Application Value of Sevoflurane Combined with Brachial Plexus Block in Children with Humeral Fracture Surgery and its Effect on Hemodynamics: A Clinical and Anatomical Study

SUMMARY: To observe the effect of sevoflurane combined with brachial plexus block (BPB) in children with humeral fracture surgery and its effect on hemodynamics. 84 children who received surgical treatment of humeral fracture in our hospital from September 2019 to September 2022 were selected. According to different anesthesia methods, the children were divided into control group and study group. The control group only received laryngeal mask sevoflurane; the study group received laryngeal mask sevoflurane combined with BPB. The operation situation, hemodynamic indexes, stress level, pain and adverse reactions of children was observed. The postoperative awakening time in the study group was lower than control group, the postoperative pain onset time in the study group was higher than control group (P0.05). Postoperative 2h, the levels of serum cortisol, b-endorpin, norepinephrine and epinephrine in the study group were lower than control group (P0.05). Sevoflurane combined with BPB is helpful to shorten the postoperative awakening time of children with humeral fracture, reduce the degree of postoperative pain, improve hemodynamics, and reduce stress response, and has good safety.

El objetivo fue observar el efecto del sevoflurano combinado con bloqueo del plexo braquial (BPB) en niños con cirugía de fractura de húmero y su efecto sobre la hemodinámica. Se seleccionaron 84 niños que recibieron tratamiento quirúrgico de fractura de húmero en nuestro hospital desde septiembre de 2019 hasta septiembre de 2022. Según diferentes métodos de anestesia, los niños se dividieron en grupo control y grupo de estudio. El grupo control solo recibió sevoflurano en mascarilla laríngea; el grupo de estudio recibió sevoflurano con mascarilla laríngea combinado con BPB. Se observó la situación operatoria, índices hemodinámicos, nivel de estrés, dolor y reacciones adversas de los niños. El tiempo hasta el despertar postoperatorio en el grupo de estudio fue menor que el del grupo control, el tiempo de aparición del dolor postoperatorio en el grupo de estudio fue mayor que el del grupo control (P0,05). A las 2 horas postoperatorias, los niveles séricos de cortisol, β-endorfina, norepinefrina y epinefrina en el grupo de estudio fueron más bajos que los del grupo control (P 0,05). El sevoflurano combinado con BPB es útil para acortar el tiempo de despertar del posoperatorio de los niños con fractura de húmero, reduce el grado de dolor postoperatorio, mejora la hemodinámica y reduce la respuesta al estrés, además de tener buena seguridad.

Deep Vein Thrombosis after a Supracondylar Fracture of the Humerus in a Child - A Rare Complication / Trombose venosa profunda após uma fratura supracondilar do úmero em uma criança - Uma complicação rara

Abstract Deep vein thrombosis in the upper extremities is uncommon, especially in the pediatric population and in the trauma setting. The diagnosis is challenging, due to its rarity, requiring a high degree of suspicion. We describe a rare case of humeral vein thrombosis after a displaced supracondylar fracture of the humerus in a 7-year-old girl. The risk factors for thromboembolism and sequelae are also discussed. The early detection and treatment are mandatory to prevent poor outcomes, such as fatal thromboembolism.

Resumo Trombose venosa profunda nas extremidades superiores é incomum, especialmente na população pediátrica e no ambiente do trauma. O diagnóstico é desafiador, devido a sua raridade, exigindo alto grau de suspeita. Descrevemos um caso raro de trombose venosa úmera após uma fratura supracondilar deslocada do úmero em uma menina de 7 anos. Os fatores de risco para tromboembolismo e sequelas também são discutidos. A detecção e o tratamento precoces são obrigatórios para evitar desfechos ruins, como tromboembolismo fatal.

Caracterización de las fracturas supracondíleas del húmero en niños que requirieron manejo quirúrgico en un hospital de Santander, Colombia / Characterization of Supracondylar Fractures of the Humerus in Children who Required Surgical Management at a Hospital in Santander, Colombia / Caracterização das fraturas supracondilianas do úmero em crianças que precisaram de tratamento cirúrgico em um hospital de Santander, Colômbia

Introducción. El objetivo del estudio fue describir las características sociodemográficas, tratamiento y complicaciones pre y posquirúrgicas de las fracturas supracondíleas del húmero distal en niños que requirieron manejo quirúrgico en un hospital de Santander, Colombia. Metodología. Se trata de un estudio observacional, descriptivo, de corte transversal con 58 pacientes que cumplieron los siguientes criterios de inclusión: edad entre 3 a 14 años, fracturas supracondíleas de manejo quirúrgico; como criterios de exclusión se tomó: antecedente de enfermedad ósea o neurológica previa y fracturas de más de 7 días de evolución. Para las variables continuas se usó medidas de tendencia central y dispersión, las categóricas en porcentajes y frecuencias absolutas. Resultados. La edad media de presentación fue de 6.2 años, el principal mecanismo de trauma fue caídas de altura con un 96.5%. El 65.5% provenía de zonas urbanas. El 13.8% se asoció con fracturas de antebrazo, y el 3.4% de epitróclea. La fijación se realizó en un 75% con técnica cruzada y un 17.2% se asoció con lesión iatrogénica del nervio ulnar. Discusión. En el estudio no se informaron lesiones vasculares; sin embargo, se documentó una alta prevalencia de lesión neurológica con la fijación medial, similar a lo descrito en la literatura (1.4%-17.7%); algunos autores describen técnicas que disminuyen estas lesiones hasta en un 0%. Conclusión. Las características sociodemográficas de nuestra población coinciden con la estadística publicada mundialmente; la principal complicación fue la lesión iatrogénica nervio ulnar, que se puede disminuir con un uso racional del pin medial y con el empleo de técnicas que busquen rechazar directamente el nervio. Palabras clave: Fracturas del Húmero; Fijación Interna de Fracturas; Clavos Ortopédicos; Codo; Niño; Nervio Cubital.

