis after 1 week, otherwise optional for documentation of consolidation after 4-6 weeks, e.g., if sports clearance is to be granted and before metal removal (12 weeks). CONCLUSION: Recommendations for surgical indications based on the extent of tilt are not reproducible and seem difficult in view of the current literature [3, 9, 12]. A pragmatic approach is recommended. The prognosis of the fracture appears to be so good, taking the algorithm into account, that restitutio ad integrum can be expected in most cases.

Acute-on-Chronic Axillary Artery Thrombus After Reverse Total Shoulder Arthroplasty for Failed Proximal Humerus Open Reduction and Internal Fixation: A Case Report.

CASE: A 71-year-old woman presented with post-traumatic arthritis 11 months after open reduction and internal fixation for a left proximal humerus fracture (PHF) dislocation. After revision to reverse total shoulder arthroplasty (rTSA), the patient's left upper extremity was found to be avascular. An emergent thrombectomy was performed with restoration of arterial flow after removal of an acute-on-chronic axillary artery thrombus. CONCLUSION: Although rare, as rTSA becomes more common for management of PHF, incidence of associated vascular injuries is likely to rise. Screening methods and clinical vigilance in diagnosis are advised for patients with anterior PHF dislocations and arterial injury risk factors.