Trends and Changes in Treating Proximal Humeral Fractures in Italy: Is Arthroplasty an Increasingly Preferred Option? A Nation-Wide, Population-Based Study over a Period of 22 Years.

Background: Proximal humeral fractures (PHFs) are common, especially in the elderly, and account for 4% to 10% of all fractures, with women more often affected than men. Treatments include conservative methods, internal fixation and arthroplasty, with surgical approaches increasingly being used due to technological advancements. This study analyzes the evolution of PHF treatments in Italy from 2001 to 2022, using data from the Italian Hospital Discharge Records (HDRs) Database, and includes a stratified analysis by age and sex. Methods: Using HDR data from 2001 to 2022, records with ICD9-CM codes for proximal humeral fractures (812.0 and 812.1) among diagnoses were selected and categorized into three treatment groups: arthroplasty, fixation and conservative. Time series were analyzed with stratification by sex and age. Results: The extracted data included 486,368 records of PHFs, with 223,742 cases treated surgically (arthroplasty or internal fixation) and 262,626 treated conservatively; the average patient age was 66.6 years, with a higher proportion of women, especially among arthroplasty patients. Over time, the use of fixation and arthroplasty increased from 20% of treatments in 2001 to over 60% in 2022, with fixation becoming the most common treatment method by 2014 and arthroplasty significantly increasing among women, particularly in the 65-74 and 75-84 age groups. Conclusions: The study shows that in Italy, over the past two decades, treatment for PHFs has shifted from conservative methods to a preference for internal fixation and increasingly for arthroplasty, particularly among women and patients aged 65-84, reflecting evolving trends and technological improvements.

Iatrogenic Brachial Artery Injury During Long Proximal Humeral Interlocking System (PHILOS) Plating.

Iatrogenic vascular injuries are rare but potentially serious complications that can occur during orthopedic procedures involving the proximal humerus. We present a case report of a patient who sustained a brachial artery injury during a long Proximal Humeral Interlocking System (PHILOS) plating procedure for a proximal humeral fracture. A 62-year-old female patient with a left humerus proximal 1/3 shaft fracture underwent open reduction and internal fixation with a long PHILOS plate. During the procedure, difficulty was encountered in achieving adequate plate positioning due to osteoporotic bone and fracture comminution. Upon insertion of a distal second last screw, brisk brachial artery bleeding was encountered. Immediate hemostasis measures were taken, and a plastic surgeon was consulted. The brachial artery injury was identified and repaired with a cephalic vein graft harvested and flushed. Postoperatively, the patient developed median nerve neuropraxia. This case highlights the risk of iatrogenic brachial artery injury during left humerus proximal 1/3 shaft fracture fixation, especially in cases with technical challenges due to osteoporotic bone or comminution. Prompt recognition, involvement of vascular surgery, and appropriate management are crucial in mitigating potential devastating consequences. Associated neurological complications, such as nerve injuries, can also occur and should be monitored. Meticulous surgical technique, anatomical awareness, and vigilant monitoring are essential to minimize the risk of vascular and neurological complications during these procedures. Iatrogenic brachial artery injury is a rare but potentially serious complication of humerus proximal 1/3 shaft fracture. Early recognition, multidisciplinary involvement, and appropriate management strategies are crucial in optimizing patient outcomes and preventing long-term morbidity.

Mini-fragment Plate Fixation after Olecranon Osteotomy for Distal Humerus Fractures.

