Fixation Of Humeral Fractures Research Articles

Functional outcome following elbow release and hardware removal after bicolumnar fixation of distal humeral fractures

IntroductionIntra-articular fractures of the distal humerus are typically treated with bicolumnar plate fixation. Despite prompt and accurate reduction and fixation, there is a high rate of complications post-surgical fixation. The purpose of this study was to determine the indications, technique, and outcomes of patients who had undergone an elbow release and hardware removal following bicolumnar plate fixation for an intra-articular fracture of the distal humerus. MethodsPatients who had undergone an elbow release and hardware removal by a single surgeon following bicolumnar fixation of an intra-articular fracture of the distal humerus were identified. Patients were contacted to participate in a chart review and to return to clinic for a follow-up visit. Patients who returned for a follow-up visit completed the DASH (Disabilities of the Arm, Shoulder and Hand), the MEPS (Mayo Elbow Performance Score), and the SF-36. ResultsForty-two patients were included in the final analysis. The average time from the original injury to the elbow release procedure was 17.5 months. There was an improvement of 33° in the mean flexion-extension arc following the procedure (p<0.001). The mean DASH score was 21 (SD=19) and the mean MEPS score was 82 (SD=16). There was a high rate of post-traumatic osteoarthritis (n=30). Two patients underwent a total elbow arthroplasty (TEA). One patient sustained a re-fracture of the distal humerus, and subsequently underwent repeat bicolumnar fixation. There were four reoperations (10%): two patients had a revision release of contracture and two patients underwent a closed manipulation. ConclusionsIt appears safe to remove both plates and to re-intervene relatively early. There is a modest but consistent improvement in flexion-extension arc, and the re-operation rate is low. Although there is a high rate of post-traumatic arthritic change radiographically, TEA was rare, and elbow-based outcome scores were good, although not normal.

Clinical and radiographic outcomes after antegrade intramedullary nail fixation of humeral fractures

Humerus fractures are frequent, accounting for about 3-4% of all fractures in adults. Treatment for fractures of the diaphyseal and proximal meta-epiphyseal regions remains controversial: there is no unanimity in the scientific community about the superiority of surgical treatment over non-surgical treatment and which is the best between possible surgical treatments. Among the choices for surgical treatment the most commonly used implants are the locking-compression plate and the intramedullary nailing. The purpose of this study was to perform a clinical and radiographic follow-up in patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of anterograde intramedullary nailing with a straight-shaped nail. A clinical and radiographic follow-up was performed in 56 patients who underwent surgical procedures for reduction and osteosynthesis of proximal or diaphyseal humeral fractures by means of antegrade intramedullary nailing using Synthes MultiLoc® system. Clinical data were collected using subjective quality of life assessment forms (SF12-v2), quality of life related to specific disabilities assessment forms (Quick-DASH, ASES score, WORC) and objective functional assessment forms (Constant-Murley score). The radiographic Follow-Up was performed at 30, 90 and 180 days from the date of the surgery. Almost all patients were able to return to a satisfactory quality of life, comparable with the one before the traumatic episode. The functional results were assessed as excellent or good with almost complete recovery of the range of motion and moderate recovery of strength. The residual pain encountered was moderate or zero. The average QuickDASH score was 17.7 ± 4.3 (range 9.1 - 27.3). The average ASES score was 73.8 ± 8.1 (range 58.3 - 88.3). The average WORC score was 543.3 ± 100 [74% ± 4.8%] (range 310 - 740). The mean Constant-Murley score was 69.6 ± 4.6 (range 61 - 84). All patients had a fair or good consolidation of the fracture on radiographic examinations. The calculated RUST score was 4.2 ± 0.4 (range 4-5) 30 days after surgery, 6.1 ± 0.9 (range 4- 8) 90 days after surgery and 9.8 ± 1.5 (range 7-12) to 180 days after surgery. No major complications were found. Treatment of the diaphyseal and proximal meta-epiphyseal humeral fractures with antegrade intramedullary nail provides excellent subjective and objective clinical results and good radiographic results. However, clinical studies with larger number of patients and longer follow-up are necessary.

