Distal Humerus Fractures Research Articles

Utilization of 1.25mm wire and locking plate fixation for a comminuted low transverse distal humerus fracture, a case report of a 78-year-old woman.

Introduction Low transverse distal humerus fractures can be challenging to treat in elderly populations—especially when there is severe comminution or underlying bone demineralization. Current operative interventions include total elbow arthroplasty or open reduction internal fixation (ORIF) with traditional plate and screw fixation. Herein, we present a unique case utilizing Kirschner wires (K-wires) and locking plate fixation as an alternative approach to managing low transverse distal humerus fractures. Case A 78-year-old right-hand dominant retired female presented with a displaced, comminuted, low transverse distal humerus fracture secondary to a fall from standing. Fixation of this fracture was achieved through a slight modification of the skinny K-wire and locking plate technique described by Olson et al. in 2021. Methods A triceps-sparing approach to the distal humerus was conducted through a direct posterior incision. The low transverse extra-articular fracture was identified and anatomically reduced. A posterior medial distal humerus plate was secured to reduce the medial column with 1.25x150mm K-wires subsequently placed through the trochlea. The K-wires were then bent as they exited the lateral side and cut short in the metaphysis, approximately 90° to the shaft of the humerus. After which, a posterolateral distal humerus plate was used to secure the lateral epicondyle and secures the K-wires beneath it. Results Seven weeks after the procedure, the patient had regained 81% elbow arc of motion, with a complete return of grip strength, pronation, and supination. At this time, radiographs demonstrated satisfactory bone healing, and the patient surpassed all therapy goals. Conclusion Our case demonstrates the modified use of the 1.25mm K-wire and locking plate technique as a satisfactory treatment option for comminuted low transverse distal humerus fracture in a 78-year-old female who sustained a ground-level fall. Ultimately resulting in the rapid return of function by postoperative week seven.

Arthroscopic Capsular Release for Post-traumatic Elbow Stiffness.

Post-traumatic elbow stiffness (PTES) may substantially affect the patient's functional range of motion and quality of life. Open elbow release has been extensively studied, but arthroscopic techniques are limited, particularly in differentiating between post-traumatic and non-traumatic stiffness. The purpose of this study is to assess the clinical outcomes after arthroscopic release of PTES regarding the range of motion (ROM), pain, functional assessment, and complications. A prospective cohort was conducted on adult patients who underwent arthroscopic arthrolysis for PTES, with 32 patients included in the final analysis. The ROM was measured using the orthopedic goniometer. Grip strength was measured using the Camry digital hand dynamometer (Camry, CA, USA) and compared to their contralateral side. The functional status of the patients was evaluated using the American Shoulder and Elbow Surgeons Score (ASES)andthe Mayo Elbow Performance Index (MEPI). All measurements were done before surgery and at the last follow-up visit. Pre-operative and post-operative changes in MEPI, ASES, and visual analog (VAS) scores were compared with the paired t-test. After surgery, the ROM significantly improved from 74 ± 11 to 110 ± 15 degrees (p<0.001). Additionally, the ASES score and MEPI index both significantly improved from 69 ± 3.4 to 79 ± 6.3 and from 64 ± 5.7 to 82 ± 8, respectively (p<0.001). VAS scores also significantly improved from 1.1 ± 0.87 to 0.31 ± 0.53 at rest (p<0.001). The complication rate was 12%, including three transient ulnar nerve paresthesia and one superficial infection. Post-traumatic elbow release was more offered in distal humerus fractures (53%), followed by proximal ulna fracture/dislocations (25%). We believe that arthroscopic arthrolysis is a safe and reliable treatment of PTES, which improves joint visibility and reduces pain. Patients can be counseled regarding the risk of a secondary surgery following distal humerus or proximal ulna fractures, including the expected recovery and complication rate.

Impact of the SARS-CoV-2 outbreak on ACGME-accredited orthopaedic trauma fellowship training