PURPOSE: While olecranon osteotomies are helpful for distal humerus visualization, traditional methods of fixation are commonly irritating for patients and require hardware removal. Recent studies have shown lower hardware removal rates for medullary screw constructs and 3.5-mm plates, but no studies have investigated the use of 2.7-mm plates for olecranon osteotomy fixation. The purpose of this study is to report on the outcomes of single 2.7-mm mini-fragment plate fixation of olecranon osteotomies for distal humerus intra-articular fractures. METHODS: Patients who sustained an intra-articular distal humerus fracture, as identified by CPT codes, were reviewed retrospectively over a 5-year study period (2016-2020) at a single Level I trauma center after IRB approval. Only patients who underwent an olecranon osteotomy for distal humerus visualization during their definitive operation and that was subsequently fixed with a single 2.7-mm plate were included. Primary outcomes were implant removal and osteotomy union. Secondary outcomes included indications for implant removal, implant failure, infection, and revision surgery. Hardware removal rates were compared to historically reported rates in the literature. χ2 versus Fisher's exact tests were used to compare fixation groups based on number of patients in each cohort (5 or less was used for the cut-off for Fisher's exact test). RESULTS: 38 patients were included in the final analysis. The average age was 50 years (standard deviation [SD] 18), 58% (22 patients) were female, and there was an average follow-up time of 9.7 months (SD 5). All patients with mini-fragment plate fixation went on to union of their olecranon osteotomy. Three (7.8%) patients had their olecranon hardware removed for all causes: one for revision open reduction and internal fixation (ORIF), one for irritation, and one removal during concomitant capsulectomy and manipulation. There was a 21% (8 patients) revision surgery rate in the cohort but only 3 of those were for issues related to the olecranon osteotomy. One patient required revision ORIF of the olecranon osteotomy for hardware loosening. Compared to other fixation constructs, mini-fragment plates had a lower removal rate than tension band wiring (P = 0.0002) and 3.5-mm plates (P = 0.05) and similar among medullary screws ± wires. Nonunion rates were similar between all constructs (P = 0.07). CONCLUSION: Single 2.7-mm mini-fragment plate fixation of olecranon osteotomies for distal humerus fractures is safe and effective with low rates of revision, hardware removal, and nonunion. This type of fixation should be considered when treating intra-articular distal humerus fractures that require an olecranon osteotomy.

Impact of augmentation strategy variations on the mechanical characteristics of patients with osteoporotic proximal humerus fractures with medial column instability.

Introduction: Low bone density and lack of medial support are the two most important factors affecting the stability of locking plate fixation for osteoporotic proximal humeral fractures (PHFs). This study aimed to compare the biomechanical characteristics of PHILOS locking plates combined with calcar screws, bone cement, fibular allografts, and medial locking plate support strategies for treating osteoporotic PHFs with medial column instability. Methods: A three-part osteoporotic PHF (AO 11-B3.2) model with metaphyseal loss was generated using 40 synthetic humeri and fixed via four distinct medial support strategies. All models were mechanically tested to quantify the mechanical characteristics. Subsequently, finite element models were created for each biomechanical test case. The stress distribution and displacement of the four different fixation structures were analyzed using finite element analysis. Results: The results demonstrated that the PHILOS locking plate combined with the medial locking plate, exhibited the greatest stability when subjected to axial, shear, and torsional loading. Furthermore, the PHILOS locking plate combined with bone cement showed structural stability similar to that of the PHILOS locking plate combined with fibular allograft but with lower stress levels on the fracture surface. Discussion: In conclusion, the PLP-MLP fixation structure showed superior biomechanical properties under axial, shear, and torsional loading compared to other medial support methods. Repairing the medial support when treating osteoporotic PHFs with medial column instability can enhance the mechanical stability of the fracture end in both the short and long term.

Study on morphometry of distal humerus and its clinical correlations.

Morphometric analysis of bones gives essential information for reconstructive surgeries and prosthetics. It is also useful in forensic medicine to identify and estimate age, sex and height from skeletal remains. We have measured and analyzed the following parameters in 100 distal humerii: the maximal length of the humerus, transverse distance between medial epicondyle and lateral epicondyle, horizontal diameter of trochlea, antero-posterior diameter of trochlea, and horizontal distance from medial epicondyle to capitulum. Distal humeral fractures are often challenging and difficult to treat which requires knowledge of distal humeral anatomy. Data from this study and the comparisons made will help in this.

