Ulnar shaft diameter as it relates to plate osteosynthesis: A cadaveric study.

Background: Ulnar shaft fractures are common and the standard of care treatment is with 3.5 â€‹mm plating. The purpose of this study was to measure diameters along the length of the ulna to provide information on screw length and appropriateness of 3.5 â€‹mm screws and plate location. Methods: Ten embalmed cadaveric ulnas were dissected free of all soft tissues. The length of the ulna was measured and then divided by four. Transverse osteotomies were performed along the length of the ulna at », ½ and ¾ its full length. The diameter of the ulna at these locations was then measured in a radio-ulnar direction as well as a volar-dorsal direction. Results: There were five female and five male specimens with an average age of 83.6 and 78.8 respectively. The smallest diameter in both the female and male specimens was in the distal ¾ shaft measured in a volar-dorsal direction with an average of 9.1 â€‹mm and 12 â€‹mm. The average volar-dorsal measurement was less than radio-ulnar measurement at all locations. The diameters increased along the ulna heading proximally. Conclusion: This study provides information pertinent to screw width and length with respect to the ulnar shaft and calls in to question the use of 3.5 â€‹mm screws in the distal and midshaft ulnar diaphysis in females. Removal of 3.5 â€‹mm screws in the mid and distal ulnar shaft in females can leave a hole corresponding to 23% and 27% of the bone which can be concerning for a stress riser.

Ultrasound-guided techniques for managing length- unstable femoral shaft fractures in children.

OBJECTIVE: The management of length-unstable femoral shaft fractures(LUFSFs) in pediatric patients is still controversial. This study aims to explore the clinical efficacy of ultrasound-guided closed reduction combined with external fixation for treating LUFSFs in children. METHODS: We conducted a retrospective analysis of clinical data from 19 pediatric patients with LUFSFs who underwent ultrasound-guided closed reduction and external fixation between January 2018 and January 2023. Ultrasound was employed not only to facilitate closed reduction of the fracture but also to guide real-time insertion of Schanz pins and monitor pin length as it traversed the opposite cortex. Surgical time, intraoperative fluoroscopy count, hospital stay length, fracture fixation duration, complication incidence, fracture reduction quality at the final follow-up were recorded. RESULTS: The patients' average age was 7.5 years( range: 5 to 11 years). The mean surgical duration was 70.4 min (range: 48-105 min), and the average intraoperative fluoroscopy count was 6.5 (range: 2-16). Fracture fixation lasted an average of 10.9 weeks (range: 7-20 weeks). All patients were followed up for more than one year. 6 cases of superficial pin tract infection occurred, which resolved with oral antibiotics and enhanced needle tract care. No deep infections were observed. Temporary stiffness of the knee joint was observed in 2 patients. According to Flynn's efficacy evaluation system, fracture reduction quality at the final follow-up was rated as excellent in 11 cases and satisfactory in 8 cases, yielding a combined success rate of 100% (19/19). CONCLUSIONS: The technique of ultrasound-guided closed reduction combined with external fixation offers favorable outcomes for children aged 5 to 11 years with LUFSFs, reducing reliance on fluoroscopic guidance.

Clinical effect of operative vs nonoperative treatment on humeral shaft fractures: Systematic review and meta-analysis of clinical trials.