Introduction. The objective of this study was to describe sociodemographic characteristic, treatment, and pre- and post-surgical complications of supracondylar fractures of the distal humerus in children who required surgical management at a hospital in Santander, Colombia. Methodology. This was an observational, descriptive, and cross-sectional study involving 58 patients who met inclusion criteria: age between 3 and 14 years old, supracondylar fractures with surgical management; exclusion criteria include previous bone or neurological illness and fractures with more than 7 days of evolution. Central tendency and dispersion measures were used for continuous variables, and categorical variables in percentages and absolute frequencies. Results. The average age at presentation was 6.2 years old, the main mechanism of trauma was fall from height (96.5%). 65.5% came from urban zones. The 13.8% were associated with forearm fractures, and 3.4% with epitrochlear fractures. Pinning was performed at 75% with crossed technique and 17.2% were associated with iatrogenic ulnar nerve injury. Discussion. Study didn't inform vascular injuries. However, a high prevalence of neurological injury with medial pinning was documented, similar to that describe in the literature (1.4%-17.7%); some author described techniques that reduce these lesions by 0%. Conclusion. The sociodemographic characteristics of our population match with worldwide published statistics; the main complication was iatrogenic ulnar nerve injury, which can be reduced with the rational use of medial pin and with the application of techniques that seek to directly spare the nerve. Keywords: Humeral Fractures; Fracture Fixation, Internal; Bone Nails; Elbow; Child; Ulnar Nerve.

Introdução. O objetivo do estudo foi descrever as características sociodemográficas, o tratamento e as complicações pré e pós-cirúrgicas das fraturas supracondilianas do úmero distal em crianças que precisaram de tratamento cirúrgico em um hospital de Santander, Colômbia. Metodologia. Trata-se de um estudo observacional, descritivo e transversal com 58 pacientes que atenderam aos seguintes critérios de inclusão: idade entre 3 e 14 anos, fraturas supracondilianas tratadas cirurgicamente. Os critérios de exclusão foram: histórico de doença óssea ou neurológica prévia e fraturas com duração superior a 7 dias de evolução. Para variáveis contínuas foram utilizadas medidas de tendência central e dispersão, as categóricas em percentuais e frequências absolutas. Resultados. A média de idade de apresentação foi de 6.2 anos, o principal mecanismo de trauma foi a queda de altura com 96.5%. 65.5% vieram de áreas urbanas. 13.8% estavam associados a fraturas de antebraço e 3.4% a epitróclea. A fixação foi realizada em 75% com técnica cruzada e 17.2% esteve associada à lesão iatrogênica do nervo ulnar. Discussão. Nenhuma lesão vascular foi relatada no estudo. No entanto, foi documentada alta prevalência de lesão neurológica com fixação medial, semelhante à descrita na literatura (1.4%-17.7%). Alguns autores descrevem técnicas que reduzem essas lesões em até 0%. Conclusão. As características sociodemográficas da nossa população coincidem com as estatísticas publicadas mundialmente. A principal complicação foi a lesão iatrogênica do nervo ulnar, que pode ser reduzida com o uso racional do pino medial e com o uso de técnicas que buscam rejeitar diretamente o nervo. Palavras-chave: Fraturas do Úmero; Fixação Interna de Fraturas; Pinos Ortopédicos; Cotovelo; Criança; Nervo Ulnar

Functional Shoulder Evaluation after Osteosynthesis of Greater Tuberosity Fracture: Is There any Influence of Glenohumeral Dislocation? / Avaliação funcional do ombro após osteossíntese da fratura da tuberosidade maior: Há influência da luxação glenoumeral?

Abstract Objective To evaluate the postoperative functional and radiographic outcomes of the shoulder of patients submitted to transosseous suturing of a greater tuberosity fracture (GTF) through an anterolateral route and the influence of the glenohumeral dislocation on these outcomes. Methods We conducted a retrospective study and functional assessment using the Constant-Murley score. The distance between the greater tuberosity and the joint surface of the proximal humerus (in true anteroposterior radiographs) after the union was calculated. We used the Fisher exact test for the categorical independent variables, and the Student t or Mann-Whitney test for the non-categorical variables. Results In total, 26 patients met the inclusion criteria, and 38% of the sample presented an association between glenohumeral dislocation and GTF. The mean Constant-Murley score was of 82.5 + 8.02 points. The presence of an associated dislocation did not alter the functional outcome. The mean distance between the greater tuberosity of the humerus and the joint surface of the humeral head after the union was of 9 + 4.3 mm below the articular line of the humeral head. The dislocation led to a lower level of reduction, but this did not influence the Constant-Murley score. Conclusion The cases of GTF submitted to surgical treatment with transosseous sutures had good functional outcomes. The presence of dislocation made the anatomical reduction of the greater tuberosity difficult. However, it did not influence the Constant-Murley score.