Radiographic Evaluation of the Surgical Treatment of Pediatric Supracondylar Humeral Fractures.

Objective To perform a radiographic assessment of the quality of supracondylar fracture fixation by identifying the factors that have contributed to inadequate reduction and increased the chance of reduction loss during outpatient follow-up. The variables analyzed were as follows: fracture line, initial displacement, time of day the surgery was performed, and chosen fixation technique. Methods Review of electronic medical records and radiographic evaluation of supracondylar fractures operated from January 2017 to December 2022. The radiograph assessment was based on the Baumann angle and the anterior humeral line. Determination of fixation quality was based on the number of cortices, crossing site, and wire divergence. Results We evaluated 194 cases, and postoperative reduction was poor in 17% of the subjects. Reduction loss occurred in 39 cases (20.10%), and 19 (48.7%) of these patients presented insufficient fixation ( p = 0.002). Among the cases operated during the day, 12.5% lost the reduction compared with 32% of the patients who underwent surgery at night and early in the morning ( p = 0.001). Conclusion Reduction quality and postoperative fixation loss were closely related to technical errors and the time of day the surgery was performed.

Man on the Mound: Pictures of a Pitcher in Pain.

Description Atraumatic ball thrower's humerus fracture is an uncommon, and poorly understood injury pattern. The majority of these cases are seen in untrained and younger individuals. A missed diagnosis could severely impact a patient's quality of life, as management is operative in most cases. Here, we present the case of a young patient, suffering an atraumatic "ball thrower's" fracture. We present images of this exceedingly rare injury pattern and showcase original artwork with a proposed mechanism of injury.

Ultrasound evaluation of radial nerve injuries by cortex overlapping screw tips after internal fixation of humeral fractures: a cadaveric study.

PURPOSE: The radial nerve may be painfully irritated or damaged by open reduction and internal fixation (ORIF) of humeral fractures. Secondary radial nerve lesions after ORIF of humeral shaft fractures are described in up to 16%. Not only peripheral nerves but also orthopaedic instruments and osteosynthesis material are well visible by ultrasound. The aim of this study was to evaluate the accuracy of ultrasound in assessing the relation between the bone overlapping screw tips and the radial nerve close to the humeral bone. METHODS: Ultrasound-guided drilling was used to place screws as close as possible to the radial nerve in 8 humeral bones of four cadavers. The relation between the radial nerve and the screw tips was assessed by high-resolution ultrasound, and the overlap of all screw tips over the bone was measured by ultrasound and fluoroscopy. Thereafter, the findings were validated by anatomical dissection. RESULTS: We could correctly identify all screw tips and their relation to the radial nerve by ultrasound. In 7 of 8 cases, the screw tip had direct contact with the radial nerve. The overlaying length of the screw tip was accurately measured by using ultrasound in all cases. In contrast fluoroscopy underestimated this length in 50% of cases. CONCLUSION: With this study, we show that ultrasound can reliable visualize the screw tips and its relation to the radial nerve. Ultrasound is a promising diagnostic tool to evaluate patients with radial nerve irritations or lesions after ORIF of humeral fractures. Furthermore, ultrasound could be an adequate tool to guide drilling.

SUPRACONDYLAR FRACTURES IN CHILDREN: A SYSTEMATIC REVIEW OF TREATMENT OPTIONS.