BACKGROUND: Whether operation is superior to non-operation for humeral shaft fracture remains debatable. We hypothesized that operation could decrease the nonunion and reintervention rates and increase the functional outcomes. AIM: To compare the clinical efficacy between operative and nonoperative approaches for humeral shaft fractures. METHODS: We searched the PubMed, Web of Science, ScienceDirect, and Cochrane databases from 1990 to December 2023 for clinical trials and cohort studies comparing the effects of operative and conservative methods on humeral shaft fractures. Two investigators independently extracted data from the eligible studies, and the other two assessed the methodological quality of each study. The quality of the included studies was assessed using the Cochrane risk bias or Newcastle-Ottawa Scale. The nonunion, reintervention and the overall complications and functional scores were pooled and analyzed using Review Manager software (version 5.3). RESULTS: A total of four randomized control trials and 13 cohort studies were included, with 1285 and 1346 patients in the operative and nonoperative groups, respectively. Patients in the operative group were treated with a plate or nail, whereas those in the conservative group were managed with splint or functional bracing. Four studies were assessed as having a high risk of bias, and the other 13 were of a low risk of bias according to the Newcastle-Ottawa Scale or Cochrane risk bias tool. The operative group had a significantly decreased rate of nonunion [odds ratio (OR) 0.30; 95%CI: 0.23 to 0.40), reintervention (OR: 0.33; 95%CI: 0.24 to 0.47), and overall complications (OR: 0.62; 95%CI: 0.49 to 0.78)]. The pooled effect of the Disabilities of Arm, Shoulder, and Hand score showed a significant difference at 3 [mean difference (MD) -8.26; 95%CI: -13.60 to -2.92], 6 (MD: -6.72; 95%CI: -11.34 to -2.10), and 12 months (MD: -2.55; 95%CI: -4.36 to -0.74). The pooled effect of Visual Analog Scale scores and the Constant-Murley score did not significantly differ between the two groups. CONCLUSION: This systematic review and meta-analysis revealed a trend of rapid functional recovery and decreased rates of nonunion and reintervention after operation for humeral shaft fracture compared to conservative treatment.

Is delayed time to surgery associated with increased postoperative complications in patients with pathologic humerus fractures?

INTRODUCTION: Delayed time to surgery, in the case of orthopedic trauma, is well known to be associated with higher morbidity and mortality, an extended duration of hospitalization, and an associated rise in overall cost. Delayed time to surgery of at least 3 days following hospital admission is associated with elevated risk of complications following surgery for a standard, non-pathologic, humeral shaft fracture. To our knowledge, it is unknown whether the same association is present for pathologic humerus fractures. The primary objective of this study was to identify risk factors, including patient characteristics, comorbidities, and postoperative complications, that are associated with delayed time to surgery following pathologic humeral fracture. METHODS: All patients undergoing surgical management of pathologic humerus fractures across a 6-year period from 2015 to 2021 were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Postoperative complications were reported within 30 days of procedure. Delayed time to surgery was defined by ≥ 2 days from hospital admission to surgery. We identified a total of 248 patients, and 39.9% (n = 99) of patients had delayed time to surgery. Multivariate logistic regression adjusted for all significantly associated variables was employed to identify predictors of delayed time to surgery for pathologic humerus fractures. RESULTS: The characteristics of patients significantly associated with delayed time to surgery were ASA classification ≥ 3 (p = 0.016), dependent functional status (p = 0.041), and congestive heart failure (p = 0.008). After adjusting for all significantly associated patient variables, the characteristics of patients independently associated with delayed time to surgery were non-home discharge (OR: 2.93, 95% CI 1.53-5.63; p = 0.001) and extended length of stay (OR: 2.00, 95% CI 1.06-3.77; p = 0.033). CONCLUSION: Delayed time to surgery of at least 2 days was independently associated with non-home discharge and extended postoperative length of stay. After controlling for baseline patient characteristics and comorbidities, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic humeral fractures. This is in contrast to standard, non-pathologic humerus fractures in which delayed time to surgery is associated with an increased risk of postoperative complications. LEVEL OF EVIDENCE III: Retrospective Cohort Comparison; Prognosis Study.

Unusual Presentation of Cerebral Fat Embolism Syndrome Post-femur Fracture: A Case Study and Diagnostic Insights.

Cerebral fat embolism syndrome (CFES) is a rare but certainly devastating impediment following long bone fractures. The diagnosis of CFES primarily depends on identifying clinical manifestations like respiratory distress, petechial rash, and neurological symptoms. However, in rare instances, CFES can manifest with atypical or absent clinical features, posing diagnostic challenges. Here, we present a rare case report of a woman in her 20s who developed CFES after suffering a femur shaft fracture devoid of conventional clinical features. The diagnosis of CFES was built upon clinical suspicion and a typical MRI brain finding of a starfield pattern. Our case highlights the importance of including CFES in the differential diagnosis of neurological deterioration, especially after long bone fractures. We suggest early plate osteosynthesis to stop more emboli from forming in people with FES, as well as continuous neuromonitoring and a reminder that CFES can show up without any other signs or symptoms in the body.

Risk factors for malalignment after intramedullary nail treatment of distal tibia fractures with associated fibula fractures.