IntroductionThe SARS-CoV-2 viral outbreak created unprecedented challenges in surgical education. Yet, its impact on reported case volume during orthopaedic trauma fellowship training remains poorly understood. We hypothesized that cases performed during orthopaedic trauma fellowship training would decrease by 8 %–17 % during the 2019–2020 academic year corresponding to the 1–2 month moratorium of non-essential cases during the initial SARS-CoV-2 outbreak in the United States. MethodsWe designed a retrospective cohort study of orthopaedic trauma fellows at Accreditation Council for Graduate Medical Education (ACGME)-accredited training programs (2018–2019 to 2021–2022). Mean case volumes were compared by case category across academic years. ResultsThere was a −13 % year-over-year decrease in reported case volume during the 2019–2020 academic year (505 ± 126 vs 441 ± 94, P = 0.079, Fig. 1). Case categories with the greatest percentage declines were Treatment of Nonunion / Malunion (−31 %), Fasciotomy (−25 %), External Fixation (−21 %), Forearm / Wrist (−21 %), and Intra-articular Distal Humerus Fracture (−17 %). There was a 7 % year-over-year increase in case volume during the subsequent 2020–2021 academic year with near universal increases in case volume across case categories. ConclusionThere was a 13 % decrease in orthopaedic trauma case volume during the 2019–2020 academic year, corresponding to the SARS-CoV-2 outbreak. Certain trauma case categories experienced the greatest negative impact, which subsequently recovered during the next academic year. These results may help inform accrediting bodies and surgical educators on the impact of future viral outbreaks on orthopaedic trauma fellowship training.

Incidence, treatment techniques, and results of distal humeral coronal shear fractures in children and adolescents-a multicenter study of the German Section of Pediatric Traumatology (SKT).

Distal humeral coronal shear fractures (CSF) are uncommon and may be challenging to treat due to their size, location, and intraarticular nature. The purpose of this study was to analyze treatment concepts of this rare entity in the growing age. Based on a multi-center data analysis we retrospectively reviewed patients below 16 years of age with CSF treated at 13 high-volume pediatric trauma centers. Data from 51 patients with a CSF treated between 01/2012 and 12/2021 were analyzed. The mean age was 12.9 years (10-15), and there was a trend towards male patients (30: 21). The initial diagnostic approach was conventional X-ray in all cases. In addition, a CT scan (n = 33), MRI scan (n = 9), or both (n = 3) were performed. All fractures except two showed relevant displacement. Consequently, only two cases received conservative treatment consisting of plaster immobilization. Surgical treatment was performed in 49 cases consisting of open or mini-open reduction and metal/resorbable screw osteosynthesis (n = 39), plates (n = 4), K-wire pinning (n = 6), and others (n = 6), as well as combinations. In 1 case open reduction without osteosynthesis was performed. Postoperative additional plaster immobilization was performed in 40 cases (for a mean of 19 days (2-42)), physiotherapy was initiated in 29 cases, and metal removal was performed in 28 cases (after a mean of 18.1 weeks (4-44)). After a mean follow-up of 9.9 months (2-25), elbow axial deviation (5° valgus) was observed in one case and mild loss of elbow ROM in six cases (11.7%). Complications included revision of the osteosynthesis because of insufficient articular reconstruction (n = 4), removal of a free joint body (n = 1), an osteonecrosis (n = 1), and a cartilage defect (n = 1). In pediatric patients CSFs start to occur at the age of 10, but are typically observed at the age of 13 and older. Because of their intraarticular nature and predilection toward displacement, these fractures are frequently treated operatively. The surgical strategy requires open reduction and anatomic reconstruction of the articular surface. Stable internal fixation, most often achieved by screws, permits early mobilization and leads to good outcomes in most cases. This is presumably due to the fact that mostly simple fractures occur in children and mostly complex injuries in older adults. III, retrospective analysis.

Treatment of Distal Third Humeral Shaft Fracture with Intramedullary Nail Combined with Anterior Minimally Invasive Plate Osteosynthesis.

The treatment of distal third humeral shaft fracture is difficult. Studies have shown that anterior minimally invasive plate has lower probability of complication and higher healing rate. However there is no applicable anatomical plate at present. This study is to investigate the clinical effect of intramedullary nail combined with anterior minimally invasive plate in the treatment of distal humeral shaft fractures. The data of 83 patients with lower humerus shaft fracture treated from September 2015 to January 2020 were analyzed. According to different treatment methods, they were divided into two groups: 40 patients were treated with intramedullary nailing combined with minimally invasive anterior plate fixation (group A), and 43 patients were treated with double plate fixation through posterior approach (group B). General preoperative data, operative time, intraoperative blood loss, total incision length, fracture healing time, shoulder and elbow visual analogue scale (VAS) score, Constant-Murley shoulder function score, Mayo elbow function score, and complications were recorded and compared between the two groups. Two independent sample t-tests was used for follow-up, age, BMI, operation time, intraoperative bleeding, total incision length, fracture healing time, Constant-Murley score and Mayo score, and rank sum test was used for VAS score of shoulder and elbow. There was no significant difference in preoperative general data between the two groups (p > 0.05), indicating comparability. There were no significant differences in operation time, total incision length, fracture healing time, Constant-Murley shoulder function score at the last follow-up, Mayo elbow function score, and shoulder and elbow VAS pain score between 2 groups (p > 0.05). The amount of intraoperative blood loss in observation group was 76.98 ± 16.46, which was significantly less than that in control group, and the difference was statistically significant (p < 0.01). There were no radial nerve injury, musculocutaneous nerve injury, incision infection and fracture nonunion in the observation group. In the control group, four cases of iatrogenic radial nerve injury, three cases of incision infection and three cases of fracture nonunion were found. The complication rate was 23.3% (10/43). There was statistical difference in the incidence of complications between the two groups (p < 0.01). A humeral intramedullary nail combined with an anterior minimally invasive plate in the treatment of distal humeral shaft fracture has the advantages of less soft tissue damage, less blood transfusion, high fracture healing rate and low risk of iatrogenic radial nerve injury, which is an effective method for clinical treatment of this type of fracture.