A study of functional outcome following proximal humeral internal locking system plating for displaced proximal humeral fractures

Introduction: The proximal humerus fractures involve head, greater tuberosity, lesser tuberosity and proximal one-fourth of the shaft. It has been estimated that proximal humerus fractures account for nearly 4% of all the fractures and 26% of all the humerus factors. Aim: To study the effectiveness of PHILOS in anatomical reduction and stability of fixation of displaced proximal humeral fractures. Materials and Methods: It was a prospective study. All adult patients with fractures of proximal humerus who were admitted in Department of Orthopaedics of KVG Medical College and Hospital, Sullia, Karnataka were included for this study after informed written consent was obtained from them. The study period of the study was two years. The sample size was 25 for the scope of the study. Results: Majority of the patients had four-part fracture according to the NEER’s score. It was found that the overall performance of PHILOS was good on the basis of the follow-up done. The postoperative complications included perforation of screw. Co-morbidities like diabetes and RA were observed in the patients. Conclusion: It was seen that the management of proximal humerus fractures with proximal humerus locking plates is associated with satisfactory (moderate) functional outcomes. Postoperative rehabilitation and encouragement for physical therapy also play a role in better functional outcomes. Keywords: Proximal humeral, PHILOS, Internal locking system plating, Fractures.

Open reduction and K-wires fixation of medial humeral epicondyle fractures with intra-articular elbow entrapment in children

Background. Medial epicondyle fracture (MEF) is a common injury of all elbow fractures in the pediatric and adolescent population and is often associated with elbow dislocation. Traditional management by cast immobilization increasingly is being replaced with early open reduction and K-wires or screws fixation. A consensus about the correct treatment of MEF is currently lacking in the medical literature.&#x0D; The aim of this study was to report the clinical and radiographic outcomes and the complications of patients affected from MEF with intra-articular fragment incarceration treated by open reduction and K-wire fixation.&#x0D; Materials and methods. Thirteen children (aged 813 years) with medial epicondyle fractures (MEF) with intra-articular elbow entrapment were retrospectively reviewed. All the enrolled patients were surgically treated with open reduction and k-wire fixation without exploration of ulnar nerve. Clinical outcomes were evaluated using upper limb alignment in the frontal plane, elbow range of motion (ROM), the Mayo Elbow Performance Score (MEPS) and with the Visual Analogue Scale (VAS). Radiographic outcomes and complications were also evaluated.&#x0D; Results. At a mean follow-up of 24.1 months no patients showed axial deformity of the upper limb or instability of the elbow and with preserved elbow ROM. The mean MEPS was 98.8 and the mean value of the VAS score was 1. The final X-rays showed fracture healing in 11 patients while 2 (15.3%) reported asymptomatic nonunion. Six patients of 13 presented with preoperative paresthesia in the ulnar nerve field but all of them reported a complete recovery after a mean of 4.3 months. All patients returned to their sporting activities at a mean of 5.4 months after surgery. One patient (7.7%) reported a superficial surgical wound infection treated with oral antibiotic medication without further surgery. No other complication was found.&#x0D; Conclusions. The results demonstrate that open reduction and K-wires fixation without exploration of ulnar nerve for MEF with intra-articular elbow entrapment treatment is a safe and effective procedure.