OBJECTIVE: To compare the outcomes of surgical stabilization of pediatric supracondylar humeral fractures with the use of crossed Kirschner wires versus divergent lateral pinning wires. METHODS: This is a systematic review with meta-analysis carried out by searching the MEDLINE/PubMed, Science Direct and Scielo databases. In these, the search for journals was carried out between January and August 2023, where 695 studies were found. To assess the quality of the studies, the Jadad and the MINORS scales were used.. The selection and reading of relevant articles were carried out by the researchers and 11 studies met the selection criteria. RESULTS: From the 11 selected studies, 963 patients who met the criteria for the surgical treatment of these fractures were grouped. After the statistical analysis, we found that the ulnar nerve injury had a higher incidence when the crossed-K wire technique was used; and the lateral fixation is safer for the ulnar nerve. CONCLUSION: Both fixation techniques determine good functional results. However, fixation with lateral Kirschner wires proves to be safer considering the risk of iatrogenic injury to the ulnar nerve. Crossed-K wire fixation is more effective in terms of stability and maintenance of fracture reduction. Level of Evidence II, Systematic Review of Level II or Level I Studies with discrepant results.

Objetivo: Comparar os desfechos da estabilização cirúrgica das fraturas supracondilianas do úmero pediátricas com o uso de fios de Kirschner cruzados versus fios laterais divergentes. Métodos: Trata-se de uma Revisão Sistemática com metanálise realizada pela pesquisa nas bases de dados MEDLINE/PubMed, Science Direct e Scielo. Nessas, a busca dos periódicos foi realizada entre janeiro e agosto de 2023, e foram encontrados 695 estudos. Para a avaliação da sua qualidade, foram utilizadas a escala de Jadad e a escala MINORS. A seleção e a leitura dos artigos pertinentes foram realizadas pelos pesquisadores e 11 estudos preencheram os critérios de escolha. Resultados: Dos estudos selecionados, agrupamos 963 pacientes que preenchiam os critérios para o tratamento cirúrgico das fraturas. Após a análise estatística, observamos que maior incidência de lesão do nervo ulnar quando foi utilizada a técnica de pinagem cruzada; e a fixação lateral demonstrou ser mais segura para tal. Conclusão: Ambas as técnicas de fixação determinam bons resultados funcionais. Entretanto, a fixação com fios de Kirschner laterais demonstra ser mais segura, considerando o risco de lesão iatrogênica do nervo ulnar. A fixação com fios cruzados é mais eficaz, levando em conta a estabilidade e a manutenção da redução das fraturas. Nível de evidência II, Revisão sistemática de Estudos de Nível II ou Nível I com resultados discrepantes.

Construction and validation of a nomogram for blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures in the elderly: a cross-sectional study.

PURPOSE: Few studies have focused on the risk factors leading to postoperative blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures (PHFs) in the elderly. Therefore, we designed this study to explore potential risk factors of blood transfusion after ORIF for PHFs. We have also established a nomogram model to integrate and quantify our research results and give feedback. METHODS: In this study, we retrospectively analyzed the clinical data of elderly PHF patients undergoing ORIF from January 2020 to December 2021. We have established a multivariate regression model and nomograph. The prediction performance and consistency of the model were evaluated by the consistency coefficient and calibration curve, respectively. RESULTS: 162 patients met our inclusion criteria and were included in the final study. The following factors are related to the increased risk of transfusion after ORIF: time to surgery, fibrinogen levels, intraoperative blood loss, and surgical duration. CONCLUSIONS: Our patient-specific transfusion risk calculator uses a robust multivariable model to predict transfusion risk.The resulting nomogram can be used as a screening tool to identify patients with high transfusion risk and provide necessary interventions for these patients (such as preoperative red blood cell mobilization, intraoperative autologous blood transfusion, etc.).

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.

Deltoid tuberosity index for proximal humerus fracture: reliability and a predictor of systemic osteoporosis in an Asian population.