A review on functional outcomes of intra-articular distal humerus fractures treated with recon plate using Mayo Elbow Performance Score (MEPS).

Objective: To Review on Functional Outcomes of Intra-articular Distal Humerus Fractures Treated with Recon Plate Using the Mayo Elbow Performance Score (MEPS). Study Design: Retrospective study. Setting: Department of Orthopaedic &amp; Spine Surgery, Ghurki Trust Teaching Hospital, Lahore. Period: 2015 to 2021. Material &amp; Methods: A total of 353 patients meeting the inclusion criteria enrolled in the study. Patients were followed up at three months postoperatively to assess functional outcome using the Mayo Elbow Performance Score (MEPS). All data were recorded on the proforma. All the collected data were entered and analyzed through SPSS version 22. The chi-square test was applied post-stratification, taking p≤0.05 as significant. Results: In this study, 353 patients were included; among these majority, 220(62.4%) were males, and 133 were female (37.7%). The mean Age of patients was 42.5±14.32, ranging from 18 to 75 years. 182(51.6%) were affected on the left side compared to the right Side 170(48.2%). In most cases, the history of a mode of injury was fall 266(75.3%), and only 87(24.6%) had RTA history. The average MEPS score was 87.37±15.81, ranging from 40 to 100. According to the distribution of functional outcome, 265(75.1%) reported excellent outcome, 52(14.7%) with good, 26(7.5%) as fair, and only 10(2.8%) reported poor outcome. Stratification of functional outcome and patient demographic history showed a statistically significant association between age, gender, side effect, mode of injury, and functional outcome as p&lt;.05. Conclusion: It is concluded that Recon plates provided patients who had distal humerus fractures an excellent functional result. It provides reliable stabilization for fractures of the distal humerus. Due to its improved stability, the device aids early mobility even in fractures with complications. Therefore, the surgeon should use this technique to avoid complications.

Operative Fixation of a Humeral Shaft Periprosthetic Fracture After IlluminOss: A Case Report.

An 82-year-old man sustained a periprosthetic fracture after IlluminOss photodynamic bone stabilization system (PBSS) stabilization for an impending pathologic fracture. Nonoperative management was unsuccessful, and he subsequently underwent operative fixation, which featured lag screw fixation of the spiral distal humeral shaft fracture and osteotomy followed by plate fixation of the pathologic humeral shaft fracture. This is the first article to report this complication with IlluminOss PBSS stabilization and details regarding revision surgery.

2021 SECEC Annual Meeting Best Paper Award: Elbow hemiarthroplasty and total elbow arthroplasty provided a similar functional outcome for unreconstructable distal humeral fractures in patients aged 60 years or older: a multicenter randomized controlled trial

