Fixation Of Humeral Fractures Research Articles

Quantifying Distal Deltoid Disruption With Linear versus Curvilinear Plating of Proximal Humerus Fractures: A Cadaveric Study

BACKGROUND: Plate fixation of proximal humeral fractures is usually associated with some degree of distal deltoid dissection. The purpose of this study was to quantify deltoid release with standard linear versus curvilinear plates used in the repair of proximal humeral fractures. METHODS: Seven nonpaired, fresh-frozen, clavicle-to-fingertip cadaveric shoulders met the inclusion criteria for this study. Four different proximal humerus implants were tested. One of these plates was curvilinear (89 mm), and the other 3 plates were linear (85, 98, 109 mm in length). Plates were compared based on the amount of deltoid insertion released for proper plate positioning. An analysis of variance with post hoc Tukey tests was conducted to compare mean deltoid disruption across the 3 shortest plate types from each manufacturer. A linear regression analysis was conducted to analyze the effect of plate length on mean deltoid release. RESULTS: The mean deltoid insertion length was 39.6 ± 8.6 mm (n = 7). The curvilinear plate (89 mm) required the least amount of average deltoid release at 4.1 ± 4.5 mm, or 12.1% of the deltoid insertion. Independent analysis of variance, including the 3 shortest plates from each manufacturer, found a significant effect of which plate was used on the amount of deltoid disruption that resulted (F(2, 18) = 18.0, P < 0.001, ω = 0.6). A linear regression including all 4 plates demonstrated a statistically significant direct relationship between the plate length and the mean deltoid released (y = 0.6x − 43.8, r2 = 4). CONCLUSION: This study demonstrates that proximal humerus plate length has a direct relationship with the amount of deltoid released during plating. Although deltoid disruption is length dependent, plate shape (curvilinear vs. linear) could also be contributory. When comparing a curvilinear and a linear plate of similar lengths, the curvilinear plate resulted in less mean deltoid release.

A clinical study on robot navigationassisted intramedullary nail treatment for humeral shaft fractures

BackgroundThe purpose of this study was to evaluate the advantages of robot navigation system-assisted intramedullary nail treatment for humeral shaft fractures and compare it’s efficacy with that of traditional surgical intramedullary nail treatment.Materials and methodsThis was a retrospective analysis of patients with humeral shaft fractures who received intramedullary nail treatment at our centre from March 2020 to September 2022. The analysis was divided into a robot group and a traditional surgical group on the basis of whether the surgery involved a robot navigation system. We compared the baseline data (age, sex, cause of injury, fracture AO classification, and time of injury-induced surgery), intraoperative conditions (surgery time, length of main nail insertion incision, postoperative fluoroscopy frequency, intraoperative bleeding), fracture healing time, and shoulder joint function at 1 year postsurgery (ASES score and Constant–Murley score) between the two groups of patients.ResultsThere was no statistically significant difference in the baseline data or average fracture healing time between the two groups of patients. However, the robotic group had significantly shorter surgical times, longer main nail incisions, fewer intraoperative fluoroscopies, and less intraoperative blood loss than did the traditional surgery group (P < 0.001).ConclusionRobot navigation system-assisted intramedullary nail fixation for humeral shaft fractures is a reasonable and effective surgical plan. It can help surgeons determine the insertion point and proximal opening direction faster and more easily, shorten the surgical time, reduce bleeding, avoid more intraoperative fluoroscopy, and enable patients to achieve better shoulder functional outcomes.

Impact of augmentation strategy variations on the mechanical characteristics of patients with osteoporotic proximal humerus fractures with medial column instability.

Low bone density and lack of medial support are the two most important factors affecting the stability of locking plate fixation for osteoporotic proximal humeral fractures (PHFs). This study aimed to compare the biomechanical characteristics of PHILOS locking plates combined with calcar screws, bone cement, fibular allografts, and medial locking plate support strategies for treating osteoporotic PHFs with medial column instability. A three-part osteoporotic PHF (AO 11-B3.2) model with metaphyseal loss was generated using 40 synthetic humeri and fixed via four distinct medial support strategies. All models were mechanically tested to quantify the mechanical characteristics. Subsequently, finite element models were created for each biomechanical test case. The stress distribution and displacement of the four different fixation structures were analyzed using finite element analysis. The results demonstrated that the PHILOS locking plate combined with the medial locking plate, exhibited the greatest stability when subjected to axial, shear, and torsional loading. Furthermore, the PHILOS locking plate combined with bone cement showed structural stability similar to that of the PHILOS locking plate combined with fibular allograft but with lower stress levels on the fracture surface. In conclusion, the PLP-MLP fixation structure showed superior biomechanical properties under axial, shear, and torsional loading compared to other medial support methods. Repairing the medial support when treating osteoporotic PHFs with medial column instability can enhance the mechanical stability of the fracture end in both the short and long term.