Resumo Objetivo Avaliar os resultados funcional e radiográfico pós-operatórios do ombro, em pacientes submetidos a sutura transóssea de fratura da tuberosidade maior (FTM) por acesso anterolateral, e a influência da luxação glenoumeral nesses resultados. Métodos Realizou-se estudo retrospectivo e avaliação funcional (pela escala de Constant-Murley). Calculou-se a distância entre a tuberosidade maior e a superfície articular do úmero proximal (por meio de radiografia em incidência anteroposterior verdadeira) após a consolidação. Usou-se o teste Exato de Fisher para as variáveis independentes categóricas, e os testes tde Student ou de Mann-Whitney para as não categóricas. Resultados Ao todo, 26 pacientes preencheram os critérios de inclusão. A associação de luxação glenoumeral com FTM foi observada em 38% da amostra. A média da pontuação na escala de Constant-Murley foi de 82,5 + 8,02. A presença de luxação associada não alterou o resultado funcional. A distância média da consolidação da tuberosidade maior do úmero em relação à superfície articular da cabeça umeral foi de 9 + 4,3 mm abaixo da linha articular da cabeça umeral. Pacientes com luxação associada evoluíram com redução menor, mas isso não influenciou na pontuação na escala de Constant-Murley. Conclusão As FTMs submetidas ao tratamento cirúrgico com sutura transóssea evoluíram com bom resultado funcional. A presença de luxação dificultou a redução anatômica da tuberosidade maior. Entretanto, isso não influenciou na pontuação na escala de Constant-Murley.

Comparison between Fixation with Smooth Kirschner Wire and Cannulated Screws in Displaced Fractures of the Lateral Humeral Condyle in Children / Comparação entre fixação de fio de Kirschner liso e de parafusos canulados em fraturas deslocadas do côndilo lateral do úmero em crianças

Abstract Objective To compare the use of cannulated screws and smooth Kirschner wires in terms of reducing the presence of exuberant callus and complications in pediatric displaced fractures of the lateral humeral condyle. Methods An analytical cross-sectional study of consecutive cases was conducted from May to October 2021 with 30 children with displaced external humeral condyle fractures. The functional results regarding pain and range of motion were stratified using the Dhillon grading system. Results A total of 19 patients underwent Kirschner wire fixation, and 11 underwent cannulated screw fixation. Closed fixation was performed in 14 cases (47%), and open fixation, in 16 (53%). Of the cases included, there was no loss to follow-up. Te sample was composed of 21 (70%) male patients, and the age ranged from 5 to 15 years, with a mean of 6.96 years. The most frequent cause of fracture was fall from height (50%), which was related to greater displacement on baseline radiographs. Complications that were not related to the reduction approach or the implant used were observed in 12 (40%) cases. Conclusion The present study shows no benefits in relation to the use of smooth pins or cannulated screws to reduce the presence of exuberant callus in the consolidation of the fracture. We see that the complications that arise are related to the severity of the injury, and benefits cannot be identified in the choice of one implant over another. We could see that the Weiss classification helps to define the behavior in favor of open or closed reduction without interfering in kindness of the smooth pin or the cannulated screw for fracture fixation.

Resumo Objetivo Comparar o uso de parafusos canulados e de fios de Kirschner lisos em termos da redução da presença de calo exuberante e de complicações em fraturas pediátricas deslocadas do côndilo lateral do úmero. Métodos Um estudo analítico transversal de casos consecutivos foi realizado de maio a outubro de 2021 com 30 crianças com fraturas deslocadas de côndilo umeral externo. Os resultados funcionais para dor e amplitude de movimento foram estratificados utilizando o sistema de classificação Dhillon. Resultados Ao todo, 19 pacientes foram submetidos à fixação de fio Kirschner, e 11 à fixação de parafusos canulados. A fixação realizada foi fechada em 14 casos (47%) e aberta em 16 (53%). Dos casos incluídos, não houve perda no acompanhamento. A amostra continha 21 (70%) pacientes do sexo masculino, e a idade variou de 5 a 15 anos, com média de 6,96 anos. A causa mais frequente de fratura foi queda de altura (50%), e esteve relacionada ao maior deslocamento nas radiografias da linha de base. Complicações que não estavam relacionadas à abordagem de redução ou ao implante utilizado foram observadas em 12 (40%) casos. Conclusão Este estudo não mostra benefícios em relação ao uso de pinos lisos ou de parafusos canulados para reduzir a presença de calo exuberante na consolidação da fratura. Vemos que as complicações que surgem estão relacionadas à gravidade da lesão, e não é possível identificar benefícios na escolha de um implante ou outro. Pudemos ver que a classificação de Weiss ajuda a definir o comportamento em favor da redução aberta ou fechada sem dar preferência ao pino liso ou ao parafuso canulado para a fixação da fratura.