PURPOSE: Malalignment of distal tibia fractures can lead to malunion/nonunion or alter the limb mechanical axis which may cause arthritis. Proposed methods to decrease malalignment include fibular fixation or multiplanar interlocking screws, however these remain controversial. This study aimed to identify factors associated with malalignment in distal tibial fractures with associated fibular shaft fractures. METHODS: A retrospective review was performed of distal tibia fractures with associated fibular shaft fractures treated with intramedullary nailing at two level one trauma centers between 2015 and 2019. Cases involving malalignment (> 5° of deviation from anatomic axis on either coronal/sagittal axis) on final follow-up (minimum three months postoperatively) were compared to those without malalignment with regard to demographics, fracture characteristics, intraoperative characteristics, and complications. RESULTS: The rate of malalignment was 13%. On multivariate analysis, multiplanar distal interlocking screw fixation (odds ratio [OR], 0.18; 95% confidence interval [CI] 0.03-0.92) was associated with a decreased rate of final malalignment, while nail diameter > 10 mm was associated with a higher rate (OR, 4.05; 95% CI 1.25-13.11). Fibular fixation was not associated with malalignment. CONCLUSION: Multiplanar distal interlocking screws may protect against malalignment. Fibula fixation does not appear associated with a decreased rate of malalignment in distal tibia fractures treated with intramedullary nails. LEVEL OF EVIDENCE: III.

Pediatric femoral shaft fractures: the American Academy of Orthopaedic Surgeons clinical practice guidelines versus actual management in a teaching hospital.

Background: In 2009, the clinical practice guidelines (CPG) were released by the American Academy of Orthopaedic Surgeons (AAOS), which outline an age-based approach for treating pediatric femoral shaft fractures (PFSF), both nonoperatively and operatively. The aim of the current study was to investigate potential disparities between the recommended treatments for PFSF based on the AAOS-CPG and the actual treatments administered in The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University. Methods: A retrospective review was conducted on the medical charts and radiographs of all PFSF treated at The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University from January 2014 to January 2022. We identified 445 children who met our inclusion criteria and evaluated their treatments according to the AAOS-CPG. Actual treatments were then compared with the treatments recommended by the AAOS-CPG. Binomial and multivariate logistic regression was used to examine whether different factors could predict the choice between operative and nonoperative management. Results: Operative treatments were undertaken in 102 of 215 (47.4%) fractures in children younger than 6 years, in 102 of 122 (83.6%) fractures in those between 6 and 12 years of age, and in 107 of 108 (99.1%) fractures in those older than 12 years. Nonoperative management was conducted in 113 of 215 (52.6%) fractures in children younger than 6 years, in 20 of 122 (16.4%) fractures in those between 6 and 12 years of age, and in 1 of 108 (0.9%) fractures in those older than 12 years of age. Surgeon decisions for non-surgery were in agreement with the CPG 52.6% of the time, whereas agreement reached 90.9% for surgical choices. Predictors of actual operative management were age (P=0.01), patient weight (P<0.001), fracture pattern (P<0.001), presence of other orthopedic injuries requiring surgery (P=0.002), and polytrauma (P=0.02). Conclusions: There was limited concordance between actual treatments and CPG recommendations, particularly for the nonoperative management of fractures in children under 6 years old. Age, patient weight, fracture pattern, presence of other orthopedic injuries requiring surgery, and polytrauma were the main predictors of our operative decision-making process.

Extra-articular proximal tibia fracture fixation with locked plating versus intramedullary nailing: A meta-analysis.

OBJECTIVES: This study compared outcomes of locked plating (LP) versus intramedullary nailing (IMN) techniques for treatment of extra-articular proximal-third tibia fractures. METHODS: Data Sources: PubMed, Ovid MEDLINE STUDY SELECTION: Studies were included if they compared LP and IMN fixation for proximal one third tibial shaft fractures without articular extension or with simple articular extension into the tibial plateau. Minimum 1 year of clinical and radiographic follow up was used. DATA EXTRACTION: Outcomes assessed included operative duration, postoperative knee range of motion (ROM), union outcomes (time to union, nonunion, malunion, delayed union), and incidence of postoperative complications (superficial and deep infection, secondary surgical intervention, compartment syndrome). DATA SYNTHESIS: Separate random-effects meta-analyses were conducted for each outcome. For categorical data, relative risks were used whereas the standardized mean difference was used for continuous variables, with corresponding 95 % confidence intervals. RESULTS: 7 studies were included reporting the outcomes of 319 patients treated with LP and 300 treated with IMN. IMN fixation had significantly shorter time to union (p = 0.049) and lower risk for superficial infection (p = 0.028). However, LP conferred a significantly lower risk for malunion (p = 0.017) and postoperative compartment syndrome (p = 0.018). CONCLUSION: IMN demonstrated significantly shorter time to union and lower risk of superficial infection when treating extra-articular proximal tibia fractures, while LP fixation demonstrated significantly lower risk for malunion and postoperative compartment syndrome. Although successful results can be achieved with good technique in LP and IMN fixation, a significant complication profile exists with these fractures regardless of construct choice. LEVEL OF EVIDENCE: Therapeutic Level III.

