Fractura compleja del húmero asociada a parálisis radial / Complex Fracture of the Humerus Associated with Radial Paralysis

Las fracturas de la diáfisis humeral son lesiones que se producen con frecuencia como parte de caídas o de accidentes de alta energía y se asocian con parálisis del nervio radial. Se presenta paciente de 43 años de edad, masculino, que sufre accidente automovilístico que le produce fractura diafisaria del húmero derecho multifragmentaria, por lo cual se le realiza reducción cerrada y osteosíntesis con clavo intramedular acerrojado y tratamiento conservador para la parálisis radial. La evolución fue satisfactoria, el paciente se recuperó de la parálisis a los 4 meses y logró la consolidación completa a los 5 meses. Tras un año de evolución no presenta dolor en el hombro, y tiene movilidad completa del hombro, muñeca y dedos a la extensión(AU)

Diaphyseal fracture of humerus are frequent lesions, resulting from falls or high energy accidents; they are associated to radial nerve palsy. We report the case of a 43 years old male patient, who suffered a multifragment diaphyseal fracture of his right humerus, as a result of a car accident. He underwent a closed reduction and osteosynthesis using a locking intramedullary nail for the radial paralysis. His evolution was satisfactory; this patient recovered from the paralysis after four months and he managed full consolidation five months later. After a year, he did not have any pain in his shoulder, he has full mobility of his shoulder, wrist and fingers when extendind(AU)

Conversion from Spanning External Fixation to Open Reduction Internal Fixation Contributes to Healing of Soft Tissues and Fractures in Open Distal Humeral Fractures.

BACKGROUND Open distal humeral fractures (DHFs) often lead to loss of elbow function, thereby seriously affecting patient quality of life. The aim of this study was to evaluate the treatment outcomes of 2 surgical techniques to determine the better method for repairing open DHFs. Both groups were treated with immediate debridement first, and then group I had only internal fixation (IF), while group II underwent initial external fixation (EF) followed by IF surgery. MATERIAL AND METHODS This retrospective study included 32 patients who had open DHFs between 2013 and 2018. Twelve patients underwent thorough debridement and temporary EF treatment and converted to IF as the ultimate treatment. Twenty patients were treated with immediate open reduction and internal fixation (ORIF). Data of final treatment outcomes were analyzed at the latest follow-up. A comparative analysis of radiological results, function observations, and complications was performed for the 2 surgical groups. RESULTS All DHFs and osteotomized olecranon united after a mean of 5.2±1.21 months. No significant differences were observed in other preoperative demographic data between the 2 groups. Moreover, there was no significant difference in postoperative complications, elbow range of motion, or fracture healing time between the 2 groups. CONCLUSIONS The evidence provided by our study highlights the efficacy of definitive IF in treating open DHFs, which is recommended whenever possible. Furthermore, the combination of EF and ORIF, according to the type of soft tissue damage, may be a promising treatment option with a low revision rate for patients with open DHFs.

Prediction of Long Bone Fractures in Multiple Myeloma Patients in an Advanced Imaging World.

BACKGROUND: Multiple myeloma (MM) affects the long bones in 25% of patients. The advent of positron-emission tomography/computed tomography (PET/CT) scanners offers the possibility of both metabolic and radiographic information and may help determine fracture risk. To the best of our knowledge, no published study correlates these two factors with long bone fractures. OBJECTIVES: To evaluate the impact of PET/CT on fracture risk assessment in multiple myeloma patients. METHODS: We identified all bone marrow biopsy proven multiple myeloma patients from 1 January 2010 to 31 January 2015 at a single institution. We prospectively followed patients with long bone lesions using PET/CT scan images. RESULTS: We identified 119 patients (59 males/60 females) with 256 long bone lesions. Mean age at diagnosis was 58 years. The majority of lesions were in the femur (n=150, 59%) and humerus (n=84, 33%); 13 lesions in 10 patients (8%) required surgery for impending (n=4) or actual fracture (n=9). Higher median SUVmax was measured for those with cortical involvement (8.05, range 0-50.8) vs. no involvement (5.0, range 2.1-18.1). SUVmax was found to be a predictor of cortical involvement (odds ratio = 1.17, P = 0.026). No significant correlation was found between SUVmax and pain or fracture (P = 0.43). CONCLUSIONS: Improved medical treatment resulted improvement in 8% of patients with an actual or impending fracture. The orthopedic surgeons commonly use the Mirels classification for long bone fracture prediction. Adding PET/CT imaging to study in myeloma long bone lesions did not predict fracture risk directly but suggested it indirectly by cortical erosion.