Short-term effectiveness of transverse antecubital incision for failed closed reduction of Gartland type Ⅲ supracondylar humerus fractures in children / 中国修复重建外科杂志

OBJECTIVE@#To investigate the short-term effectiveness of transverse antecubital incision in the treatment of failed closed reduction of Gartland type Ⅲ supracondylar humeral fractures (SHFs) in children.@*METHODS@#Between July 2020 and April 2022, 20 children with Gartland type Ⅲ SHFs who failed in closed reduction were treated with internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision. There were 9 boys and 11 girls with an average age of 3.1 years (range, 1.1-6.0 years). The causes of injuries were fall in 12 cases and fall from height in 8 cases. The time from admission to operation ranged from 7 to 18 hours, with an average of 12.4 hours. The healing of the incision and the occurrence of complications such as nerve injury and cubitus varus were observed after operation; the elbow flexion and extension range of motion after removing the gypsum, after removing the Kirschner wire, and at last follow-up were recorded and compared, as well as the elbow flexion and extension and forearm rotation range of motion at last follow-up between healthy and affected sides; the Baumann angle was measured on the X-ray film, and the fracture healing was observed. At last follow-up, the effectiveness was evaluated according to the Flynn elbow function evaluation criteria.@*RESULTS@#All incisions healed by first intention, and there was no skin necrosis, scar contracture, ulnar nerve injury, and cubitus varus. Postoperative pain occurred in the radial-dorsal thumb in 2 cases. The gypsum was removed and elbow flexion and extension exercises were started at 2-4 weeks (mean, 2.7 weeks) after operation, and the Kirschner wire was removed at 4-5 weeks (mean, 4.3 weeks). All the 20 patients were followed up 6-16 months, with an average of 12.4 months. The fracture healing time was 4-5 weeks, with an average of 4.5 weeks, and there was no complication such as delayed healing and myositis ossificans. The flexion and extension range of motion of the elbow joint gradually improved after operation, and there were significant differences between the time after removing the gypsum, after removing the Kirschner wire, and at last follow-up ( P<0.017). There was no significant difference in the flexion and extension of the elbow joint and the forearm rotation range of motion between the healthy and affected sides at last follow-up ( P>0.05). There was no significant difference in Baumann angle between the time of immediate after operation, after removing the Kirschner wire, and at last follow-up ( P>0.05). According to Flynn elbow function evaluation standard, 16 cases were excellent and 4 cases were good, the excellent and good rate was 100%.@*CONCLUSION@#The treatment of Gartland type Ⅲ SHFs in children with failed closed reduction by internal and external condylar crossing Kirschner wire fixation through transverse antecubital incision has the advantages of complete soft tissue hinge behind the fracture for easy reduction and wire fixation, small incision, less complications, fast fracture healing, early functional recovery, reliable reduction and fixation, and can obtain satisfactory results.

Effect of tuberosity repair on functional outcome of reverse shoulder arthroplasty in proximal humerus fractures / 中华创伤杂志(英文版)

PURPOSE@#Unsatisfactory results of hemiarthroplasty in Neer's 3- and 4-part proximal humerus fractures in elderly, have led to the shift towards reverse shoulder arthroplasty (RSA). The objective of our study was to repair the tuberosities that are generally overlooked during RSA and observe its impact on the functional outcome and shoulder scores.@*METHODS@#We include elderly patients with acutely displaced or dislocated 3- or 4-part proximal humerus fractures from July 2013 to November 2019 who were treated with RSA along with tuberosity repair by non-absorbable sutures and bone grafting harvested from the humeral head. Open injuries and cases with neuro-muscular involvement of the deltoid muscle were excluded. According to the tuberosity healing on radiographs of the shoulder at 9th postoperative month, the patients were divided into 2 groups, as the group with successful tuberosity repair and the other with failed tuberosity repair. Statistical analysis of the functional outcome and shoulder scores between the 2 groups were done by independent t-test for normally distributed parameters and Mann-Whitney test for the parameters, where data was not normally distributed.@*RESULTS@#Of 41 patients, tuberosity healing was achieved in 28 (68.3%) and failed in 13 (31.7%) cases. Lysis of the tuberosity occurred in 5 patients, tuberosity displacement in 2, and nonunion in 2. Mean age was 70.4 years (range 65 - 79 years) and mean follow-up was 58.7 months (range 18 - 93 months). There were no major complications. Group with successful tuberosity repair showed improvement in mean active range of movements, like anterior elevation (165.1° ± 4.9° vs. 144.6° ± 9.4°, p < 0.000), lateral elevation (158.9° ± 7.2° vs. 138.4° ± 9.6°, p < 0.000), external rotation (30.5° ± 6.9° vs. 35.0° ± 6.3°, p = 0.367), internal rotation (33.7° ± 7.5° vs. 32.6° ± 6.9°, p = 0.671) and in mean shoulder scores including Constant score (70.7 ± 4.1 vs. 55.5 ± 5.7, p < 0.000), American shoulder and elbow surgeons score (90.3 ± 2.4 vs. 69.0 ± 5.7, p < 0.000), disability of arm shoulder and hand score (22.1 ± 2.3 vs. 37.6 ± 2.6, p < 0.000).@*CONCLUSION@#Successful repair and tuberosity healing around the RSA prosthesis is associated with statistically significant improvement in postoperative range of motion, strength and shoulder scores. Standardized repair technique and interposition of cancellous bone grafts, harvested from the humeral head can improve the rate of tuberosity healing.

