Hemiarthroplasty versus angle-stable locking compression plate osteosynthesis in the treatment of three- and four-part fractures of the proximal humerus in the elderly: design of a randomized controlled trial.

BACKGROUND: The optimal surgical management of dislocated three- and four-part fractures of the proximal humerus in elderly patients remains unclear. Most used techniques are hemiarthroplasty and angle-stable locking compression plate osteosynthesis. In the current literature there is no evidence available presenting superior results between hemiarthroplasty and angle-stable locking compression plate osteosynthesis in terms of speed of recovery, pain, patient satisfaction, functional outcome, quality of life or complications. METHODS/DESIGN: A randomized controlled multicenter trial will be conducted. Patients older than 60 years of age with a dislocated three- or four-part fracture of the proximal humerus as diagnosed by X-rays and CT-scans will be included. Exclusion criteria are a fracture older than 14 days, multiple comorbidity, multitrauma, a pathological fracture, previous surgery on the injured shoulder, severely deranged function caused by a previous disease, "head-split" proximal humerus fracture and unwillingness or inability to follow instructions. Participants will be randomized between surgical treatment with hemiarthroplasty and angle-stable locking compression plate osteosynthesis. Measurements will take place preoperatively and 3 months, 6 months, 9 months, 12 months and 24 months postoperatively. Primary outcome measure is speed of recovery of functional capacity of the affected upper limb using the Disabilities of Arm, Shoulder and Hand score (DASH). Secondary outcome measures are pain, patient satisfaction, shoulder function, quality of life, radiological evaluation and complications. Data will be analyzed on an intention-to-treat basis, using univariate and multivariate analyses. DISCUSSION: Both hemiarthroplasty and angle-stable locking compression plate osteosynthesis are used in the current treatment of dislocated three-and four-part fractures of the proximal humerus. There is a lack of level-1 studies comparing these two most-used surgical treatment options. This randomized controlled multicenter trial has been designed to determine which surgical treatment option provides the fastest recovery of functional capacity of the affected upper limb, and will provide better outcomes in pain, satisfaction, shoulder function, quality of life, radiological evaluation and complications. TRIAL REGISTRATION NUMBER: The trial is registered in the Netherlands Trial Registry (NTR2461).

[Osteomyelitis of the talus in a limping child]. / Osteomyelitis van de talus bij een mank lopend kind.

BACKGROUND: Haematogenous osteomyelitis of the talus is a rare cause of limping in children. Due to the slow onset and atypical pattern of symptoms, it is difficult to diagnose. This can result in delays in the provision of adequate treatment. CASE DESCRIPTION: A 3-year old girl was examined in the outpatient ward for pain in the right leg and limping. A diagnosis of coxitis fugax was suspected initially. Supplemental laboratory testing, conventional roentgenograms and bone scintigraphy however, showed a haematogenous osteomyelitis of the talus. The patient was treated with flucloxacillin. She was symptom-free four months after the first outpatient visit, with full recovery of function in her right ankle and foot. CONCLUSION: Haematogenous osteomyelitis of the talus is rare in children. The diagnosis is often missed because symptoms are often subtle in the early phase. It is important to choose imaging techniques carefully because treatment with antibiotics is sufficient when this type of osteomyelitis is detected at an early stage.