The AMANDUS Project PART II-Advanced Microperfusion Assessed Non-Union Diagnostics with Contrast-Enhanced Ultrasound (CEUS): A Reliable Diagnostic Tool for the Management and Pre-operative Detection of Infected Upper-Limb Non-unions.

The management of upper-limb non-unions can be challenging, especially when infection is existent. Thus, pre-operative detection of infection plays a relevant role in non-union treatment. This study investigated in a large cohort the diagnostic potential of contrast-enhanced ultrasound (CEUS) as stand-alone method for differentiating between aseptic and infected upper-limb non-unions. Osseous perfusion of 50 upper-extremity non-unions (radius/ulna, n = 20; humerus, n = 22; clavicle, n = 8) was prospectively assessed with CEUS before revision surgery. The perfusion was quantified via time-intensity curves and peak enhancement (in arbitrary units). Significant perfusion differences between aseptic and infected non-unions could be detected (peak enhancement, p < 0.001). The sensitivity and specificity for the detection of infected upper-limb non-unions were 80% and 94.3% (cutoff peak enhancement: 130.8 arbitrary units). CEUS reliably differentiates between aseptic and infected upper-limb non-unions. Consequently, CEUS should be integrated into the daily diagnostic routine algorithm to plan non-union revision surgery more precisely as a single- or multi-step procedure.

The patient-specific implant created with 3D printing technology in treatment of a severe open distal humerus fracture with complete loss of the lateral column.

The open distal humeral fracture associated with the major loss of the articular surface and bony structure is a challenging problem for orthopedic surgeons. In this case report, we describe a case of complete missing lateral column of the distal humerus with severe articular destruction of capitellum and lateral trochlear ridge which was treated with the patient-specific implant created with three-dimensional printing technology. Apart from anatomic replacement of the articular surface, the lateral collateral ligament complex and extensor muscle which are the key soft tissue stabilizers of elbow were repaired by reattaching their bony origins to the impacted iliac crest bone graft inside the implant. Due to the favorable result at 2-year follow-up, this modality is a potentially viable surgical option in treating of the severe open distal humeral fracture associated with entire lateral condylar damage.

Pediatric Type II Supracondylar Humerus Fractures: Factors Associated With Successful Closed Reduction and Immobilization.