PACS and Photoshop assisted isosceles triangle osteotomy and Kirschner wire tension buckle fixation in the treatment of cubitus varus in children / 中国骨伤

OBJECTIVE@#To investigate the clinical efficacy of picture archiving and communication system (PACS) and Photoshop assisted isosceles triangle osteotomy and Kirschner wire fixation with tension band in the treatment of cubitus varus in children.@*METHODS@#The clinic data of 20 children with cubitus varus treated with isosceles triangle osteotomy of distal humerus and Kirschner wire fixation with tension band from October 2014 to October 2019, were retrospectively analyzed. There were 13 males and 7 females, aged from 3.2 to 13.5 years old, the median age was 6.65 years old. PACS system was applied for the osteotomy design preoperatively, simulating and measuring the side length of isosceles triangle osteotomy. Then, Photoshop system was used to simulate the preoperative and postoperative osteotomy graphics, which could guide precise osteotomy during operation.@*RESULTS@#All the 20 patients were followed up for 20 to 24 months, with a median of 22.5 months. At the last follow-up, the carrying angle of the affected limb was 5 ° to 13 °, with a median of 8.3 °. The clinical efficacy was evaluated according to the Flynn elbow function score:excellent in 16 cases, good in 2 cases, and fair in 2 cases.@*CONCLUSION@#The treatment of cubitus varus in children by isosceles triangle osteotomy and Kirschner wire fixation with tension band assisted by PACS and Photoshop system has shown good clinical outcome.

Olecranon osteotomy approach for Dubberley type Ⅲ coronal fractures of the distal humerus / 中国骨伤

OBJECTIVE@#To retrospectively analyze the clinical efficacy of olecranon osteotomy approach in the treatment of Dubberley type Ⅲ coronal fractures of the distal humerus and summarize the treatment experience.@*METHODS@#From January 2016 to June 2020, 17 patients (5 males and 12 females) with Dubberley type Ⅲ coronal fractures of the distal humerus were treated by olecranon osteotomy approach. The age ranged from 37 to78 years old with an average of (58.5±12.9) years old. According to Dubberley classification, there were 5 cases of type Ⅲ A and 12 cases of type Ⅲ B. The curative effect was evaluated using the Borberg-Morrey elbow function score. The flexion, extension and rotation range of motion of the elbow joint, complications and postoperative imaging evaluation were recorded.@*RESULTS@#All the 17 patients got bony union. The follow-up time ranged from 12 to 33 months with an average of (15.6±5.6) months. There was 1 case of ischemic necrosis of capitulum humeri, 2 cases of traumatic arthritis and 1 case of heterotopic ossification, 1 case of malunion of fracture. The range of motion was (114.80±19.50) °. The Broberg-Morrey score was 85.3±8.2, excellent in 5 cases, good in 9 cases, fair in 3 cases and poor in 0 case.@*CONCLUSION@#Through olecranon osteotomy approach, the articular surface of distal humerus could be fully exposed, and the operation is convenient. Anatomical reduction and rigid fixation of the articular surface of distal humerus are the key factors for the succesful outcome.

Treatment of four-part proximal humerus fractures with depressed humeral head collapse using strut allograft with locking plates / 中国骨伤

OBJECTIVE@#To evaluate the clinical outcomes of allogeneic femoral head as strut allograft combined with proximal humeral internal locking system (PHILOS) in the treatment of proximal humeral Neer grade Ⅳ fracture with humeral head collapse.@*METHODS@#From January 2018 to November 2020, 18 patients with Neer grade Ⅳ fracture with humeral head collapse were treated with strut allograft with PHILOS, including 4 males and 14 females, aged from 55 to 78 years old, with an average of (68.11±7.20) years old. The operation time, intraoperative bleeding, postoperative drainage volume, fracture healing time, neck-shaft angle and the height of the humeral head, failure of internal fixation the shoulder function at the last follow-up was assessed using Neer's scoring system.@*RESULTS@#All 18 patients were followed up, and the duration ranged from 10 to 12 months, with an average of (11.08±0.65) months. The operation time was (66.44±5.06) min, the intraoperative bleeding volume was (206.67±36.14) ml, the postoperative drainage volume was (76.11±9.63) ml, and the fracture healing time was (17.28±3.92) weeks. At the last follow-up, the degree of loss of neck-shaft angle was (5.44±0.86) ° and the loss of the height of humeral head was (1.43±0.27) mm. All 18 patients had healing without complications such as fracture, withdrawal, penetration of internal fixation and necrosis of humeral head. According to Neer's evaluation standard, the total score was (89.61±5.60), 10 cases got an excellent result, 6 good, 2 fair.@*CONCLUSION@#Allogeneic femoral head combined with PHILOS is an appropriate treatment for the four-part proximal humerus fractures with humeral head collapse, exhibiting good clinic outcome.