Semiconstrained total elbow arthroplasty (TEA) is an established treatment for elderly patients with distal humeral fractures not amenable to stable internal fixation (unreconstructable). In recent years, there has been increasing interest in elbow hemiarthroplasty (EHA), a treatment option which does not entail restrictions on weight-bearing as opposed to TEA. These 2 treatments have not been compared in a randomized controlled trial (RCT). The aim of this study was to compare the functional outcome of EHA and TEA for the treatment of unreconstructable distal humeral fractures in elderly patients. This was a multicenter randomized controlled trial (RCT). Patients were included between January 2011 and November 2019 at one of 3 participating hospitals. The inclusion criteria were an unreconstructable distal humeral fracture, age ≥60years and independent living. The final follow-up took place after ≥2years. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand (DASH) score. Secondary outcome measures were the Mayo Elbow Performance Score (MEPS), the EQ-5D index, range of motion (flexion, extension, pronation, and supination) and grip strength. Forty patients were randomized to TEA (n=20) and EHA (n=20). Five patients died before completing the final follow-up, leaving 18 EHA and 17 TEA patients for analysis. There were 31 women. The mean age was 74.0 (SD, 8.5) years in the EHA group and 76.9 (SD, 7.6) in the TEA group (P=.30). The mean DASH score was 21.6 points in the EHA group and 27.2 in the TEA group (P=.39), a difference of -5.6 points (95% CI: -18.6 to 7.5). There were no differences between treatment with EHA and TEA for the mean values of the MEPS (85.0 vs. 88.2, P=.59), EQ-5D index (0.92 vs. 0.86, P=.13), extension (29° vs. 29°, P=.98), flexion (126° vs. 136°, P=.05), arc of flexion-extension (97° vs. 107°, P=.25), supination (81° vs. 75°, P=.13), pronation (78° vs. 74°, P=.16) or grip strength (17.5kg vs. 17.2kg, P=.89). There were 6 adverse events in each treatment group. In this RCT, both elbow hemiarthroplasty (EHA) and total elbow arthroplasty (TEA) resulted in a good and similar functional outcome for unreconstructable distal humeral fractures in elderly patients at a minimum of 2years of follow-up.

Widening Access: Sterile Tourniquets for Surgery to the Distal Humerus.

Purpose of the study The use of tourniquets during surgery of the distal humerus can improve visibility and reduce surgical time. However, the available operating field can be limited due to the size and placement of the tourniquet. This proof-of-concept study aimed to determine if sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus. Methods Volunteers (n = 5) were positioned to simulate access to the distal humerus. The distance from the posterior corner of the acromion to the tip of the olecranon was measured. Participants were draped according to the standard protocol for the use of a non-sterile or sterile tourniquet for distal humerus and humeral shaft fractures. Two non-sterile pneumatic tourniquets (standard and narrow) and two sterile tourniquets (pneumatic and elastic exsanguination) were tested. The surgical field was measured from the sterile drape or tourniquet proximallyto the tip of the olecranon. A one-way repeated measures ANOVA was conducted to examine the effect of each tourniquet on the surgical field. Results The sterile elastic exsanguination tourniquet had the largest available field with a mean of 24.4 cm (71% of arm available for incision after application), followed by the sterile pneumatic tourniquet of 20.0 cm (58%), narrow non-sterile pneumatic of 19.2 cm (55%), and standard non-sterile pneumatic of 17.0 cm (49%). Repeated measures ANOVA determined that mean surgical field length is statistically significant between tourniquet devices (F (1.729, 6.914) = 21.783, p = .001). The surgical field length was statistically significantly increased from a non-sterile standard tourniquet to a sterile elastic tourniquet (7.4 (95% CI, 2.9-11.9) cm, p = .008)but not the other two tourniquet devices tested. Conclusion The use of certain types of sterile tourniquets can provide a wider surgical field compared to non-sterile tourniquets for procedures around the distal humerus, specifically the sterile elastic exsanguination tourniquet providing a statistically significant mean gain of 7.4 cmfrom the non-sterile tourniquets. These findings suggest that the use of sterile tourniquets should be considered more frequently in surgery of the distal humerus, and a sterile exsanguinating tourniquet could be considered for midshaft humeral fractures, facilitating safer exposure of the radial nerve and reduced blood loss.

Reverse end-to-side technique (RETS) – supercharge and babysitting effect in median and ulnar nerve injuries. Case studies and surgical technique

High nerve damage at the shoulder or elbow is associated with a long regeneration period for effectorsmuscles located within the hand, leading to their irreversible atrophy and permanent dysfunction. Advanced microsurgical reconstructive techniques, such as end-to-side (ETS ) sutures, reverse end-to-side (RETS ) reconstruction (so-called supercharge/babysitting procedure), or nerve transfers within the hand, shorten the interval and thus the recovery time or provide continuous stimulation of the effector before the regeneration of the native axons of the nerve. The paper aims to present the authors’ results after treatment of a high injury of the ulnar and median nerves with additional RETS performed based on the results of three clinical cases. Two patients No 1 and 2 had a high ulnar nerve injury at the elbow level due to a distal humerus fracture. Nerve neurolysis was performed at the level of the primary lesion, followed by a reverse end-to-side transfer of the anterior interosseous nerve to the deep motor branch of the ulnar nerve. The patient No 3 with damage to the median nerve due to a fracture of the shaft of the radius. Neurolysis of the preserved part of the nerve, resection of the neuroma, and direct suture of the damaged part of the nerve were performed, as well as a simultaneous RETS transfer of the anterior interosseous nerve to the thenar motor branch of the median nerve. All presented patients had significant signs of improvement, with full to partial motor recovery of the nerves supported by supercharge/babysitting RETS technique. It is valuable, especially in borderline cases when the decision is between neurolysis/repair alone or nerve transfer is difficult to take and not clearly defined.