Results of surgical management of displaced or complex proximal humeral fractures with proximal Humerus internal locking system: A prospective study of 55 cases

Background: The optimal treatment of proximal humeral fractures remains always challenging and controversial. The purpose of this prospective study was to evaluate the functional outcome of proximal humerus internal locking system (PHILOS) plate fixation for displaced or complex proximal humeral fractures and to establish the influencing factors of an unfavourable outcome. Materials and Methods: After obtaining approval from institutional ethics committee, 55 patients with the displaced proximal humeral fractures were managed by open reduction and PHILOS plate fixation through delto-pectoral approach and as per standard protocol. The results of follow-ups were analysed radiologically and clinically, using the “Constant and Murley scoring system” at once in a month for first three months, once in three months for next six months and once in six months thereafter upto 2 years post-operatively. Results: In the present study, out of 55 patients, clinical results were excellent in 50.9%, good in 21.8%, fair in 16.4% and poor in 10.9% patients. Radiological union was achieved in all patients, including two cases of mal-union and one case of delayed union. Post- traumatic frozen shoulder (7 cases), secondary arthritis (5 cases), secondary screw penetration (3 cases), and AVN humeral head (3 cases) were the main complications observed in this study during 2 years of follow-ups, which were treated accordingly. Conclusion: Pre-contoured PHILOS plate preserves shape of humeral head, provides angular stability, facilitates to restore the medial column and prevent secondary varus collapse in severe comminuted and osteoporotic proximal humeral fractures. With proper patient selection, PHILOS plate provides favourable clinical and radiological outcome with acceptable complication rates.

Iatrogenic Nerve Palsy Occurs With Anterior and Posterior Approaches for Humeral Shaft Fixation

To determine if surgical approach impacts the rate of nerve palsy after plate fixation of humerus shaft fractures and whether or not iatrogenic nerve palsy recovers in similar ways to preoperative palsy. Retrospective. Two trauma centers. Patients 18+ years of age with nonpathologic, extra-articular humerus shaft fractures (OTA/AO 12A/B/C and 13A2-3) treated with plate fixation. Plate fixation of humerus shaft fractures, from 2008 to 2016. Rate of iatrogenic nerve palsy by a surgical approach and injury characteristics. Two hundred sixty-one humeral shaft fractures were included. The rate of preoperative palsy was 19%. Radial nerve palsy (RNP) was present in 18%. Iatrogenic RNP occurred in 12.2% and iatrogenic ulnar palsy in 1.2%. Iatrogenic palsy occurred in 15.6% of middle and 15% of distal fractures, with fracture location significantly different in those developing RNP (P = 0.009). Iatrogenic RNP occurred in 7.1% of anterolateral, 11.7% of posterior triceps-splitting, and 17.9% of posterior triceps-sparing approaches (P = 0.11). Follow-up data were available for 139 patients at an average of 12 months. Preoperative RNP resolved less often than iatrogenic RNP, in 74% versus 95% (P = 0.06). Time to resolution was longer for preoperative RNP, at 5.5 versus 4.1 months (P = 0.91). Twenty-two percent with preoperative RNP underwent tendon transfer or wrist fusion, versus 0% after iatrogenic RNP (P = 0.006). Iatrogenic RNP is not uncommon with humeral fracture fixation and occurs at similar rates in anterior and posterior approaches and with midshaft and distal fractures. Iatrogenic RNP had a high rate of recovery. Preoperative RNP more often requires surgery for unresolved palsy. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of proximal humeral fracture

