Evaluation of the Davos self-assisted technique for reduction of anterior glenohumeral dislocations: a comparative study with the traction/countertraction technique.

Background: Few studies have compared conventional and self-assisted shoulder reduction maneuvers. The goal of this study was to evaluate the results of self-assisted Davos vs. traction/countertraction (T/Ct) techniques in the treatment of acute anterior shoulder dislocations. Methods: This was a single-center, prospective study carried out at a tertiary hospital emergency department. Patients aged 18-69 years old, with radiographic confirmation of anterior glenohumeral dislocations, were consecutively allocated to treatment groups. Recorded data included pain at admission (visual analog scale [VAS] score at admission), analgesia before reduction, maximum pain during reduction (maximum VAS score), demographic characteristics, lesion mechanism, laterality, prior dislocation, and immediate complications. The primary outcomes were reduction success rate and pain. Results: Eighty individuals were included (40/group). Regarding the success rate, no statistically significant differences were found between Davos or T/Ct (87.5% vs. 85%; P = .058). The maximum VAS score was significantly lower in Davos than that in T/Ct (4.18 ± 2.00 vs. 6.30 ± 2.13; P < .001). The effect of analgesia in the maximum VAS score was more evident among Davos patients, with significantly lower pain in the subgroup who were provided analgesia (3.63 ± 2.02 vs. 5.31 ± 2.01; P = .01). Discussion: Davos was as effective as T/Ct for reduction of acute anterior shoulder dislocations (highest reported success rate: 87.5%) and conditioned a less traumatic experience, with significantly lower pain during reduction (the maximum VAS score was more than 2 points lower in the Davos group; P < .001). Analgesia had a synergistic effect among patients submitted to the Davos technique, suggesting that T/Ct is inherently more painful. Conclusion: The Davos is a patient-controlled, atraumatic, and safe technique, allowing successful, gentle, and less painful glenohumeral reduction. These findings favor Davos as an easy-to-teach and effective first-line treatment for first-time and recurrent shoulder dislocations.

Proximal humerus fractures: epidemiology and trends in surgical management of hospital-admitted patients in Portugal.

Background: Proximal humerus fractures (PHFs) are frequent and associated with significant health care burden. National epidemiological data are limited. Our objective is to characterize the Portuguese population admitted with PHFs and analyze therapeutic management, the impact of associated lesions, and mortality rate. Methods: This was a retrospective, observational study of admissions from mainland public hospitals (2000-2015), with primary or secondary diagnosis of PHFs. Incomplete records, pathologic lesions, malunion/nonunion, and hardware removal were excluded. Age, gender, admission date, hospitalization period, associated injuries, treatment, and mortality were recorded. Results: A total of 19,290 patients were included. Through the analyzed period, an increase in the absolute number and incidence of PHFs was observed. The mean age at diagnosis was 62.6 ± 21.0 years old (57% elderly; 63.5% female). The mean length of stay was 10.0 ± 14.1 days, higher in patients submitted to arthroplasty (P < .001) and in those with associated fractures (25%; P < .001). A total of 14,482 patients were operated, most frequently with open reduction and internal fixation (28%). The inpatient mortality rate was 3.2%, significantly higher in patients with associated fractures (odds 2.77 for lower limb vs. upper limb). Conclusion: There is a trend toward an increase in surgical management of PHFs. The relative proportion of open reduction and internal fixation and arthroplasty (particularly reverse arthroplasty) increased, probably reflecting biomechanical implant properties, fracture pattern, and demand for better functionality. Associated fractures are an important comorbidity, associated with increased mortality and length of stay.

Fracture pain-Traveling unknown pathways.

An increase of fracture incidence is expected for the next decades, mostly due to the undeniable increase of osteoporotic fractures, associated with the rapid population ageing. The rise in sports-related fractures affecting the young and active population also contributes to this increased fracture incidence, and further amplifies the economical burden of fractures. Fracture often results in severe pain, which is a primary symptom to be treated, not only to guarantee individual's wellbeing, but also because an efficient management of fracture pain is mandatory to ensure proper bone healing. Here, we review the available data on bone innervation and its response to fracture, and discuss putative mechanisms of fracture pain signaling. In addition, the common therapeutic approaches to treat fracture pain are discussed. Although there is still much to learn, research in fracture pain has allowed an initial insight into the mechanisms involved. During the inflammatory response to fracture, several mediators are released and will putatively activate and sensitize primary sensory neurons, in parallel, intense nerve sprouting that occurs in the fracture callus area is also suggested to be involved in pain signaling. The establishment of hyperalgesia and allodynia after fracture indicates the development of peripheral and central sensitization, still, the underlying mechanisms are largely unknown. A major concern during the treatment of fracture pain needs to be the preservation of proper bone healing. However, the most common therapeutic agents, NSAIDS and opiates, can cause significant side effects that include fracture repair impairment. The understanding of the mechanisms of fracture pain signaling will allow the development of mechanisms-based therapies to effectively and safely manage fracture pain.

[Post Traumatic Pseudoaneurysm of the Axillary Artery with Late Clinical Presentation]. / Pseudoaneurisma Pós-Traumático da Artéria Axilar com Apresentação Clínica Tardia.

Traumatic lesions of the axillary artery are rare in fractures of the proximal humerus. Clinical manifestations are sparse, generally presenting in the acute form, although in some cases the clinical signs only emerge later after the traumatic event. The early diagnosis might prevent serious complications. The authors present a case of a traumatic lesion of the axillary artery, with a delayed presentation, resulting from a traumatic fracture of the proximal third of the humerus that required emergent surgical management.

Epithelioid hemangioendothelioma presenting as a vertebral fracture.

Epithelioid hemagioendothelioma (EH) is a rare vascular tumor with an intermediate biological behavior between hemangioma and angiosarcoma. Vertebral location is even more rare, and because the number of reported cases of EH is small and the follow-up periods short, the best surgical treatment, the role of radiotherapy and chemotherapy, as well as the definitive prognosis are still not established. The authors report a case of EH which presented as a vertebral fracture with neurological impairment, where a percutaneous biopsy was inconclusive. Treatment included vertebrectomy, with complete excision of the lesion, spinal canal decompression and vertebral stabilization. Anatomopathological study revealed an epithelioid vascular neoplasm with low mitotic index, and tumor cells reactive to vimentin, CD31 and CD34, leading to the diagnosis of Grade I Epithelioid Hemangioendothelioma. Because of the wide resection achieved and the low aggressiveness of the lesion, no adjuvant radio or chemotherapy was undertaken, and at 6 years follow-up there are no signs of recurrence or metastasis.