PURPOSE: The debate on the treatment of type IIa supracondylar humerus fractures has yet to be resolved. The purpose of this study was to assess the factors associated with successful closed reduction and immobilization and to assess the efficacy of a novel radiographic "hourglass" angle measurement in the management of type IIa supracondylar humerus fractures within the pediatric population. METHODS: An institutional review board-approved retrospective review of all children who underwent closed reduction and casting or splinting of an isolated type IIa supracondylar humerus fractures treated at 2 pediatric hospitals from January 1, 2009 to August 31, 2016. Analyzed radiographic parameters included Baumann angle (BA), humerocondylar angle (HCA), perpendicular distance (PD) from the anterior humeral line to the capitellum, and the hourglass angle (HGA). These parameters were measured on injury radiographs (XR), postreduction XR, and at the first and final follow-up XR. The success of closed reduction was defined as maintenance of an acceptable reduction without a secondary procedure. The interobserver reliability was calculated. RESULTS: There were 77 elbows treated with closed reduction and long-arm cast or splint immobilization. Of those closed reductions, 76.62% of elbows (59/77) maintained their reduction alignment and did not require surgical treatment for percutaneous pinning. In this series, the BA was not significantly different following closed reduction ([INCREMENT]1.04 degrees; P=0.081); however, the PD ([INCREMENT]1.89 mm), HGA ([INCREMENT]7.38 degrees), and HCA ([INCREMENT]5.07 degrees) had significant improvement following closed reduction (P<0.001 for all). The use of procedural sedation during reduction was strongly associated with success, 83.05% (49/59) with sedation compared with 55.56% (10/18) success without sedation (P=0.025). Furthermore, fractures that underwent a secondary procedure had 6.20 degrees less HGA following a closed reduction (P=0.016) and required additional follow-up visits (P=0.0037). The success of type IIa supracondylar humerus fractures did not significantly differ based on sex (P=0.5684), laterality (P=0.6975), mechanism of injury (P>0.9999), location of care-emergency department versus clinic (P=0.1160), or type of fracture immobilization (P=0.7411). The mean HGA in normal elbows was 177.8 degrees. The interobserver reliability for HCA was poor [intraclass correlation coefficient (ICC)=0.342]; fair for BA (ICC=0.458); and excellent for both PD and HGA (ICC=0.769 and 0.805, respectively) (P<0.001 for all). CONCLUSIONS: Improved and acceptable radiographic parameters were achieved by a closed reduction in the majority of minimally displaced type IIa fractures treated by closed reduction and immobilization in this series. HCA upon presentation was significantly greater in successful cases, and failure to improve and maintain HGA and PD following closed reduction was associated with loss of reduction. Procedural sedation during reduction was strongly associated with success. The HGA and PD were consistent parameters used to determine effective management of type IIa fractures. This study adds support for a nonoperative closed reduction under sedation with immobilization of selected type IIa supracondylar humerus fractures.

Fractura de húmero por estrés en lanzador de beisbol. Presentación de un caso / Humerus fracture by stress in baseball pitcher. Case presentation

RESUMEN Se presentó el caso de un adolescente que sufrió fractura por estrés del húmero izquierdo, mientras lanzaba en un partido de béisbol. Las fracturas de húmero por estrés son infrecuentes. Generalmente ocurre en los atletas que practican deportes de lanzamiento, es más frecuente en los lanzadores de béisbol amateurs de poca experiencia. Esta lesión es debida a la tracción muscular incoordinada y fuerza de torsión cuando la pelota es lanzada, asociada a la fatiga física. Puede ocurrir a nivel de los tercios medio y superior del húmero, entre las inserciones del deltoides y el pectoral mayor, así como en el tercio distal. Es común la presencia de dolor poco antes de producirse la fractura. Se enfatizó en la importancia de tener presente la posibilidad de presentación de este tipo de fractura en los atletas que practican deportes de lanzamientos, así como tener presente además las complicaciones que puedan presentarse a partir de este tipo de lesión. Se analizaron los datos recogidos en la historia clínica del paciente. Es importante pensar en este tipo de lesión, pues en ocasiones el cuadro clínico no es evidente. Se señaló además la necesidad de realizar un estricto seguimiento del paciente ante la posibilidad de lesión del nervio radial (AU).

ABSTRACT The authors present the case of a teenager who suffered left humerus fracture due to stress while he was pitching a baseball game. Humerus fractures caused by stress are infrequent. They commonly occur in athletes practicing throwing sports, being more frequent in amateur baseball pitchers with little experience. This lesion is due to uncoordinated muscular traction and torsion strength when the ball is thrown, all associated to physical fatigue. It can happen at the level of the medial and upper third of the humerus, between the insertions of deltoids and pectoral major muscles, and also in the distal third. The presence of pain is common a little before the fracture happens. The authors emphasize in the importance of taking into account the possibility of this kind of fracture occurring in athletes practicing throwing sports, and also the complications appearing after this kind of lesion. Data collected from the patient?s clinical record were analyzed. It is important to think in this kind of lesion because sometimes clinical characteristics are not evident. It was also pointed out the necessity of performing a strict follow-up of the patient given the possibility of radial nerve lesion (AU).

Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus.

BACKGROUND: We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach. METHODS: Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows. RESULTS: The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection. CONCLUSIONS: The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.

Capitellum fractures: Treatment with headless screws and outcomes.