To summarize the effectiveness of two-stage reverse total shoulder arthroplasty for treating postoperative deep infection after internal fixation of the proximal humeral fracture. Between June 2014 and January 2018, 17 patients with deep infection and humeral head necrosis or bone nonunion after internal fixation of proximal humeral fractures were treated. There were 8 males and 9 females, aged from 52 to 78 years (mean, 63.8 years). The infection occurred at 19-66 months after the initial internal fixation (mean, 34.8 months). Microbial culture of joint fluid was positive in 14 cases and negative in 3 cases. The preoperative Constant score, American shoulder and elbow surgeons (ASES) score, and visual analogue scale (VAS) score were 36.41±8.65, 31.06±7.43, and 7.29±0.99, respectively. The preoperative ranges of forward flexion, abduction, external rotation were (45.88±12.46), (42.18±12.31), and (16.76±4.92)°, respectively. The preoperative range of internal rotation was buttock in 9 cases, lumbosacral joint in 3 cases, L 3 in 5 cases. At the first-stage surgery, the thorough debridement was done and the antibiotic-impregnated bone cement spacer was placed after the removal of internal fixation. After the infections disappeared, the two-stage reverse total shoulder arthroplasty was performed. The mean interval between the two procedures was 4.2 months (range, 3.0-6.5 months). All the incisions healed primarily and no complications such as recurrent infection or vascular nerve injury occurred. All patients were followed up 15-32 months (mean, 22.0 months). At last follow-up, the ranges of forward flexion, abduction, and external rotation were (109.00±23.66), (98.53±16.92), (41.41±6.82)°, respectively; and the range of internal rotation was lumbosacral joint in 5 cases, L 3 in 8 cases, T 12 in 4 cases. The range of motion of shoulder joints at last follow-up was significant improved when compared with the preoperative range of motion ( P<0.05). The Constant score (64.88±8.70), ASES score (65.18±8.10), and VAS score (2.94±1.25) were significantly superior to the preoperative scores ( P<0.05). X-ray films showed that no prosthesis loosening occurred. Two-stage reverse total shoulder arthroplasty is an effective treatment for the postoperative deep infection after internal fixation of the proximal humeral fracture, which has advantages of low risk of infection recurrence, good shoulder function, and satisfactory short-term effectiveness.

Outcomes and revision rates of primary vs. secondary reverse total shoulder arthroplasty for proximal humeral fractures

Abstract Background Reverse total shoulder arthroplasty (RSA) is a standard treatment for proximal humeral fractures (PHF) and its sequelae. In this study we analyzed the clinical outcomes of primary vs. secondary RSA for displaced PHF in elderly patients. Methods We retrospectively reviewed 68 cases of primary or secondary RSA for displaced PHF. For 51 patients (28 primary RSA, 23 secondary RSA), a minimum 12-month follow-up with clinical and radiological assessment was available. Clinical assessment comprised joint active range of motion, DASH, Constant–Murley Score (CMS), Subjective Shoulder Value, and Visual Analog Scale for pain. Outcomes and complications of patients with primary RSA were compared with those of patients with secondary RSA. Results Follow-up data were available for 45 women and six men with a mean age of 73 years (range, 59–87) at the time of implantation. In 28 cases, primary RSA was performed; in 23 cases, RSA was performed as a revision procedure for fracture sequelae after failed plating, nailing, or hemiarthroplasty. The mean age- and gender-related CMS was 82.2 ± 34.2% (raw mean CMS: 46.8 ± 19.6 points). Among nine of the 51 patients with follow-up data (17.6%), ten complications occurred with six surgical revisions. Primary RSA (n = 28) resulted in better clinical shoulder function compared with secondary RSA (n = 23). Significantly more complications and revision surgeries were observed following secondary than primary RSA (p = 0.013). Conclusion In this study, primary RSA for displaced PHF in the elderly was associated with better clinical function and lower complication and revision rates than secondary RSA. Predictive parameters for failure of humeral head-preserving fracture fixation and anatomic hemiarthroplasty should be carefully evaluated. Primary RSA should be considered when surgical treatment of PHF is indicated in elderly patients.

Iatrogenic combined lesion of musculocutaneous and radial nerve following external fixation of humeral fracture

article: Iatrogenic combined lesion of musculocutaneous and radial nerve following external fixation of humeral fracture - Minerva Ortopedica e Traumatologica 2020 March;71(1):36-7 - Minerva Medica - Journals

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients\u2014which scores can be evaluated by a telephone-based assessment?

BackgroundThe aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders.MethodsNinety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score.ResultsIn the first and second interview, we could state fair outcomes: CS 91 (range 40–100) and 65.5 (23–86), DASH 12.5 (0–64.2) and 18.3 (0–66.7), and OSS 58 (33–60) and 55 (25–60) points.The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of − 22.3, 4.9, and − 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74).ConclusionPatients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients.Trial registration(250/2011BO2).