Development of the humeral head offset index for control of humeral torsion

BackgroundControl of humeral torsion can present a challenge, especially intraoperatively during closed reduction and fixation of humeral shaft fractures or 2-part surgical neck fractures of the proximal humerus. The objective of this study is to develop and validate an indirect method for the assessment of humeral torsion using an index that is linearly correlated with rotational arm position and can be derived from only a single plain radiographic image of the proximal humerus.MethodsThe Humeral Head Offset Index (HHOI) is calculated as the ratio of the medial and lateral offset of the humeral head measured from the outer cortices of the shaft on a plain radiographic or fluoroscopic image. The relationship of HHOI with humeral torsion was first verified on a sawbone model with radiopaque characteristics under fluoroscopic control. Different degrees of retroversion were simulated through manual rotation of the humerus with a digital protractor in 5° increments until 40° internally rotated and then in 5° increments until 40° externally rotated from the neutral position. The same procedure was subsequently performed digitally on Digitally Reconstructed Radiographs (DRRs) from computed tomography (CT) dataset of the sawbone. Next, the HHOI index was applied to eight randomly selected patients with total humerus CT using the same method. Spearman’s rho was calculated for the bivariate analysis of correlation between the simulated degree of retroversion and the HHOI. Strength of correlation was classified according to Koo and Li. Interrater and intrarater reliability of three blinded observers with repetition of measurement after three months were analyzed by assessing the intraclass correlation coefficient (ICC).ResultsBoth in the sawbone model and in DRRs, we demonstrated a high to very high significant linear correlation between simulated retroversion and the HHOI. ICC values demonstrated excellent interrater reliability and excellent intrarater reliability for measurement of the HHOI.ConclusionsThe HHOI is a new, simple, reliable index that has a linear relationship to the rotation of the humerus and can therefore allow an indirect control of humeral torsion in comparison to the contralateral side.

Open Reduction and Fixation of Late-Presenting Pediatric Supracondylar Humeral Fractures: A Prospective Study.

Supracondylar humeral fracture (SCHF) is a common injury in children, and early treatment provides excellent results and prevents disabilities. Delayed presentation is still prevalent, mainly in developing countries, because many factors hinder the opportunity to receive appropriate treatment. Currently, there are no standard treatment protocols, and there is insufficient published literature on this topic. This study aimed to evaluate the effectiveness and outcomes of open reduction and Kirschner wire fixation using a triceps-sparing posterior approach in neglected cases with complicated fractures. This was a prospective multicenter clinical study conducted between July 2016 and June 2021, which included 28 pediatric patients with neglected SCHF who presented to the hospital for definitive treatment five days or more after initial trauma without previous surgical intervention. All the patients underwent open reduction and K-wire fixation using a posterior triceps-sparing approach. The final functional outcome was assessed using the Mayo Elbow Performance Index (MEPI) and Flynn criteria. All fractures (100%) united within 3-5.5weeks (mean 4 ± 0.7 weeks). Excellent scores observed in 67.9% (n = 19), good in 21.4% (n = 6), fair in 7.1% (n=2), and poor in 3.6% (n = 1) patients according to MEPI. Correspondingly, Flynn's criteria showed 96.4% (n = 27) satisfactory and 3.6% (n = 1) unsatisfactory outcome. Open reduction and fixation using Kirschner wires through the posterior triceps-sparing approach is an effective treatment method for late-presenting SCHF in children with consequent satisfactory results.