OBJECTIVES: This study aims to present the results of 21 patients with capitellum fractures treated with open reduction and headless screws by a single experienced surgeon. PATIENTS AND METHODS: Twenty-one patients (13 males, 8 females; mean age 39 years; range, 18 to 63 years) who were admitted to our clinic between June 2011 and January 2018 with the diagnosis of capitellum fracture and followed-up for a mean period of 45 months (range, 12 to 90 months) were included in this retrospective study. The fractures were fixed with headless cannulated screws by a single surgeon. RESULTS: The mean range of motion was 102° (range, 65° to 140°) during flexion-extension and 165° (range, 130° to 180°) during supination-pronation. The mean preoperative visual analog scale (VAS) score was 8.5 (range, 6 to 10), whereas the mean postoperative VAS score was 2.2 (range, 0 to 6). According to the Mayo Elbow Performance score, nine patients were evaluated as excellent, six patients as good, four patients as fair, and two as poor. The mean Quick-Disabilities of the Arm, Shoulder and Hand score was 25.1 (range, 4 to 57). Avascular necrosis developed in three patients (14%) and heterotopic ossification was detected in one patient (4%). CONCLUSION: Capitellum fractures are difficult to diagnose and treat, and good results can only be achieved by an accurate diagnosis, careful surgical technique, and stable fixation. Larger and more comprehensive studies are required to establish a generalization and more accurate inferences on this limitedly studied subject.

Management of nonunion of humeral medial condyle fracture: A case series and review of the literature.

Pediatric humeral medial condyle fracture (HMCF) is a rare condition and is difficult to detect, especially in young children. The management of late presentation of HMCF is challenging and lacks consensus. Herein, we reported four cases of HMCF nonunion received open reduction and internal fixation (ORIF) or supracondyle osteotomy from our institution. In addition, 12 cases of ORIF and 4 cases of osteotomy reported in the previous studies were also reviewed. The HMCF nonunion can heal after ORIF, but the indication and the optimal techniques need to be clarified. Supracondylar osteotomy alone is an effective and safe treatment option to improve the functional and cosmetic outcomes of HMCF nonunion.

Mid-term Patient-reported Outcomes After Lateral Versus Crossed Pinning of Pediatric Supracondylar Humerus Fractures.

BACKGROUND: Closed reduction and percutaneous pinning in a crossed or lateral configuration is the standard treatment for supracondylar humerus (SCH) fractures. We compared mid-term patient-reported outcomes (PROs), radiographic outcomes, and complication rates between patients treated with crossed versus lateral pinning. METHODS: We reviewed 508 pediatric patients treated surgically for Gartland type-III SCH fractures from 2008 to 2017. We included patients aged 5 to 17 years at the time of telephone interviews, who had available radiographs. We excluded those unable to be reached by telephone; those who declined to be surveyed; and those lost to follow-up. Our sample comprised 142 participants (28%) (mean±SD age at surgery, 5.2±2.0 y), 93 (65%) of whom were treated with lateral pinning and 49 (35%) with crossed pinning. Participants' parents completed the Quick Disabilities of the Arm, Shoulder, and Hand and the Patient-Reported Outcomes Measurement Information System Parent Proxy at a mean 4.4 years (range: 2 to 10 y) postoperatively. Postoperative radiographs were reviewed to assess reduction. Bivariate analysis was performed to determine whether outcomes differed by pinning technique (α=0.05). RESULTS: The proportions of participants achieving complete reduction were not significantly different between pin configuration groups (P=0.71). At follow-up, the 2 groups did not differ significantly in any PRO scores (all, P>0.05). CONCLUSION: We found no differences between crossed and lateral pinning of Gartland type-III SCH fractures in terms of radiographic reduction, PROs, or complication rates at mid-term follow-up. LEVEL OF EVIDENCE: Level III.

Comparison of internal fixation vs. external fixation after corrective osteotomy in children with cubitus varus.