Humeral shaft fractures treated by closed retrograde intramedullary kirschner wire fixation

Context: Flexible intramedullary nails have been reported to provide a stable humeral fixation with satisfactory results in terms of union and complications. In this study, Kirschner wire (K-wire) was used to achieve a closed intramedullary fixation of humeral shaft fractures. Subjects and Methods: This study included forty cases of the displaced diaphyseal fracture of the humerus based on inclusion and exclusion criteria. The study was done at Kasturba Hospital, Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sevagram, between the periods January 2003 and November 2006. All the cases were operated after clinical evaluation. The final evaluation of the result was done by Qidwai's clinical and radiological criteria. Results: A total of forty cases were available for the study. K-wire of different sizes was used; the average duration of surgery was 45.3 ± 7.2 min. The average time taken for radiological union was 12.1 ± 1.9 weeks. The patients were analyzed by Qidwai's criteria and had excellent result in 30 (83.3%) cases, good in 4 (11.1%) cases, and poor in 2 (5.6%) cases. Three patients were lost to follow-up, and one patient was died due to medical illness. Conclusion: Intramedullary K-wire fixation is a satisfactory, safe, simple, minimally invasive technique and cost-effective treatment for humeral shaft fractures. It gives elastic mobility and stability.

New, Minimally Invasive, Anteromedial-Distal Approach for Plate Osteosynthesis of Distal-Third Humeral Shaft Fractures: An Anatomical Study.

Background:Fractures of the distal third of the humeral shaft remain a challenge today. Plate osteosynthesis is the most commonly used method of treatment. Current minimally invasive plate osteosynthesis (MIPO) techniques applied to the distal part of the humerus have shown a high risk of radial nerve injury, and they are unable to adequately fix distal-most fractures. Our hypothesis was that using a new MIPO approach, distal humeral shaft fractures can be safely fixed. The aim of this study was to develop this new anteromedial-distal MIPO approach.Methods:We conducted a laboratory descriptive study using 16 arms from adult human specimens. A new anteromedial-distal MIPO approach, starting distally through a small window in the pronator teres muscle, was developed. A premolded plate was introduced in the anterior side of the medial epicondylar area, through the anterior face of the humerus, up to the proximal part of the humeral shaft. Several anatomical parameters were measured on dissection to define the distances of the plate and screws to the neurovascular structures that could be at risk.Results:The radial nerve was not at risk because of its pathway through the posterior and lateral aspects of the arm. The mean distance from the most distal border of the medial epicondyle to the proximal border of the coronoid fossa was 3.36 cm (95% confidence interval [CI], 3.23 to 3.50 cm). At least 3 screws could be inserted in all specimens in this area and up to 5 when the fixation area was extended 2 cm proximally. The mean width of the medial epicondylar area was 2.19 cm (95% CI, 2.03 to 2.33 cm), space enough for the distal fixation of the plate. The ulnar nerve was at risk only from the tip of the most distal screw (mean distance of 2.50 mm; 95% CI, 1.60 to 3.40 mm) in specimens with a very narrow medial epicondylar area.Conclusions:This approach provides adequate fixation for distal humeral shaft fractures, but proper clinical studies must be undertaken.Clinical Relevance:This new approach avoids the risk of radial nerve injury.

Comparing fin intramedullary nailing with standard locked intramedullary nailing in the fixation of humeral shaft fractures

