[Electrophysiological diagnostics in choosing treatment strategy for neuropathies in children with transcondylar fractures]. / Rol' elektrofiziologicheskoi diagnostiki v vybore taktiki lecheniya neiropatii u detei s chrezmyshchelkovymi perelomami.

BACKGROUND: A common complication of transcondylar fractures (TCF) in children is neuropathy requiring not only therapeutic but also surgical treatment. Despite numerous reports, clear criteria for selecting patients for surgical treatment have not been defined. OBJECTIVE: To clarify the role of clinical and electrophysiological diagnostics in choosing treatment tactics for neuropathies in children with TCF. MATERIAL AND METHODS: There were 20 patients with neuropathies after TCF between 2020 and 2022. Of these, 10 ones were selected for surgical treatment according to electrophysiological diagnostic data. Inclusion criteria: age 6-12 years, closed TCF within previous 3-12 months, symptoms of neuropathy confirmed by electroneuromyography (ENMG), no nerve disruption according to ultrasound data. Exclusion criteria: elbow joint contracture and post-traumatic ulnar nerve dislocation. All patients underwent needle myography with functional assessment of motor and sensory fibers, spontaneous activity in muscles, recruitment pattern and motor unit potentials. Intraoperative electrophysiological diagnostics included stimulation of motor fascicles with registration of M-responses from the target muscles. The follow-up period was 3-6 months. RESULTS: The study included 20 patients aged 6-12 years without peripheral nerve disruption. A group of 10 patients who required surgical treatment was identified. The control group consisted of 10 patients who did not require surgical treatment. To choose treatment tactics, we considered ENMG data. Surgical procedure was determined according to intraoperative neuromonitoring (IONM) data. CONCLUSION: When choosing treatment strategy, surgeons should consider objective ENMG and IONM criteria, as well as fascicular anatomy.

Achieving Bone Healing Non-Operatively in Humeral Fractures in Two Patients with Risk Factors for Nonunion Utilizing a Specialized Orthosis.

We report the treatment of two patient with humeral fractures with one or more risk factors for nonunion. The first patient was elderly with a previously diagnosed central nervous sys-tem injury. The second elderly patient previously sustained a cerebral vascular accident affecting the fractured arm. The fracture was oblique in the proximal third of the humerus. We achieved bone healing non-operatively utilizing a spe-cialized plastic orthosis that included a deforming element made of dense foam. This device asymmetrically increases the soft tissue pressure around the fracture.

Associated Factor and Long-Term Clinical Outcomes for Patients with Postoperative Rotational Malreduction in Pediatric Supracondylar Humeral Fractures.

Background and Objectives: Long-term outcomes of immediately postoperative rotational malreduction in the axial plane after operative treatment of supracondylar humeral fractures (SCHF) are unknown. This study aimed to investigate the long-term clinical outcomes and associated factors for immediately postoperative rotational malreduction of SCHF. Materials and methods: In this retrospective case-control study, 88 patients who underwent surgery for Gratland type III SCHF were enrolled between January 2012 and January 2020. Among them, 49 patients had immediately postoperative malrotational reduction (rotational malreduction group) and 39 patients had no rotational deformity (control group). To evaluate the associated factors for immediately postoperative rotational malreduction, demographic data, fracture patterns, physical examination signs, and preoperative radiological parameters were analyzed. To compare the clinical outcomes, operation time, range of motion of the elbow, time from operation to full range of motion, and Flynn criteria were evaluated. The Oxford elbow score was used to investigate long-term clinical outcomes for patients five years after operation. Results: The mean age was 5.7 ± 2.3 years and mean follow-up period was 15.7 ± 4.0 months. The rotational malreduction group had significantly more patients with oblique fracture pattern (p = 0.031) and Pucker sign (p = 0.016) and showed a significantly longer operative time (p = 0.029) than the control group. Although there was no significant difference in the range of elbow motion and the Flynn criteria, the Kaplan-Meier survival curve showed a longer time to recover the full range of elbow motion in the rotational malreduction group (p = 0.040). There were no significant differences in the long-term clinical outcomes assessed using the Oxford elbow score (p = 0.684). Conclusions: Oblique fracture pattern and Pucker sign may be associated with immediately postoperative rotational malreduction in the axial plane. Although patients with immediately postoperative rotational malreduction showed favorable results of long-term clinical outcomes, they required more weeks to recover the full range of elbow motion.