Treatment preferences and current practices regarding open tibial shaft fractures.

Purpose: The purpose of this study was to reveal the treatment preferences and current practices regarding open tibial shaft fracture (OTSF). Patients and methods: Online surveys of treatment preferences and current practice of OTSF were conducted by orthopedic trauma doctors from various medical institutions in Zhejiang Province. The survey contains three modules. The first module is the basic information of the participants, the second module is the treatment patterns for Gustilo-Anderson type I-II (GA I/II), and the third module is the treatment patterns for Gustilo-Anderson type IIIA (GA IIIA). Furthermore, each treatment pattern was divided into four aspects, including antibiotic prophylaxis, irrigation and debridement, fracture stabilization, and wound management. Results: A total of 132 orthopedic trauma doctors from 41 hospitals in Zhejiang province, participated the online surveys. In GA I-IIIA OTSF, more than three-quarters of participants considered <3 h as the appropriate timing of antibiotic administration after trauma. In fact, only 41.67% of participants administered antibiotics within 3 h after trauma. 90.91 and 86.36% of participants thought debridement within 6 h was reasonable for GA I/II and GA IIIA OTSF, respectively. However, in reality only about half of patients received debridement within 6 h on average. The most common reason for delayed debridement was patients' transport delay. 87.88 and 97.3% of participants preferred secondary internal fixation following external fixation for GA I/II and GA IIIA OTSF, respectively. Additionally, over half of participants preferred use of locking plate for treating GA I-IIIA OTSF. The most common reasons for choosing delayed internal fixation for GA I-IIIA OTSF were infection risk and damage control. 78.79 and 65.91% supported immediate internal fixation after removing the external fixation for GA I-IIIA OTSF, respectively. Regarding wound closure, 86.36 and 63.64% of participants reported primary closure for GA I/II and GA IIIA OTSF, respectively. Over three fourths of participants agreed that preoperative and postoperative multiple wound cultures should be performed to predict infection for GA I-IIIA OTSF. Conclusion: The study first presents the current preference and practice regarding management of GA I-IIIA OTSF in Zhejiang. Majority of surgeons in our study preferred secondary internal fixation following external fixation for GA I-IIIA OTSF and over half of surgeons preferred use of locking plate for treating GA I-IIIA OTSF. This study may provide a reference for trauma orthopedic surgeons in the treatment of GA I-IIIA OTSF.

Intramedullary nailing in a tibial shaft fracture distal to a total knee prosthesis with compromised soft tissue condition.

Case: We present a case report on the management and outcome of a periprosthetic tibial shaft fracture treated with intramedullary nailing. The patient, a 78-year-old female, presented with a history of having undergone total knee arthroplasty ten years ago due to osteoarthritis. She sustained a periprosthetic fracture of the tibial shaft with compromised soft tissues surrounding the fracture site following a motor vehicle accident. Plain radiographs revealed a displaced tibial shaft fracture with a flipped large spiral wedge fragment located distal to the total knee prosthesis. Due to the poor soft tissue condition and the risk of complications in wound healing, as well as the desire to avoid prolonged bed rest and immobilization, intramedullary nailing was chosen as the primary treatment modality. Despite the challenging circumstances, the patient achieved satisfactory healing and recovered her pre-injury ambulation status with no significant complications at the six-month follow-up. Conclusion: Managing periprosthetic tibial shaft fractures in the presence of compromised soft tissues presents significant challenges for orthopedic surgeons. In this case, intramedullary nailing proved to be a suitable treatment option, minimizing soft tissue trauma and providing stable fixation to facilitate early mobilization and weight bearing.