Background: Standard interlocking intramedullary nailing of the humeral shaft fractures has its attending complications such as difficulty in locking the nail distally and associated nerve injuries. Aim: To compare the rate of fracture healing, functional outcome and complication rate between SIGN standard locked intramedullary nail (SSLIN) and SIGN intramedullary fin nail (SIFN) in the management of humeral shaft fractures. Method: This is a retrospective comparative study comprising of patients who were treated with either SSLIN or SIFN for humeral shaft fractures. They were followed up until full activities of daily living was achieved. Data collected were processed with SPSS. Comparisons were made between the two groups using student t-test for the continuous variables and Chi-square for the categorical variables. Results: Forty-three patients with humeral shaft fracture were included in this study. Thirty-one of them constituted the SSLIN group while 12 of them constituted the SIFN group. At 6 weeks, radiographic evidence of fracture healing was seen in 64.5% and 58.3% of the patients in the SSLIN and SIFN groups respectively and by the third month, 96.8% and 100% of the patients respectively had achieved radiographic evidence of fracture healing. The differences were not significantly different. There was also no significant difference in the findings from the comparative assessment of functional outcomes in both groups. Conclusion: SIFN compared favorably with the SSLIN in terms of rate of fracture healing and resumption of functional activities. SIFN is therefore encouraged to be used for humeral shaft fractures.

Comparison of Radiographic and Clinical Results between MIPO Internal Fixation and Auxiliary Tension Suture Fixation for Proximal Humeral Fractures

The aim of this study was to evaluate the efficacy of auxiliary tension suture fixation and minimally invasive percutaneous osteosynthesis internal fixation on proximal humeral fractures in patients. From May 2012 to May 2017, 66 patients with proximal humeral fractures were enrolled in the Affiliated Suzhou Hospital of Nanjing Medical University. A prospective follow-up cohort study was conducted on 47 patients with proximal humeral fractures, including 11 males and 36 females, average age 64.6 y, range 27-92 y. According to the Neer’s classification system, there were 10 two-part, 30 three-part and 7 fourpart fractures. Twenty four patients were treated with minimally invasive percutaneous osteosynthesis internal fixation while 23 patients were managed with minimally invasive percutaneous osteosynthesis plus auxiliary tension suture fixation. Standard X-ray and physical examination post operation was performed. Consistant-visual analogue scale pain score, Constant-Murley score, University of California at Los Angeles score and disabilities of the arm, shoulder and hand score were comparable between the 2 groups. There were no significant differences between the 2 groups, however, a significantly greater supraspinatus force was observed in minimally invasive percutaneous osteosynthesis plus auxiliary tension suture fixation group compared to the minimally invasive percutaneous osteosynthesis alone group. Minimally invasive percutaneous osteosynthesis group had 2 cases of migration of great tuberosity and 1 case of acromial impingement. The auxiliary tension suture fixation group had 1 case of might valgus deformity and 1 case of fixation loosening and the complication rate was 12.5 % of minimally invasive percutaneous osteosynthesis group compared to the 8.6 % of auxiliary tension suture fixation group. Treatment of proximal humeral fractures with an auxiliary tension suture fixation was a good alternative to minimally invasive percutaneous osteosynthesis or conservative treatment, and should be performed routinely in displaced 2, 3 and 4-part fractures.

Use of the Humeral Head as a Reference Point to Prevent Axillary Nerve Damage during Proximal Fixation of Humeral Fractures: An Anatomical and Radiographic Study.

IntroductionTreatment of proximal humeral fractures with plate osteosynthesis or intramedullary nail fixation in humeral shaft fractures with a proximal locking bolt carries the risk of iatrogenic injury of the axillary nerve. The purpose of this anatomical study is to define a more reliable safe zone to prevent iatrogenic axillary nerve injury using the humeral head instead of the acromion as a (radiographic) reference point during operative treatment.Materials and methodsAnatomical dissection and labeling of the axillary nerve and branches was performed on 10 specially embalmed human specimens. Standard AP and straight lateral radiographs were made. The distances were measured indirectly from the cranial tip of the humerus to the axillary nerve on radiographs.ResultsThe median distance from the cranial tip of the humerus to the axillary nerve was 52 mm. The mean number of axillary nerve branches was 3. The distances from the cranial tip of the humerus to the nerve (branch) varied from 23 to 78 mm. The median distance from the proximal (anterior) branch was 36 mm, to the second branch 47 mm, 54 mm to the third branch and 73 mm to the fourth branch. The axillary nerve moves along with the humerus in cranial and caudal direction when the subacromial space varies.ConclusionThis study shows that the position of the axillary nerve can be better determent using the cranial tip of the humerus as a reference point instead of the acromion. Furthermore, it is unsafe to place the proximal locking bolts in the zone between 24 mm and 78 mm from the cranial tip of the humerus. The greatest chance to cause a lesion of the main branch of the axillary nerve is in the zone between 48 mm and 58 mm caudal from the tip of the humeral head.How to cite this articleTheeuwes HP, Potters JW, Bessems JHJM, et al. Use of the Humeral Head as a Reference Point to Prevent Axillary Nerve Damage during Proximal Fixation of Humeral Fractures: An Anatomical and Radiographic Study. Strategies Trauma Limb Reconstr 2020;15(2):63–68.