Postoperative malrotation of humerus shaft fracture causes degeneration of rotator cuff and cartilage.

We hypothesized that postoperative malrotation of humeral shaft fractures can alter the bio-mechanical environment of the shoulder; thus, rotator cuff and cartilage degeneration could be induced. Therefore, we designed an animal experiment to evaluate the impact of malrotation deformities after minimally invasive surgery for humeral fractures on the rotator cuff and cartilage, which has rarely been described in previous studies. Twenty-four New Zealand white rabbits were randomly divided into the sham control group (A), negative control group (B) and malrotated group (C). A sham operation with surgical exposure alone was performed in group A. Humeral shaft osteotomy was performed in Group B and C. In Group B, the fractures were fixed in situ with plate -screw system. While in Group C, iatrogenic rotational deformity was created after the proximal end of the fracture being internally rotated by 20 degrees and then subsequently fixed. The animals with bone healing were sacrificed for pathological and biochemical examination. In group C, the modified Mankin scale for cartilage pathology evaluation and the modified Movin scale for tendon both showed highest score among groups with statistical significance (P < 0.05); Disordered alignment and proportion of collagen I/III of rotator cuff were confirmed with picrosirius red staining; Transmission electron microscopy also showed ultrastructural tendon damage. Immunohistochemistry showed that both MMP-1 and MMP-13 expression were significantly higher in group C than groups A and B(P < 0.05). Minimally invasive techniques for humerus shaft fracture might be cosmetically advantageous, but the consequent postoperative malrotation could increase the risk of rotator cuff and cartilage degeneration. This conclusion is supported here by primary evidence from animal experiments.

Modified Closed Reduction and Percutaneous Kirschner Wires Internal Fixation for Treatment of Supracondylar Humerus Fractures in Children.

OBJECTIVE: Supracondylar humerus fractures are the most frequent fractures of the paediatric elbow. The present study introduced a modified surgical procedure for treatment of supracondylar humerus fractures in children. METHODS: From February 2015 to August 2019, 73 patients with Gartland's type II and III supracondylar fractures were treated with this modified method. Totally, 68 of all patients were followed up for 3-12 months (mean 8.25 months). The evaluation results included fracture nonunion, ulnar nerve injury, pin track infection, carrying angle and elbow joint Flynn score. RESULTS: The results showed that bone union was observed in all children, one case had an iatrogenic ulnar nerve injury, and the symptoms were completely relieved in 4 months after removing of the medial-side pin. All children had no cubitus varus deformity and no pin track infection, and the rate of satisfactory results according to Flynn's criteria score was 100%. CONCLUSION: The modified closed reduction and Kirschner wires internal fixation could effectively reduce the rate of open reduction, the risk of iatrogenic ulnar nerve injury, and the incidence of cubitus varus deformity in treatment of supracondylar humerus fractures in children.

Location of the radial nerve along the humeral shaft between the prone and lateral decubitus positions at different elbow positions.

Identification of the radial nerve is important during the posterior approach to a humerus fracture. During this procedure, the patient can be placed in the prone or lateral decubitus position depending on the surgeon's preference. The distance from the radial nerve to the osseous structures will be different in each position. The purpose of this study was to identify the safety zones in various patient and elbow flexion positions. The distances from the olecranon to the center of the radial groove and intermuscular septum and lateral epicondyle to the lateral intermuscular septum were measured using a digital Vernier caliper. The measurements were performed with cadavers in the lateral decubitus and prone positions at different elbow flexion angles. The distance from where the radial nerve crossed the posterior aspect of the humerus measured from the upper part of the olecranon to the center of the radial nerve in both positions at different elbow flexion angles varied from a mean maximum distance of 130.00 mm with the elbow in full extension in the prone position to a minimum distance of 121.01 mm with the elbow in flexion at 120° in the lateral decubitus position. The mean distance of the radial nerve from the upper olecranon to the lateral intermuscular septum varied from 107.13 to 102.22 mm. The distance from the lateral epicondyle to the lateral edge of the radial nerve varied from 119.92 to 125.38 mm. There was not significant contrast in the position of the radial nerve with osseous landmarks concerning different degrees of flexion, except for 120°, which is not significant, as this flexion angle is rarely used.

InSafeLOCK® humeral nailing for humeral nonunions: Clinical and radiological results.