Distal humeral hemiarthroplasty compared to total elbow replacement for distal humeral fractures: a registry analysis of 906 procedures

Total elbow replacement (TER) is an accepted treatment for complex intra-articular distal humerus fractures in elderly patients. Distal humeral hemiarthroplasty (HA) is also a potential surgical option for unreconstructable fractures and avoids the concerns regarding mechanical wear and functional restrictions associated with TER. In the current literature, there are limited data available to compare the revision rates of HA and TER for the treatment of fracture. We used data from a large national arthroplasty registry to compare the outcome of HA and TER undertaken for fracture/dislocation and to assess the impact of demographics and implant choice on revision rates. Data obtained from the Australian Orthopaedic Association National Joint Replacement Registry from May 2, 2005, to December 31, 2021, included all procedures for primary elbow replacement with primary diagnosis of fracture/dislocation. The analyses were performed using Kaplan-Meier estimates of survivorship and hazard ratios from Cox proportional hazards models. There were 293 primary HA and 631 primary TER procedures included. The cumulative percent revision (CPR) rate at 9 years was 9.7% for HA (95% confidence interval [CI] 6.0, 15.7), and 11.9% (95% CI 8.5, 16.6) for TER. When adjusted for age and gender, there was a significantly higher risk of revision after 3 months for TER compared to HA (HR=2.47 [95% CI 1.22, 5.03], p=0.012). There was no difference in the rate of revision for patients aged <55 years or ≥75 years when HA and TER procedures were compared. In primary TER procedures, loosening was the most common cause of revision (3.6% of primary TER procedures) and the most common type of revision in primary TER involved revision of the humeral component only (2.6% of TER procedures). TER has a higher rate of 1st revision for loosening compared to HA (HR=4.21(1.29, 13.73); p=0.017). In HA procedures instability (1.7%) was the most common cause for revision. The addition of an ulna component was the most common type of revision (2.4% of all HA procedures). For the treatment of distal humerus fractures, HA had a lower revision rate than TER after 3 months when adjusted for age and gender. Age <55 or ≥75 years was not a risk factor for revision when HA is compared to TER. Loosening leading to revision is more prevalent in TER and increases with time. In HA, the most common type of revision involved addition of an ulna component with preservation of the humeral component.

Can the reduction quality of distal humeral transphyseal fractures be determined using reference measurements on conventional radiography?

Our objective was to compare the radiological outcomes of transphyseal fractures treated using closed reduction and percutaneous fixation, without arthrography, with those of supracondylar humerus fractures treated using the same method within a similar age group. Additionally, we aimed to assess the efficacy of the reference points in the lateral and anteroposterior radiographs utilized for the evaluation of reduction. The study included patients aged 0-3 years who underwent surgery for supracondylar and transphyseal fractures between 2013 and 2022. All the patients were diagnosed using anteroposterior (AP) and lateral elbow X-rays. No arthrographic intervention was used either in the diagnosis or treatment phase. On the AP X-rays, we assessed the alignment between the humeral shaft line and the ulnar long axis line to determine the positioning of the distal humeral physis segment in relation to the humerus. Additionally, we evaluated the relationship between the anterior cortex line of the humerus and the coronoid process on lateral radiographs. At the final follow-up visit, Flynn criteria were used for functional assessment. The study comprised 24 patients with supracondylar humerus fractures and 24 patients with transphyseal fractures. In the early post-operative radiographs, the humero-ulnar angle measured 6.43° (-7° - 16.6°) in the supracondylar group and 9.8° (-4.3° - 25.3°) in the transphyseal group (p = 0.087). The distance between the coronoid and the anterior humeral line was 9.19 mm (4.27 - 16.08) for the supracondylar fracture group and 8.05 mm (3.29 - 14.85) for the transphyseal fracture group (p = 0.513). The current study's findings suggest that both the humero-ulnar angle and the distance between the coronoid and the anterior humeral line are valuable indicators for assessing the quality of reduction in transphyseal distal humerus fractures.