Are patients without insurance coverage less likely to undergo surgery for humeral shaft fractures? A national database analysis

Historically, humeral shaft fractures have been managed nonoperatively in a functional brace. However, recent studies suggest an increase in rates of operative fixation. Disparities in surgical management based on insurance status have been demonstrated across many orthopedic conditions. This study aimed to identify if a correlation exists between insurance coverage and the probability of undergoing operative fixation for a humeral shaft fracture. A retrospective examination of the National Readmissions Database from 2016 to 2021 was conducted. Patients diagnosed with isolated closed humeral shaft fractures were identified via International Classification of Disease, 10th Revision codes, and surgical interventions were identified using International Classification of Disease, 10th Revision procedural codes. Utilizing weighted data, a total of 56,468 patients with isolated closed humeral shaft fractures were identified, 25,075 (44.4%) of whom underwent operative fixation. A univariate analysis was conducted using Pearson's chi-square test to isolate variables for inclusion in a multivariable analysis. A binary logistic regression analysis was then employed to explore demographic and other pertinent factors. Findings were reported as odds ratios. After controlling for social and demographic variables, patients with Medicaid (OR, 0.54; 95% CI, 0.50-0.58; P<.001), Medicare (OR, 0.64; 95% CI, 0.60-0.68; P<.001), and self-pay patients (OR, 0.75; 95% CI, 0.67-0.84; P<.001) were less likely to undergo operative fixation of humeral shaft fracture than those with private insurance. Patients without private insurance or those with no insurance coverage are less likely to undergo operative fixation for humeral shaft fractures compared to those with private insurance, even after adjusting for social and demographic variables. The observed variability underscores the necessity for more refined treatment guidelines for humeral shaft fractures. Surgeons should be aware of these potential biases affecting management decisions.

Lateral Wall Integrity of the Greater Tuberosity Is Important for the Stability of Osteoporotic Proximal Humeral Fractures After Plate Fixation.

Previous studies assessing surgical fixation of osteoporotic proximal humeral fractures have primarily focused on medial calcar support. In this study, we utilized a specific model for 2-part surgical neck fracture of the osteoporotic proximal humerus to investigate how severe comminution of the greater tuberosity (GT) lateral wall affects biomechanical stability after fixation with a plate. Ten matched pairs of cadaveric humeri (right and left) were assigned to either a surgical neck fracture alone (the SN group) or a surgical neck fracture with GT lateral wall comminution (the LW group) with use of block randomization. We removed 5 mm of the lateral wall of the GT to simulate severe comminution of the lateral wall. Axial compression stiffness, torsional stiffness, varus bending stiffness, and the single load to failure in varus bending were measured for all plate-bone constructs. Compared with the SN group, the LW group showed a significant decrease in all measures, including torsional stiffness (internal, p = 0.007; external, p = 0.007), axial compression stiffness (p = 0.002), and varus bending stiffness (p = 0.007). In addition, the mean single load to failure in varus bending for the LW group was 62% lower than that for the SN group (p = 0.005). Severe comminution of the GT lateral wall significantly compromised the biomechanical stability of osteoporotic, comminuted humeral surgical neck fractures. Although the generalizability of this cadaveric model may be limited to the extreme clinical scenario, the model showed that severe comminution of the GT lateral wall significantly compromised the stability of osteoporotic humeral surgical neck fractures fixed with a plate and screws alone.

Kirschner wire vs screw osteosynthesis of lateral condyle fractures in paediatric patients: a systematic review.

This systematic review compares Kirschner wires versus a single cannulated screw for the treatment of lateral humeral condyle fractures in children. The purpose of this review is to review the current literature on fixation of lateral condyle fractures of the humerus, and to ascertain whether there is a difference in clinical outcomes of these fractures when fixated with K-wires vs screws. This systematic review of the literature comparing surgical management of paediatric (0-17years of age) lateral condyle fractures with K-wire versus screw fixation was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Electronic searches of three databases from inception to March 2022 yielded 17 studies which satisfied inclusion criteria, comprising 1,272 patients with a median age of 8.5years. Eight hundred and fifty-five (67.2%) patients underwent K-wire fixation and 417 (32.8%) underwent screw fixation. Results were divided into comparative and single-arm studies. The median follow-up time was 23.3months (range 3months-22years). A lateral prominence was observed in 114 (13.3%) patients with K-wires and 41 (9.8%) patients with a cannulated screw. An infection developed in 52 (6.1%) patients with K-wires, while only five (1.2%) patients with a screw developed an infection. A carrying angle deformity occurred in 61 (7.1%) patients with K-wires and seven (1.7%) patients with a screw. K-wires and cannulated screws are effective and safe methods of fixation for lateral humeral condyle fractures in children. K-wire fixation may have a greater incidence of infection but allows for safe non-operative removal and versatility with fractures of greater comminution, while screw fixation necessitates a second operation for removal following union.Level of Evidence III Systematic review.