OBJECTIVES: This study aims to evaluate the clinical and functional results of patients treated with InSafeLOCK® humeral nail and iliac crest autograft for humeral nonunion. PATIENTS AND METHODS: A total of 15 patients (11 males, 4 females; mean age: 52.1±15.3 years; range, 31 to 78 years) who were followed conservatively for humeral fractures and operated with the InSafeLOCK® humeral nail and iliac bone graft in our center between June 2018 and January 2020 were retrospectively analyzed. Data including demographic and clinical characteristics of the patients, operative data, and pre- and postoperative Visual Analog Scale (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH), and Constant-Murley Scores (CMS) were recorded. RESULTS: The mean time from injury to nonunion treatment was 10.9±1.6 months. Five patients had atrophic, eight patients had oligotrophic, and two patients had hypertrophic nonunion. Preoperatively, the mean DASH was 37.7±9.1, the mean CMS was 69.7±6.3, and the mean VAS was 3.8±0.7. In all patients, union was achieved. The mean operation time was 59.0±16.2 min. The mean postoperative DASH score was 16.1±8.7, CMS 87.4±3.4, and VAS score 0.8±0.7. Regarding the shoulder joint, the mean abduction was 164.7±11.3 degrees, the mean internal rotation was 82.0±6.8 degrees, the mean external rotation was 81.3±8.3 degrees, and the mean flexion was 162.0±12.1 degrees. During follow-up, complications such as vascular-nerve injury, reflex sympathetic dystrophy, screw migration or loosening, implant failure, and loss of reduction did not occur in any of our patients. CONCLUSION: Considering the satisfactory functional and radiological results, the InSafeLOCK® humeral nail can be used safely in humeral nonunions.

Therapeutic analysis of Herbert screw fixation for capitellar fractures via the anterior approach in adolescent patients.

OBJECTIVE: The aim of this study is to analyze the efficacy of open reduction and Herbert screw fixation for coronal fractures of the capitellum via the anterior approach in adolescents. METHODS: We retrospectively analyzed the clinical and imaging data of 15 adolescents with capitellar fractures who were admitted to our hospital from May 2014 to May 2019. The fracture was reduced through the cubital crease incision via the anterior approach and was internally fixated with Herbert screws. A follow-up was conducted after the operation to examine fracture healing and elbow function. The postoperative functional recovery of patients was evaluated with the Mayo Elbow Performance index (MEPI) and the Broberg-Morrey rating system. RESULTS: Patients underwent surgery 3.7 days after injury on average. Intraoperative fracture reduction was satisfactory. No vascular injury or nerve injury occurred. Bony union occurred in an average of 6 weeks after the operation. All adolescents completed a 12- to 36-month follow-up. At the last follow-up, the Mayo Elbow Performance index was considered excellent in 12 patients and good in three patients. The Broberg-Morrey score was considered excellent in 12 patients, good in two patients, and fair in one patient. CONCLUSION: Open reduction with Herbert screw fixation via the anterior approach is a feasible surgical method for the treatment of coronal fractures of the capitellum in adolescents. LEVELS OF EVIDENCE: Therapeutic, retrospective study-Level IV.

Lateral entry pins and Slongo's external fixation: which method is more ideal for older children with supracondylar humeral fractures?

OBJECTIVE: The standard surgical treatment for supracondylar humeral fractures in children is closed reduction and percutaneous pinning. Given the need for greater fixation strength and higher risk of joint stiffness for children older than 8 years, external fixation is often performed for treating supracondylar humeral fractures in older children. The aim of this study was to compare the efficacy of lateral entry pins and Slongo's external fixation for treating supracondylar humeral fractures in older children. METHODS: Children older than 8 years who underwent surgery for supracondylar humeral fractures at our hospital for surgery from January 2016 to December 2020 are to be retrospectively assessed. One group (n = 36) underwent internal fixation and percutaneous pinning with three lateral Kirschner wires, and the other group (n = 32) underwent Slongo's external fixator surgery. The demographic data, operation duration, number of fluoroscopies, and fracture healing time were compared between both groups. The elbow joint function was evaluated 6 months after the surgery on the basis of fracture healing time, lifting angle, elbow joint range of motion (ROM), and Flynn score. The incidence of postoperative complications was also recorded. RESULTS: There was no significant difference between the two patient groups in terms of the demographic parameters. Compared to external fixation surgery, Kirschner wire surgery required shorter duration and fewer fluoroscopies (P < 0.05). Nevertheless, the fracture healing time was significantly less (P < 0.05), and the elbow ROM and Flynn scores were higher in the external fixator group compared to the Kirschner wire fixation group (P < 0.05). There was one case of secondary fracture displacement in the Kirschner wire group and one of pin tract infection in the external fixator group. No other iatrogenic injuries or complications were observed. CONCLUSION: Maybe Slongo's external fixator is a suitable alternative treatment option for supracondylar humeral fractures in children older than 8 years since it can achieve better fixation strength and early restoration of elbow joint movement with a lower risk of joint stiffness.