Static stability of novel uncemented elbow hemiarthroplasty stabilized with ligament reconstruction

The purpose of this study was to create a model to simulate treatment of unreconstructable distal humerus fractures with hemiarthroplasty. Stability was restored with a new plate-system that simultaneously tensions medial and lateral collateral ligament grafts. Static varus and valgus elbow stability was tested in 11 cadaver elbows with intact ligaments and capsule at five flexion angles (0, 30, 60, 90, 120 degrees). The elbows were then destabilized via release of all ligaments and capsular attachments. The distal humerus articular cartilage was excised and replaced with an uncemented hemiarthroplasty. Ligament reconstruction was subsequently performed, and elbow stability was measured and compared to the native state. Dimensions of the hemiarthroplasty component were compared to native elbow dimensions to assess and quantify any existing relationship to elbow stability. A hemiarthroplasty was implanted in all specimens. A size mismatch occurred between the distal humerus trochlea and the olecranon fossa in all specimens and averaged 6.3 mm. Following ligament reconstruction, specimens reproduced the flexion angle-dependent stability of native elbows to both varus and valgus stress. On the medial side, elbow joint stability in mid-flexion was approximately 7% tighter after hemiarthroplasty. Laterally, the elbow was approximately 15% tighter after hemiarthroplasty and demonstrated peak stability in full flexion. The three assessed hemiarthroplasty components and bony dimensions did not exhibit any relationship between implant-bone mismatch and elbow stability after ligamentous reconstruction. Cadaveric elbow specimens underwent uncemented hemiarthroplasty with soft tissue stabilization with a novel technique for ligament reconstruction. Following hemiarthroplasty and ligament reconstruction, these specimens maintained secure fixation between ligament and bone. Static stability was maintained at varying degrees of elbow flexion regardless of variable mismatch between the hemiarthroplasty component and the native olecranon fossa.

Extra-Articular Distal Humerus Plate 3D Model Creation by Using the Method of Anatomical Features.

Proper fixation techniques are crucial in orthopedic surgery for the treatment of various medical conditions. Fractures of the distal humerus can occur due to either high-energy trauma with skin rupture or low-energy trauma in osteoporotic bone. The recommended surgical approach for treating these extra-articular distal humerus fractures involves performing an open reduction and internal fixation procedure using plate implants. This surgical intervention plays a crucial role in enhancing patient recovery and minimizing soft tissue complications. Dynamic Compression Plates (DCPs) and Locking Compression Plates (LCPs) are commonly used for bone fixation, with LCP extra-articular distal humerus plates being the preferred choice for extra-articular fractures. These fixation systems have anatomically shaped designs that provide angular stability to the bone. However, depending on the shape and position of the bone fracture, additional plate bending may be required during surgery. This can pose challenges such as increased surgery time and the risk of incorrect plate shaping. To enhance the accuracy of plate placement, the study introduces the Method of Anatomical Features (MAF) in conjunction with the Characteristic Product Features methodology (CPF). The utilization of the MAF enables the development of a parametric model for the contact surface between the plate and the humerus. This model is created using specialized Referential Geometrical Entities (RGEs), Constitutive Geometrical Entities (CGEs), and Regions of Interest (ROI) that are specific to the human humerus bone. By utilizing this anatomically tailored contact surface model, the standard plate model can be customized (bent) to precisely conform to the distinct shape of the patient's humerus bone during the pre-operative planning phase. Alternatively, the newly designed model can be fabricated using a specific manufacturing technology. This approach aims to improve geometrical accuracy of plate fixation, thus optimizing surgical outcomes and patient recovery.

Outcome of Percutaneus K Wire Fixation for Paediatric Supracondylar Humerus Fracture

Introduction: Elbow joint is the most common part of upper limb involved in pediatric fractures and 85% of which occur in the distal humerus. In distal humeral fractures, supracondylar humeral fractures are very difficult to treat in the pediatric population.-3Frequently, the mechanism of injury is direct or indirect traumas like falls ,on out stretched hand .This type of fracture requires instant diagnosis and proper management, because any undue delay may complicate the condition and treatment. Methodology: This prospective cross-sectional study was carried out at the department of Orthopaedics Surgery in Dhaka Orthopaedics Hospital, Dhaka, Bangladesh from January 2018 to December, 2019. The Ethical clearance of this study was obtained from the ethics committee of the hospital. A written informed consent was obtained from all the patients (by their parents) and a total of, 18 children aged (5-15) years ,with Grade II and III closed supracondylar fractures of humerus were included in this study. The collected data were analyzed using Statistical Package for Social Sciences (SPSS) software, version-23.0. Chi-square tests were performed to compare the results of the follow up, where p&lt;0.05 considered as the level of significance. Results: A total of 18 children were enrolled in this study. According to sex distribution, 12(67%) children were male and 6(33%) children were female. According to age distribution, 12(67%) children were aged (5-10) years and 6(33%) children were aged (11-15) years. The mean age of the children was 9.16 years. The mode age was 7 years and the median age was 9 years. According to fracture classification, 12 (67%) had Gartland class II and 6(33%) children had Gartland class III. According to mechanism of injury distribution,10(55%) children fall while playing, and followed by 5(28%) fall from the height, 2(11%) children met road traffic accident and 1(6%) children had blunt trauma. On an average, the children aged (5-10) years started .......