Healing the Index Humeral Shaft Nonunion: Risk Factors for Development of a Recalcitrant Nonunion in 125 Patients.

Humeral shaft nonunions are challenging to treat, and those that require >1 surgical procedure in order for a nonunion to heal are termed recalcitrant. Most studies on nonunion have evaluated the union rate independent of the number of procedures required to achieve union. The aims of the present study were (1) to compare the healing rates after the index operation for the treatment of a nonunion with conventional versus locked plating with or without graft augmentation, (2) to report the prevalence of recalcitrant nonunion, and (3) to identify risk factors that predict a recalcitrant nonunion. We performed a retrospective analysis of a prospectively collected database of 125 humeral shaft nonunions treated with open reduction and plate fixation by a single surgeon over 25 years. Univariate and multivariate regression analyses were performed to compare healing rates by type of plate fixation and biological augmentation and to identify demographic, injury, and treatment-related risk factors for the development of a recalcitrant nonunion. One hundred and five patients (84%) had healing after the index procedure for the treatment of nonunion. Twenty patients (16.0%) required secondary procedures and were defined as having a recalcitrant nonunion. Eight of these patients (6.4% of the overall group) healed after the secondary interventions, and 12 (9.6% of the overall group) had a failure to unite. There were no significant differences in healing rates between conventional and locked plates or between the types of bone graft (autogenous or recombinant human bone morphogenetic protein). Risk factors for the development of a recalcitrant nonunion were plate fixation of the acute humeral fracture, a history of deep infection, and ≥2 prior procedures. Plate fixation with bone graft augmentation remains a successful method for the treatment of humeral shaft nonunions. Neither plate type nor graft type reduced the risk of a recalcitrant nonunion. Factors that predicted a recalcitrant nonunion were operative fixation of the acute fracture with a plate, a history of deep infection, and ≥2 surgical procedures. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Paratricepital approach for open reduction and internal fixation of delayed presentation of pediatric supracondylar humerus fracture

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Delayed presentation of pediatric displaced supracondylar humerus fracture is relatively common. Management of such cases have higher incidence of perioperative complications and usually require open reduction and pinning. Open reduction can be done by various approaches, each having its own advantage and disadvantages.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective study was done comprising 20 children with displaced Supracondylar fracture presented 2-14 days of injury, Mean patient age was 6 years. 15 were boys and 5 were girls. Children in whom closed reduction and percutaneous pinning was achieved, vascular injury and more than 2 weeks old fracture cases were excluded. Paratricepital approach was used for Open reduction and pinning for all the cases. The functional outcome was assessed using Flynn criteria.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; In all cases the fracture had united at complete follow-up and the mean follow-up period was 16 months. The outcome was excellent in 15 (75%), good in 3 (15%), fair in 1 (5%), and poor in 1 (5%) patients. The mean Baumann angle was 76º in the affected elbow and 73º in the normal elbow. Average time for complete union in the current study was 7 weeks. Pin tract infection was seen in 2, stiffness in 2 patients, cubitus varus in 1 patient. No case of compartment syndrome or iatrogenic nerve injury was seen was recorded.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Finally, we concluded that triceps sparing paratricepital approach is an easy, simple and safe approach for exposure and internal fixation of supracondylar humeral fractures in children with excellent functional outcome.&lt;/p&gt;