Assessing Functional Outcome of PHILOS Plate Fixation in Proximal Humerus Fractures- A Prospective Study

Introduction: Despite the availability of numerous treatment options, managing unstable proximal humeral fractures remains a significant surgical challenge. Utilizing a PHILOS plate is an effective surgical technique for addressing these fractures. This approach provides stability and support to the fracture site, promoting proper healing and potentially improving patient outcomes. Aim of the study: The aim of this study was to assess the functional outcome of PHILOS plate fixation in proximal humerus fractures. Methods: This prospective study was conducted in the the Department of Orthopedic Surgery, National Institute of Traumatology and Orthopedic Rehabilitation (NITOR), Sher-e-Bangla Nagar, Dhaka, Bangladesh during the period from January 2009 to December 2010. A total of 80 patients aged over 18 years were included in the study. Patients with open, pathological and ipsilateral distal fractures in the same limb were excluded from the study. Result: The youngest and the oldest one were 23 and 78 years respectively. Majority of the patients were male and business was their main occupation. Fifty patients (62.5%) presented with 3-part fractures, ten (12.5%) with four-part fractures and twenty (25%) with fracture dislocation. The interval between injury and plate fixation was 18 days and minimum and maximum interval was 2 and 78 days respectively. Majority (92.5%) of the injury was caused by high-velocity accident. Evaluation of the outcome at 6 months showed that 62.5 percent of patients had good outcome, 25 percent patients had fair outcome. Conclusion: PHILOS plate fixation for proximal humeral fractures provides stable fixation and good functional outcomes, particularly in elderly patients.

Greater Socioeconomic Deprivation is Associated with Increased Complication Rates and Lower Patient-Reported Outcomes Following Open Reduction and Internal Fixation of Humeral Shaft Fractures.

This study explored the hypothesis that social determinants of health (SDOH), including racial and economic differences, may impact orthopaedic trauma outcomes in patients undergoing open reduction and internal fixation (ORIF) of humeral shaft fractures. Design: Retrospective. Single, academic, tertiary Level-I trauma center. Adults with midshaft humerus fractures (AO/OTA 12) treated operatively with plate fixation from 05/2011 to 05/2021 with a minimum follow-up of nine months. Radiographic fracture healing, complication rates, and patient-reported outcomes were investigated. SDOH were assessed using the Area Deprivation Index (ADI). Demographics, complications rates, and patient-reported clinical outcomes were compared between the first and fourth ADI quartiles. 196 patients fit the study criteria. The average age of the cohort was 47 years with 50 women (51%). Comparisons of the least deprived quartile (n=49) to the most deprived quartile (n=49) yielded similar sex distribution (59% vs 43% female, p=0.15), fewer non-white patients (8% vs 51%, p<0.01), older average age (51 years vs 43 years, p=0.05), similar BMI (30.5 vs. 31.8, p=0.45), and higher Charlson Comorbidity Index (CCI) (2.2 vs.1.1, p=0.03). While nonunion rates were similar (p=0.20) between groups, the most deprived quartile had 2.3 times greater odds of post-operative complications (p=0.04). Patients in the most deprived group exhibited higher PROMIS Pain Interference (PI) scores (p<0.01) and PROMIS Depression (D) scores (p=0.01), with lower PROMIS Physical Function (PF) scores (p<0.01) at 6-month follow-up than the least depriver cohort. The most deprived cohort had three times higher odds of missing scheduled appointments within the first post-operative year (p<0.01), resulting in a significantly higher no-show rate (p<0.01) than the least deprived cohort. Regression analysis including several demographic and injury factors identified that ADI was significantly associated with the occurrence of any missed appointments (p<0.01), no-show rates (p=0.04), and experiencing one of the following post-operative complications during recovery: Nonunion, radial nerve injury, or dysfunction (p=0.03). Patients experiencing greater resource deprivation faced increased odds of complications, missed appointments, and poorer PROMIS outcomes following humeral shaft fracture fixation, emphasizing that baseline socioeconomic disparities predict unfavorable post-operative outcomes even given favorable baseline health status according to the CCI score. Level III. See Instructions for Authors for a complete description of levels of evidence.