BACKGROUND: Cubitus varus deformity is a well-known late complication of supracondylar fractures in children. In this retrospective study, the primary objective was to compare clinical and radiologic outcomes of lateral closing-wedge osteotomy with either internal fixation or external fixation in pediatric patients with cubitus varus deformities. MATERIALS AND METHODS: From 2010 to 2017, 35 consecutive patients with cubitus varus deformities secondary to supracondylar fractures were included in this study. After corrective osteotomy was performed via a limited lateral approach, the method of definitive fixation was chosen between internal and external. Retrospectively, patients who underwent external fixation on the lateral aspect of the elbow were defined as group I (n = 16) whereas patients with unilateral single-plate fixation were defined as group II (n = 19). The functional outcome was evaluated using the Mayo Elbow Performance Score and Flynn criteria. RESULTS: No significant difference in age was found between the 2 groups (P = .15). Significantly lower costs, a shorter operation duration, smaller scars, and a shorter time for plaster cast use postoperatively were found in group I (P < .001). No nonunion or failure of fixation was found. No significant difference was noted in postoperative elbow range of motion or Mayo Elbow Performance Score (P = .64). Both groups achieved satisfactory functional and cosmetic results. CONCLUSIONS: In pediatric patients with cubitus varus, both methods of fixation after lateral closing-wedge corrective osteotomy are reliable, with a low rate of complications and satisfactory functional results. External fixation is more advantageous in terms of easier preoperative planning, shorter operative times, lower costs, and easier postoperative fixation removal.

Trends in fracture development of the upper extremity in Germany-a population-based description of the past 15 years.

BACKGROUND: Recent studies investigating fracture development in Germany are not available especially with regard to demographic change. The primary aim of this study was to report trends in fracture development of the upper extremity in Germany between 2002 and 2017 and to evaluate changes over time. METHODS: Evaluating inpatient data from the German National Hospital Discharge Registry (International Classification of Diseases, ICD-10) between 2002 and 2017. Total count, incidences and percentage changes of the following fracture localizations were analysed: proximal humerus, distal humerus, proximal ulna, proximal radius, ulna diaphysis (including Monteggia lesion) and distal radius. Ten age groups for men and women were formed: 35-44, 45-54, 55-64, 65-74; 75-84; 85-90, and > 90 (years). RESULTS: The total count of proximal humeral fractures increased from 40,839 (2002, men/women 9967/30,872) to 59,545 (2017, men/women 14,484/45,061). Distal humeral fractures increased from 5912 (2002, men/women 1559/4353) to 6493 (2017, men/women1840/4653). The total count of forearm fractures increased from 68,636 (2002, men/women 17,186/51,450) to 89,040 (2017, men/women 20,185/68,855). Women were affected in 70-75% of all cases with rising incidences among nearly every age group in female patients. CONCLUSION: Total count of nearly every evaluated fracture increased. Also, incidences increased especially in the older female age groups. Fracture development already seems to reflect demographic changes in Germany.

Healing the Index Humeral Shaft Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 125 Patients.

BACKGROUND: Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion. METHODS: We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. RESULTS: One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures. CONCLUSIONS: Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in the elderly.

PURPOSE: The aim of this paper was to present our experience and the outcomes in 3 elderly patients who underwent combined shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus in our center. Also, we evaluate difficulties in their treatment and report their final follow-up. MATERIAL AND METHODS: Three cases of elderly patients who underwent shoulder and elbow arthroplasty after ipsilateral fractures of the proximal and distal humerus were reviewed. Demographic, clinical, and radiological data were analyzed. Also, Constant Shoulder Score, Mayo Elbow Performance Score, Short-Form Health Survey, and four-point Likert scale were evaluated. RESULTS: All patients were females (100%). Mean age was 75 years (range 73-78). Mean follow-up was 36.6 months (SD 11.5). Mean time between injury and surgery was 12 days (SD 7.6). The 3 patients had a displaced and comminuted fracture of the humeral head (4-part, by Neer classification) and a comminuted intraarticular fracture of the distal humerus (13-C3, by AO classification). One patient presented a wound infection that required debridement. Despite the complications, at final follow-up, all patients showed a sufficient capacity to perform comfortably in their daily activities. Radiographs showed good fixation of all components, without evidence of prosthetic loosening or migration. All evaluated scores had good or excellent results. CONCLUSIONS: Our study provides further evidence that the shoulder and elbow arthroplasty could be a reliable management for ipsilateral fractures of the proximal and distal humerus in the elderly. In our study, this technique showed in the final follow-up patient's good outcomes.