Characteristics of Cubitus Varus Deformity after Lateral Condylar Fracture of the Humerus.

Background: Lateral humeral condylar fractures often heal with some residual elbow deformity. However, details of angulation or tilting angle of the lateral condyle after the fracture have not been evaluated so far. Methods: Between 2008 and 2016, we followed up 80 mild fractures of the lateral humeral condyle for more than a year. Thirty fractures were treated by open reduction and internal fixation (ORIF) with Kirschner wires. Fifty cases were treated with a long arm splint for 3 weeks (Fig. 1). The average age of the patients at the time of the injury was 5.5 years. The humerus-elbow-wrist angle (HEWA), Baumann's angle (BA), and tilting angle (TA) were measured on the radiographs. The active range of motion (ROM) was clinically assessed at unaffected and affected sides at the final follow-up. Results: No significant differences were detected between the sides about TA or ROM at the final follow-up. However, HEWA/ BA showed more significant loss of correction. There were significant differences in BA at the affected side between the ORIF and splint groups. Conclusions: Cubitus varus deformity after lateral humeral condylar fracture is not accompanied by a change in TA or ROM, unlike the deformity after supracondylar or distal epiphyseal fracture of the humerus (Fig. 2). Operative treatment to precisely correct and fix the lateral condylar fracture still retained some cubitus varus deformity, although it might lessen or prevent the deformity when compared to conservative treatment with a splint.

Repurposing denosumab for recalcitrant bone healing.

Fracture healing has four phases: haematoma formation, soft callus, hard callus and remodelling. Often, non-healing fractures have an arrest of one of these phases, which need resurgery. We have repurposed denosumab for impaired fracture healing cases to avoid surgical intervention. Here, we report a series of three cases of impaired fracture healing where denosumab was given 120 mg subcutaneous dosages for 3 months to enhance healing. All the three cases have shown complete bone union at a mean follow-up of 6.7 months (5-9 months) as assessed clinically and radiologically, and have observed no adverse effect of the therapy. Denosumab given in this dose aids fracture healing by increasing callus volume, density and bridges the fracture gap in recalcitrant fracture healing cases where the callus fails to consolidate.

Determining the stability of minimally displaced lateral humeral condyle fractures in children: ultrasound is better than arthrography.

BACKGROUND: Evaluating of the articular cartilage status of the distal humeral epiphysis is difficult. Ultrasound imaging of the elbow is increasingly being used to confirm the integrity of the articular cartilage of minimally displaced lateral humeral condyle fractures in children with minimally displaced fractures. The aims of this study were to assess the correlations between ultrasound and arthrography findings for predicting the integrity of the cartilage hinge and to describe the utility of ultrasound in determining the need for pre-treatment. METHODS: Thirty-nine patients with minimally displaced lateral humeral condyle fractures who underwent ultrasound and arthrography examinations before surgery from May 2018 to December 2019 were included in this study. Ultrasound and arthrography predictors of the cartilage hinge status were independently measured. The ultrasound and arthrography results were compared. RESULTS: The mean displacement of the fractures was 3.1 mm (range, 2.0~5.0 mm). Arthrography showed incomplete fractures in 24 patients (61.5%) and complete fractures in 15 patients (38.5%). Ultrasound showed incomplete fractures in 25 patients (64.1%) and complete fractures in 14 patients (35.9%). The ultrasound and arthrography results of the integrity of the articular surface were consistent in 92.3% of the cases, including 23 that were predicted to have an intact articular surface and 13 that were predicted to have an incongruity articular surface. There was no correlation between the displacement and the fracture appearing complete on the ultrasound scan. The Pearson coefficient between ultrasound and arthrography for assessing the integrity of the articular surface was 0.837. CONCLUSIONS: Ultrasound and arthrography assessments of the integrity of the cartilage hinge status appear to be highly consistent. Ultrasound can be used as a complementary tool with arthrography to predict the integrity of the cartilage hinge status in children with minimally displaced lateral humeral condyle fractures. LEVEL OF EVIDENCE: Prospective study; level II.