Clinical study of double plate system in the treatment of complex proximal humeral fractures in the elderly / 中国骨伤

OBJECTIVE@#To explore the clinical outcomes of anteromedial combined with lateral locking plate for complex proximal humeral fractures in the eldery.@*METHODS@#From June 2018 to October 2020, 30 patients who underwent surgical treatment for Neer grade 3 to 4 proximal humeral fractures, including 8 males and 22 females, aged from 51 to 78 years old with an average of (61.5±7.5) years old. Of them, 15 patients had fractures fixed with anteromedial combined with lateral locking plate(ALLP group), whereas 15 received internal fixation with proximal humerus locking plate only(PHLP group). The clinical data, simple shoulder test (SST), humeral head height loss, varus angle and shoulder range of motion were compared between the two groups.@*RESULTS@#All fractures were healed. The follow-up time ranged from 12 to 24 months, with an average of(14.3±2.9) months. The operation time of ALLP group was longer than that of PHLP group (P<0.05). There was no significant difference in intraoperative blood loss between the two groups (P>0.05). There was no significant difference in SST score between the two groups at 1, 3 and 12 months after operation (P>0.05). In terms of radiographic measurement, there was no significant difference in humeral head height loss and varus angle between the two groups at 1 and 3 months after operation (P>0.05). At 12 months after operation, the height loss and varus angle of humeral head in ALLP group were lower than those in PHLP group (P<0.05). In shoulder range of motion, the range of forward elevation in ALLP group was larger than that in PHLP group 1 year after operation(P<0.05). There was no significant difference in external rotation between the two groups.@*CONCLUSION@#Anteromedial combined with lateral locking plate in the treatment of complex proximal humeral fractures in the elderly can increase the stability of the medial column and obtain a good fracture prognosis. But there are also disadvantages such as longer operation time, so it should be individualized according to the fracture type of the patient.

Tratamiento quirúrgico para fracturas bifocales de húmero Maresca tipo A2 / Surgical treatment in Maresca type A2 bifocal humeral fractures

Las fracturas bifocales de húmero son lesiones infrecuentes, más aun las que ocurren asociadas con fracturas en el húmero proximal y diáfisis. Presentamos a cuatro pacientes con fracturas bifocales de húmero proximal y diafisario (Maresca A2), la planificación quirúrgica, los detalles técnicos y sus resultados funcionales. Nivel de Evidencia: IV

Bifocal humeral fractures are infrequent injuries, and fractures involving the proximal and diaphyseal humerus are even rarer. We present four patients with bifocal humeral fractures of the Maresca type A2 classification. We detail the surgical plan, technical pearls, and functional outcomes. Level of Evidence: IV

Lesiones iatrogénicas del nervio radial en la osteosíntesis de la diáfisis humeral / Intraoperative iatrogenic injury of the radial nerve in humerus osteosynthesis

Introducción: Los objetivos de este estudio fueron determinar la incidencia de lesión iatrogénica intraquirúrgica del nervio radial durante la osteosíntesis de la diáfisis y el extremo distal del húmero, distinguir factores de riesgos asociados y reconocer elementos pronósticos que participan de su recuperación. Materiales y Métodos: Se evaluó, en forma retrospectiva, a 82 pacientes con osteosíntesis de húmero entre 2005 y 2021, sin parálisis radial preoperatoria. Se consideraron los sistemas de fijación utilizados, y se compararon las cirugías primarias con las reoperaciones y el tiempo transcurrido entre estas. El diagnóstico de parálisis radial posoperatorio fue clínico. Todos los pacientes fueron tratados con férula en extensión de muñeca, electroestimulación, kinesiología y vitaminas B1, B6, B12. La electromiografía se solicitó a los fines del pronóstico. Resultados: Nueve pacientes tuvieron déficit motor del nervio radial en el posoperatorio inmediato. El sistema de fijación era una placa (7 casos), sistema de cable-placa (1 caso) y clavo endomedular acerrojado anterógrado (1 caso). Siete ocurrieron en cirugías primarias y dos en reoperaciones. El 88% recuperó su función motora completamente antes de los 6 meses después de la parálisis. La electromiografía reveló un nervio radial no excitable en el 22% restante con parálisis definitiva. Conclusiones: El uso de placa de osteosíntesis, la disección intraoperatoria del nervio radial y las reoperaciones aumentan la incidencia de parálisis. Un nervio radial no excitable se relaciona con un peor pronóstico de recuperación espontánea. Nivel de Evidencia: IV

Introduction: The purpose of this study is to determine the incidence of intraoperative iatrogenic radial nerve injury after osteosynthesis of the diaphysis and distal end of the humerus, identify associated risk factors, and determine the prognostic factors involved in its recovery. Materials and Methods: We retrospectively assessed 82 humerus osteosynthesis cases between 2005 and 2021 who had normal radial nerve function before surgery. We evaluated the fixation systems used, the type of surgery (primary versus revision), and the intervals between surgeries. The diagnosis of postoperative radial palsy was made by clinical examination. All patients were treated with wrist extension splint, physiotherapy, and vitamins B1, B6, and B12. Results: After humerus fixation, 9 patients developed motor palsy. Seven cases were fixed with plates, one with a cable-plate system, and one with an anterograde locking intramedullary nail. Seven cases (22%) occurred after primary procedures, while two occurred during revisions. Within 6 months, 88% had regained full motor function. In the remaining 22% of patients with definite palsy, electromyography revealed no excitability of the radial nerve. Conclusions: The use of an osteosynthesis plate, as well as intraoperative dissection and neurolysis of the radial nerve, were identified as risk factors for the development of radial palsy. Reoperations on the humerus, on the other hand, are a risk factor that increases the likelihood of postoperative radial nerve palsy. A radial nerve with no excitability on the postoperative electromyogram has a poor prognosis of spontaneous radial nerve function recovery. Level of Evidence: IV