Changes in femoral anteversion after intramedullary nailing for pediatric femoral shaft fracture: a multicenter study.

BACKGROUND: The rotational change after using a flexible intramedullary (IM) nail for femoral shaft fractures has been a concern for many surgeons. Recently, a statistical shape model (SSM) was developed for the three-dimensional reconstruction of the femur from two-dimensional plain radiographs. In this study, we measured postoperative femoral anteversion (FAV) in patients diagnosed with femoral shaft fractures who were treated with flexible IM nails and investigated age-related changes in FAV using the SSM. METHODS: This study used radiographic data collected from six regional tertiary centers specializing in pediatric trauma in South Korea. Patients diagnosed with femoral shaft fractures between September 2002 and June 2020 and patients aged < 18 years with at least two anteroposterior (AP) and lateral (LAT) femur plain radiographs obtained at least three months apart were included. A linear mixed model (LMM) was used for statistical analysis. RESULTS: Overall, 72 patients were included in the study. The average patient age was 7.6 years and the average follow-up duration was 6.8 years. The average FAV of immediate postoperative images was 27.5 ± 11.5°. Out of 72 patients, 52 patients (72.2%) showed immediate postoperative FAV greater than 20°. The average FAV in patients with initial FAV > 20° was 32.74°, and the LMM showed that FAV decreased by 2.5° (p = 0.0001) with each 1-year increase from the time of initial trauma. CONCLUSIONS: This study explored changes in FAV after femoral shaft fracture using a newly developed technology that allows 3D reconstruction from uncalibrated 2D images. There was a pattern of change on the rotation of the femur after initial fixation, with a 2.5° decrease of FAV per year.

Combining robotics and 3D printing facilitates closed reduction of humeral shaft fractures using a minimally invasive plate as a reduction template: A proof-of-concept study.

BACKGROUND: Minimally invasive percutaneous plate osteosynthesis for humeral shaft fractures (HSFs) has limitations due to malreduction and radiation exposure. To address these limitations, we integrated robotics and 3D printing by incorporating plates as reduction templates. METHOD: The innovative technology facilitated closed reduction of HSFs in the operating theatre using 18 models with cortical marking holes. The dataset of the precontoured plate was imported into 3D planning software for virtual fixation and screw path planning. The models were divided into half to simulate transverse fractures. During the operation, the software generated drilling trajectories for robot navigation, and precise plate installation achieved automatic fracture reduction. RESULTS: The evaluation results of reduction accuracy revealed variations in length, apposition, alignment, and rotation that meet the criteria for anatomic reduction. High interoperator reliabilities were observed for all parameters. CONCLUSIONS: The proposed technology achieved anatomic reduction in simulated bones.

Displaced humeral shaft fractures: Assessment of fracture union and complications following dual plate fixation using an anterior approach.

The humeral bone is subject to torsional forces. In case of displaced shaft fractures, internal fixation remains the standard of care. This retrospective two-center study assessed the fracture union rate and complications after dual 3.5 mm locking compression plate (LCP) fixation using an anterolateral approach. Over a 9-year period, 38 patients underwent surgery in two centers. They had a mean age of 53.7 years (15-97, ± standard deviation (SD) 26) and there were three open fracture cases (7.9 %). The dominant side was affected in 21 cases (55.3 %) and there were 11 polytrauma patients (29 %). Mean operative time was 78 min (40-124, ± 19.8 SD). Patients were treated with dual 3.5 mm LCP fixation (6 screws on either side of the fracture line, anterolateral approach without a tourniquet). The first two orthogonal views showing at least 3 cortical bridges out of 4 determined fracture healing, as assessed by two independent raters. Pre- and postoperative complications were tabulated. Clinical outcomes included range of motion (ROM) and return to activities, while functional outcomes were assessed with the Disability of the Arm Shoulder and Hand (DASH), the Constant score, the Subjective Shoulder Score (SSV) and the Mayo Elbow Performance Score (MEPS). Minimum follow-up was 1 year. Four patients were given a shoulder immobilizer to wear for 3 weeks; immediate mobilization was the standard of care for the other patients. Fracture union was achieved in all cases within a mean of 11.7 weeks (6-28 ± 7.1 SD) without any heterotopic ossification of the brachialis muscle. There were eight patients with preoperative radial nerve palsy and two cases of postoperative palsy. There was one surgical site infection (2.6 %). Return to work for active patients was possible in 87 % of cases within a mean of 23 weeks (6-72 ± 11 SD). The Constant score was 84.6 (35-100, ± 13.4 SD), the SSV score was 80.7 (60-100, ± 8.2 SD), the DASH score was 13.5 (0-38.3, ± 8.8 SD) and the MEPS score was 85 (55-100, ± 11.9 SD). Traditional fixation methods provide little control over torsional forces, leading to non-union rates between 3 % and 12 % and delayed union (12 to 20 weeks). The simplicity of the technique described here, and the short operative time, may help explain the low infection rate. Dual plate fixation makes it possible to use more screws and allows nerve exploration and decompression in case of preoperative nerve palsy. Dual plate fixation to treat humeral shaft fractures is a simple and reliable technique.