HYPOTHESIS AND BACKGROUND: Fragility fracture of the proximal humerus is a common occurrence. Current literature suggests that poor local bone density is a significant predictor of surgical fixation failure. The deltoid tuberosity index (DTI) is a simple radiographic tool that strongly correlates with local humeral bone mineral density (BMD), aiding surgical planning to consider adjuncts or arthroplasty. However, there is a lack of data in the reliability of assessment of DTI, as well as its correlation to systemic osteoporosis. Our study investigates the reliability of DTI as a predictor of systemic osteoporosis. METHODS: A retrospective cohort of patients with proximal humeral fracture (PHF) treated at a trauma center in Singapore from August 2017 to July 2018 were recruited. Four raters at different levels of varying clinical seniority measured DTI using shoulder radiographs. The dual-energy x-ray absorptiometry (DEXA) BMD scan of the hip and lumbar spine was used to diagnose osteoporosis. Area under the receiver operating characteristic curve analysis was calculated to study the diagnostic utility of DTI for predicting the risk of osteoporosis. RESULTS: Our study sample had 87 patients comprising 18 men and 69 women, mainly of Chinese ethnicity (84%), and with a mean age of 69.7 years (standard deviation 9.52, range 39-92). For assessment of DTI, there was good intrarater reliability among 4 raters (correlation coefficient range 0.805-0.843) and excellent interrater reliability between all raters (intraclass correlation coefficient 0.898, 95% confidence interval [CI] 0.784-0.950, P < .001). Based on the BMD, 55.2% (n = 48) had osteoporosis, with a T score <2.5. The highest correlation of DTI to BMD was with femoral neck density at 0.580. The DTI cutoff of 1.6 had the highest combined sensitivity and false positive rate, with areas under the curve of 0.682 (95% CI 0.564-0.799) for the overall population and 0.706 (95% CI 0.569-0.842) for patients aged <75 years. CONCLUSION: The DTI is a simple and reliable tool and has a strong applicability in clinical practice to enhance preoperative planning in the surgical fixation of PHF. DTI with a cutoff of 1.6 may help prompt clinicians to initiate workup and thus manage underlying osteoporosis.

Challenges and Outcomes in the Management of Periprosthetic Humeral Fractures: A Retrospective Study and Review of Current Approaches.

INTRODUCTION: Periprosthetic humeral fractures are a rare and increasing entity due to the rising number of shoulder arthroplasties. These fractures pose a significant challenge for surgeons, with incidence rates ranging from 1.2% to 19.4%. They can occur intraoperatively or as late complications, often influenced by trauma, prosthetic wear, or loosening. PATIENTS AND METHODS: A retrospective study was conducted on all patients admitted with periprosthetic humeral fractures over a four-year period (2018-2022). Inclusion criteria were postoperative periprosthetic humeral fractures with a minimum follow-up of six months. Exclusion criteria included intraoperative fractures, fractures of the glenoid or coracoid process, and cases with follow-up of less than six months or incomplete data. RESULTS: The study included six patients with an average age of 83.1 years, predominantly female (four females and two males). All fractures occurred postoperatively: four on reverse shoulder prostheses, one on an anatomical prosthesis, and one on a hemiarthroplasty. The mechanism was low-energy trauma, with fractures occurring an average of 96 months post-initial surgery. Fractures were classified using the Campbell system: three in region 4, two in region 3, and one in region 2. Radiographs showed four cemented and two uncemented stems. Three patients underwent surgical treatment with either prosthetic replacement using a long stem and fracture cerclage or locking compression plate (LCP). The remaining three patients were treated conservatively with a Sarmiento brace due to advanced age, bone fragility, low functional demand, and comorbidities. Radial nerve palsy was a complication in two patients post-trauma, with one recovering fully and the other not recovering before death due to associated complications. All fractures consolidated within an average of seven months (range: 5-8 months). Functional recovery was satisfactory with a median Constant-Murley Shoulder Score of 69 in surgically treated patients, with range of motion between 100 and 140 degrees. Only two conservatively treated patients achieved fracture consolidation, and functional recovery was inadequate. DISCUSSION: Managing periprosthetic humeral fractures remains challenging. Treatment goals include fracture healing, maintaining prosthetic stem stability, preserving glenohumeral motion, and restoring shoulder function. Despite various classification systems, the literature shows limited and variable data on incidence and treatment outcomes. Conservative treatment may be considered for stable implants and acceptable alignment, but surgical intervention is often necessary for displaced fractures or implant loosening. CONCLUSION: The management of periprosthetic humeral fractures requires a tailored, multidisciplinary approach to optimize outcomes and improve patient quality of life. With the increasing incidence of these fractures due to the growing use of shoulder arthroplasty, ongoing research and development of new techniques and therapeutic strategies are essential to address this clinical challenge effectively.