Lateral Condyle Fracture of the Humerus in Children: Kirschner Wire or Screw Fixation?

INTRODUCTION: The treatment of the displaced fracture of the lateral condyle of the distal humerus in children aims not only to avoid nonunion, malalignment, and impairment of the range of motion of the elbow but also to prevent delayed healing and the development of any prearthrotic deformity. To date there is no agreement on what kind of osteosynthesis should be used. So far, the screw fixation and Kirschner wire fixation have both been applied. Therefore, the goal of this study was to compare the outcome of these two methods. MATERIALS AND METHODS: A retrospective cohort study was undertaken including 43 patients aged 2 to 13 years who underwent osteosynthesis for a condylar fracture of the humerus over a period of 10 years. The electronic archive, including the radiological diagnostics, was analyzed. Statistical analysis was performed using IBM SPSS Statistics 20.0. Statistical significance was set at an α level of p = 0.05. RESULTS: Kirschner wire fixation was performed in 48.9% of condylar fractures of the humerus while screw fixation (alone or in combination with a pin) was assessed with a percentage of 51.1% of the cases in this study. Screw fixation only was applied in 20.9% of fractures of the lateral condyle. The selection of the method was independent of the age of the patient (p = 0.2). The comparison of the rate of complications and an impaired range of motion after Kirschner wire osteosynthesis to the rate after screw osteosynthesis showed a significantly lower percentage for the Kirschner wire group (p = 0.046). No case of nonunion, nerve palsy, or pin migration was detected in any patient in this study. CONCLUSION: Kirschner wire fixation of condylar humeral fractures in children resulted in a lower rate of complications than screw fixation. No case of nonunion of the fracture was found in the patients that we investigated so that we conclude that Kirschner wires sufficiently adapt the fracture in these cases. LEVEL OF EVIDENCE: Level III.

Arthroscopic fixation of humeral greater tuberosity fracture using a W-shaped suture.

BACKGROUND: Patients with greater tuberosity fractures of the humerus often require surgery. Therefore, there is a need to find a minimally invasive and effective surgical procedure with great patient outcomes. AIM: To evaluate the clinical outcomes of the W-shaped suture technique under shoulder arthroscopy in the treatment of greater tuberosity fractures of the humerus. METHODS: In this retrospective study, a total of 17 patients were included. The fractures were closed, and there was no neurovascular injury. These patients underwent arthroscopically assisted reduction and internal fixation of the greater tuberosity fractures. Fixation was performed using sighting nails combined with a W-shaped suture. The imaging data of the patients were collected, and the ASES score, Constant-Murley score, and VAS score were used to evaluate the patient's outcome. At the last follow-up (at least 1 year), the range of motion in the affected shoulder was compared with that of the contralateral side. RESULTS: The operation was successful in all the patients. The average follow-up time was 13 months. There were no reported complications such as fracture displacement, nonunion, and internal fixation failure during the follow-up period. Post-operative X-ray examinations revealed good function recovery, with a healing time of between 10 and 12 weeks, and an average healing time of 11.5 weeks. Following the operation, patients reported reduced shoulder joint pain that no longer influenced their activity or caused discomfort in their daily life. The patient's VAS score ranged from 0 to 3, with an average of 0.52 ± 0.73, while at the last follow-up, the Constant-Murley score ranged from 83 to 97, with an average of 92.33 ± 7.55. The ASES score ranged from 81 to 98, with an average of 93.15 ± 6.93. At the last follow-up, there was no significant difference in the overall range of motion with the unaffected limb. CONCLUSION: This study demonstrates that the W-shaped suture can be used to effectively fix the fractures of the greater tuberosity of the humerus, by increasing the fixed area to promote healing.

Comparison of the Posterior and Anterolateral Surgical Approaches in the Treatment of Humeral Mid-Shaft Fractures: A Retrospective Study.