Ultrasound evaluation of radial nerve injuries by cortex overlapping screw tips after internal fixation of humeral fractures: a cadaveric study

PurposeThe radial nerve may be painfully irritated or damaged by open reduction and internal fixation (ORIF) of humeral fractures. Secondary radial nerve lesions after ORIF of humeral shaft fractures are described in up to 16%. Not only peripheral nerves but also orthopaedic instruments and osteosynthesis material are well visible by ultrasound. The aim of this study was to evaluate the accuracy of ultrasound in assessing the relation between the bone overlapping screw tips and the radial nerve close to the humeral bone.MethodsUltrasound-guided drilling was used to place screws as close as possible to the radial nerve in 8 humeral bones of four cadavers. The relation between the radial nerve and the screw tips was assessed by high-resolution ultrasound, and the overlap of all screw tips over the bone was measured by ultrasound and fluoroscopy. Thereafter, the findings were validated by anatomical dissection.ResultsWe could correctly identify all screw tips and their relation to the radial nerve by ultrasound. In 7 of 8 cases, the screw tip had direct contact with the radial nerve. The overlaying length of the screw tip was accurately measured by using ultrasound in all cases. In contrast fluoroscopy underestimated this length in 50% of cases.ConclusionWith this study, we show that ultrasound can reliable visualize the screw tips and its relation to the radial nerve. Ultrasound is a promising diagnostic tool to evaluate patients with radial nerve irritations or lesions after ORIF of humeral fractures. Furthermore, ultrasound could be an adequate tool to guide drilling.

Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury

ObjectivesTo compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery.MethodsThe online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches.ResultsFifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p > 0.05).ConclusionIntramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation.Level of evidenceLevel IV.

Construction and validation of a nomogram for blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures in the elderly: a cross-sectional study

PurposeFew studies have focused on the risk factors leading to postoperative blood transfusion after open reduction and internal fixation (ORIF) of proximal humeral fractures (PHFs) in the elderly. Therefore, we designed this study to explore potential risk factors of blood transfusion after ORIF for PHFs. We have also established a nomogram model to integrate and quantify our research results and give feedback.MethodsIn this study, we retrospectively analyzed the clinical data of elderly PHF patients undergoing ORIF from January 2020 to December 2021. We have established a multivariate regression model and nomograph. The prediction performance and consistency of the model were evaluated by the consistency coefficient and calibration curve, respectively.Results162 patients met our inclusion criteria and were included in the final study. The following factors are related to the increased risk of transfusion after ORIF: time to surgery, fibrinogen levels, intraoperative blood loss, and surgical duration.ConclusionsOur patient-specific transfusion risk calculator uses a robust multivariable model to predict transfusion risk.The resulting nomogram can be used as a screening tool to identify patients with high transfusion risk and provide necessary interventions for these patients (such as preoperative red blood cell mobilization, intraoperative autologous blood transfusion, etc.).

Transmediastinale migratie van een Kirschner-pin na fixatie van een proximale humerusfractuur: een casus

Transmediastinal migration of a Kirschner pin after fixation of a proximal humeral fracture: a case report Fractures of the proximal humerus are common lesions in the elderly population. In some cases, they are surgically stabilized via a minimally invasive technique, namely percutaneous osteosynthesis with fixation pins. Intrathoracic migration of these pins or wire is a rare complication after percutaneous osteosynthesis of a proximal humeral fracture. In this article, the authors describe an extremely rare transmediastinal migration of a Kirschner pin from the humeral head. The purpose of this case report is to call for awareness and to open a debate in which appropriate prevention can be freely discussed. The consideration of a conservative management, the choice of alternative osteosynthesis techniques, the use of a sling bandage to restrict the shoulder movement, the use of fixation pins with a threaded tip, bending of the external free end of the pin and an appropriate time to remove the pin are possible recommendations from the literature. Furthermore, it is important to provide additional information and awareness to health care providers in rehabilitation centers, geriatricians and orthopedists concerning the possibility of such a life-threatening postoperative complication. Thus, specific policies for clinical and radiographic monitoring of the position of fixation pins should be developed in hospitals and rehabilitation centers with the aim of prevention, early detection and prompt action when this life-threatening complication is suspected.

Olecranon Osteotomy Exposure for Distal Humeral Fracture Treatment.