Functional outcome of modified technique of intramedullary fixation of diaphyseal humeral fractures

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; The aim of this study was to evaluate the functional outcomes with intramedullary fixation using flexible nails and to follow up for any other complications.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Study was a prospective study in Lata Mangeshkar Hospital, Nagpur during 2014 to 2016. All the patients enrolled in the study were briefed about the nature of the study. All cases in this series were operated by combined antegrade and retrograde approach.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Total of 30 patients of closed diaphyseal humeral fractures was studied. Maximum i.e., 16 (53.33%) were in the age range of 21-40 years, followed by 10 (33.33%) patients in the range of 41-60 years. 21 (70%) cases had fracture union between 10-16 weeks with a score&lt;strong&gt; &lt;/strong&gt;of 8 points, followed by 8 (26.67%) patients with fracture union duration&lt;strong&gt; &lt;/strong&gt;of less than 10 weeks with a score of 10 points. Only one of the patients landed up with non-union. The mean functional score of patients at 3rd month was 64.03±4.99, 9th month was 73.46±2.56. 86.66% patients had good to fair outcome, 3.33% patient each had excellent and poor outcome.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Comparing results of our study with other studies, we found that our results are almost comparable but not better than open reduction and plating. Complications encountered in our series are comparatively less compared to those encountered during interlock nailing. The trauma to rotator cuff is minimum and this method is good alternative method. Thus, multiple nailing gives better functional outcomes as compared to locked nail. &lt;/p&gt;

Results of plate fixation for humerus fractures in a large single-center cohort.

This study aims to describe the results of plate fixation in one of the largest single-center cohorts that employs plate fixation as the golden standard. Additionally, risk factors related to a negative outcome were identified. This was a retrospective cohort study of all patients treated for a humeral shaft fracture in a level-one trauma center between January 2010 and December 2017 with a mean follow-up of 1year. Plate fixation was performed in 102 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 54.9% (n = 56) being male. Forty-eight percent (n = 48) had an AO type-A, 34.3% (n = 35) type-B, and 18.7% (n = 19) type-C fracture. Deep surgical site infections and non-union occurred in 1% (n = 1) and 3.9% (n = 4) of patients, respectively. Revision of the implant was performed in 15.7% (n = 16) mainly due to implant-related complaints. Only one patient developed radial nerve palsy after surgery. The median duration to radiological fracture healing and full-weight bearing was 18 (range 7-65) weeks and 14 (range 6-56) weeks, respectively. Risk factors for negative outcome included higher age, osteoporosis, open and higher AO class fractures, performing surgery during out-office hours, and the use of LCP 3.5-mm plate and an anterolateral approach. Plate fixation for humeral shaft fractures has low risks of complications. It should be emphasized that the complications can be further minimized with a greater surgical expertise and by refraining from performing a surgery during out-office hours.

The functional outcome of direct lateral approach for fixation of proximal humeral fractures: A case series from a tertiary care hospital.

Displaced proximal humeral fractures warrant surgical fixation for early rehabilitation and better functional outcome. These fractures are traditionally fixed by delto pectoral surgical approach. Direct lateral approach has recently gained interest as it involves less soft tissue dissection and is particularly helpful in certain fracture patterns. However, there have been concerns of axillary nerve damage with this approach. We report a case series of proximal humerus fractures fixed by direct lateral approach from our institution. All displaced Type 2 and 3 fractures were included in our study. Pathological and comminuted Type 4 fractures and fractures with ipsilateral clavicle or elbow fractures were excluded. Oxford Shoulder Score was done at regular intervals for assessment of functional outcome. We did not observe any axillary nerve damage in our case series and the outcomes of 70.5% of our patients were excellent while in 29.5% it was good. We recommend direct lateral approach for specific pattern of proximal humerus fractures.