BACKGROUND The aim of this study was to retrospectively assess and compare the functional outcomes and complications following anterolateral versus posterior surgical approaches for the treatment of mid-shaft fractures of the humerus. MATERIAL AND METHODS This study included 107 patients treated for mid-shaft fractures between May 2015 and July 2018. Demographic and surgical data were collected for each patient. During follow-up visits, radiographs were acquired and evaluated. The clinical outcomes of the involved joints were assessed by the Constant scoring system, range of motion (ROM), and the Mayo Elbow Performance Scoring system at the 12-month follow-up. RESULTS The posterior approach was performed in 57 patients with type A fractures (group I, n=28) and type B or C fractures (group III, n=29). The anterolateral approach was performed in 50 patients with type A fractures (group II, n=32) and type B or C fractures (group IV, n=18). There were no significant differences between group I and group II nor between group III and group IV with respect to patient demographic data, surgical data, Constant score, ROM, or Mayo Elbow Performance score. A significant difference in the total complication rate was observed between group I and II. CONCLUSIONS The anterolateral approach showed an advantage over the posterior approach for treating simple humeral mid-shaft fractures. However, this advantage was not observed in treating comminuted fractures.

Correlation between modified trochleocapitellar index and post-traumatic elbow stiffness in type C2-3 distal humeral fractures among adults.

BACKGROUND: The purpose of this study was to propose the modified trochleocapitellar index (mTCI), assess its reliability, and evaluate its correlation with post-traumatic elbow stiffness in type C2-3 distal humeral fractures among adults. METHODS: From January 2013 to June 2017, a total of 141 patients with type C2-3 distal humeral fractures were included. The mTCI was calculated as the ratio between the modified trochlear and capitellar angles relative to the humeral axis (mTCI-HA), lateral humeral line (mTCI-LHL), and medial humeral line (mTCI-MHL) from anteroposterior radiographs taken immediately after the operation. The patients were divided into group A (with elbow stiffness) and group B (without elbow stiffness) based on follow-up results. To determine risk factors for elbow stiffness, univariate and logistic regression analyses were performed on each radiographic parameter separately, together with other clinical variables. Interrater reliability was assessed for all measurements. RESULTS: Specific optimal ranges of value were identified for mTCI-HA (0.750-0.875), mTCI-LHL (0.640-1.060), and mTCI-MHL (0.740-0.900), beyond which the likelihood of elbow stiffness significantly increased (P < .001). By multivariate analysis, mTCI-HA (odds ratio [OR] 26.22, 95% confidence interval [CI] 3.39-203.07, P = .002), mTCI-LHL (OR 5.37, 95% CI 2.17-13.28, P < .001), and mTCI-MHL (OR 5.95, 95% CI 1.91-18.56, P = .002) values beyond the optimal ranges were identified as the independent risk factors for elbow stiffness. The interrater reliability of mTCI-HA, mTCI-LHL, and mTCI-MHL was 0.986, 0.983, and 0.987, respectively. CONCLUSION: The mTCI measurement method is reliable. Either too small or too large mTCI values were associated with post-traumatic elbow stiffness among adult patients with type C2-3 distal humeral fractures. The mTCI-HA showed a better predictive value than mTCI-LHL and mTCI-MHL.

Association of Patient-reported Outcomes With Clinical Outcomes After Distal Humerus Fracture Treatment.

In this study, we assessed the patient-reported outcomes of distal humerus fracture treatment using Patient-Reported Outcomes Measurement Information System (PROMIS) or QuickDASH (Disabilities of the Arm, Shoulder, and Hand) scores and the association between patient-reported outcomes and clinical outcomes. Methods: We performed a retrospective cohort study of 76 adult patients who sustained an acute distal humerus fracture between 2016 and 2018; 53 patients completed at least one patient-reported outcome measure used to assess physical function (PF) during their routine follow-up care (69.7% response rate). The average time to follow-up patient-reported outcome measure was 10.3 months. Patients completed the PROMIS PF 10a, PROMIS upper extremity (UE) 16a, and/or QuickDASH based on the treating institution/service. In addition, the PROMIS Global (Mental) subscale score was used as a measure of self-rated mental health. To assess clinical outcomes, we measured radiographic union, range of motion, and postoperative complications. Results: Most fractures were intra-articular (67.9%), and 84.9% were treated surgically. After treatment, 98.1% of fractures united radiographically. By the final follow-up, the average arc of motion was 18° to 122°. Average (±SD) PROMIS PF and UE scores were 41.7 ± 11.1 and 40.8 ± 12.4, respectively. The average QuickDASH score was 39.4 ± 26.5. The arc of flexion-extension and PROMIS Global (Mental) score were independently associated with PROMIS PF and PROMIS UE scores. Conclusions: We found that clinical factors (the arc of flexion-extension) and patient psychological factors (PROMIS Global [Mental] score) were independently associated with PROMIS measures of PF after distal humerus fracture treatment. These data can be used to contextualize patient outcomes and guide patient expectations.