Olecranon osteotomy (OO) is commonly utilized to improve exposure when treating intra-articular distal humeral fractures. A chevron-shaped osteotomy facilitates reduction and increases surface area for healing1. Following distal humeral fracture reduction and fixation, the OO fragment is fixed with a precontoured plate. The OO technique yields comparable outcomes to alternative techniques1,2. The technique is performed as follows. (1) Imaging is reviewed and preoperative planning is performed. (2) The patient is positioned in the lateral decubitus position with the operative extremity placed over a bolster. (3) A longitudinal posterior skin incision is centered just medial or lateral to the tip of the olecranon. Full-thickness skin flaps are raised medially and laterally. (4) The ulnar nerve is identified and mobilized for later anterior subcutaneous transposition. (5) An OO is performed at the non-articular "bare area" of the trochlear notch with an oscillating saw and completed with an osteotome. (6) Open reduction and internal fixation of the distal humerus is performed. (7) The osteotomy fragment is reduced, and a precontoured plate is applied. (8) A small longitudinal slit in the distal triceps over the proximal edge of the plate decreases plate prominence and is repaired with suture. (9) The subcutaneous tissues and skin are closed in the usual manner. Alterative techniques include extra-articular OO, triceps splitting, triceps reflecting, and lateral para-olecranon combined with a medial approach. Multiple drill holes and a thin osteotome can help mitigate the kerf created by the oscillating saw. Alternative fixation methods include a predrilled 6.5-mm intramedullary screw, a tension band construct, suture fixation, or a one-third tubular plate. The OO technique provides improved exposure when compared with alternative techniques, enabling accurate reduction and fixation of distal humeral fractures1-3. Wilkinson and Stanley found that OO exposed the distal humeral articular surface to a greater degree than the triceps-splitting and triceps-reflecting approaches3. OO has not been associated with triceps weakness, unlike some of the alternative techniques2. The incidence of good-to-excellent outcomes is similar when comparing the techniques for exposure of intra-articular distal humeral fractures4. Osteotomies united in all patients in 2 reported series, totaling 84 cases1,2. Removal of symptomatic hardware used in OO fragment fixation can occur in a small subset of patients1,2. Provisionally size a precontoured plate and fix it on the olecranon to aid in later reduction and fracture fixation.The bare area is the desired position for the OO because of its natural lack of cartilage5,6. This non-articular bare area is located just distal to the deepest portion of the trochlear notch, approximately 2 to 2.5 cm distal to the olecranon tip5,6.An (apex-distal) chevron osteotomy angle of ∼130° will help to keep the osteotomy within the non-articular bare area6.Beginning on the dorsal surface of the ulna, directly posterior to the bare area, an oscillating saw is utilized to create a chevron osteotomy to subchondral bone, perpendicular to the long axis of the ulna5,6.The OO is completed by fracturing through the osteochondral surface, which leaves an irregular chondral cancellous surface that can accurately interdigitate. This facilitates later reduction and stability of the osteotomy.Anatomic articular reduction of the OO is not solely judged on the dorsal cortical bone because of the kerf removed by the saw blade. Instead, examination of the articular surface of the trochlear notch is the primary assessment of reduction.Placement of suture through the proximal portion of the plate aids in the repair of the longitudinal split of the distal triceps.Successful treatment of distal humeral fractures requires accurate reduction and rigid fixation aided by adequate exposure achieved through OO. ORIF = open reduction and internal fixationOT = occupational therapyHWR = hardware removalK-wire = Kirschner wireROM = range of motion.

Clinical outcomes of triceps reflecting anconeus pedicle and olecranon osteotomy approach for distal humerus intercondylar fractures.