The modified anterolateral approach to the humerus.

INTRODUCTION: The anterior and anterolateral approaches to the humerus describe splitting brachialis longitudinally, assuming its fibres run parallel to the shaft. Recent improvements in the understanding of brachialis anatomy however have demonstrated it has two distinct heads, with the bulk of its fibres running oblique relative to the humerus. Attempting to split brachialis longitudinally to the extent required for plate osteosynthesis invariably leads to transection of a significant number of muscle fibres. The authors present a less muscle destructive modification to the anterolateral approach (ALA) based on a bicipital brachialis muscle. METHOD: In order to preserve brachialis muscle fibres, the modified ALA elevates the superficial head from the underlying humerus and longitudinally splits the deep head to allow a fixation device to be tunnelled. Case notes of patients with a humeral shaft fracture fixed via the modified ALA were retrospectively reviewed. RESULTS: Ninteen humeral shaft fractures were fixed via the modified ALA. No post-operative nerve palsies were reported. Of the 19 patients, 14 (73.7%) received clinical and radiological follow-up. All reported being satisfied with their outcome. One developed a superficial wound infection and one (previous diagnosis of spondyloepiphyseal dysplasia tarda) developed a non-union requiring revision surgery. Of the five patients lost to follow-up, two died, and three reported no ongoing orthopaedic issues via telephone. CONCLUSIONS: Improved anatomical understanding of brachialis has resulted in the described modification to the ALA which is less muscle destructive and follows a truer inter-nervous plane. This small series demonstrates satisfactory outcomes using this approach.

InSafeLock humeral nail provides a safe application for proximal and distal locking screws with distal endopin - An anatomical study.

INTRODUCTION: Efforts to prevent iatrogenic neurovascular injuries with humeral intramedullary nailing lead to design new implants and inside to out distal locking technique using an endopin aims to provide a safer screw application. InSafeLock (TST, Istanbul, Turkey) humeral nail have been recently developed to minimize the possible screw related complications. The anatomical relationship between locking screws and neurovascular structures with the application time were compared between Trigen Humeral Nail (Smith and Nephew, Memphis, USA) and InSafeLock Humeral Nail. HYPOTHESIS: InSafeLock humeral nail would be safer than Trigen Humeral nail in terms of neurovascular injury. MATERIALS AND METHODS: Seven cadavers were used with both shoulders and surgical application of two nails was performed as the manufacturer guide. An Insafelock humeral nail was used for each right humerus and a Trigen humeral nail was used for each left humerus. Once the nails were placed, proximal and distal region of the nails were dissected to evaluate the relationship between screws and adjacent anatomical structures. The duration of the each screw was assessed via a stopwatch. RESULTS: No significant finding was noted for the relationship between the neurovascular structures and proximal screws in two groups (p<0.05). The distal locking of the InSafeLock humerus nail had a shorter application time and no neurovascular damage was recorded. DISCUSSION: The newly developed Insafelock humerus nails are at least as safe and effective as current humeral nails available on the market. Additional benefits include the preservation of neurovascular structures, as the Insafelock humerus nail does not require the use of an extra incision. Furthermore, surgical time is significantly shorter with using distal endopin. LEVEL OF STUDY: III, controlled laboratory study.

Lateral condylar retrograde humeral nail for management of high-energy distal humeral fractures.