The Impact of Race/Ethnicity on Disparities in Utilization and Outcomes of Neuraxial Anesthesia for Hip and Femoral Shaft Fractures.

Background/Objectives: The use of neuraxial anesthesia versus general anesthesia for hip fracture surgery remains an active area of research, with recent studies demonstrating mixed findings supporting neuraxial over general anesthesia. The benefits of neuraxial anesthesia have been documented in associated surgeries, including total joint arthroplasty. However, racial disparities in the administration of neuraxial anesthesia have been identified in numerous procedures. We aimed to examine the association of race/ethnicity with neuraxial anesthesia use and the effect of neuraxial anesthesia on length of stay, non-home discharge, 30-day severe adverse events, and rates of readmission among patients undergoing isolated hip and femoral shaft fracture operations. Methods: The American College of Surgeons National Quality Improvement Program database was queried for isolated hip or femoral shaft fractures from 2015 to 2019. Stepwise logistic regression was performed to assess the relationship between race/ethnicity and neuraxial anesthesia use. Within each sex-race stratum, neuraxial anesthesia recipients were propensity-matched to general anesthesia recipients in a 1:2 ratio. Logistic regression and negative binomial regression were performed on the propensity-matched cohort. Results: A total of 12,004 neuraxial and 64,250 general anesthesia hip and femoral shaft fracture patients were identified. Compared to White patients, Black and Hispanic patients were between 0.64 and 0.61 times less likely to receive neuraxial anesthesia over general anesthesia, respectively (p < 0.05). 11,993 patients who received neuraxial anesthesia were propensity matched to 23,946 patients who received general anesthesia. Propensity-matched logistic regressions found that neuraxial anesthesia was associated with decreased length of stay, 30-day severe adverse events, and acute rehab/skilled nursing facility discharge for White patients (p < 0.05 for all), but only decreased length of stay in Black and Hispanic patients (p = 0.01 and p = 0.02, respectively). Conclusions: Notable disparities exist in the administration of neuraxial anesthesia for isolated hip and femoral shaft fracture patients. Hispanic and Black race/ethnicity in particular influences provision of neuraxial anesthesia. Further research is required to understand the degree of effect modification and root causes of regional anesthesia access and benefits for this high-volume patient population.

Flexor Pollicis Longus Weakness Post-proximal Radius Shaft Open Reduction and Internal Fixation: A Case Report.

We report the case of a patient who sustained a right proximal radial shaft fracture. He experienced isolated flexor pollicis longus weakness as a result of a partial anterior interosseous nerve (AIN) injury. The incidence of AIN injury is recognized as an exceptional postoperative complication for this particular type of fracture. It might be helpful to do electrodiagnostic investigations to confirm the diagnosis. A complete clinical recovery of the nerve occurred 16 weeks following the surgical operation.

Trends in reported outcomes and patient reported outcome measures (PROMs) in humeral shaft fracture literature: a systematic review.