Reverse Shoulder Prosthesis for Proximal Humeral Fractures: Primary Treatment vs. Salvage Procedure.

Background: The optimal treatment for complex proximal humerus fractures (PHFs) lacks consensus, with reverse total shoulder arthroplasty (RTSA) often being a final resort rather than a primary approach. This study aimed to compare outcomes and satisfaction rates of primary RTSA for PHFs versus salvage RTSA for previously unsuccessful treatments. We hypothesized that primary RTSA would yield superior clinical outcomes, functional scores, and patient satisfaction. Methods: A retrospective analysis of RSA procedures between 2011 and 2021 was conducted, focusing on primary RTSA for PHFs or salvage RTSA for failed osteosynthesis. Patients meeting inclusion criteria underwent clinical and radiological follow-up for at least two years. Demographic characteristics, outcomes scores, and range of motion (ROM) were assessed. Results: Of 63 patients, 42 underwent primary RTSA and 21 underwent salvage RTSA. The median follow-up was 50 months. Statistically significant differences favored primary RTSA in forward flexion, abduction, internal rotation, and Constant shoulder score. Patient satisfaction levels did not significantly differ between groups. Complications occurred in 7.15% of primary RTSA cases and 14.28% of salvage RTSA cases. Conclusions: Primary RTSA may yield slightly better outcomes and lower complication rates compared to salvage RTSA. Further prospective studies are necessary to validate these findings.

Correlation between Peripheric Blood Markers and Surgical Invasiveness during Humeral Shaft Fracture Osteosynthesis in Young and Middle-Aged Patients.

The treatment for humeral shaft fractures (HSFs) is still controversial, consisting of a wide variety of orthopedic osteosynthesis materials that imply different grades of invasiveness. The aim of this study is to investigate the correlation between inflammatory blood-derived markers and the magnitude of the surgical procedure in young and middle-aged patients who sustained these fractures. Observational, retrospective research was conducted between January 2018 and December 2023. It followed patients diagnosed with recent HFSs (AO/OTA 12-A and B) and followed operative treatment. They were split in two groups, depending on the surgical protocol: group A, operated by closed reduction and internal fixation (CRIF) with intramedullary nails (IMNs), and group B, operated by open reduction and internal fixation (ORIF) with dynamic compression plates (DCPs). Statistically significant differences (p < 0.05) between the two groups could be observed in injury on the basis of surgery durations, surgical times, pre- and postoperative neutrophil-per-lymphocyte ratio (NLR), postoperative platelet-per-lymphocyte ratio (PLR), monocyte-per-lymphocyte ratio (MLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI) and aggregate inflammatory systemic index (AISI). The multivariate regression model proposed revealed that NLR > 7.99 (p = 0.007), AISI > 1668.58 (p = 0.008), and the surgical times (p < 0.0001) are strongly correlated to the magnitude of the surgical protocol followed. Using receiver operating characteristic (ROC) curve analysis, a balanced reliability was determined for both postoperative NLR > 7.99 (sensitivity 75.0% and specificity 75.6) and AISI > 1668.58 (sensitivity 70.6% and specificity 82.2%). Postoperative NLR and AISI as inflammatory markers are highly associated with the magnitude of surgical trauma sustained during humeral shaft fracture osteosynthesis in a younger population.

Anatomical study of the safety corridor for bridge plating positioned on the lateral border of the humerus.