The preferred treatment for distal humeral intercondylar fractures is open reduction and internal fixation. While there is consensus about the posterior approach, several posterior approaches have been developed. It is debatable as to which approach is best. To compare triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy approaches for internal fixation of distal humeral intercondylar fracture. In total, 40 cases of Arbeitsgemeinschaft für Osteosynthesefragen/Association of the Study of Internal Fixation type C, closed, and Gustilo type I intercondylar humeral fractures were included. Patients ranged in age from 18 years to 70 years. The patients were randomized into two groups: TRAP group and olecranon osteotomy group, with 20 cases in each. All were followed up at 6 wk, 3 months, 6 months, and 12 months. Functional outcomes were measured in terms of flexion-extension arc, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score. The mean age was 43.2 years in the TRAP group and 37.5 years in the olecranon osteotomy group. The mean operative time and mean duration of hospital stay in the TRAP group were significantly higher than in the olecranon osteotomy group (119.5 vs 111.5 min and 9.85 vs 5.45 d, respectively). The mean arc of flexion-extension, Disabilities of Arm, Shoulder and Hand score, and Mayo Elbow Performance Score were comparable without any significant difference in the groups at the 12-month follow-up (107.0 vs 106.2, 18.3 vs 15.7, and 84.2 vs 86.2, respectively). Ulnar paresthesia and superficial infections were comparable in both groups (2 cases vs 3 cases and 3 cases vs 2 cases, respectively). Hardware prominence was significantly higher in the olecranon osteotomy group, mostly due to tension band wiring. Both approaches were equivalent, but there is a need for further study including higher numbers of subjects and longer study duration to prove the benefits of one approach over the other.

Comparison of ultrasound-guided closed reduction and percutaneous pinning fixation for unstable humeral lateral condylar fractures.

Ultrasound-guided techniques have become popular in severe humeral lateral condylar fractures (HLCFs). This study compared the results of ultrasound-guided closed reduction and percutaneous pinning (UG-CRPP) for Song types 4 and 5 and dislocation type of HLCFs. This retrospective study was conducted in patients with HLCFs treated between January 2021 and October 2022 at three hospitals. The patients were divided into three groups according to Song's classification and elbow dislocation. The surgical time, reduction failure rate, and outcomes of the three groups were compared. The mean surgical time of the 94 patients across the three groups (Song 4 group, 42 cases; Song 5 group, 38 cases; and dislocation group, 14 cases) was the longest for Song 4 (66.14 ± 23.05 min), followed by the dislocation group (59.71 ± 21.07 min) and Song 5 (52.16 ± 14.94 min) (for all, P = 0.009). The failure rate decreased in the following order: dislocation group (5/14), Song 4 group (7/42), and Song 5 group (2/38). The failure rate of closed reduction in Song 4 was 3.2-fold higher than that in Song 5, and for the dislocation group, it was 7.6-fold higher than that in Song 5. Significant differences were observed between the Song 4, Song 5, and dislocation groups in terms of shaft-condylar angle and supination (P = 0.015, P = 0.043). No significant differences (P > 0.05) were observed in the carry angle, flexion, extension, or pronation of the three groups. Two cases of delayed healing, four cases of superficial infection, one case of trochlear necrosis, and 39 cases of lateral spur in the Song 4 group were observed. In the Song 5 group, five had a superficial infection, one had re-displacement, and 26 had a lateral spur. In the dislocation group, there were two cases of superficial infection and 10 of lateral spurs. Song 4 HLCFs require longer surgical time and present more postoperative complications than Song 5 and dislocation-type HLCFs and can easily lead to lateral spurs. The failure rates of closed reduction in Song 4 and the dislocation type were higher than those in Song 5. Thus, UG-CRPP can be used to treat patients with unstable HLCFs.

Factors influencing shoulder stiffness after open reduction and internal fixation of proximal humeral fractures.

The study aimed to investigate the factors associated with shoulder stiffness following open reduction and internal fixation (ORIF) of proximal humeral fractures. The retrospective study included a total of 151 patients who underwent ORIF of proximal humeral fractures between January 2016 and May 2021. Based on their shoulder joint motion at the latest follow-up, the patients were divided into two groups. The stiffness group (n=32; 8 males, 24 females; mean age: 62.4±9.3 years; range, 31 to 79 years), exhibited restricted shoulder forward flexion (<120°), limited arm lateral external rotation (<30°), and reduced back internal rotation below the L3 level. The remaining patients were included in the non-stiffness group (n=119; 52 males, 67 females; mean age: 56.4±13.4 years; range, 18 to 90 years). Various factors were examined to evaluate the association with shoulder stiffness following ORIF of proximal humeral fractures by multivariate unconditional logistic regression models. The mean follow-up duration was 31.8±12.6 (range, 12 to 68) months. Based on the results of the multivariate regression analysis, it was found that high-energy injuries [compared to low-energy injuries; adjusted odds ratio (aOR)=7.706, 95% confidence interval (CI): 3.564-15.579, p<0.001], a time from injury to surgery longer than one week (compared to a time from injury to surgery equal to or less than one week; aOR=5.275, 95% CI: 1.7321-9.472, p=0.031), and a body mass index (BMI) >24.0 kg/m2 (compared to a BMI between 18.5 and 24.0 kg/m2 ; aOR=4.427, 95% CI: 1.671-11.722, p=0.023) were identified as risk factors for shoulder stiffness following ORIF of proximal humeral fractures. High-energy injury, time from injury to surgery longer than one week, and BMI >24.0 kg/m2 were identified as independent risk factors for shoulder stiffness after proximal humeral fracture surgery, which should be treated with caution in clinical treatment.