Low risk of postoperative ulnar nerve affection in surgically treated distal humeral fractures when the nerve is released in situ.

Adult distal humeral fractures (DHF) comprise 2%-5% of all fractures and 30% of all elbow fractures. Treatment of DHF may be technically demanding due to fracture complexity and proximity of neurovascular structures. Open reduction and internal fixation (ORIF) are often the treatment of choice, but arthroplasty is considered in case of severe comminution or in elderly patients with poor bone quality. Ulnar nerve affection following surgical treatment of distal humerus fractures is a well-recognized complication. To report the risk of ulnar nerve affection after surgery for acute DHFs. We retrospectively identified 239 consecutive adult patients with acute DHFs who underwent surgery with ORIF, elbow hemiarthroplasty (EHA) or total elbow arthroplasty (TEA) between January 2011 and December 2019. In all cases, the ulnar nerve was released in situ without anterior transposition. We used our institutional database to review patients' medical records for demographics, fracture morphology, type of surgery and ulnar nerve affection immediately; records were reviewed after surgery and at 2 wk and 12 wk of routine clinical outpatient follow-up. Twenty-nine percent patients were excluded due to pre- or postoperative conditions. Final follow-up examination was a telephone interview in which ulnar nerve affection was reported according to the McGowen Classification Score. A total of 210 patients were eligible for interview, but 13 patients declined participation and 17 patients failed to respond. Thus, 180 patients were included. Mean age at surgery was 64 years (range 18-88 years); 121 (67.3%) patients were women; 59 (32.7%) were men. According to the AO/OTA classification system, we recorded 47 patients with type A3, 55 patients with type B and 78 patients with type C fractures. According to the McGowen Classification Score, mild ulnar nerve affection was reported in nine patients; severe affection, in two. A total of 69 patients were treated with ORIF of whom three had mild temporary ulnar nerve affection and one had severe ulnar nerve affection. In all, 111 patients were treated with arthroplasty (67 EHA, 44 TEA) of whom seven had mild ulnar nerve affection and one had severe persistent ulnar nerve affection. No further treatment was provided. The risk of ulnar nerve affection after surgical treatment for acute DHF is low when the ulnar nerve is released in situ without nerve transposition, independently of the treatment provided.

Biomechanical analysis of different osteosynthesis configurations in the pin and plate fixation method for distal humerus fractures

Distal humerus fractures commonly occur in adults with low bone mineral density causing major technical challenges for orthopedic surgeons. Persian fixation method was introduced as a novel technique to stabilize small fragments in comminuted distal humerus fractures using a set of K-wires and a reconstruction plate. The present study aims to measure this technique's stiffness and stability of this technique and analyze the effect of influential parameters with numerical simulation and biomechanical testing on a cadaveric specimen. Validation of the finite element (FE) model was conducted based on results of experiments. The results indicated that Delta configuration mainly led to a higher stiffness in the case of axial loading and anterior bending compared to L configuration. Analyzing the influential factors of this technique suggests that changes in diameter and number of K-wires have a similarly significant effect on the construct stiffness while the height of plate had a slight influence. Also, the diameter of wires was the most effective parameter for implant failure, particularly in the 3-pin construct, which caused a reduction in failure risk by about 60%. The results revealed that the Persian fixation method would achieve suitable stability compared to the dual-plating technique.

A Soft-Tissue Landmark to Assess Humeral Component Rotation in Total Elbow Arthroplasty.