PURPOSE: Distal metaphyseo-diaphyseal humeral fractures are challenging particularly if open, comminuted, or associated with nerve injury. In cases of open distal complex metaphyseo-diaphyseal humeral fractures inamenable for traditional methods of fixation, retrograde intramedullary locked humeral nail with a new lateral condylar point of entry has been proposed. METHODS: Two phases of study were conducted; phase I comprised computerized tomography evaluation of right humeri of 120 adult subjects, while phase II entailed prospective analysis of 18 patients who sustained firearm injuries resulting in open distal metaphyseo-diaphyseal humeral fractures associated with radial nerve injuries. All patients were surgically managed using lateral condylar retrograde humeral nailing with primary radial nerve exploration. RESULTS: Distal sagittal medullary diameter of the humeral medulla was the narrowest in comparison to axial and coronal medullary diameters in phase II, which matched the results of phase I. The mean postoperative disability of the arm, shoulder, and hand score was 11.2 ± 6.4. Only five patients underwent subsequent successful tendon transfer. CONCLUSIONS: Lateral condylar retrograde humeral nail with early radial nerve exploration in cases of high-energy distal metaphyseo-diaphyseal humeral fractures yielded good results regarding union and spontaneous radial nerve recovery or later on reconstruction.

External Fixation as a Definitive Treatment for Humeral Shaft Fractures: Radiographic and Functional Results With Analysis of Outcome Predictors.

OBJECTIVES: To evaluate the results obtained using unilateral external fixation as a definitive treatment for humeral shaft fractures and to identify possible predictors of radiographic and functional outcomes. DESIGN: Retrospective study. SETTING: One large metropolitan hospital. PATIENTS: A consecutive cohort of 107 patients who underwent external fixation for 109 humeral shaft fractures. MAIN OUTCOME MEASURES: Union rate, time to fracture healing, and functional assessment with disabilities of the arm, shoulder, and hand questionnaire, Constant score, Mayo Elbow Performance Index, and return to prefracture sports activity at a minimum of 2 years after surgery. Comorbidities were evaluated using the Cumulative Illness Rating Scale. Multiple linear regression analysis was used to determine whether any explanatory variables were significantly associated with the outcomes. RESULTS: The union rate in 109 humeral shaft fractures was 97.2% (106/109) at a mean of 99.2 days. Two patients (1.8%) had delayed union, and 1 patient (0.9%) did not achieve union. At the latest follow-up, the mean Constant score, Mayo Elbow Performance Index, and disabilities of the arm, shoulder and hand questionnaire score was 85.6, 97.4, and 7.4 points, respectively. All patients engaged in sports activities before fracture resumed a sport activity. At the multiple linear regression analysis, obesity was directly related to a delayed healing of fracture (P = 0.010) and comorbidity was the most important determinant of the functional outcomes at follow-up (P < 0.001). CONCLUSIONS: These data support the use of unilateral external fixation as an effective therapeutic option in patients with humeral shaft fracture. Comorbidity as assessed by Cumulative Illness Rating Scale score is the most important determinant of functional outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Medial humeral condyle fracture in childhood: a rare but often overlooked injury.

The medial condyle fracture of the humerus is-in comparison to the lateral condyle fracture-a very rare Salter-Harrison IV-fracture of the elbow. In this prospective study 14 children were included and reviewed. One child had minimal displacement fracture type I, one child had type II, and 12 children had type III-fractures. One patient was treated conservatively by an upper arm cast; thirteen were surgically treated using open reduction and osteosynthetical treatment. Postoperatively the elbow was immobilized in 90° flexion and neutral position in a long-arm cast for 4-6 weeks. In 11 children the diagnosis was made immediately after trauma, in 3 children the fracture was overlooked initially. Medial condyle fractures may be difficult to diagnose in children younger than 6 years and the lesion may be mistaken for a simple avulsion of the medial epicondyle or even missed. The C-sign is a hint for a medial condyle fracture. The development of nonunion happens in consequence of failure to recognize the fractures. Results after an average follow-up of 36 months showed that children who were diagnosed immediately and received operative stabilization had very good functional and aesthetical results. Three children with delayed diagnosis of the fracture had open surgery with reposition and osteosynthetical fixation. In two of the overlooked cases a slight contracture and angular misalignment persisted. If in this injury the diagnosis is made without delay, an appropriate therapy is implemented and radiographical controls are performed until consolidation, good results can be expected. The main risk in medial condyle fractures of the humerus is to overlook them. This can lead to the development of a nonunion with joint malformations.