Screw versus Kirschner wire fixation for lateral humeral condyle fractures in children:a meta analysis

To compare screw versus Kirschner wire fixation in the treatment of lateral humeral condyle fractures in children. A systematic search was conducted in PubMed, Embase, the Cochrane library, Web of Science, China National Knowledge Internet(CNKI), Wanfang Datebase from in ception to February 2022. Studies comparing screws and Kirschner wire fixation in the treatment of lateral humeral condyle fractures in children were included. Outcome measures included and excluded by a set of inclusion and exclusion criteria and evaluated for their quality, their excellent and good rate of fracture healing, malunion, delayed union or nonunion, infection, limitation of elbow flexion or extension(>10°) were extracted and analyzed using software Rev Man 5.3. A total of 9 retrospective studies involving 647 patients were included, with 255 patients in the screw fixation group(including screw combined with Kirschner wire) and 392 patients in the Kirschner wire fixation group. Meta analysis showed the following:infection rate in the screw group was significantly lower than that in the Kirschner wire group[OR=0.22, 95%CI(0.09, 0.56), P=0.001]. There were no significant differences between the 2 groups in excellent and good rate of fracture healing, malunion rate(P>0.05). Subgroup analysis showed that infection rate in the screw-only group was significantly lower than that in the Kirschner wire group[OR=0.18, 95%CI(0.05, 0.65), P=0.009]. For lateral humeral condyle fractures, Screw fixation alone had a lower infection rate than kirschner wire fixation and screw combined with Kirschner wire fixation. There were no significant differences in the excellent and good rate of fracture healing, malunion. In terms of postoperative efficacy and safety of internal fixation, orthopaedic surgeons are more likely to recommend screws for fixation of lateral humeral condyle fractures in children.

Anterolateral versus anteromedial plate osteosynthesis of midshaft humeral fractures; is there a difference in the rates of iatrogenic radial nerve palsy?

The anterolateral (AL) and anteromedial (AM) surfaces of the humerus are typically used for plate placement during plate osteosynthesis of midshaft humeral fractures via the anterolateral approach. The purpose of this study was to determine if a significant difference exists in the rates of iatrogenic radial nerve palsy (IRNP) following either AL or AM humeral fracture plating. The research question is stated as follows: is anteromedial plating of humeral fractures associated with lower rates of IRNP when compared with anterolateral plating? This multicenter prospective randomized study was undertaken following ethical review and approval with eligible patients who had midshaft humeral fractures or nonunions randomized into 2 groups, viz AL plate osteosynthesis group and AM plate osteosynthesis group. Following diagnostic and preoperative evaluation, patients had open plate osteosynthesis through the anterolateral approach with plate placement according to their study groups. Post-operatively, they were assessed for IRNP while obtained data was analyzed with SPSS version 23 and inter-group differences with P values less than 0.05 were considered statistically significant. Eighty-five eligible patients participated in the study with 43 patients in Group A (AL plate osteosynthesis group) and 42 patients in Group B (AM plate osteosynthesis group). The observed inter-group differences with regard to gender distribution, mean age and clinical diagnosis; acute fracture (AF) versus nonunion were not statistically significant. Furthermore, four (9.3%) patients amongst the 43 patients in Group A (AL plate osteosynthesis group) developed IRNP while two (4.8%) patients amongst the 42 patients in Group B (AM plate osteosynthesis group) had IRNP. The inter-group difference with regard to rates of IRNP was not statistically significant (P = 0.694). This study found that (in contrast to previous studies) there was no significant difference in the rates of IRNP following either open anterolateral or anteromedial plate osteosynthesis of midshaft humeral fractures through the anterolateral approach. Orthopaedic surgeons should therefore remain cautious when obtaining consent for surgery as well as when performing internal fixation of midshaft humeral fractures to limit medicolegal disputes that may arise from IRNP.