The Baumann Angle: An Analysis from Theory to Practice / O ângulo de Baumann: Uma análise da teoria à prática

Abstract Objective To analyze how the Baumann angle (BA) is affected by inadequate radiographic inclinations. Methods The study was performed from radiographs of the distal humerus of children aged 3 to 10 years. The BA measurements performed by five observers were compared, and each radiograph was evaluated for its quality as "adequate" or "inadequate." The correlation between radiographic quality and the normality of the angles was evaluated. Results Sample was composed of 141 patients, 44% between 3 and 6 years of age and 56% between 7 and 10. We observed the BA between 52.01 and 89.82 degrees, with about 16% of the measurements outside the normal limits of the literature. A total of 33.3% of the evaluated radiographs were classified as "inadequate". On the BA measurements outside the normality parameter, we observed that its proportion was higher among images with inadequate radiographic quality (31.1 vs. 6.2%), and this difference was significant (p< 0.001). Conclusions The BA is a very variable measurement and, alone, it is unreliable for the evaluation of angular deformities of the pediatric elbow, with radiographic quality proven to be an important causal factor of this variability.

Resumo Objetivo Analisar como o ângulo de Baumann (AB) é afetado por inclinações radiográficas inadequadas. Métodos Estudo realizado a partir de radiografias do úmero distal de crianças de 3 a 10 anos. Foram comparadas as aferições do AB realizadas por cinco observadores, e cada radiografia foi avaliada quanto à sua qualidade em "adequada" ou "inadequada". A correlação entre a qualidade radiográfica e a normalidade dos ângulos foi avaliada. Resultados Amostra composta por 141 pacientes, 44% entre 3 e 6 anos e 56% entre 7 e 10. Observamos AB entre 52,01 e 89,82 graus, tendo cerca de 16% das medidas fora dos limites de normalidade da literatura. Um total de 33,3% das radiografias avaliadas foram classificadas como "inadequadas". Sobre as medidas do AB fora do parâmetro da normalidade, observamos que sua proporção foi maior entre as imagens com qualidade radiográfica inadequada (31,1% vs. 6,2%), tendo essa diferença se mostrado significativa (p< 0,001). Conclusões O AB é uma medida muito variável e, isoladamente, pouco confiável para a avaliação de deformidades angulares do cotovelo pediátrico, tendo a qualidade radiográfica se mostrado um fator causal importante dessa variabilidade.

How to Choose Between the Transolecranon and Triceps-Reflecting Approaches to Treat Distal Humerus Fractures in Adults: A Prospective Study / Como escolher entre as abordagens transolecraniana e por reflexão do tríceps para tratar fraturas distais do úmero em adultos: Um estudo prospectivo

Abstract Objective To choose an appropriate posterior approach for distal humerus fractures in adults. Methods Fifty patients with distal humerus fractures were analyzed prospectively. The fractures were classified using the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO, Working Group for Bone Fusion Issues, in German/OTA) classification. The patients were divided into group A and group B. Olecranon osteotomy (the transolecranon approach) was performed in 30 patients, and the triceps-reflecting approach was used in 20 patients. The functional results were evaluated using the Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results The average operative time was of 92.62 8.73 minutes for group A, and of 78.63 7.02 minutes for group B, (p< 0.01), and the average blood loss was of 222.78 34.93 mL for group A, and of 121.61 19.85 mL for group B, (p< 0.01), which were statistically significant. The mean scores on the MEPS and DASH of both groups were found to be insignificant. Complications like infection, neurapraxia and soft tissue irritation where observed more in group A. Conclusion The triceps-reflecting approach results in a shorter operative time, a lower levels of blood loss, and a low rate of complications, and olecranon osteotomy provides better accuracy in terms of articular reduction. But there were no significant differences between the two groups regarding the functional outcome. Therefore, we have proposed a new classification that is a modification of the AO/OTA classification: type 1 includes AO grades 13A to C2 (B3 excluded); and type 2, AO 13C3. For type-1 fractures, the triceps-reflecting approach may be considered, and, for type-2 fractures, olecranon osteotomy.

Resumo Objetivo Escolher uma abordagem posterior adequada para fraturas distais do úmero em adultos. Métodos Cinquenta pacientes com fraturas distais do úmero foram analisados prospectivamente. As fraturas foram classificadas por meio da classificação Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA). Os pacientes foram divididos em grupo A e grupo B. A osteotomia olecraniana (abordagem transolecraniana) foi realizada em 30 pacientes, e a abordagem por reflexão do tríceps foi usada em 20 pacientes. Os resultados funcionais foram avaliados por meio do Mayo Elbow Performance Score (MEPS) e do questionário Disabilities of the Arm, Shoulder and Hand (DASH). Resultados O tempo médio da cirurgia foi de 92,62 8,73 minutos para o grupo A, e de 78,63 7,02 minutos para o grupo B (p< 0,01) e a média da perda sanguínea foi de 222,78 34,93 mL no grupo A, e de 121,61 19,85 mL no grupo B (p< 0,01), os quais foram estatisticamente significativos. As pontuações médias no MEPS e no DASH de ambos os grupos foram consideradas insignificantes. Complicações como infecção, neurapraxia e irritação de tecidos moles foram mais observadas no grupo A. Conclusão A abordagem por reflexão do tríceps resulta em menor tempo de operação, menor perda de sangue, e baixas taxas de complicações, e a osteotomia olecraniana proporciona uma melhor precisão da redução articular. Mas não houve diferença significativa entre os dois grupos em termos do resultado funcional. Por isso, propusemos uma nova classificação, que é uma modificação da classificação AO/OTA: o tipo 1 inclui os graus AO 13A a C2 (excluído o B3); e o tipo 2, AO 13C3. Para fraturas do tipo 1, a abordagem por reflexão do tríceps pode ser considerada, e, para as fraturas do tipo 2, a osteotomia olecraniana.