Conservative vs. operative treatment for humeral shaft fractures: a meta-analysis and systematic review of randomized clinical trials and observational studies.

BACKGROUND: This meta-analysis aimed to compare conservative vs. operative treatment for humeral shaft fractures in terms of the nonunion rate, reintervention rate, permanent radial nerve palsy rate, and functional outcomes. Secondarily, effect estimates from observational studies were compared with estimates of randomized clinical trials (RCTs). METHODS: The PubMed/Medline, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases were searched for both RCTs and observational studies comparing conservative with operative treatment for humeral shaft fractures. RESULTS: A total of 2 RCTs (150 patients) and 10 observational studies (1262 patients) were included. The pooled nonunion rate of all studies was higher in patients treated conservatively (15.3%) vs. operatively (6.4%) (risk difference, 8%; odds ratio [OR], 2.9; 95% confidence interval [CI], 1.8-4.5; I2 = 0%). The reintervention rate was also higher for conservative treatment (14.3%) than for operative treatment (8.9%) (risk difference, 6%; OR, 1.9; 95% CI, 1.1-3.5; I2 = 30%). The higher reintervention rate was predominantly attributable to the higher nonunion rate in patients treated conservatively. The permanent radial nerve palsy rate was equal in both groups (OR, 0.6; 95% CI, 0.2-1.9; I2 = 18%). There appeared to be no difference in mean time to union and mean Disabilities of the Arm, Shoulder and Hand scores between the treatment groups. No difference was found between effect estimates form observational studies and RCTs. CONCLUSION: This systematic review shows that satisfactory results can be achieved with both conservative and operative management; however, operative treatment reduces the risk of nonunion compared with conservative treatment, with comparable reintervention rates (for indications other than nonunion). Furthermore, operative treatment results in a similar permanent radial nerve palsy rate, despite its inherent additional surgery-related risks. No difference in mean time-to-union and short-term functional results was detected.

Validity of the distance between the anterior humeral line and capitellum as a quantitative measure of supracondylar humeral fracture in children.

INTRODUCTION: The anterior humeral line (AHL) is a radiographic marker used to quantify anterior-posterior displacement in supracondylar humeral fractures on lateral radiographs. As both the anterior border of the capitellum and the undeveloped ossific nucleus are clearly recognisable on lateral radiographs, we analysed the distance between the AHL and capitellum (AC distance). We hypothesised that the AC distance would provide a highly reproducible and useful index of correction losses in supracondylar humeral fractures. MATERIALS AND METHODS: Forty-two patients (mean age: 6.5 years) who had suffered supracondylar humeral fractures were enrolled in this study. The fractures were corrected by cross pinning in 28 patients and by lateral or lateral and posterior pinning in 14 patients. The AC distance, Baumann angle, and tilting angle were measured in radiographs of the supracondylar humeral fractures obtained immediately after surgery and after bone union. Correction losses were calculated and defined as changes in the AC distance, tilting angle, and Baumann angle. We investigated inter-observer and intra-observer variability in all three radiological parameters and also compared these parameters between children who underwent lateral pin fixation and those who underwent crossed pin fixation. RESULTS: An analysis of intra-observer variability yielded values of 0.93, 0.73, and 0.92 for the AC distance, tilting angle, and Baumann angle, respectively. An analysis of inter-observer variability yielded corresponding values of 0.84, 0.46, and 0.79, respectively. Notably, the change in AC distance was significantly smaller in the cross pinning group than in the lateral pinning group. DISCUSSION: Compared with the Baumann angle and tilting angle, the AC distance was identified as the most reliable method for measuring radiographs. Moreover, smaller correction losses were observed with cross pinning than with lateral pinning. Therefore, the AC distance is a useful and accurate quantitative parameter when analysing supracondylar fractures in children using sagittal plane images.