PURPOSE: This study shows the danger zone and the safety corridor in the lateral approach with bridge plating by measuring the distance between the lateral side of the plate positioned on the lateral aspect of the humerus and the radial nerve after it pierces the lateral intermuscular septum, in the different forearm positions. METHODS: Forty arms of 20 human cadavers were used, the radial nerve was identified and marked on the lateral surface the radial nerve at the exit of the lateral intermuscular septum and anteriorisation of the nerve in relation to the humeral shaft and the lateral epicondyle was also marked. The distances were measured with a digital caliper. A submuscular extraperiosteal corridor was created, proximally between the biceps brachialis and deltoid muscle and distally between the triceps and brachioradialis muscle, followed by the positioning of the low contact large fragments contoured plate with 14 combined holes (fixed and cortical angle), inserted from distal to proximal. Measurements were performed in four positions (elbow flexion with forearm pronation, elbow flexion with forearm supination, elbow extension with forearm pronation and elbow extension with forearm supination). RESULTS: Significant statistical differences occurred with the different positions, and the elbow flexion with forearm supination was shown to be the position that provides the safest submuscular extraperiosteal corridor in a lateral approach of the humerus. CONCLUSION: The danger zone of radial nerve is an area that extends from 15 cm to 5 cm proximal to the lateral epicondyle and the safest way to create a submuscular and extraperiosteal corridor in the lateral region of the humerus is with the elbow in flexion and the forearm in supination.

Analysis of risk factors for failed closed reduction in pediatric Gartland Type III supracondylar humerus fracture.

BACKGROUND: Gartland Type III supracondylar humerus fractures (SCHFs) are commonly treated using closed reduction followed by percutaneous pin fixation. However, conversion to open reduction may be necessary if closed reduction fails. This study aimed to identify risk factors associated with failed closed reduction and provide a theoretical basis for clinical decision-making in the treatment of Gartland Type III fractures. METHODS: A retrospective analysis was conducted on children with Gartland Type III SCHF who underwent surgical treatment between April 2017 and June 2018. Based on whether or not the closed reduction was successful, patients were split into the open reduction group and the closed reduction group. Within the closed reduction group, subgroup analysis based on surgery duration was carried out. Data were collected from medical records and X-ray images. Univariate and multivariate regression analyses were utilized to evaluate the relationship between variables and failed closed reduction. RESULTS: The study included 36 patients in the open reduction group and 135 patients in the closed reduction group. Multivariate analysis revealed that the presence of angle (P = .024, OR = 3.199), rotation (P = .000, OR = 6.359), skin creases (P = .013, OR = 4.077), anterior-posterior displacement ratio (P = .011, OR = 4.337), fracture angle in the anteroposterior view (P = .014, OR = 0.939), and fracture distal displacement direction (P = .002, OR = 5.384) were independent risk factors for failed closed reduction. Subgroup analysis showed that fracture distal displacement direction (P = .013), skin folds (P = .013), lateral displacement ratio (P = .016), and anterior-posterior displacement value (P = .005) significantly influenced the duration of closed reduction surgery. CONCLUSION: The presence of sharp angle or rotation at the fracture ends, skin folds on the anterior elbow, minor anterior-posterior displacement of the fracture, higher medial inclination of the fracture plane, and distal fracture displacement toward the radial side are independent risk factors for failed closed reduction in pediatric Gartland Type III SCHF.

Reverse Shoulder Arthroplasty for Proximal Humeral Fractures: Is the Bigliani-Flatow Stem Suitable for Tuberosity Fixation and Healing?