Tratamiento de las fracturas supracondíleas de húmero en niños y fijación interna percutánea versus reducción sin fijación interna / Treatment of Supracondylar Fractures of the Humerus in Children and Percutaneous Internal Fixation versus Reduction with no Internal Fixation

Introducción: Las fracturas supracondíleas de húmero constituyen el segundo tipo de fracturas más frecuentes en niños. La prevalencia mundial oscila entre 3 y 16 por ciento, con predominio en varones. La urgencia de una atención inmediata radica en la prevención de complicaciones y secuelas. Objetivo: Describir los resultados del tratamiento de las fracturas supracondíleas de húmero en niños con fijación interna percutánea. edad, sexo, tipo de tratamiento empleado, complicaciones, y resultados finales obtenidos. Métodos: Se realizó un estudio descriptivo retrospectivo, en pacientes con fracturas supracondíleas de húmero en niños, atendidos en el Hospital Carlos Manuel de Céspedes de Bayamo, entre 2018 y 2019. Se calcularon frecuencias absolutas y porcentajes. Se evaluaron las siguientes variables: edad, sexo, tipo de tratamiento empleado, complicaciones, y resultados finales obtenidos. Resultados: Las fracturas supracondíleas de húmero fueron más frecuentes en el sexo masculino (69,6 por ciento) y en el grupo de edad comprendido entre 6 y 10 años para ambos sexos. El 60,8 por ciento de estas fracturas se trataron con reducción y fijación interna con agujas de Kirchner. En el grupo con fijación interna predominaron las de tipo IV y en el grupo que no requirió fijación interna predominó el tipo I. En general, en los pacientes con fijación interna predominaron los resultados excelentes y buenos. Conclusiones: Se obtuvieron mejores resultados en los casos donde se realizó la reducción combinada con fijación interna(AU)

Introduction: Supracondylar fractures of the humerus are the second most frequent type of fractures in children. The worldwide prevalence ranges between 3 and 16 percent, with predominance in males. The urgency of immediate care lies in the prevention of complications and sequelae. Objective: To describe the results of the treatment of supracondylar fractures of the humerus in children with percutaneous internal fixation. Methods: A retrospective descriptive study was carried out in patients with supracondylar fractures of the humerus in children, treated at Carlos Manuel de Céspedes Hospital in Bayamo, from 2018 to 2019. Absolute frequencies and percentages were calculated. The variables evaluated were age, sex, type of treatment used, complications, and final results obtained. Results: Supracondylar fractures of the humerus were more frequent in males (69.6 percent) and in the age group between 6 and 10 years for both sexes. 60.8 percent of these fractures were treated with reduction and internal fixation with Kirchner wires. In the group with internal fixation, type IV predominated, also type I predominated in the group that did not require internal fixation. In general, excellent and good results predominated in patients with internal fixation. Conclusions: Better results were obtained in patients who underwent reduction combined with internal fixation(AU)

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)

Humerus Diaphyseal Stress Fracture in a Teenage Tennis Athlete: Case Report / Fratura por estresse diafisária do úmero em atleta de tênis adolescente: Relato de caso

Abstract A teenage male tennis player had chronic pain in his dominant arm during tennis practice. Magnetic resonance imaging (MRI) suggested humerus diaphyseal stress injury. After 4 weeks, he became asymptomatic and resumed playing. However, pain recurred after 3 days. A new MRI revealed a diaphyseal undisplaced humerus fracture and significant bone marrow edema. The patient remained in rest for 4 weeks. After that, strengthening exercises were introduced and return to training was allowed after 12 weeks. Even if asymptomatic, we suggest that these patients should not return to play before 12 weeks, depending on the physical exam and imaging findings.

Resumo Um tenista adolescente tinha dor crônica no braço dominante durante os treinos de tênis. A ressonância magnética (RM) sugeriu lesão por estresse na diáfise do úmero. Depois de 4 semanas, ele se tornou assintomático e voltou a jogar. No entanto, houve recidiva da dor após 3 dias. A nova RM revelou fratura diafisária não desviada do úmero e edema significativo da medula óssea. O paciente ficou em repouso por 4 semanas. Depois disso, exercícios de fortalecimento foram introduzidos e o retorno aos treinamentos foi permitido após 12 semanas. Mesmo que assintomáticos, sugerimos que esses pacientes não voltem a jogar antes das 12 semanas, dependendo dos exames físicos e dos achados por imagem.