Assessing the rotational alignment of the humeral component during total elbow arthroplasty is dependent upon bony landmarks that can be absent or altered in cases of distal humerus fractures, revision arthroplasty, severe bone loss, or deformity. We hypothesize that the intermuscular septum can be used as a reliable soft-tissue landmark to set the rotation of the humeral component intra-operatively when previously described bony landmarks are not reliable or present. Forty-eight unpaired cadaveric human subjects (mean age and standard deviation 63 ± 12 years; 24 males, 24 females) underwent computed tomography (CT) scans. The geometric centers of the trochlea and capitellum were assessed, and the line through these two points was set as the flexion-extension axis (FEA) of the elbow. The intermuscular septum axis (IMSA) was drawn proximal to the olecranon fossa and at least 4 cm proximal to the most distal point of the articular surface, where the posterior humeral cortex was flat. The angles between the FEA and IMSA were calculated and compared using a two-tailed t-test. Regression analysis was used to assess the inter- and intra-observer reliability of the IMSA. The IMSA was externally rotated 10.3° ± 2.8 compared to the FEA (p < 0.001 and confidence interval (CI) of 2.8 with α set to 0.01). The inter- and intra-observer reliability of the IMSA was high, with an R-value of 0.91 and 0.97, respectively. The intermuscular septum can be used as a soft-tissue landmark to set humeral component rotation and is 10.3° externally rotated with respect to the FEA of the ulnohumeral joint.

Linking the distal humerus columns in articular fracture fixation

IntroductionConcerning rates of nonunion in articular distal humerus fractures indicate an unsolved problem. The fixation principles of O'Driscoll describe linking the fractured articular segment to the distal humerus columns with compression screws which creates a stable fixed angle construct. A novel device has been introduced which utilizes an interlocking beam through the articular segment to connect the distal aspect of the medial and lateral plates, creating a linked construct. We sought to evaluate the stability of this linked construct using an articular model of distal humerus fracture. Materials and methodsTen matched pair specimens of 65 years of age or older were randomized to the use (LB group) or non-use (NLB group) of an interlocking beam to link the medial and lateral locking plates in fixation of an AO Type C3 fracture model. Outside of the linking beam, fixation between the matched pairs was consistent using 2.7 mm locking screws distally with fixed trajectories and +/- 2 mm lengths. ResultsMean stiffness was 273 Newtons/mm in the LB group and 225 Newtons/mm in the NLB group (p = 0.001). Mean maximum displacement was 0.28 in the LB group and 0.93 mm in the NLB group (p = 0.006). Mean load to failure was 277 pounds in the LB group and 280 pounds in the NLB group (p = 0.94). DiscussionOur results indicate that an interlocking beam which links the medial and lateral plates provides greater stability compared to a similar construct without an interlocking beam. We attribute this finding to the beam's double supported design which resists cantilever bending and provides robust compression of the fractured fragments.

Comparison of clinical outcomes between the olecranon osteotomy approach and the Bryan-Morrey approach for total elbow arthroplasty.

This study aims to investigate the clinical efficacy of the olecranon osteotomy approach and the Bryan-Morrey approach in total elbow arthroplasty (TEA). In this retrospective study, 49 patients with elbow disease were treated with TEA. A total of 22 patients with TEA by olecranon osteotomy approach were designated as group A, and 27 patients with TEA by Bryan-Morrey approach were designated as group B. There were 22 males and 27 females, aged 32-82years with a mean age of 62years. There were 44 cases of unilateral elbow joint, including 27 cases on the left elbow and 17 cases on the right elbow, and 5 cases of the bilateral elbow joint. There were 6 cases of osteoarthritis (7 elbows), 18 cases of rheumatoid arthritis (22 elbows), 14 cases of traumatic arthritis (14 elbows), 7 cases of distal humeral fractures (7 elbows), and 4 cases of elbow tuberculosis (4 elbows). For each group, we recorded the operative time, intraoperative bleeding, elbow flexion, extension, pronation, supination, postoperative complication rates, and Mayo Elbow Performance Score after surgery. Operative time and intraoperative bleeding were less in group A than in group B (53-120min [70 (62.5, 78) min] vs. 64-105min [77 (73, 87) min], and 10-200ml [50 (20, 90) ml] vs. 5-250ml [100 (50, 150) ml], P<.028). The elbow flexion, pronation activity, and Mayo Elbow Performance Score were higher in group A than in group B, [(121±12)° vs. (112±10)°, 85 (85,85)° vs. 80 (77,85)°, and (94±3) points vs. (91±4) points, P<.036], while elbow extension and supination activity and complication rates were not statistically significant in either group. Compared to Bryan-Morrey approach, the olecranon osteotomy approach to TEA provides adequate visualization, saves operative time and reduces bleeding, provides better flexion activity, effectively improves elbow function, and achieves satisfactory clinical outcomes.