Background/Objectives: The aim of the study was to investigate the clinical, functional, and radiographic results of patients affected by three- or four-part proximal humeral fractures treated with reverse total shoulder arthroplasty, to investigate whether a prosthetic stem nonspecifically designed for fractures (i.e., the Bigliani-Flatow stem) promotes tuberosities' healing, and to evaluate the impact of tuberosity fixation and healing on the outcomes. Methods: Patients' data such as gender, age, side and dominancy, comorbidities, complications during or after surgery, and time lapse between trauma and surgery were prospectively collected. The type of fixation of the stem, the thickness and type of liner, and whether the tuberosities were fixed or not were also recorded. The Constant score weighted on the contralateral limb, QuickDASH, Oxford Shoulder Score, and Subjective Shoulder Value were collected. Tuberosities' healing was assessed with X-rays (anteroposterior, Grashey, and axillary views). Results: Overall, 34 patients were included, with an average follow-up of 42 months. Tuberosities were reinserted in 24 cases and their healing rate was 83%. The mean values were the following: a Constant score of 64, Oxford Shoulder Score of 39, Subjective Shoulder Value of 71, and QuickDASH score of 27. There were no significant differences in the scores or range of motion between patients with tuberosities healed, reabsorbed, or not reattached. There was a better external rotation in the group with healed tuberosities and a longer duration of surgery to reattach tuberosities. Conclusions: The treatment of proximal humerus fractures with the Bigliani-Flatow stem is associated with good clinical and functional results. The healing rate of the tuberosities was high and comparable, if not even better, than the mean rates reported for the stems dedicated to fractures of the proximal humerus and was, therefore, also appropriate for this indication.

Procrustes analysis of a shape of pediatric supracondylar humerus fractures.

Shape of supracondylar fracture of the humeral of pediatric patients is analysed with Procrustes method. XR-images of fractures are considered both in anterio-posterior (AP) view and in a lateral (L) view. Applying Procrustes method for both views mean images are constructed and compared. Variability of shapes is quantified with a shape principal component analysis. Possibility of predictions of typical shape of humeral fracture and its variability using statistical shape analysis offers additional information on injury characteristics important in preoperative planning. Non-parametric tests (permutational and bootstrap) do not indicate statistical difference between Procrustes mean shapes in anterio-posterior and lateral projections. It is shown, however, that AP and L shapes of humeral fractures differ in their variability quantified by shape principal components.

Anterolateral Dual Plate Fixation for Distal Metaphyseal-Diaphyseal Junction Fractures of the Humerus: Biomechanical Finite Element Analysis with Clinical Results.

Background: Distal metaphyseal-diaphyseal junction fractures of the humerus are a subset of injuries between humeral shaft fractures and distal intra-articular humerus fractures. A lack of space for distal fixation and the unique anatomy of concave curvature create difficulties during operative treatment. The closely lying radial nerve is another major concern. The aim of this study was to determine whether anterolateral dual plate fixation could be effective for a distal junctional fracture of the humerus both biomechanically and clinically. Methods: A right humerus 3-dimensional (3D) model was obtained based on plain radiographs and computed tomography data of patients. Two fractures, a spiral type and a spiral wedge type, were constructed. Three-dimensional models of locking compression plates and screws were constructed using materials provided by the manufacturer. The experiment was conducted by using COMSOL Multiphysics, a finite element analysis, solver, and simulation software package. For the clinical study, from July 2008 to March 2021, a total of 72 patients were included. Their medical records were retrospectively reviewed to obtain patient demographics, elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, Mayo Elbow Performance Scores (MEPS), and hand grip strength. Results: No fracture fixation construct completely restored stiffness comparable to the intact model in torsion or compression. Combinations of the 7-hole and 5-hole plates and the 8-hole and 6-hole plates showed superior structural stiffness and stress than those with single lateral plates. At least 3 screws (6 cortices) should be inserted into the lateral plate to reduce the load effectively. For the anterior plate, it was sufficient to purchase only the near cortex. Regarding clinical results of the surgery, the range of motion showed satisfactory results in elbow flexion, elbow extension, and forearm rotation. The average DASH score was 4.3 and the average MEPS was 88.2. Conclusions: Anterolateral dual plate fixation was biomechanically superior to the single-plate method in the finite element analysis of a distal junctional fracture of the humerus model. Anterolateral dual plate fixation was also clinically effective in a large cohort of patients with distal junctional fractures of the humerus.