PURPOSE: With a lack of standardization among outcome measures in fracture literature, cross-study comparisons remain limited. This systematic review aimed to identify trends in outcome measures reported by studies of the treatment of humeral shaft fractures. METHODS: A systematic review was performed of studies reporting clinical outcomes of humeral shaft fractures indexed in PubMed. Extracted data included demographics, fracture characteristics, treatment modalities, outcomes, patient reported outcome measures (PROMs), and journal characteristics. Cochran-Armitage tests and linear regressions were used to identify data trends. Pearson chi-square and Kruskal-Wallis tests were used for comparisons between studies. RESULTS: This review included 197 studies with outcomes of 15,445 humeral shaft fractures. 126 studies reported PROMs and 37 different PROMs were used. The Constant Score was most commonly reported (34% of studies), followed by ASES Score (21%), MEPS (21%), and DASH Score (20%). There was a significant increase in PROM usage over time (p = 0.016) and in articles using three or more PROMs (p = 0.005). The number of PROMs were significantly greater in prospective cohort studies and RCTs (p = 0.012) compared to retrospective cohort studies and case series (p = 0.044 for both). Post-treatment shoulder motion was reported in 43% of studies and 34% reported elbow motion. 86% of studies reported complications as an outcome parameter. Time to union and nonunion rate were published in 69% and 88% of studies, respectively. CONCLUSION: This study identified increasing PROM usage over time and disparities in the reporting of outcomes in humeral shaft fracture literature requiring further validation and standardization of available outcome measures.

Risk factors of poor mid-term shoulder functional outcomes of osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures: a retrospective study with a minimum 5-year follow-up.

BACKGROUND: Osteosynthesis using antegrade intramedullary nailing for humeral shaft fractures yields satisfactory bone union rates; however, it may adversely affect postoperative shoulder function. To date, factors affecting mid- or long-term shoulder functional outcomes following intramedullary nail fixation have not been clarified. In this study, we aimed to identify the risk factors for poor mid-term functional outcomes over 5 years postoperatively following antegrade intramedullary nail osteosynthesis for humeral shaft fractures. METHODS: We retrospectively identified 33 patients who underwent surgery using an antegrade intramedullary nail for acute traumatic humeral shaft fractures and were followed up for at least 5 years postoperatively. We divided the patients into clinical failure and no clinical failure groups using an age- and sex-adjusted Constant score of 55 at the final follow-up as the cutoff value. We compared preoperative, perioperative, and postoperative factors between the two groups. RESULTS: Five of the 33 patients had poor shoulder functional outcomes (adjusted Constant score < 55) at a mean follow-up of 7.5 years postoperatively. Proximal protrusion of the nail at the time of bone union (P = 0.004) and older age (P = 0.009) were significantly associated with clinical failure in the univariate analyses. Multivariate analysis showed that proximal protrusion of the nail (P = 0.031) was a risk factor for poor outcomes. CONCLUSIONS: The findings of this study provide new information on predictive factors affecting mid-term outcomes following osteosynthesis using antegrade nails. Our results demonstrated that proximal protrusion of the nail was significantly associated with poor mid-term functional shoulder outcomes. Therefore, particularly in older adults, it is essential to place the proximal end of the intramedullary nail below the level of the articular cartilage.

Percutaneous Coronary Intervention (PCI)-Related Coronary Artery Perforation Permanently Sealed by a Severed Inflated Balloon After Shaft Fracture: A Case Report.

Percutaneous coronary intervention (PCI) is an essential modality for the treatment of coronary artery disease. However, rare complications, such as coronary artery perforation and equipment failure, pose significant challenges. This case report describes a unique case of PCI-related coronary artery perforation and a cascade of subsequent complications managed successfully by an unconventional approach. We present a case of an 86-year-old patient who underwent coronary angiography for unstable angina and was treated with implantation of two drug-eluting stents into his right coronary artery (RCA). Implantation of the second stent caused an Ellis grade III perforation. The attempt to seal the perforation with two covered stents failed, the leak persisted, and a balloon had to be reinflated in proximal RCA. However, the patient descending into obstructive shock abruptly flexed his upper extremities breaking off the inflated balloon in proximal RCA, effectively sealing the perforation. Successful pericardiocentesis with drainage of 250 ml of blood stabilized the patient's condition and he regained consciousness. Despite moderate-intensity chest pain and extensive consultation with members of the heart team, the patient refused cardiac surgery opting for a conservative approach. The patient was discharged on post-PCI day 7, eventually resumed a physically active lifestyle, and returned for frequent follow-up visits. This case highlights the challenges in managing rare PCI complications like coronary artery perforation and balloon shaft fracture. It emphasizes the importance of rapid recognition, discusses individual techniques for the management of these complications, and focuses on the value of shared decision-making.